FEMORAL NECK FRACTURES:

Physiotherapy ManagementDr. D. N. BID

Sarvajanik College of Physiotherapy, Surat

Definition

• A Femoral Neck # is a # occurring proximal to the intertrochanteric line in the intracapsular region of the hip.

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Classification

• Pauwels [1935]

– Angle describes vertical shear vector

Classification

• Garden [1961]

I Valgus impacted or incompleteII Complete Non-displacedIII Complete Partial displacementIV Complete Full displacement** Portends risk of AVN and

Nonunion

I II

III IV

Classification

• Functional Classification – Stable • Impacted (Garden I)• Non-displaced (Garden II)

– Unstable• Displaced (Garden III and IV)

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Femoral neck # classified as Garden’s type 1: an incomplete impacted femoral neck # in valgus position. All femoral neck #s are intracapsular.

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Garden’s type 2: nondisplaced complete femoral neck #.

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Garden’s type 3: displaced femoral neck # in varus position. There is often disruption of the joint capsule.

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Garden’s type 4: completely displaced femoral neck #. It has the poorest prognosis. The femoral head may go on to AVN. In older patients, this # is usually treated with a endoprosthesis.

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Subcapital femoral neck # at the proximal end of the neck. This # is displaced and in varus position (Garden’s type 3)

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Subcapital # of the femoral neck impacted and in valgus position (Garden’s type 1).

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Mechanism of Injury• Most femoral neck # in the elderly are spontaneous

or caused by low energy trauma.

• This population is subject to senile osteoporosis (type II), which causes weakness in both the cortical and trabecular bone of the femoral neck and predisposes it to #.

• In younger patients, high energy trauma is necessary to cause a femoral neck # , and therefore displacement of the # and damage to the blood supply is usually greater in those cases. 12

HIGH-ENERGY INJURY

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LOW ENERGY INJURY14

Treatment Goals

• Orthopaedic Objectives• Alignment• Stability

• Rehabilitation Objectives• Range of Motion• Muscle Strength• Functional Goals

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• Orthopaedic Objectives• Alignment– Restore fragments to their correct anatomic

position for unstable hip #s. –Maintain alignment in nondisplaced or impacted

stable #s. – Satisfactory alignment after reduction of an

unstable # should have no more than 15 degrees of valgus and 10 degrees of anterior posterior angulation.

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• Orthopaedic Objectives• Stability

– Compress the # fragments with lag screws to restore cortical and cancellous contact.

– Replace the femoral head in the elderly patient with an unstable# to achieve immediate stability.

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Subcapital # of the femoral neck.

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Fracture fixed with a screw and side plate to compress the # in an attempt to restore cortical and cancellous contact.

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To achieve immediate stability, the femoral head and neck are replaced in an elderly patient with an unstable #.

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• Rehabilitation Objectives• Range of Motion: Improve and restore ROM of the knee

and hip. ROM of Hip & KneeMotion Normal Functional

Knee

Flexion 130-140° 110°

Extension 0° 0°

Hip

Flexion 125-128° 90-110°

Extension 0-20° 0-5°

Abduction 45-48° 0-20°

Adduction 40-45° 0-20°

Internal Rotation 40-45° 0-20°

External Rotation 45° 0-15°21

• Rehabilitation Objectives• Muscle Strength: Improve the strength of the muscles that are affected

by the #.» Gluteus medius: most important for postop stability» Iliopsoas» Gluteus maximus» Adductor longus, magnus, brevis» Quadriceps: vast. lateralis is exposed during surgery.» hamstrings

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• Rehabilitation Objectives• Functional Goals: Normalize the patient’s gait pattern. Achieve 90 degree hip flexion for proper sitting

position.

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• Expected time of Bone Healing12-16 weeks.

• Expected Duration of Rehabilitation15-30 weeks.

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Methods of Treatment• Closed or Open Reduction and Internal Fixation

– Biomechanics: Stress sharing device

– Mode of Bone Healing: Primary in non-displaced, impacted, or anatomically reduced #s.

