Fracture NOF Case Presentation

CASE PRESENTATION

INTRODUCTION:

           Fracture of the neck of the femur is an important injury for many reasons.

Ø  It is common and the incidence is increasing.

Ø  It is not always easy to diagnose.

Ø  Fractures can occur in all age groups but the majority of are caused by falls in the elderly and the fracture usually occurs through osteoporotic bone. An understanding of fractured neck of femur requires an understanding of falls and osteoporosis. (women > men)

Ø  Patients with this injury often have many co-morbidities and the fracture has a substantial mortality rate. Management of this injury is often used as a model for management of acute problems in the elderly.

Ø  Pathophysiology

ü  healing potential

§  femoral neck is intracapsular, bathed in synovial fluid

§  lacks periosteal layer

§  callus formation limited, which affects healing

Ø  Associated injuries

ü  femoral shaft fractures

§  6-9% associated with femoral neck fractures 

§  treat femoral neck first followed by shaft

Ø  Prognosis

ü  mortality

§  ~25-30% at one year (higher than vertebral compression fractures) 

ü  predictors of mortality

§  pre-injury mobility is the most significant determinant for post-operative survival 

§  in patients with chronic renal failure, rates of mortality at 2 years postoperatively, are close to 45%

ANATOMY:

CLASSIFICATION:

  GARDEN CLASSIFICATION:

             

PAUWELS CLASSIFICATION:

PATIENT INFORMATION:

Ø  Patient Name: “ X”

Ø  Age: 83yrs/Female.

Ø  Date of Admission: 21/11/2018.

Ø  Date of Surgery: 28/11/2018.

CHIEF COMPLAINT:

                Patient had pain over the left hip joint, restricted left hip movements and inability to stand and walk few steps since today (21/11/2018).

HISTORY OF PRESENT ILLNESS:

               Patient came with complaints of pain over the left hip, deformity over the left hip and was unable to stand and walk few steps since today (21/11/2018). Patient gave history of slip and fall at bathroom (at home) today (21/11/2018). Since then patient complaints of pain, swelling, deformity and inability to use left hip (left thigh region). After the injury patient came to emergency department of our hospital.

v  Previous Injury: Fracture neck of femur right side in the year 2007

v  Developmental History: No any developmental histories

v  Drug History: No known drug allergies. Not on any chronic medication

v  Past medical History: No Diabetes Mellitus; No Hypertension; No Bronchial Asthma;No Thyroid diseases.

ON EXAMINATION:

            Patient is conscious, oriented.

Vital Signs: 

·         BP – 130/70 mm/Hg

·         PR – 78 b/min

·         SpO2 – 98%

·         Temp – 99° F

LOCAL EXAMINATION:

Ø  Pain and swelling over the left hip and thigh are present.

Ø  Tenderness and crepitus over the left hip are present.

Ø  Deformity and angulation over the left hip are present.

Ø  Any attempted movements of the left hip are painful.

Ø   Distal pulse palpable (A. Dorsalis Pedis).

  X-RAY FINDING:

                NORMAL PELVIS

                                                                 Patient X-ray Findings:

Ø  CT

·         helpful in determining displacement and degree of comminution in some patients

• MRI 

·         helpful to rule out occult fracture 

·         not helpful in reliably assessing viability of femoral head after fracture

PREPARATION:

Preoperative planning

Whatever arthroplasty is chosen, the procedure should be carefully planned with sufficient detail. Select the prosthesis with the aid of radiographic templates (or electronic planning software with digital x-rays) and appropriate x-rays of the normal and injured hip.
In addition to the selected prosthesis, possible alternatives should be available in the operating room.

Lateral decubitus position

The patient is positioned lateral with the ipsilateral arm in arm sling. Place padded cushions under bony prominences to avoid excessive pressure.

SKIN INCISION:

      Anterolateral approach:

            Start the slightly anteriorly curved skin incision about 7-10 cm proximal of the lateral part of the greater trochanter (directed towards the tubercle of the iliac crest – the posterior landmark of tensor fascia lata origin). Distally, the incision extends along the femur about 10 cm below the greater trochanter.

 

 Opening of the joint capsule

Make a T-shaped incision in the capsule

Removal of femoral head:

Post Operation X-ray:

CLASSIFICATION:

          According to the classification. The fracture is classified:

Ø  Garden type IV: Complete fracture, completely displaced.

Ø  Simplified Garden: Displaced.

Ø  Pauwels type III: >50 degree from horizontal (most unstable and high risk of non-union and AVN).

CONCLUSION:

Ø  Early surgery, good anatomical reduction and internal fixation help to recover the full range of movements.

Ø  Stability has been RESTORED.

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