|Year : 2005 | Volume
| Issue : 2 | Page : 130-136
|Management of fracture neck of femur
Hardas Singh Sandhu
Department of Orthopaedics, Medical College, Amritsar, India
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|How to cite this article:|
Sandhu HS. Management of fracture neck of femur. Indian J Orthop 2005;39:130-6
Fracture neck of femur is commonly seen in old people but in India quite a good number of patients are young adults below the age of 50. It is however infrequent in children. The management of this fracture has been changing from time to time. With better understanding of mechanism of hip, blood supply of the upper end of femur (especially the head of femur) , and improvement in design and quality of implants, the results have become better. However the number of procedures available and practiced show that no one is universally applicable and surgeon has to select one which would be ideal in a given situation. The treatment varies with the age of the patient, the level of the fracture and displacement of fragments. It also depends upon the duration of the fracture. There are certain anatomical features peculiar to this fracture which needs consideration. (1) Fracture is situated inside the joint and fracture surfaces are exposed to synovial fluid and its enzymes. (2) The blood vessels supplying the head of femur run in retinaculae in close contact with the bone. These vessels particularly those on the anterior aspect are likely to be disrupted by the fracture. (3) Because of the anatomical configuration of the bone and action of various groups of muscle, this fracture is subjected to a very high degree of shearing stain. As a result of these a displaced fracture neck of femur does not unite unless it is reduced and internally fixed. Even undisplaced fracture can get displaced and go on to non union. (4) This is one fracture where one fragment (proximal) can be totally excised and replaced by prosthesis or even whole hip joint can be replaced restoring good function in shortest possible time. This procedure is often adopted as an easy way out of difficult solution.
In most of the cases femoral neck fracture posterior retinaculum and blood vessels running in it remain intact and maintain blood supply to the head of femur through circulus minor around the articular margin  . As there are many procedures available for the treatment of fracture neck of femur, Indian Orthopaedic Association decided to have a white paper on this subject to provide guide lines for its young members to choose an ideal one for a particular patient under his care.
| Method|| |
In order to finalize this paper one hundred orthopaedic surgeons (known to have interest in this subject) in different parts of the country were sent a proforma/questionnaire to get their views/recommendations on the treatment of fracture neck of femur. Thirty eight surgeons responded. A round table discussion on this subject was held in All India Institute of Medical Sciences, New Delhi (arranged by Prof. Surya Bhan).
The aim of treatment is to achieve union of fracture and a durable hip joint afterwards. If union of fracture is not likely to be achieved then what alternative method should be adopted which will suit the patient keeping in mind his age, life style, profession and economic status. Majority of our patients are not covered by health insurance, hence all the expenditure on the treatment has to be born by the patient himself. Government resources are limited which can at best subsidize the treatment in a few cases. It is therefore desirable on the part of treating orthopaedic surgeon to choose a method which these patients can afford. Detailed history and clinical examination should be carried out.
A good quality X-ray picture of the pelvis or involved hip should be taken to note (a) site of fracture and direction of fracture line. (b) Direction and degree of displacement and posterior comminution. (c) Size (Caudocephalic) thickness of neck. (d) Any pathology or associated injury. Other investigations to assess the fitness of the patient for contemplated surgical procedure should be carried out.
| Treatment|| |
From treatment point of view following points are considered.
1. Age of the patient: Based on the age the following groups were made.
a) 1-16 years before the closure of upper femoral epiphysis
b) 16-50 years young adults
c) 50-60 years middle age group
d) above 60 years (old age)
2. Site of fracture
c) Basal type
3. Displacement of fragments : For displacement of fragments Garden's classification/staging was discussed I, II, III, IV.
A simplification of this adopted:
i) Undisplaced fracture.
ii) Displaced fracture
4. Duration of fracture : 1-21 days - fresh, more than 21 days - neglected fracture
Age 1-16 years (When the growth plate is intact) ,, :
Any implant used for internal fixation either should not cross the epiphysial plate or only that implant should be used which will produce least possible damage to it.
Subcapital fracture: In undisplaced fracture the internal fixation with 2 to 2.5 mm Kirschner wire (K-wire) or Moore's pin is done. Two to three pins or wires should be used. If the fracture is displaced then closed reduction and internal fixation with K-wires or Moore's pins is used.
Trans cervical fracture : In undisplaced fractures internal fixation with K-wires or Moore's pins is recommended. If the fragments are displaced then closed reduction and internal fixation with K-wires or Moore's Pins is required.
