FEMORAL NECK

FRACTURES:
Physiotherapy
Management
Dr. 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.

Classification
Pauwels

[1935]

Angle describes vertical shear vector

Classification
Garden
I

II
III

IV
**

[1961]

Valgus impacted or
incomplete
Complete
Non-displaced
Complete
Partial
displacement
Complete
Full displacement
Portends risk of AVN
and Nonunion

III

II

IV

Classification
Functional Classification
Stable
Impacted
Non-displaced

(Garden I)
(Garden II)

Unstable
Displaced

(Garden III and IV)

Femoral neck # classified as Gardens

type 1: an incomplete impacted femoral
neck # in valgus position. All femoral
neck #s are intracapsular.
6

Gardens type 2: nondisplaced

complete femoral neck #.
7

Gardens type 3: displaced femoral neck # in varus

position. There is often disruption of the joint capsule.

Gardens 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.
9

Subcapital femoral neck # at the proximal end of

the neck. This # is displaced and in varus position
(Gardens type 3)

10

Subcapital # of the femoral neck impacted

and in valgus position (Gardens type 1).

11

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

13

LOW ENERGY INJURY

14

Treatment Goals
Orthopaedic Objectives
Alignment
Stability

Rehabilitation Objectives
Range of Motion
Muscle Strength
Functional Goals

15

 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.
16

 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.
17

Subcapital # of the femoral

neck.

18

Fracture fixed with a screw and side plate to

compress the # in an attempt to restore cortical
and cancellous contact.

19

To achieve immediate stability, the femoral head

and neck are replaced in an elderly patient with an
unstable #.

20

 Rehabilitation Objectives
Range of Motion: Improve and restore ROM
of the knee and hip.
ROM of Hip & Knee
Motion

Normal

Functional

130-140

110

125-128

90-110

0-20

0-5

45-48

0-20

40-45

21
0-20

Knee
Flexion
Extension
Hip
Flexion
Extension
Abduction

 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
22

 Rehabilitation Objectives
Functional Goals:
Normalize the patients gait pattern.
Achieve 90 degree hip flexion for proper
sitting position.

23

 Expected time of Bone Healing

12-16 weeks.

Expected Duration of Rehabilitation

15-30 weeks.

24

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
Gardens 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.

26

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.

28

Gardens type 4: femoral neck #,

completely displaced, in an older
patient.

29

Bipolar endoprosthesis replacement of the #ed

femoral neck during the immediate postoperative
period. Note the drains and staples in place.

30

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
31

Associated Injuries
#s of wrist, shoulder & ribs etc.

32

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..
33

Leg length discrepancy

More than inch LLD requires shoe lift
Progressing LLD indicated loss of
correction of #.

34

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).

35

 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..
36

 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
37

 Push-off
Not affected

38

 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.

39

Treatment
Early to Immediate (Day of Injury to
One Week)
Two Weeks
Four to Six Weeks
Eight to Twelve Weeks
Twelve to Sixteen Weeks
40

Early to Immediate (Day of

Injury to One Week)

41

Day One to One Week

Prescription

42

Treatment : Two weeks

43

44

45

46

Treatment: Eight to 12
Weeks

47

48

49

50

51

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.
52

53

54

55

56

57

Thank
You
58