Fracture of the neck of the femur

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 As a consequence of hip fractures, distortion of the hip joint, disturbance of gait and inability to move independently may occur. In the case of the elderly, the healing process is very long and often does not end with complete recovery.

The femur - anatomy

The femur bone is the longest, heaviest and one of the strongest bones in the entire human body. It belongs to the long bones, consisting of a shaft and a proximal and distal end. The part closer to the femur forms the hip joint through the spherical head of the femur, which is located in the socket of the joint. The head of the femur is about 3/4 of the segment of the ball covered with articular cartilage. At its top, there is the fovea of ​​the femoral head where the femoral head ligament is attached.

Between the head of the femur and the shaft there is the neck of the femur (collum femoris), the axis of which forms an obtuse angle with the shaft: in men it is about 135⁰, and in women it is about 126⁰. In both sexes, the angle decreases with age. Two tumors, the greater trochanter and the minor trochanter of the femur, depart from the posterior surface at the site where the cervix passes into the body. The area between the neck and body, where the greater and lesser trochanter are located, is the site of muscle attachments. The greater trochanter of the femur serves as an attachment for the muscles:

- anterior surface of the trochanter - small gluteus, large lateral m.

- lateral trochanteric surface - medium gluteal area,

- the upper surface of the trochanter - pear-shaped.

The lesser trochanter, on the other hand, is the site of attachment for the greater lumbar muscle, which, together with the iliac muscle, forms the ilio-lumbar muscle.

Such anatomical and biomechanical structure of the proximal femoral epiphysis predisposes to the occurrence of injuries, because the loads are not transmitted through the bone in an axial manner, but in an angular manner. The angular settings between the individual bone elements: neck, body, show that the bone is subjected to very high constant stresses and stresses at the connection point. If, in addition, there is a large force acting from the side (fall), the most common fracture is the neck of the femur, which is the weakest part of the entire thigh. As a result of the injury, a fracture fissure is created, which is influenced by very strong skeletal muscles responsible for the upright posture and causing the bone fragments to move apart.

The distal end is formed by two large condyles: the medial condyle and the lateral condyle. The condyles are covered with hyaline cartilage, as is the patellar surface that connects them on the anterior side. From the back, between the two condyles is the intercondylar fossa, not covered with cartilage. On the lateral surfaces of both condyles there are small bony prominences called epicondyles (medial and lateral epicondyle). At the medial epicondyle, there is a slight prominence called the adductor tubercle - the site of the adductor muscle attachment.

Fracture of the neck of the femur - causes

A fracture in the femoral neck is the domain of the elderly. This type of fracture in young people is rare due to the fact that the femur is very thick and strong and it requires enormous strength to fracture it. Therefore, in young people, fractures most often occur during high-energy injuries (traffic accidents). However, the situation is different in the elderly, in whom bone strength is reduced as a result of various components. Among the factors that predispose to the occurrence of a hip fracture, the following are distinguished:

- osteoporosis and osteopenia,

- neoplastic diseases (bone tumors),

- congenital fragility / fragility of bones,

- endocrine disorders,

- taking anti-inflammatory steroid drugs,

- malnutrition,

- physical inactivity.

Osteoporosis is by far the most common cause of fractures, which gradually leads to bone demineralization. It is a consequence of the aging of the skeleton, which manifests itself in the susceptibility to fractures even with minor and low-energy injuries. Therefore, fracture of the neck of the femur in an elderly person can occur even after a simple trip or fall from a chair or bed. Sometimes it can even break spontaneously without any noticeable trauma. This is the case when lesions within the hip joint or general skeletal changes are already very advanced.

Femoral neck fractures more often affect women than men, which results from hormonal disorders during the menopause, which adversely affect the condition of the skeleton.

The mechanism of hip fracture in young patients is usually due to the high axial load arising from high-energy trauma (e.g. in a traffic accident or a fall from a height).

Fracture of the neck of the femur - symptoms

When a hip fracture occurs as a consequence of a sudden trauma, symptoms include:

 - very strong pain in the hip area,
 - inability to load a limb,
 - severe pain during passive rotation of the hip,
 - local tenderness,
 - distortion of the outlines of the hip joint,
 - shortening of the lower limb in the case of displaced fractures,
- characteristic position of the lower limb - in external rotation.