Basal fractures : Undisplaced: Internal fixation with 2.5 mm K-wire or Moore's pins or cancellous or cannualated screws is recommended. When screws are used for internal fixation; these must remain distal to the epiphyseal plate to avoid destruction of the plate (which is likely to lead to deformity of the head of femur and shortening of the limb).
If the fracture is displaced, then closed reduction and internal fixation with K-wire, Moore's pins or screws should be done.
If closed reduction fails then, open reduction and internal fixation with K-wires, Moore pins or screws (it is easier to do open reduction on an ordinary operation table than fracture table) is recommended.
Alternatively McMurrays osteotomy with POP one and a half hip spica or abduction osteotomy with internal fixation with 135 angled paediatric blade plate or paediatric DHS sparing the epiphyseal plate can be done.
Post operatively skin traction for 4-6 weeks or POP hip spica is applied to prevent the child from bearing weight before the fracture unites.
Age 16-50 years :
1. Sub-capital fracture ,, :
Undisplaced: Internal fixation with 2-3 cancellous or cannulated screws should be used.
Displaced: Closed reduction and internal fixation with cancellous or cannulated screws is recommended. Abduction osteotomy and internal fixation with modified DHS or 135 degree blade plate or double angled blade plate converts shearing force into compression force can be used. Closed reduction internal fixation with 2 screws and one free fibular graft has also been used.
2. Transcervical fracture:
Undisplaced: Internal fixation with cancellous or cannulated screws should be used.
Displaced fractures: Closed reduction and internal fixation with cancellous or cannulated screws, 2-3 screws are used ,.If closed reduction fails then
1. Open reduction and internal fixation with cancellous or cannulated screws is done.
2. Open reduction and internal fixation with screws and free fibular graft or muscle pedicle bone graft based on quadratus femoris or sartorius or tensor fascia femoris are useful.
3. Basal fracture:
Undisplaced: Internal fixation with DHS should be used.
Displaced fractures: Closed reduction and internal fixation with DHS or cancellous or cannulated screws is done. If closed reduction fails then open reduction and internal fixation with screws DHS.
Age 50-60 years :
Undisplaced: Internal fixation with cancellous or cannulated screws should be done.
Displaced : 1. Closed reduction and internal fixation with cancellous or cannulated screws is recommended.
2. Closed reduction and internal fixation with two screws and one free fibular graft or even one screw and fibular graft should be used (if the femoral neck is narrow).
3. Abduction osteotomy and internal fixation with DHS or 135 degree angled blade plate or double angled blade plate may be used.
4. Replacement arthroplasty: Bipolar or hemiarthroplasty using Moore's or Thompsons prosthesis or total hip arthroplasty may be done.
If closed reduction fails:
1. Open reduction and internal fixation with screws and free fibular graft is an alternative.
2. Replacement arthoplasty: Bipolar or hemiarthroplasty or total hip arthroplasty (cemented or non cemented) may be used.
Undisplaced: Internal fixation with cancellous or cannulated screws should be done.
Displaced: Closed reduction and internal fixation with cancellous or cannulated screws, closed reduction and internal fixation with two screws and one free fibular graft or even one screw and one fibular graft is useful.
If closed reduction fails then:
1. Open reduction and internal fixation with screws and free fibular graft or bone muscle pedicle graft is recommended.
2. Alternatively replacement arthroplasty, bipolar, hemiarthroplasty or total hip arthroplasty (cemented or non cemented) may be used.
Undisplaced: Internal fixation with cancellous or cannulated screws or DHS should be done.
Displaced: Closed reduction and internal fixation with cancellous or cannulated screws or DHS or 135 degree angled blade plate may be used.
If closed reduction fails: Open reduction and internal fixation as above or replacement arthroplasty, hemiarthroplasty or bipolar arthroplasty or total hip arthroplasty is useful.
Above 60 years of age:
Sub-capital fracture :
1. Internal fixation with cancellous or cannulated screws.
2. Replacement arthroplasty, hemiarthroplasty, bipolar or total hip arthroplasty.
Replacement arthroplasty as above is the treatment of choice:
Closed reduction and internal fixation with cancellous or cannulated screws and free fibular graft may be tried, if closed reduction fails replacement arthroplasty should be done.
1. Internal fixation with cancellous or cannulated screws.
2. Replacement arthroplasty.
1. Closed reduction and internal fixation with screws.
2. Replacement arthroplasty - - hemi arthroplasty, bipolar or total hip arthroplasty.
If closed reduction fails - Replacement arthroplasty.
