The hip joint is one of the largest joints of our body. Due to the fact that people as a result of evolution stood on two legs, the hip joint is a basic joint support and contain a significant load when walking, running, carrying heavy loads. The shape of the hip joint can be imagined as a ball, located in a deep socket with a rounded shape.
A joint cavity of the hip joint formed by the pelvic bone called the acetabulum (acetabular) socket. It is the head of the femur, which is connected with the body of the femur through the neck. Often the femoral neck is called the “neck of femur”, but it’s a jargon. Slightly below the femoral neck are bony elevation, called the large and small skewers. They attach powerful muscles. Around the joint has a joint capsule which contains ligaments that reinforce the hip joint. On the one hand these powerful ligaments are attached at one end to the pelvic, and the other end to the femur. Another powerful ligament (called the ligament of the femoral head, often also called round ligament) connects the femur head with the bottom of the acetabulum.
The hip joint is covered by muscles of the gluteal region and back of the muscles of the anterior group of the thigh in the front. The femoral head located in the acetabular cavity, covered with articular cartilage. Articular cartilage in the hip joint reaches an average of 4 mm in thickness, has a very smooth surface and whitish color plotnoelasticheskuyu consistency. Due to the presence of articular cartilage decreases the friction between contacting articular surfaces.
Bone can live only when it comes to blood. The blood supply of the femoral head is performed by three major ways:
- Vessels going to the bone through the capsule of the hip
- Vessels running inside the bone
- Vessel running within the ligament of the femoral head. This vessel works well in young patients, but in adulthood, this blood vessel normally closes and becomes thinner.
At fracture of the femoral neck (hip fracture) not only damaged the bone, but broken blood vessels, and bone fragments (the head and part of femoral neck), devoid of blood supply, may disappear, gradually disappear. This condition is called osteonecrosis or avascular necrosis of the head and neck of the femur (“hip”). In addition, deprived of the blood supply to the bone fragments of the head and neck of the femur (“hip”) may not increase, i.e. there is such a condition as a nonunion fracture or so-called false joint. Especially high risk of necromania after hip fracture in the elderly, in which the vessel is passing within the ligaments of the head, is closed.
In elderly patients with fracture of the femoral neck (“hip”) or the femoral head bone fragment is deprived of blood supply and the fracture may not heal at all.
- Hip Fracture is a severe and dangerous injury that can occur both in elderly and in young people.
- Hip Fracture in elderly dangerous complications. Prolonged bed rest in elderly patients with femoral neck fractures lead to catastrophic deterioration of health and in most cases ends in death within several months from complications due to forced bed regime (heart failure, pneumonia, thromboembolism).
- Common dangerous misconception: “an old man with a hip fracture will not survive the surgery, anesthesia”… unfortunately, elderly patients are much more likely not endure a long and painful conservative treatment (de-rotational boots, gypsum), and it all ends in tragedy – the death of a close and loved one.
- If an elderly person before the hip fracture could walk, we need to be treated only operative to perform arthroplasty of the joint.
- In most cases, the optimal treatment of femoral neck fractures – operative. In young patients, perform osteosynthesis with three screws and older – replacement.
- Young people, even in the absence of displacement of bone fragments, it may be appropriate to the surgery (fracture fixation with three screws). Otherwise, the flow may fracture to necrosis or resorption of the femoral head (osteonecrosis). Even minimal displacement of fragments in fracture of the neck of the femur can significantly degrade the function of the hip joint.
Video: Hip fracture – symptoms and treatment
Frequency of fractures and mechanism of injury
The femoral neck fractures (fractures of the “hip”) is a serious medical problem. This is due to its high frequency (statistics show that hip fractures account for 6% of all fractures) and the truly dramatic consequences that this change may entail. A hip fracture is a 90% fate of the elderly over 65, women suffer from femoral neck fractures three times more often than men. Unfortunately, even in developed countries, 30% of elderly patients die during the year after hip fracture. This is because if the patient does not perform surgery, they have to be permanently bedridden, elderly patients catastrophically affects the health of: aggravated concomitant disease aggravated heart failure, due to impaired ventilation occur pneumonia (called hypoventilation or “stagnant” pneumonia).