Fatigue fractures (spontaneous) of the femoral neck are manifested by pain in the joint area that tends to radiate to the groin, thigh, and even the knee. The increase in pain while loading the lower limb and at the extreme position of the joint is also very characteristic, as is the disappearance of these ailments at rest. There are also severe night pains. Persistent ailments lead to the patient's functional disorders, which are manifested by gradual limping and decreasing internal rotation in the hip joint.

Fracture of the neck of the femur - diagnosis

In order to diagnose and confirm a hip fracture, it is necessary to perform imaging tests, such as:

- X-ray examination (X-ray), which allows to assess the fracture gap, the size of the bone fragments displacement, and enables the selection of further surgical treatment. A photo is taken in the AP projection of the pelvis and in the axial projection of the injured hip joint;
- Magnetic resonance imaging of the hip (MRI) when the X-ray image is unclear and raises doubts among doctors.

Fracture of the neck of the femur - classification of fractures

There are many classification systems for hip fractures in the literature. The most frequently used division is Garden and Pauwels.

Classification of hip fractures according to Garden:
I⁰ - Fracture with incomplete bone fracture - without damage to the cortex bone;
II⁰ - Total fracture without displacement - fracture with complete damage to the cortical bone;
III⁰ - Complete fracture with partial displacement (bone fragments touch each other on a certain surface);
IV⁰ - Complete fracture with complete displacement of bone fragments.

Classification of hip fractures according to Pauwels:
Type I - the fracture line forms an angle of 30⁰ with the horizontal line (transverse of the body); the pressing forces outweigh the shear forces, which gives a good prognosis for treatment and a low risk of complications in the form of femoral head necrosis,

Type II - the value of the angle ranges from 30-50⁰; the pressing forces are equal to the shear forces, which gives worse conditions for bone healing,
Type III - the angle value exceeds 50-70⁰; shear forces outweigh the pressure forces, which causes poor conditions for bone union.
Based on the above classifications, but also taking into account the patient's age and the coexistence of other injuries and diseases, the therapeutic procedure is selected.

Fracture of the neck of the femur - surgical treatment

The aim of the treatment is to restore the anatomical relations of the joint and obtain a stable fixation, which will facilitate the revascularization of the femoral head, as well as allow the patient to be quickly upright and regain the joint function.

Nonsurgical treatment is used only in the case of absolute contraindications to surgery and is based on functional treatment.

Surgical anastomosis is the most common and most effective treatment in the event of a femoral fracture and is the treatment of choice, i.e. regardless of the patient's age, which is largely related to the course of blood vessels, but also to the long period of bone union. Prolonged immobilization of the hip joint could lead, first of all, to thromboembolic complications. Another very important factor supporting the surgical treatment is the fact that the head and neck of the femur are supplied by blood vessels on the side of the shaft, and at the time of neck fracture, the vessels are broken, which disturbs the circulation and, as a consequence, disrupts the bone union process and tissue necrosis.

The choice of the method of surgical treatment depends on the type of fracture, the extent of the injury, age and activity of the patient. Depending on these factors, the following are performed:

- anastomosis of broken bone fragments with the use of screws or nails,
- reposition and internal stabilization with the use of dynamic hip screw (DHS),
- arthroplasty, i.e. replacement of a damaged fragment of the femur with an artificial element. The endoprosthesis may be partial (replacement of one joint member) or complete (replacement of both joint members).