1. Closed reduction and internal fixation with screws or D.H.S.
2. If closed reduction fails then Replacement arthroplasty
FRACTURE NECK OF FEMUR OF MORE THAN 3 WEEKS DURATION
When the fracture neck of the femur is of more than 3 weeks duration, internal fixation alone has a very high failure rate. Internal fixation has to be combined with some type of bone graft or osteotomy particularly in young patients below the age of 50 years (or 55 years) in whom it is desirable to preserve the joint ,,, . In patients above the age of 55 replacement arthroplasty is the preferred treatment if he can afford and his life style permits.
Age 1-16 years
1. Mc Murray's osteotomy and POP one and half hip spica.
2. Abduction osteotomy and internal fixation with 135 degrees angled paediatric blade plate or paediatric DHS care is taken not to damage the epiphyseal plate as far as possible.
3. Closed or open reduction and internal fixation with a screw and free fibular graft 17 . It is likely to disturb the growth of the upper end of the femur resulting in shortening of the limb and deformity of the head of the femur. Therefore this procedure should preferably be avoided. If it is absolutely necessary as when there is a gap of more than 1 cm between the fragments then this procedure may be carried out.
Age 16-55 years
In this age group patient's own hip joint should be preserved. Osteosynthesis is carried out aiming at union of fracture and obtaining a durable hip joint. The results of various procedures depend upon the changes which have already taken place at the site of fracture with passage of time. These changes are:
a) Fracture surfaces get smoothened out
b) There is progressive absorption of the neck of femur resulting in increase in the gap between the fragments and decrease in the size of the proximal fragment
c) The head of the femur may start showing signs of avascular necrosis
A good quality X-ray of pelvis including both hip joints in as identical position as possible should be taken. The length of the proximal fragment is measured from upper margin of fovea centralis to the mid point of fracture margin. CT scan or MRI of pelvis can be extremely useful in accurately measuring the gap between the fragments and the size of the proximal fragment. Sometimes the absorption of the proximal fragment is more marked in the centre than the periphery giving it the shape of a cup or moon. This may not be clearly seen on routine. AP view X-ray of the hip and can be better appreciated on CT scan or MRI. Avascular necrosis of the head of the femur may be seen earlier on MRI / CT scan than on plain X-ray of the hip.
Based on these changes the fracture can be allocated to one of the following 3 stages  .
a) Fracture surfaces are still irregular (Fresh)
b) The size of proximal fragment is 2.5 cm or more
c) Gap between the fragments is 1 cm or less
d) Head of the femur is viable. There is no sign of avascular necrosis on X-ray picture or MRI or CT Scan.
a) Fracture surfaces are smoothened out
b) The size of the proximal fragment is 2.5 cm or more
c) The gap between the fragments is more than 1 cm but less than 2.5 cm
d) The head of the femur is viable.
If either of the feature a or c is present it is allocated to stage II.
a) fracture surfaces are smoothened out
b) The size of the proximal fragment is less than 2.5 cms
c) The gap between the fragments is more than 2.5 cms
d) The head of the femur shows signs of avascular necrosis
If any of the feature b, c or d is present the fracture is allocated to stage III.
Stage I: In this stage the success rate of various procedures aimed at osteosynthesis is very high. The procedures which are useful are:
1. Closed reduction and internal fixation with one screw and double fibular graft or 2 screws and one fibular graft. If the neck of the femur is narrow then one screw and one fibular graft may be given.
2. Closed reduction or open reduction and bone muscle pedicle graft based on quadratus femoris or sartorius or tensor fascia femoris can be used.
3. Abduction osteotomy and osteosynthesis with DHS or 135 degree angled blade plate. This procedure is particularly useful when the fracture is situated more near the base and length of proximal fragment is 3.5 cms or more.
4. McMurrays osteotomy with one and half POP hip spica.
Stage II: In this stage when the fracture surfaces are smoothened out (as in case of established nonunion) and the gap between the fragments is more than 1 cm various methods of osteosyntehsis which have given good results are
1. Closed reduction and internal fixation with one screw and double fibular graft or 2 screws and 1 fibular graft.
2. Open reduction, freshening of fracture surfaces and internal fixation with 2 screws and one free fibular graft.
3. Open reduction and internal fixation with multiple screws and bone muscle pedicle graft based on quadratus femoris or sartorius or tensor fascia femoris.
