hip fractures dr sami nugod 10/1/2015 1 hip fractures- dr sami nugod - sept 2013
TRANSCRIPT
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HIP FRACTURES
Dr Sami Nugod
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Overview
Incidence is highest in >65 years of age but also in young adults due to RTA
320,000 admission in the US each year15-20% die within 1 year of fractureF>MTwo types: intracapsular and extracapsular
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Anatomy
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Blood Supplyintracapsular are at
risk of non union and avascular necrosis due to interruption of the blood supply to the femoral headVia cruicate (med and
lat circumflex) and intramedullary
Garden classification
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Risk FactorsAge: >65 yearsCo-morbid factors: osteoporosis, endocrine disorders
(hyperthyroidism, hypogondaism), GIT disorders interfering with calcium/ Vit D absorption, neurological disorders (Parkinsons, MS)
Gender: FRTA
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Risk FactorsNutrition: lack of calcium and Vit D in diet, eating
disorders (anorexia), high caffeine intake
SmokingAlcoholMedication: steroids, anticonvulsants, diuretics
Environmental factors: loose rugs, dim lighting, cluttered floors
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Osteoporosis:
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PresentationP/C: severe pain, bruising, swelling unable to weight bear on that leg.O/E: may have shortened leg with external
rotation
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InvestigationsFull history and physical examAssess patient as per ATLS protocolX-rays AP and lateral, CT, MRI, bone scanRoutine bloods, group and holdECG, CXR
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ClassificationClassified on
geographical position: intracapsular:
SubcaptialTranscervicalbasicervical
Extracapsular:Intertrochantericsubtrochanteric
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Garden ClassificationGarden I: incomplete
fracture of the femoral neckGarden II: complete
fracture without displacement
Garden III: complete fracture with partial displacement
Garden IV: complete fracture with full displacement
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Pauwels ClassificationThe more vertical the line the greater the
risk of non union because increased shear stresses across the fracture
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Subcapital Fracture:Most common
intracapsular fracture of the hip
X-ray: white line of increased density of impacted bone may be seen at base of femoral head
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Transcervical FractureOccurs across neck
of femurEasy to view when
hip x-ray obtained in internal rotation
a/w varus deformity
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Basicervical FractureBase of femoral
neckAre Intracapsular
two part fractures with fracture plane running along line of capsular insertion
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Management of Femoral Neck FractureConservative: analgesia, bed rest, traction
if pt not willing to consent for surgery or if not expected to survive surgery
Surgical: Manninger et al showed significant reduction in osteonecrosis and segmental collapse if performed within 6 hrHead sparing: screws, DHSHead sacrificing: hemi, THR
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Young PatientsNon-displaced fractures
At risk for secondary displacement Urgent ORIF recommended
Displaced fracturesPatients native femoral head bestAVN related to duration and degree of displacementIrreversible cell death after 6-12 hoursEmergent ORIF recommended
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Elderly PatientsOperative vs. Non-operative
Displaced fractures Unacceptable rates of mortality, morbidity, and poor
outcome with non-operative treatment [Koval 1994]Non-displaced fractures
Unpredictable risk of secondary displacement AVN rate 2X
Standard of care is operative for all femoral neck fracturesNon-operative tx may have developing role in select
patients with impacted/ non-displaced fractures [Raaymakers 2001]
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Cannulated Screws.
