Fracture of neck of femur

Anatomical factors The structure of the head and neck of femur is developed for the transmission of body weight efficiently, with minimum bone mass, by appropriate distribution of the bony trabeculae in the neck. The tension trabeculae and compression trabeculae along with the strong calcar femorale on the medial cortex of the neck of the femur form an efficient system to withstand load bearing and torsion under normal stresses of locomotion and weight bearing. In old age, osteoporosis of the region occurs. The incidence of fracture neck of femur is higher in old age.
Blood supply to the head and neck of femur The profunda femoris artery arising from the femoral artery gives off medical circumflex femoral artery. This gives off the lateral epiphyseal and superior and inferior metaphyseal arteries. The lateral epiphyseal arteries are important and supply the laterial 2/3 of the femoral head. The superior metaphyseal artery supplies the superior aspect of the femoral neck. The inferior metaphyseal artery supplies the inferior part of the neck and the adjacent part of the head derived from the metaphysis. The medial epiphyseal artery supplies a circumfoveal sector of the head. It is a continuation of the artery of the ligamentum teres which arises from the acetabular branch of the obturator artery.
Femoral neck fractures that are intracapsular and may threaten any or all of the three sources of blood to the femoral head:
the cervical vessels in the retinaculum of the joint capsule - usually damaged if the fracture is displaced
intramedullary vessels - always torn
from the ligamentum teres - usually contributes minimally in the elderly and not uncommonly, may be non-existent
In addition to the damage to the blood supply, the intracapsular nature of the fracture hinders recovery from the injury:
intra-articular bone has only a thin periosteum and has no contact with soft tissues - the response to injury - callus formation - is weak
blood remains inside the joint capsule, increasing intracapsular pressure and further damaging the femoral head; synovial fluid hinders clotting
Incidence and Mechanism The fracture of the neck of femur is common in the elderly. It does occur occasionally in young adults and even in children. It occurs more frequently in women. In India, the incidence of fracture neck of femur in children is higher than in the Western countries. The fracture may result either from rotation violence at the hip due to tripping over something on the floor and falling or a direct violence over the lateral aspect of the hip by a fall on the side.

Classification (Garden).This classification relies only upon the appearance of the hip on the AP radiograph. It is used to determine the appropriate treatment.
stage I : incomplete fracture of the neck (so-called abducted or impacted)

stage II : complete without displacement

stage III: complete with partial displacement: fragments are still connected by posterior retinacular attachment; there is malalignment of the femoral trabeculae

stage IV : this is a complete femoral neck fracture with full displacement: the proximal fragment is free and lies correctly in the acetabulum so that the trabeculae appear normally aligned

Subcapital fractures are classified along two continuums: the Pauwels and Linton classifications.
Pauwels Classification:Type I has an obliquity ranging from 0 to 30 degreesType II has an obliquity ranging from 30 to 50 degreesType III has an obliquity of 70 or more degrees
The greater the obliquity in the fracture, the higher the chances of either delayed or nonunion. This woman's fracture is Pauwels Type II and therefore has an intermediate chance of delayed or nonunion.
Linton Classification:Stage I: Incomplete fractureStage II: Complete but undisplaced fractureStage III: Complete, partially displaced fractureStage IV: Displaced and totally free fracture

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