4. Other methods of treatment which can be useful in developing countries (although they will not achieve union of fracture but improve the function of hip) are
a. McMurrays osteotomy
b. Osteotomy with internal fixation
c. Bachelor's or Girdlestone procedure
Stage III: In this stage when the size of the proximal is less 2.5 cms, it cannot give good hold to the implant as well as the graft or there is a gap of more than 2.5 cm between the fragments or femoral head is showing signs of avascular necrosis, chances of union are less. Osteosynthesis is likely to have very high failure rate. The treatment options available are
1. Total hip arthroplasty - - if the patient can afford and his life style permits. It may preferably be non-cemented or may be cemented.
2. Bipolar or hemi arthroplasty
3. McMurray's osteotomy
4. Subtrochantric osteotomy with internal fixation
5. Excision hip Girdlestone's or Bachelor's procedure
6. Patient may be left alone if the patient is poor and can not afford treatment or is unfit for surgery. He can start walking with the support of a walker or crutches. Later on he can walk with the support of stick or even without than in about 3-4 months time. They are often able to squat or sit in cross legged position (Budha position).
After the age of 55 years
1. Replacement arthroplasty : if the patient can afford or his life style permits. It may be total hip replacement or bipolar or hemi-arthroplasty
2. Osteosynthesis if the patient wants it and is prepared to wait for 5 - - 7 months for independent walking. This should be carried out only in stage I and stage II.
3. Excision hip (Girdlestone procedure or Bachelor's procedure)
4. Osteotomy with internal fixation
5. Leave him alone.
There are rough guidelines to help the orthopaedic surgeon to manage fracture neck of femur in different age groups and fracture at different levels of neck for fresh as well as neglected cases. The decision regarding the choice of operative procedure rests with the surgeon depending upon the patient's requirements, his life style, profession and financial position. It also depends upon the training of the Orthopaedic surgeon and facilities available to him. Use of free fibular graft in addition to internal fixation with screws particularly where there is posterior comminution improve the chances of union and may be carried out in such cases. If the reduction of the fracture is less than anatomical but otherwise satisfactory addition of free fibular graft can improve the chances of union.
If the patient is suffering from a generalized disease like diabetes mellitus, congestive heart failure, chronic kidney or liver disease, malignancy etc., or is taking steroids adversely affecting the chances of union of fracture, replacement arthroplasty may be a better option even in younger.
Closed reduction and internal fixation with screw and free fibular graft
The procedure is carried out on fracture table under image intensifier or X-ray control. The fracture is reduced by traction and internal rotation. Through a lateral longitudinal incision femur is exposed, subperiosteally in sub trochanteric region. After drilling, a cancellous screw is passed into the femoral neck reaching subchondral area of the head. Two guide wires are passed into the neck in relation to the screw. Tunnels are created over the guide wires with triple reamer. Two fibular grafts taken from the same limb are threaded over the guide wires reaching subchondral region of the femoral head. If one fibular graft is to be used then it is threaded over one guide wire and the other guide wire is replaced by a cancellous or cannulated screw. Wounds are closed over suction drains.
Post operative: Skin traction is given for 2-4 weeks. Antibiotics are given for 3-7 days. Suction drains are removed after 48 hours and stitches on the 12-14 th day. Walking with support without weight bearing is permitted after 3-4 weeks. Gradual weight bearing is allowed after radiological union of fracture.
McMurray's Osteotomy 
The procedure is carried out on fracture table. If facility is available then X-ray or image intensifier should be used, otherwise procedure can be carried out without imaging. Fracture is reduced as far as possible by traction and internal rotation. Through a lateral longitudinal incision femur is exposed sub-periosteally in the subtrochanteric region. The osteotomy has to pass through the upper part of lesser trochanter above the insertion of iliopsoas tendon. It has to be outside the capsule of the hip joint just below the level of inferior margin of the acetabulum. Levers are introduced to protect the soft tissues and land marks for osteotomy are identified. Lesser trochanter is palpated with a finger, starting point of osteotomy is marked on the outer side of the femur.
It has to be oblique osteotomy making an angle of about 3045 degrees with the longitudinal axis of the femur (the line of osteotomy may be verified on X-ray by introducing a guide wire). Osteotomy starts from the base of greater trochanter or a little below that and goes upwards and medially passing through the upper part of lesser trochanter. If osteotome is to be used for osteotomy then it is better to drill one or two holes in the femur in the line of osteotomy and medial cortex is cut anteroposteriorly with a small osteotome, then with a 1.5 - - 2 cms osteotome the femur is cut from lateral to the medial side. When osteotomy is complete, osteotome is used as a lever to displaced the distal fragment medially by 1/3 to ˝ of the transverse diameter of the femur and is abducted by about 30 degrees. This maneouver should be done carefully so that displacement of distal fragment is not too much leading to non union of osteotomy. Wound is closed and POP one and a half hip spica is given.