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Cannulated Screws (Richard)Used for undisplaced femoral neck fracturesGood for fracture which are more horizontalKrastman (2004):
112 pt study had 95% consolidation rate with 2 cannulated screws in intracapsular stable fracture
Position of screw did not interfere w consolidationRates negatively affected by inadequate
anatomical reduction and unstable fractures
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Dynamic Hip Screw Good for fracture with more vertical fracture line Problem w this is that cannulated screw will prevent fracture
impaction non union Sacrifices large amount of bone Anti-rotation screw often needed
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Hemiarthroplasty Hip: Indications:
Poor general healthPathological hip
fractureSevere osteoprosisPhysiological age
>70 Inadequate closed
reductionPre-existing hip
disease
Contraindication:Pre existing sepsisYoung patientFailure of internal
fixation devicePre-existing
disease of the acetabulum
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Hemiarthroplasty Hip:Hemi associated with (Luyao 1994, lorio 2001)
Lower reoperation rate (6-18% vs. 20-36%)Improved functional scoresLess painMore cost-effectiveSlightly increased short term mortality
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Bipolar Bipolar theoretical advantages
Lower dislocation rateLess acetabular wear/ protrusionLess PainMore motion
Bipolar DisadvantagesCostDislocation often requires open reductionLoss of motion interface (effectively unipolar)
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Femoral Neck Fracture ComplicationsFailure of Fixation
Inadequate / unstable reductionPoor bone qualityPoor choice of implant
TreatmentElderly: ArthroplastyYoung: Repeat ORIF
Valgus-producing osteotomy Arthroplasty
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Femoral Neck AVN5-8% Non-displaced fractures20-45% Displaced fracturesIncreased incidence with
INADEQUATE REDUCTIONDelayed reductionInitial displacementassociated hip dislocation
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Femoral AVNTreatment
Elderly patientsoOnly 30-37% patients require
reoperationArthroplasty
Results not as good as primary elective arthroplasty
Girdlestone Resection Arthroplasty
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Femoral AVNTreatment
Young PatientsNO good option exists
Proximal OsteotomyLess than 50% head collapse
ArthroplastySignificant early failure
ArthrodesisSignificant functional limitations
** Prevention is the Key **
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Extracapsular Fractures
Inter-trochanteric fracture NOF.Sub-trochanteric fracture NOF.
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Intertrochanteric FractureMost common
extracapsular hip fracture
a/w varus deformityClassified by Evans as
stable or unstableMost commonly used
classification is Jensen where type 1&2 are stable and 3-5 are unstable
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Jensen Classification
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Subtrochanteric Fracture
Classified by Seinsheimer: divided into undisplaced, two part, and comminuted
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Seinsheimer classification
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Isolated fracture of Greater Trochanter:
Occurs mainly in osteoporotic females
Result of a fall on the greater trochanter or avulsion type fracture from pull of gluteus medius insertion
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Management of Extra-capsular Fractures:
DCSDHSIM nailing
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Compression Hip Screw W Plate
Compression hip screws with a plate have gained increased popularity for the treatment of intertrochanteric fractures
These implants provide secure fixation and controlled impaction of the fracture
The rate of complications is relatively low with most frequent mode of failure being cut out of the screw from the femoral head (Davis 1990)
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Percutaneous Compression PateInserted at parallel to femoral diaphysis
through a small incision therefore less blood loss
Shorter operating time compared to DHS (30 min)
Neck screws are telescopic and provide double axis fixation in femoral neck increases rotational stability by fracture compression and preventing collapse of neck (Giancola 2004)
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Percutaneous compression plate Vs. DHSA decreased trend in overall mortality was
seen in the PCCP group [95% CI, 0.48-1.47, Chi-square = 1.36, P = 51]
Similar trends favouring the PCCP technique were seen with the other outcomes
PCCP has the potential to become the gold standard in the repair of intertrochanteric hip fractures (Panesar 2008)
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IM Nailingintramedullary nails combine the advantages
of intramedullary fixation with those of a sliding screw
Mechanically, the shorter lever arm of the intramedullary nail decreases the tensile strain on the implant and reduces the risk of failure of the implant (Kaufer medline)
• Rates of clinical failure range from 0-4.5% (Dean 2004)
• Has a better mobility score at 1 year when compared to sliding hip screw (Hardy 1998)
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IM Nail
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Hip dislocation
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Became more common (RTA).Classified according the direction of the
femoral head.
Posterior Anterior Central
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Posterior dislocationMechanism :Dashboard injury.
Clinical features:PainDeformity Signs of nerve injury ?
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X-rays:
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Treatment
ABCs.Urgent reduction.Surgery Rehabilitation
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Complications Early Nerve injury (sciatic)Vascular injuryAssociated #sLateAVNMyositis ossificansUnreduced dislocationOsteoarthritis
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Anterior dislocation
Rare injury.Caused mainly by RTAs or air crash.
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Central dislocation
Associated with acetabular #Caused by lateral force.Treatment is always surgical.
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Thank- you
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