The causes of hip fracture are very different in young and elderly patients. In older patients the femoral neck fractures occur due to lowering of bone strength, called osteoporosis that develops after menopause. Osteoporosis develops in men and in older age, but usually to a lesser degree. Bones, prone to osteoporosis, can break during normal fall of the blue. Risk factors of hip fracture are also neurological diseases, impaired vision, cancer, malnutrition and reduced physical activity.
In younger patients the fractures of the femoral neck (“hip”) are associated with the so-called high – energy trauma: traffic accidents, falls from great heights, etc.
Classification of fractures
In order to standardize approaches to the treatment of femoral neck fractures we developed several classifications. Each of them takes into account any criterion of fracture influencing the further course of the disease and, consequently, the choice of treatment.
Important to predict the course of fracture line in the neck of the femur. The closer it is located to the head of the femur, the less chance that there will be sufficient blood supply of the femoral head. This increases the risk of avascular necrosis of the head (death of bone tissue) and necromania of hip fracture. Especially this risk increases in older people in whom the blood supply and so decreased.
The femoral neck fractures according to their anatomical localization are divided into basisarticle (located at the base of the femoral neck, the most distant from the fractures to the head), transcervical (passing directly through the neck of the femur) and subcapital fractures (located in close proximity to the head of the femur).
Left: subapically a hip fracture, fracture line passes just below the head. This option is the most unfavorable in terms of prediction of the seam, since the head is very poorly supplied. In the centre: transcervical fracture of the femoral neck, the fracture line passes through the middle of the neck. Right: basiccally fracture, fracture line passes at the beginning of the femoral neck. Compared to the previous two options, it is more beneficial in terms of prediction of the seam.
However, it is important not only what is the line of fracture in the neck of the femur, but also its angle. In particular, the more vertical fracture line, the higher the chances that the fracture will be displaced and will not heal. To describe the fractures according to this feature is used the classification proposed by F. Pauwels in 1935 the First degree corresponds to the angle less than 30°, the second corner 30 to 50°, and the third corner more than 50°.
Quite often used classification of femoral neck fractures according to Garden. It divides fractures of the femoral neck depending on the displacement of fragments in the range of I (incomplete fracture of the femoral neck without displacement) through IV (complete separation of the fragments in fracture of the femoral neck).
Classification of femoral neck fractures according to Garden.
You Can generalize that the more vertically is the line of fracture of the femoral neck, the closer the fracture to the femoral head and the older the patient the higher the chance that the fracture will not heal.
Symptoms of a hip fracture
A hip fracture can be suspected by the typical mechanism of injury, the typical clinical signs and confirmed with the help of x-rays.
Elderly patients with hip fracture, as a rule, mark the accidental fall and injury in the area of the hip joint (greater trochanter – a bony protrusion that can be felt on the outer surface of the thigh in its upper third).
In young patients the femoral neck fractures occur in more severe injuries when falling from a height or motor vehicle accidents.
At rest in fractures of the femoral neck the pain is mild in nature. Pain in the hip joint increases with the attempt of foot movements. In fractures of the femoral neck bruising in the hip area usually does not happen. In fractures of the femoral neck effleurage on the heel causes pain in the hip joint, groin.
At fracture of the femoral neck (“hip”) leg can be shortened due to the displacement of fragments of bone. In addition, the outer edge of the foot may lie on the surface of the bed (external rotation) is also due to the displacement of bone fragments. In this case the patient is not able to withdraw the leg from this position. In addition, when a hip fracture in the majority of cases the patient is not able to detach the heel from the bed surface. This symptom got its name – “symptom of the stuck heel”. Sometimes patients with hip fracture when you try to turn themselves say the crunch in the area of the fracture. Effleurage the area of the greater trochanter in fracture of the femoral neck (“hip”) usually causes pain in the hip joint.
