Orthopedics-Online

Femoral neck fracture

General / Introduction

The femoral neck fracture (syn. Femoral neck fracture), denotes one Broken bone of the thigh near the hip joint. Usually is a Fall on the side Reason for a femoral neck fracture. Because of the increased tendency to fall and slower reflexes, it is one frequent injury of the elderly.

Epidemiology

The femoral neck fracture is a very common injury pattern, especially of the elderly. This is due to the less mobility, the reduced reflexes and one clear increased tendency to fall. Because of the major risk factor osteoporosis are Women affected significantly more often as men.

root cause

The reason for the fracture of the femoral neck is a Fall on the hipwhile that leg in the hip angled (Abduction position) or sharply angled (Adduction position) is.

Classification

On the one hand, the femoral neck fracture will decrease anatomical features, on the other hand after the causal injury mechanism assigned.
Anatomically a distinction is made:

the side (lateral) lying fractures
and the one to the middle (medial) lying fracture gap.

There towards the middle the femoral head supplying blood vessels run away, increases in one middle femoral neck fracture the risk of a Insufficient supply of the femoral head and its loss of function.
After this Injury Mechanism the femoral neck fracture is divided into Pauwels and Garden. The Pauwels classification refers to the Breakage during expansion (Abduction fracture) of the leg. The following one O-leg misalignment (Varus deformity) or X-leg misalignment (Valgus deformity) is also part of the Pauwels classification.

Pauwels I means a break line to the horizontal up to 30 °. Because the angle is small, there is still good stability despite the break.
Pauwels II denotes a break line to the horizontal between 30 and 50 °
Pauwels III describes the break line over 50 °. Because of the shear forces, the two fractions are displaced at this large angle of fracture.

Of the angle refers to the Horizontal between the greater trochanter and the center of rotation of the femoral head, as well as the fracture line.

Garden refers to the fracture of the femur Displacement of the individual fragments:

Garden 1 denotes an incomplete fraction without shifting the fractions.
Garden 2 describes a complete fraction without displacement
Garden 3 a complete break with partial displacement of the break ends.
Garden 4 is the most severe form of the femoral neck fracture. The fractions are completely displaced and the fracture surfaces no longer have any contact with one another.

Since the two classifications complement each other, will any femoral neck fracture to Pauwels and Garden is divided into its severity and thereby determines the subsequent therapy and prognosis.

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Symptoms

The main complaints are strong pain, the movement dependent are and increase with passive hip flexion. Often there is also a misalignment of the leg in the hip. This is also a diagnostic sign of the course of the fracture.
Typically found, for example, at one completely displaced fraction a Shortening of the affected leg, as well as a External rotation. If the fractures are not displaced, these malpositions may not occur. In addition, the affected leg can be due to the strong Pain are no longer burdened.

Diagnosis

Besides the anamneseif this is still possible due to the pain, the clinical examination and the Consideration of any existing misalignments the leg of an orientation.
To make the final diagnosis, however, are X-rays in two planes indexed. If recorded correctly, these show the Fracture gap and let Conclusions about the shift and the necessary therapy too.

Therapy of the femoral neck fracture

The fractions of the degree Pauwels I can, due to their stability and because the break ends are not displaced, conservative be treated. Conservative therapy consists of one Partial load with approx. 20 kg on forearm crutches for approx. 6 weeks. In order not to overlook a possible tilting of the fragments regular x-ray checks after 7, 14 and 21 days.

Femoral neck fractures of the division Pauwels II or III have a clearly increased risk of instability and displacement. Because of this, these breaks should always operational be treated. Depending on age and mobility of the patient takes place Therapy with femoral head or with a prosthesis:

younger patients:
You should always keep your femoral head as far as possible to keep the subsequent complications as low as possible.
In order to preserve the femoral head, the operation must be performed within the first 6 hours after the accident. Only then is the adequate blood supply to the femoral head guaranteed. The supply takes place either with lag screws or with a dynamic hip screw, which are inserted into the femoral head and are intended to hold the fragments together.
elderly patients:
With them it is endoprosthetic care preferable. After this operation, the patients are already resilient within the first 48 hours after the operation The risk of postoperative complications, pneumonia or thrombosis is reduced.
If the hip socket is preserved, a hemiprosthesis can be inserted; if there is already arthrosis of the hip joint, a total endoprosthesis with replacement of the femoral head and the hip socket is indicated.

Operation of the femoral neck fracture

Surgical treatment of femoral fractures is usually preferable to conservative treatment, for example with a cast. On the one hand, it is generally possible to start rehabilitation and load the leg earlier, on the other hand, the complication rate is significantly lower.

Surgical treatment of a thigh fracture is performed under general anesthesia. The operation of a femoral shaft fracture itself is usually performed in adults using intramedullary screws.

More complicated fractures, such as comminuted or open fractures, or fractures of the thigh in polytrauma patients, however, are first treated with an external fixator, which is replaced by an intramedullary nail as soon as the patient's condition or the conditions in the wound area have improved.

