Fractured neck of femur

From Ganfyd

Compartmentalisation of care is rife and is associated with poor outcome Good outcome of care is a fair surrogate for good process of care

Fractured neck of femur (#NOF) refers to a number of slightly different fractures around the femoral head and neck. These fractures are most commonly seen in the osteoporotic bone of the elderly, often after relatively insignificant trauma, but may also occur in high-speed injuries in younger people.

Sub-capital neck of femur fracture.

Fractures may be extracapsular or intracapsular. Intracapsular fractures are particularly important as the majority of the blood supply of the femoral head is disrupted, which means that untreated there is a high incidence of avascular necrosis.

Types of fracture:

• Subcapital
• Cervical
• Basicervical
• Intertrochanteric
• Peritrochanteric
• Trochanteric
• Subtrochanteric

Garden's classification is used in the diagnosis and management of fractured neck of femur.

Diagnosis

• Usually suspected by history and examination. Spontaneous hip fracture leading to the fall is well described in the most osteoporotic.
• Plain radiography of the pelvis and hip is usually diagnostic
• Occult hip fracture is problematical and suggested where patient can not weight bear with classic history. MRI is more sensitive, cost effective and accurate at detecting a fracture than a bone scan. CT pelvis is as effective as MRI^[1].

Treatment

Is all too easily to do poorly as it usually involves far more than a technical repair of a fracture. The necessary elements for good practice involves specialist skills in systems management, emergency care, anaesthesia, rehabilitation and internal medicine as well as orthopaedic and trauma surgery. The article on orthogeriatrics is complementary to this one. National guidelines for better practice may exist and should be referred to.

• Conservative
  • Generally only considered where risks of immobility less than operative risk.
  • Undisplaced fractures with adequate pain control
  • Pain control and dependency risk not major consideration
    • Some evidence that regional nerve block reduces parentral analgesic requirements and achieves pain relief faster
• Operative
  • Technique may be fracture type dependent
  • While evidence base has gaps many generalisations are possible
    • Displaced femoral neck fractures
      • Arthroplasty
        • Unipolar hemiarthroplasty
        • Bipolar hemiarthroplasty
        • Total hip arthroplasty
          • Consider in younger patients as best long term morbidity outcome
        • Consistent evidence that most appropriate for most elderly patients^[2]
        • Unclear preferences general anesthesia (general anesthesia popular), surgical approach (posterior approach popular), implant type (most unipolar)^[3].
        • Fair consensus on cement fixation, Capsule repair preferable, no drain postoperatively^[4]
      • Internal fixation
        • Less traumatic
        • Fair consensus if used for closed fracture reduction techniques, three cannulated screws, no capsulotomy or aspiration haematoma^[5].

External links

• The care of patients with fragility fractures: the 'blue book' BOA BGS 2007

References