External rotation and shortening of the leg with the fractured femoral neck – the left foot to its outer edge lies on a bed. You can also note the shortening of the leg.
Accurate diagnosis of fracture of the femoral neck (“hip”) can be supplied according to the radiographs. In some cases, to clarify the nature of displacement of fragments may need a CT scan.
X-ray patterns of different variants of fractures
In some unclear cases, when standard radiographs is questionable fracture of the femoral neck, confirm the diagnosis by using MRI or scintigraphy, but in most cases they do not need.
Magnetic resonance tomogram basisarticle, almost intertrochanteric fracture of the femur
Treatment of hip fracture
Approaches to the treatment of femoral neck fractures had changed with the development of traumatology and surgical orthopedics. Initially, any alternatives to the conservative treatment of fractures of the femoral neck (“hip”) did not exist. In the Arsenal of the surgeon were immobilization, i.e. immobilization of the joint with different casts and skeletal traction, which allows to compare fragments during prolonged exercise. All of these methods slightly increased the chance of fracture healing of the femoral neck and were accompanied by many complications. Gradually began to appear techniques to fix bone fragments. These methods as you improvement found more and more supporters. Currently the “gold standard” of treatment of femoral neck fractures with few exceptions is the operational method.
Conservative treatment of femoral neck fractures may be applied only if the patient has serious comorbidities, such as, for example, a recent myocardial infarction. Another exception – if for any organisational reasons, surgery is not possible (for example, no equipment or competent surgeon) and if the fracture of the femoral neck without displacement, and the fracture line is at an angle less than 30 degrees, i.e. nearly horizontal, and the hip fracture has no tendency to displacement.
In General, conservative treatment of femoral neck fractures is the method of despair, and we must clearly understand that it is often the operation when the femoral neck fractures in elderly patients is aimed at saving lives, because being bedridden for many months, these patients gradually “fade” and there are cases of deaths. In young patients conservative treatment of fractures of the femoral neck also is very painful, and surgery is needed not only to alleviate the suffering of bed rest, but for maximum restoration of function of the hip joint, muscles, in fact for a long time immobilization in the hip fracture, muscle atrophy, hip and knee joints arise immobilization contractures, which developed sometimes very hard and sometimes limitation of movement remains for life.
Complications in the treatment of femoral neck
The main complication of conservative treatment of fractures of the femoral neck (“hip”) is a nonunion fracture. As we have already noted, this occurs because the head is often devoid of blood supply and hip fracture simply could not grow together.
Not fused fractures of the necks of both femurs after unsuccessful conservative treatment. Lysis occurred, i.e. the resorption of the femoral necks. Subsequently, in this embodiment, the flow happens and lysis of the femoral head bone
The main cause of complications during conservative treatment of fracture of the femoral neck is the loss of patient ability to walk. In conjunction with advanced age forced bed rest for many patients becomes fatal.
In the elderly, on bed rest in connection with hip fracture, there is often a congestive pneumonia, which responds poorly to treatment. Pneumonia leads to respiratory failure and can cause death of the patient.
Prolonged forced presence in the bed of elderly patients with femoral neck fractures often occur a bedsores, which are usually located in the sacrum and buttocks. The development of bedsores, i.e. the area of necrosis of tissues due to disruption of blood circulation in them caused by prolonged pressure on the skin and pubrelease tissue.
In patients with hip fracture often experience various psycho-emotional disorders until the development of psychosis and depressive States.
Threatening complication of hip fracture is the development of deep vein thrombosis of the lower limbs, also caused by prolonged immobility of the patient, which happens both when operational and in the conservative treatment of fractures of the femoral neck. The risk of thrombosis that formed clots in the veins the blood can get into the lungs, causing pulmonary embolism, a life-threatening complication.