Fractures in the femoral neck area pose greater risks for the patient, since a good blood supply to the femoral head is often no longer given. For patients over 65 years of age, a total endoprosthesis (TEP), i.e. the complete replacement of the joint, is usually the procedure of choice.

In the case of young patients, on the other hand, a measure to preserve the femoral head, such as the dynamic hip screw or lag screw fixation, is usually used. The prognosis here is generally quite good.

Read more on the topic: Pain after hip surgery

Rehabilitation for femoral neck fracture

Since immobilization of the leg significantly increases the risk of thrombosis, each patient is prescribed heparin. This will subcutaneous, that is, injected under the skin.

Compression stockings, compression bandages and the earliest possible exercise also help reduce the risk of a blood clot (thrombus) to lower further.

Finally, with follow-up follow-up by means of x-rays, intensive rehabilitative follow-up treatment should be started as early as possible in order to ensure mobility and mobility in everyday life and to strengthen the muscles.

Depending on the operation, this is done step-by-step with the help of forearm crutches or under immediate full load. Additional measures such as cold treatments for the operating area or occupational therapy can also be used.

Read more on the topic: Rehabilitation after a femoral neck fracture

Healing process

As with any other bone, there are two types of possible fracture healing in femoral fractures; a primary and a secondary.

Primary or direct fracture healing takes place when either the periosteum remains intact (so-called greenwood fracture) or the ends of the fracture remain in contact (as is the case, for example, after an operation).

In its course, inflammatory cells, hormones and growth factors first reach the hernia with the blood. A bruise (Hematoma) forms. This ultimately results in connective tissue, which is rich in blood vessels. In the further course of the process, bone-forming cells attach to the vessels and begin to connect both ends of the bone. Already after about 3 weeks the bone is largely functional again.

If the above conditions for primary fracture healing are not met, secondary (indirect) fracture healing begins. Here, too, a bruise initially forms, and here too, after the inflammation has subsided, vascular connective tissue gradually develops - the so-called soft callus, which represents a first bridging of the fracture gap.

Specialized cells begin to break down dead bone tissue and build new bone substance. This process takes about 4-6 weeks.

The crucial difference to primary fracture healing is the mineralization of the callus through the storage of calcium, which now takes place. It forms for the time being Braided bone in the gap, the framework of which is still undirected. It gradually replaces the connective tissue. This takes another 3-4 months for adults. In the following months, the bone is remodeled Lamellar bones and the restoration of its original structure takes place.

Bones have a considerable regenerative capacity and with good treatment heal smoothly and completely without scars.

Read more on the topic: Healing time after a femoral neck fracture

Femoral neck fracture in children

Of the Thigh bone (Femur) is the strongest bone in the human body, and therefore only breaks in healthy young people when subjected to strong violence, such as a Fall from a great height.

Due to generally better healing processes in children, are conservative therapies to justify far more often in these than in adults. Fractures heal very quickly, especially in children under 2 years of age. So is one Immobilization an uncomplicated fracture using a pelvic leg cast mostly possible with babies and toddlers. The complete healing the injury increases roughly 3 to 4 weeks in claim.

More complicated fractions but usually do one surgery necessary. These include, for example, fractures, which the Epiphyseal plate (Growth plate) include. This can make it longer term Growth inhibitions or misalignments of the leg, which is why a regular follow-up care is necessary at intervals of usually one month.

A number of surgical procedures are available here especially for children. Among other things, the External fixator or the elastic stable intramedullary nailing (ESIN).

Compared to conservative therapy, surgery generally enables the child to remove the leg load again earlier to be able to.This takes place under increasing stress in the context of the physiotherapy.

forecast

The blood supply to the femoral head is decisive for the prognosis of the femoral neck fracture. If this is interrupted and cannot be restored, there is a high risk of femoral head necrosis. The femoral head dies because it is no longer nourished and there is a loss of function. In these cases the femoral head must be replaced with a prosthesis. However, if the femoral neck fracture is treated quickly and efficiently, the prognosis is relatively good. Nevertheless, the patient should be aware that the mobility after a femoral neck fracture usually no longer corresponds to the mobility in the time before the accident.
Very old patients in particular often have difficulty recovering and moving after the operation. For this reason, there is a very high mortality in the elderly in the first few years due to the complications of being bedridden. These consist mainly of pneumonia or thrombosis with pulmonary embolism.

Read more on this topic at: Femoral neck fracture late effects

Summary

The femoral neck fracture is that Disease of the elderly and is usually by the Causing fall to the side. He leaves after the Angle of the fracture gap (Pauwels) and the Displacement of the fragments (Garden) divide. These classifications are used to make therapy decisions and estimate the prognosis.
The femoral neck fracture manifests itself in severe pain the affected side and possibly a misalignment and shortening of the affected leg. Especially dangerous is the femoral neck fracture with Interruption of the blood supply to the femoral head. In this case it is often the complete replacement of the hip joint necessary with a prosthesis.
Depending on the age and mobility of the patient, the Femoral head replacement aspired early on. This offers the Advantage of quick mobilization and the ability to put stress on the injured leg. Early mobilization greatly reduces the risk of post-operative complications. For this reason, artificial hip replacements are particularly popular with the elderly.