Clinical Scenario
NOF#
(Young Patient)

Please interpret the radiograph and tell me what you are concerned about in this patient?

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An AP radiograph is presented of both hips in a 37-year-old male. There is evidence of a right sided, displaced intra-capsular neck of femur fracture with disruption of trabeculae. I would want further orthogonal imaging with a lateral of the right hip to assess for the degree of AP displacement.

 

Key Concerns

1. High energy injury - Manage as per ATLS

2. NOF# - Manage as per guidelines:

   1. NICE Guidelines: Hip Fracture Management [1]

   2. NOF# in young adult - requires prompt + anatomical reduction to preserve blood supply and prevent AVN

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How would you initially manage this patient?

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History

• Allergies

• Medication

• Past medical history

• Last ate

• Events

  • Mechanism of injury

 

Examination

• NV Status

• Axial loading / pin rolling

• Ensure haemodynamically stable

 

Investigation

• Trauma CT Series: guided by ATLS assessment

• CXR, ECG

• Trauma bloods including G&S

 

Management

• Analgesia + regular medications

• Fascio-iliaca block in A+E

• VTE assessment

• Best Practice Tariff

• Consented + Marked for ORIF

  • Added to trauma list as priority next available

  • Discuss with trauma nurses

• Inform consultant in charge

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What is the difference in goals in NOF# management between young and elderly patients?

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Elderly NOF#s

In an elderly patient, the goals are to restore mobility with weight bearing as tolerated in order to avoid complications of prolonged bed rest

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Young NOF#s

To preserve the femoral head to avoid AVN and achieve fracture union. Anatomic reduction and internal fixation are paramount for a good outcome.

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What is the blood supply to the femoral head? 

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The main supply to the femoral head is from the trochanteric anastomosis between the medial and lateral femoral circumflex arteries (branch of profunda femoris artery).

 

There is also a small contribution from the artery of ligamentum teres and small supply from nutrient arteries within the medullary canal.

 

1. Medial femoral circumflex artery

2. Lateral femoral circumflex artery

3. Nutrient vessels from medullary canal

4. Artery from ligamentum teres

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Due to the AVN risk would you take this patient to theatre overnight? 

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• The key to successful management of these injuries is ANATOMIC REDUCTION and fixation

• Formerly these patients were tkaen to theatre overnight within 6 hours

• However, studies have shown that the key is anatomic reduction performed by an experienced hip surgeon

• Therefore this patient should go onto the next available list with specialist hip surgeon who is comfortable with open reduction if required 

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Note: For the interview can state that you would want this patient placed first on trauma list next day with specialist hip surgeon available (unless your consultant is a hip specialist overnight)

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What is the Pauwel’s classification? 

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​Pauwel's Classification [2]

 

Pauwel's classificaiton utilises the fracture pattern can indicate the relative stability of the fracture and predict the difficulty of obtaining stable fixation. Useful for predicting difficulty of fixation and risk of failure in femoral neck fractures in young adults

 

Based on the degree of angulation of fracture from the horizontal plane

• Type I (stable)            <30 degrees

• Type II                         30-50 degrees

• Type III (unstable)       >50 degrees

 

Type III fractures are more unstable and suggests increasing risk of:

• Fracture Failure

• Mal / Non-union

• Osteonecrosis

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How would reduce this fracture closed on table?

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Most NOF#s in young patients will require closed or open reduction prior to internal fixation. Stepwise approach:

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Closed Reduction (Leadbetter Technique)

• Leg flexed up to 90 degrees with the hip in adduction

• Then in-line traction with the femur + internal rotation to 45 degrees

• Reduction can then be checked using intra-operative imaging

 

Open Reduction

• Anterior approach can be utilised to access hip

• Reduction techniques include:

  • K-wires to joystick the femoral head into position

  • Schanz pins (5mm) can be placed distal to fracture site to aid in position of distal fragment

  • Bone-hooks can also be used on distal fragment helping to apply lateral and longitudinal traction

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Note: do not perform repeated closed reductions as may disrupt blood supply to femoral head. Attempt once and proceed to opening if required.

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What operation would you perform and how?

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3x cannulated screws can be inserted with an apex-distal screw orientation (inverted triangle). Most important screws are inferior (along calcar) and posterior screw which prevent posterior collapse.

 

Note: Alternatively can use 2-hole DHS. 

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What factors can reduce the risk of femoral head osteonecrosis in these patients?

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• Early diagnosis

• Early surgery by hip specialist

• ANATOMIC REDUCTION (including open reduction)

• Capsular haematoma decompression (prevents compression of retinacular vessels) 

• Stable fixation

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How would you manage this patient post-operatively? Would you allow them to weight bear?

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• Ensure adequate analgesia

• VTE prophylaxis

• Protected weight bearing - 6 weeks

• Follow up in fracture clinic - monitor for AVN

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References

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[1] NICE. Hip Fractures: Management. Available at: https://www.nice.org.uk/guidance/cg124 

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[2] Pauwels F. Der Schenkelhalsbruch, ein mechanisches problem. Stuttgart: F. Enke; 1935.

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