The most effective method to prevent or reduce the likelihood of these complications is early activation of the patient with hip fracture – a person need to put on your feet!
Thus, operative treatment of fractures of the femoral neck, resulting in greater patient, to put him on his feet and start to walk with the additional help of the crutches, or walkers, often saves the patient’s life and is done for health reasons. In young patients with femoral neck fractures surgery to reduce the likelihood of necromania fracture, to achieve a better functional outcome and faster return to normal lifestyle.
Surgical treatment of hip fracture
Currently there are several options for surgical treatment of femoral neck fractures. The choice of a particular technique depends on the patient’s age, comorbidities, General health of the patient.
This table provides examples of criteria that may guide the physician in choosing a method of treatment for fractures of the femoral neck. Be aware that each patient requires an individual approach taking into account a much larger number of criteria, and this table shows only approximate and possible options.
Tell more about each of the possible methods of treatment of fracture neck of the femur.
Reduction is a mapping of the bone fragments. Before fixing fragments of bone in the hip fracture, they need to match. In some cases, in order to improve the chances of healing of the hip fracture, anatomic reduction is not carried out, i.e. restore the original, pre-fracture position of the bone, and special – i.e. fragments displaces so that a fracture has become more “simple”. In particular, the fracture of the femoral neck trying to give a more “horizontal” position, which reduces the risk of displacement in the postoperative period. Once completed reposition, perform fixation of a fracture.
Special reduction in which the displacement of fragments give a more “horizontal” position.
In young patients with femoral neck fractures fixation is usually performed by three big screws. The screws can be kannelirovannymi, i.e. having within itself a hollow channel, as the injection needle. When using them, first in the bone are put a few thin metal spokes, chosen by the most well-situated of them, the spokes on these put the screws and screwed into the bone as the guide wire.
Osteosynthesis with three screws in the hip fracture in young patients. This introduction provides the speed and accuracy of operation. The screws entered this way squeeze between the fragments of bone, which increases the stability of fixation and the probability of fusion.
Fixation of bone fragments at fracture of the femoral neck can be made more massive and metal (compression hip screw DHS, condylar compression screw of the DCS), but it is quite bulky clamps, and if only a broken femoral neck, surgeons prefer to use several separate screws.
Osteosynthesis of a hip fracture, the DHS system (Dynamic Hip Screw dynamic hip screw)
Previously used fixation in fractures of the femoral neck using the bundle of thin spokes, three-blade nail now almost never used as unreliable, and preference is given unconditionally more modern and stable methods of fixation.
In cases where after a hip fracture is too great a risk of complications such as not to fracture healing, osteonecrosis of the head and neck of the femur (avascular or aseptic necrosis), which is more often in older patients, with significant displacement of fragments of bone complicated fracture of the femoral neck, the optimal treatment is total hip replacement.
When endoprotezirovanie hip fracture hip replacement is performed only neck and head of femur (unicompartmental arthroplasty), or as a replacement neck with the head and acetabulum (dopoluchaet or total knee replacement).
When replacing both components of the joint (head and trough) is called total arthroplasty. The components of the prosthesis can be fixed by valaceline into the bone during surgery – so-called fixation of a cementless press-fit (press-fit). Subsequently, the bone grows into the porous surface or the special grooves of the prosthesis. Cup prosthesis (pelvic component, a replacement hip socket) with cementless fixation also has a porous coating for subsequent germination of the bone. Cup can additionally be fixed with screws.
Cementless method of fixation is preferred for young patients: it provides a good fixation due to the high density of the bone and more favorable with respect to reoperation for replacement of prosthesis. Although the service life of implants is constantly increasing thanks to technology, they remain limited and in younger patients may eventually need a planned replacement of the prosthesis.