– Indications: – #s that are impacted, nondisplaced, or adequately reduced in

patients younger than 65 years of age should be internally fixed with multiple parallel cannulated screws or pins.

– A compression screw and side plate and an additional antirotation screw may be used for basicervical #s ( to prevent the loose head from spinning on the screw) that have a comminuted lateral cortex or severe osteoporosis. 25

Multiple parallel cannulated screw for internal fixation of a Garden’s type 1 #. Fractures that are adequately reduced in patients younger than 65 years of age are treated with internal fixation in situ.

Compression screw and slide fixation. This is an alternative to multiple parallel cannulated screws. An additional proximal antirotational screw may be used to prevent the loose head from spinning on the screw.

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Methods of Treatment• Prosthetic Replacement of Femoral Head

– Biomechanics: Stress bearing device.

– Mode of bone healing : None

– Indications: – A fixed unipolar (Austin-Moore or Thompson type) or

bipolar endoprosthesis may be used to treat an unstable displaced # when a satisfactory reduction cannot be achieved and the patient is older that 65 years of age. –Other indication include cases in which rheumatoid,

degenerative, or malignant disease has caused preexisting articular damage. 27

Bipolar endoprosthesis for treatment of an unstable displaced femoral neck #. This is frequently used in patients older than 65

years of age when satisfactory reduction cannot be achieved.

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Garden’s type 4: femoral neck #, completely displaced, in an older patient.

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Bipolar endoprosthesis replacement of the #ed femoral neck during the immediate postoperative period. Note the drains and

staples in place.

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Special considerations of the Fracture

• High rate of non-union• No periosteum in this area; all healing occurs

through endoosteum• # sites is bathed by synovial fluid—dissolves

the fibrin clot – retards healing.• DVT• Pulmonary embolism – chest pain, shortness

of breath

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Associated Injuries

• #s of wrist, shoulder & ribs etc.

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Weight Bearing

• Depends on stability of the reduction achieved and method of fixation..

• Begin early mobilization out of bed….with an appropriate degree of weight on the affected extremity with a walker…

• Stable #s: WB as per tolerance after they are fixed with pins..

• Unstable #s: kept NWB after surgery; also in osteopenic pts..

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Leg length discrepancy

• More than ¾ inch LLD requires shoe lift

• Progressing LLD indicated loss of correction of #.

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Watch out the Gait

• Stance Phase:

• Heel Strike:– (a)Jack knifing/G. Max lurch may be present due to G Max weakness

(probably it may have been incised in post approach)..

– (b) Lack of full knee extension may be present due to weakness & pain in Vast lateralis (as it is incised in lat approach)……….

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• Foot Flat:– Contracture of rectus femoris causes hip flexion

contracture or reduces knee flexion

– Vast lateralis (incised) is weakened & painful due to surgery: leads to reduced foot flat phase..

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• Mid-stance– Double stance diminishes due to # site pain..– Iliopsoas may be weak: takes short steps due to

reduces propulsion of this muscle…– G medius (if incised) may be weakened:

Trendelenburg gait– Altered length-tension relationship in case

endoprothesis: Trendelenburg gait

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• Push-off– Not affected

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• Swing Phase– The iliopsoas is responsible for concentric

contraction to power hip flexion and advance NWB leg

– Quadriceps functions to extend the knee to assist in acceleration.

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Treatment• Early to Immediate (Day of Injury to One Week)

• Two Weeks

• Four to Six Weeks

• Eight to Twelve Weeks

• Twelve to Sixteen Weeks

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Early to Immediate (Day of Injury to One Week)

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Day One to One WeekPrescription

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Treatment : Two weeks

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Treatment: Eight to 12 Weeks

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Long term considerations and problems

• AVN of the femoral head may require prosthetic replacement if it becomes symptomatic and causes pain.

• Nonunion may require prosthetic replacement of the femoral head and neck.

• Leg length discrepancy [LLD] is rare, but may be a long term problem requiring a shoe lift.

• Prominent and painful screws, pins, and plates may require removal.

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Thank You

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