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Orthopaedics
Fractures of the Femoral Neck
Built from Tang — Orthopaedic Trauma Vol 2: Lower Extremity
What’s inside
11 sections · 104 slides
Why This Fracture Is High-Stakes
A break inside the joint capsule, on the artery that feeds the femoral head
- What is a femoral neck fracture, and why care?
- The numbers that make displacement the enemy
- The guiding principle of treatment: individualize
Applied Anatomy
Shape, buttress, trabeculae, and the fragile arteries of the neck
- The neck's changing shape guides the screws
- Neck cross-section and three-screw layout
- Adams' arch: the built-in buttress under the neck
- The angles that a prosthesis must respect
- Shaft-neck angle and neck anteversion
- Trabeculae: internal scaffolding along the stress
- Trabeculae and Ward's triangle
- Ward's triangle: the weakest spot
- Blood supply: why it is unforgiving
- Blood supply of neck and head
- Timing is a blood-supply decision
Mechanism of Injury
High-energy in the young, a simple stumble in the old
- How the neck actually breaks
- Low-energy fall causing an elderly neck fracture
Classifying the Fracture
Location tells you the blood risk; Garden tells you the displacement
- Classification by location of the fracture line
- Fracture location: three zones
- Garden classification — grading by displacement
- Garden types I to IV
- Reading Garden in practice
Assessing the Patient and the X-ray
What the leg looks like, and what the films must measure
- Clinical picture depends on displacement
- Don't miss the bigger picture
- Positioning for a true lateral neck view
- Pauwels angle — mechanics of the fracture line
- Measuring the Pauwels angle
- Singh index — grading osteoporosis from the trabeculae
- Singh index of proximal femur osteoporosis
- Beyond plain films
- CT and 3D reconstruction of the fracture
Deciding the Operation
Age, bone quality and expectations pick the procedure
- Why we operate, and when conservative care is chosen
- Age-based treatment framework
- Timing and clot prevention
- The purposes of surgery
Reduction and Internal Fixation
Position, projection, a one-shot reduction, then three parallel screws
- Setup: position and fluoroscopy are half the battle
- Projection angles for lateral imaging
- Closed reduction: a choreographed sequence
- Closed reduction step 1: traction for length
- Closed reduction step 2: restore anteversion
- Closed reduction step 3: check and fine-tune
- Keeping the patella upright during rotation
- Judging whether the reduction is good enough
- S-curve sign and the Garden alignment index
- Open reduction via the Watson-Jones approach
- Watson-Jones incision landmarks
- Deep exposure to the anterior capsule
- Reducing the fracture with a bone hook
- Choosing the implant: DHS vs cannulated screws
- DHS combined with a cannulated screw
- Placing three screws in an inverted triangle
- Three cannulated screws in an inverted triangle
- Postoperative management after fixation
- Lesson 1: projection angle fools screw depth
- How C-arm angle distorts screw depth
- Lesson 2: spread the screws, keep them parallel
- Wide screw distribution in a Garden IV case
- Femoral neck fracture with a shaft fracture
Salvaging Nonunion
Triangular stable fixation and three-element stability theory for the young patient's failed neck
- The problem: young necks that refuse to heal
- Three-element stability theory of the proximal femur
- Triangular stability pattern of the proximal femur
- The device: DCS plus a medial anatomical buttress plate
- The triangular stable fixation system
- Surgical procedure for the triangular system
- Nonunion salvage: pre-op and early post-op
- Nonunion salvage case: early healing on CT
- Nonunion salvage: healed, good function
Hip Arthroplasty
Replacing the head via the posterolateral approach when fixation cannot win
- Setup and the posterolateral exposure
- Lateral decubitus positioning for arthroplasty
- Removing the head and cutting the neck
- Femoral neck osteotomy with a swing saw
- Preparing and seating the acetabular component
- Safe screw zone for the acetabular cup
- Preparing the femur and the cement warning
- Femoral canal preparation and cement plug
- Postoperative X-rays after hip replacement
- After arthroplasty: protect the posterior approach
- Choosing the type of replacement
Complications
Malunion, nonunion, and ischemic necrosis
- Malunion: the price of a poor reduction
- Malunion progressing to head collapse
- Malunion case: late necrosis of the head
- Nonunion: when the fracture never knits
- Nonunion from poor reduction, eccentric screws
- Nonunion case: progressive collapse on CT
- Ischemic necrosis of the femoral head
Putting It Together
The through-line of femoral neck fracture care
- Key takeaways
- Why does an inferior neck screw need support at three points, and what are they?
- References (1/5)
- References (2/5)
- References (3/5)
- References (4/5)
- References (5/5)
- Orthopaedic Trauma Surgery — Volume 2: Lower Extremity