In the case of hip fractures, the vascularization of the proximal part is impaired. Only in young people and the elderly with Garden I ° and II ° fracture (Pauwels type I and II), treatment is undertaken with the use of internal fixation (cannulated screws, DHS) in order to fix the fragments and obtain union. In III ° and IV ° fractures (Pauwels type III), especially in patients with poor quality bone treatment, arthroplasty is considered due to the possibility of developing necrosis of the femoral head. An Austin-Moor hemi endoprosthesis is usually used in the elderly. It is a one-piece prosthesis, consisting of a head that replaces the head and neck of the femur, and a pin inserted on a bone cement into the shaft of the femur. In the case of younger, physically fit and active patients, total hip arthroplasty should be considered. Modular dentures are used, consisting of a acetabular part, a prosthesis head and a stem

The use of hip arthroplasty eliminates the need to wait for bone union and enables earlier loading of the operated limb. Surgical intervention allows for a much faster upright positioning of the patient, which is important in the process of recovery and in the prevention of thrombosis. In order to avoid the development of complications resulting from the fracture, the procedure should be performed within 12–24 hours of the injury.

However, not all patients qualify for the procedure, which is related to their age and the existing internal and cardiological contraindications. In patients who are not qualified for surgery, an extract is placed on the diseased limb or immobilized in a gypsum derotation shoe, which protects the lower limb from excessive external rotation in the hip joint. Such treatment usually requires 6-8 weeks of bed rest and is associated with a very high risk of numerous complications.

Complications after a fracture of the neck of the femur

The most dangerous complication of hip fracture is the patient's death (20% of patients die as a consequence of the fracture). Research shows that about 50% of patients regain their full fitness, which allows them to move independently and live without restrictions. The other half is exposed to numerous complications that significantly adversely affect the daily functioning and life of the patient.

The complications of a hip fracture include:

• no bone union,
• circulatory and respiratory failure,
• pneumonia,
• inflammation of the urinary tract,
• damage to blood vessels,
• femoral head necrosis,
• thromboembolic complications - blockages of the pulmonary and cerebral vessels,
• the formation of a neck pseudo-pond,
• degenerative changes in the hip joint,
• bedsores,
• thrombophlebitis
• muscle contractures and severe limitation of mobility in the joint.

Due to the fact that the main treatment of choice is surgery, the patient is also exposed to:

- anemia that can lead to femoral necrosis - there is a lot of blood loss as a result of fractures and during surgical intervention,
- infection and suppuration of a postoperative wound,
- displacement of bone fragments,
- complications within the implant - the prosthesis may loosen (it happens very rarely, most often in the case of advanced osteoporosis, when the bone is very soft and prone to damage)

Rehabilitation after surgical treatment of a hip fracture

The aim of rehabilitation activities after surgery should be to ensure that the patient is in an upright position as quickly as possible. Rehabilitation procedure begins on the first day after the surgery and includes mainly:

- isometric exercises of the quadriceps muscle of the thigh,
- isometric exercises of the gluteal muscles - depending on the surgical approach used,
- breathing exercises,
- anticoagulant exercises,
- in the case of arthroplasty, it is necessary to pay attention to the correct positioning of the limb - adduction of the limb and rotational movements in the hip joint are forbidden in order to - protect the patient against dislocation of the prosthesis.

On the second day after the procedure, the patient is upright using a walker or elbow crutches and the gait re-education process begins. Depending on the type of fracture (stable, unstable) and the type of surgical procedure performed, a marked three-stroke gait with partial load or full relief of the lower limb (in the case of unstable fractures) is recommended. In addition, rehabilitation procedures include active exercises for the ankle and knee joints, exercises to relieve the hip joint and exercises in closed kinematic chains. These activities should be carried out up to the 6th postoperative day.

The 7th day after the procedure is the time when the exercise intensity increases significantly, the ranges of mobility during exercise also increase. Active hip exercises are introduced into the rehabilitation procedure. In addition, the gait with a greater load on the limb is gradually introduced, and orthopedic aids (one-ball gait) are abandoned. Patients are advised to walk regularly over short and medium distances. This stage lasts up to approximately 12 weeks (3 months) after surgery.

Rehabilitation should last until the patient reaches the normative values ​​in clinical trials and locomotion tests. The lower limb is fully loaded approximately 12 weeks after the procedure. It is also the time when you should strive to increase muscle strength and regain the full range of motion in the operated hip joint.

It should be remembered that the patient rehabilitation program must be fully individualized, and the given time frames for the individual stages of rehabilitation should result from the patient's exercise results and general health.

Frequently asked questions about hip fracture: