Femoral Neck Fracture

By :
Andy Wahab

Pendamping
dr. Hj. Muasriyani

Supervisor
dr. A.Sirfa,Sp.OT

RSUD PANGKEP
KABUPATEN PANGKEP
2016
 Patient Identity
Name : Mrs. Hj. N
Age : 73 years old
Sex : Female
Admittance : 29th September 2016
RM number : 19 34 00
History Taking
Chief complaint : Pain at Left hip
Anamnesis : suffered since + 1 day ,spreading
through left leg, before admitted to RSU
Pangkep
Injury mechanism : She was sitting on her
chair then suddenly she went out of balance
then falls on her left side, impacting her left
buttock with sitting position
History of unconsciousness (-), nausea (-),
vomit (-)
PHYSICAL
EXAMINATION
Internal Status
General appearence: Moderate
illnes/Well nourished/Compos Mentis

Vital signs:
- BP : 130/80 mmHg
- HR : 100x/menit
- Breathing : 18x/menit
- Temperature : 36,6
Regional Status
Head:
Facial exp : bearing with pain
Hair : black, straight
Form : normocephali
Eye:
Conjungtiva : anaemic (-/-)
Sklera : icteric (-/-)
Exophtalmus (-), Nystagmus (-), Lagophtalmus ( - /
-)
Lips : cyanotic (-)
 Thorax :
Pulmo :
Breath sound : Bronchovesicular
Crackles : -/-
Wheezing : -/-
Heart :
S1 & S2 normal, regular, murmur -

Abdomen :
Distention (-), Peristaltic (+), Tenderness (-),
Organomegaly (-)
 Left proximal thigh region :
Look : Deformity (+), swelling (+), hematoma (+),
wound (-)
Feel: Tenderness (+)
Move: Active and passive motion at hip and
femoral joints are limited due to pain
NVD : Sensibility is good , pulsation of dorsalis
pedis and tibialis posterior artery are palpable,
capillary refill time is <2
CLINICAL
FINDING
Leg Length
Discrepancy
R L
ALL 81 cm 78 cm
TLL 79 cm 76 cm
LLD 3 cm
 Hip X-Ray AP

Fracture @ neck of left femur

 Resume
A 73 years old woman was admitted to the
hospital with pain at left upper thigh, which
suffered + 1 day before admitted due to falling
accident

From the PE : Remarkable tenderness,

deformity, and limited active and passive motion
of hip joint and due to pain. LLD (+). The Distal
Neurovascular assessment is normal.
From the Radiological finding : Fracture of left
femur neck
 Fracture of left femoral neck
Management
Immobilisation
IVFD RL
Analgesic
Plan for Total Hip Arthroplasty
Femoral
Neck
Fracture
 EPIDEMIOLOGY
The average age of occurrence is 77 years for
women and 72 years for men.
80% occur in women, and the incidence
doubles every 5 to 6 years in women age >30
years.
The incidence in younger patients is very low
and is associated mainly with high-energy
trauma.
Risk factors include female sex, white race,
increasing age, tobacco and alcohol use, fall
history, and low estrogen level.
ANATOMY
ANATOMY
 Clinical Evaluation
Patients with displaced femoral neck fractures typically present with
shortening and external rotation of the lower extremity. Some
patients however exhibit subtle findings, such as anterior capsular
tenderness, pain with axial compression, lack of deformity, and they may
be able to bear weight.
Pain is evident on range of hip motion, with possible pain on axial
compression and tenderness to palpation of the groin.
An accurate history is important in the low-energy fracture that usually
occurs in older individuals. Obtaining a history of loss of consciousness,
prior syncopal episodes, medical history, chest pain, prior hip pain
(pathologic fracture)
One should assess the wrist and shoulders in elderly individuals
because 10% have associated upper extremity injuries
Radiographic Evaluation
AP view of Pelvic
CT scan or MRI for subtle fracture or younger patient
 Garden Classification
Type 1 stable; involves a minor crack in the femoral
neck.
Type 2 involves a complete crack in the femoral neck
but no bone displacement.
Type 3 a displaced fracture with the fragments
remaining connected to one another; also may involve
rotation of the bone fragments, angulation, or both.
Type 4 completely displaced with no connection
between the fractured fragments; likely to disrupt blood
supply to the femoral head.
Pauwel Classification
 MECHANISM OF
INJURY
Low-energy trauma; most common in older
patients
High-energy trauma: This accounts for
femoral neck fractures in both younger and
older patients, such as motor-vehicle
accident or fall from a significant height.
DEFORMING MUSCLE
(external rotation)
Piriformis
Superior gemellus
Inferior gemellus
Obturator internus
Quadratus femoris
Gluteus maximus
EFORMING MUSCLE
(shortening)
Gluteal muscles
Hamstring
Adductors
Illiopsoas
Quadriceps femoris
Treatment
Treatment Goal
 TREATMENT
Nonoperative treatment for traumatic fractures is
indicated only for patients who are at extreme
medical risk for surgery; it may also be considered
for demented nonambulators who have minimal
hip pain.
Early bed to chair mobilization is essential to avoid
increased risks and complications of prolonged
recumbency, including, venous stasis, and
pressure ulceration.
 Operative or non-
operative?
Young patient with high-energy injury and normal
bone: Urgent closed/open reduction with internal
fixation and capsulotomy is performed.
Elderly patients: Treatment is controversial:
High functional demands and good bone density: Use open
reduction and internal fixation versus total hip replacement.
Normal to intermediate longevity but poor bone density,
chronic illness, and lower functional demands: Perform
modular unipolar or bipolar hemiarthroplasty.
Low demand and poor bone quality: Perform hemiarthroplasty
using a one-piece unipolar prosthesis.
Severely ill, demented, bedridden patients: Consider
nonoperative treatment or prosthetic replacement for intolerable
pain.
 COMPLICATION
Nonunion
Osteonecrosis (avascular necrosis) of
displaced fracture
Fixation failure