Antibiotics are given for 5-7 days. Patient lies on hard bed, exercise of muscles in the spica and deep breathing exercise are carried out. The spica may be changed after six weeks. But it has to be continued for 3 months. The osteotomy unites in about 3 months time. After removing spica, he is given active hip and knee movements and quadriceps exercises. When he is able to lift the leg up, walking with support with gradual weight bearing allowed. Instead of POP one and half hip spica the osteotomy may be fixed with DHS or 135 degree double angled blade plate.
| Discussion|| |
Fracture neck of femur continues to be a problem fracture from the point of view of its management[ 20], . Treatment of fracture neck of the femur has been changing from time to time. It has passed through stages of immobilization in POP hip spica, Internal fixation with Smith Peterson nail, nail plate, low angle nail before 1970. Now a day's popular fixation in adults is with cannulated or cancellous screws. Orthopaedic surgeon in India (also in other developing countries) has to treat patients from different economic strata from very rich to a very poor person who may not be able to afford even one meal a day. Majority of the patients have no health insurance and have to pay from their own pocket. Government resources are limited and can at the most subsidize the treatment. The life style of the patients requiring them to squat or sit in Buddha position makes it desirable to preserve the patients own hip joint. The range of movements at the hip required to adopt these postures are neither possible nor permissible in any artificial joint available at present.
Quite often the patients report late for treatment may be after many weeks or even months when internal fixation alone has high failure rate. Under these circumstances internal fixation has to be combined with some type of bone graft or osteotomy. Good results have been reported with open reduction and muscles bone pedicle graft in addition to internal fixation ,, . Nagi et al24,25 have reported good results with open reduction and internal fixation combined with free single fibular graft. If open reduction is required it can be carried out better on ordinary operation table then fracture table. The idea of use of double fibular graft was put forward by Yadav  in fresh fracture of femoral neck in old people thinking it to be osteopaenic fracture. Vascularised free fibular graft have also been reported ,, . These grafts have improved the rate of union of fracture particularly if the treatment is delayed beyond 3 weeks or if closed reduction is not anatomical. The functional results after union are quite satisfactory and lasting in very high percentage of cases.
Replacement arthroplasty (total hip arthroplasty, bipolar prosthesis and hemi-arthroplasty) are very useful procedures and have to be carried out when it is not possible to achieve union of fracture or in old people who have to be put on their feet without loss of time. These procedures have to be offered to those who can afford and are capable of modifying their life style so that the artificial joint lasts for longer period. These have to be done extremely carefully and after due thought and consideration in young adults but should not be denied in those who need and want it.
McMurray's osteotomy, excision hip (Girdlestone and Bachelor procedure) were very popular as salvage procedures before the advent of replacement arthroplasty. They are still useful in circumstances, living conditions and habits of people in developing countries. After these procedures patient can squat and may even be able to sit in cross legged position. Patient is able to walk without any aid though with some limp and remains free of pain for many years. Authors have patients still having useful hip after 40 years of McMurray's osteotomy and Girdlestone or Bachelor procedure.
It is amazing to see untreated patient with non-union of fracture and absorption of the neck of the femur walking about with limp but without any support. They are able to squat and often sit in Budha position however, the limp is quite marked.
Acknowledgement: Following orthopaedic surgeons have contributed their opinion for this paper. DP Baksi, NS Laud, HKT Raza, MT Mehta, PM Desai, MM Prabhakar, PA Divatia, Devadas, Vergese Chacko, Amritsar Orthopaedic Forum, SS Sangwan, RC Siwach, Sansar S Sharma, Zile Singh Kundu, ON Nagi, PS Maini, KP Srivastava, Anil Srivastava, SM Tuli, SS Yadav, R Bhalla, SP Mandal, Surya Bhan, NK Aggarwal, PK Dave, DK Taneja, RL Mittal, BK Dhaon, VK Gautam, Dilip Patel, Sudhir Babhulkar, HS Sohal, Shalindra Bhattacharya, Vergese Mathews, PS Sandhu, Anil Jain, Anuj Kapoor, Rajinder Rajan, AK Gupta, MK Mam, MS Dhillon.
I am grateful to Prof. Surya Bhan for arranging Round Table Conference in AIIMS, New Delhi on this subject.
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Hardas Singh Sandhu
Department of Orthopaedics, Medical College, Amritsar
Source of Support: None, Conflict of Interest: None
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