Total (dupayne, i.e. replaced and the neck of the femur, and acetabulum) cementless arthroplasty in hip fracture. On the left is the radiograph after surgery. Right – widescreenthe external prosthesis with a porous coating. Presents one of the most common layouts cementless endoprosthesis, consisting of Cup, liner of high molecular weight polyethylene, metal head and legs.
In elderly patients with femoral neck fractures often choose the fixation of endoprostheses by using a special polymer cement, which ensures fast and reliable fixing even in the face of declining strength and bone density, frequently observed in this group of patients. However, if concomitant diseases in elderly patients with hip fracture is not critical, and the state of the bones is good, then it is possible to install and cementless prosthesis.
Endoprosthesis of cement fixation
The difference between cement and cementless models of hip replacements is in principle engaged. Cementless components of the endoprosthesis is covered with a porous or evaporated hydroxyapatite coating, are installed in bone according to the method of press fit and subsequently, the bone grows into the implant surface. Cement implants are fixed in bone with a special polymer cement, typically made of polymethylmethacrylate.
Cement and cementless fixation of the endoprosthesis legs
In patients with fractures of the femoral neck even more elderly, physically impaired, who need to perform more conservative surgery, usually performed the substitution only the neck and head of the femur, keeping the native acetabulum. This reduces the duration of surgery, reduces blood loss and improves the portability of the operation.
If you choose this method of treatment of hip fracture can be used single-pole (unipolar) implants, the head of which is in direct contact with the surface of the cartilage of the glenoid cavity. This is the most sparing surgery, it is performed older patients in the most severe condition. The disadvantage of this operation is that direct contact of the head with the implant leads to a rather rapid wear of the articular cartilage.
Reduce wear and tear by reducing friction between the cartilage and the head of the prosthesis. This head is made in the form of two hemispheres, nested one inside another (like dolls-dolls), the movements at this joint occur between the hemispheres of the head, which reduces the wear and destruction of the articular cartilage. Such implants are called bipolar.
Bipolar and monopolar hip implants used in elderly frail patients with femoral neck fractures, and high risk of complications – in this model, the endoprosthesis Cup is not made, i.e. the Cup of the endoprosthesis is not set and the head of the prosthesis slides on the cartilage of the acetabulum
Radiograph of hip joint of the patient, which was performed bipolar hip replacement for fracture neck of the femur. The Cup was installed, the head of the prosthesis slides on the cartilage of the acetabulum
Complications of osteosynthesis
Avascular osteonecrosis (the death of bone tissue heads).
And nonunion of fracture osteonecrosis is associated with the degree of initial injury and degree of displacement of fragments. Osteonecrosis is observed in 11-19 % of cases, fractures with displacement. That is why in fractures with displacement of the fracture repozicija should be performed promptly, neatly, and completed a reliable fixation of bone fragments, especially in young patients.
Failure of osteosynthesis.
The failure of osteosynthesis (fixation of bone fragments with the help of metalwork) can be caused by the following reasons: infectious process in the area of the fracture (2) loss of fixation, (3) nonunion of fracture, (4) osteonecrosis. If the fracture is not fused despite treatment, the eruption usually occurs of metal or so-called cut-off process. When properly performed operation and in compliance with the rules of conduct in the postoperative period, the likelihood of this complication is minimized.
Infections after osteosynthesis of femoral neck fractures usually lead to significant dysfunction of the hip joint. The frequency of this complication is less than 1 %. The risk depends on many factors, primarily related diseases (diabetes), harmful habits (Smoking, alcohol abuse).
The femoral neck fractures are intra-articular, that is, the fragments washed by the synovial fluid, normally contained in the joints and contain substances that prevent germination vessels and impairing fracture healing. Accurate mapping of fragments (reposition the fracture) reliable fixation and reduce the risk of fracture necromania to an acceptable level. The average frequency of necromania fracture is approximately 8.9 %. Fractures with displacement requiring open repositi accompanied by the frequency of nonunion in 11.2%. If you are able to perform a closed reduction, the frequency is reduced to 4.7%. When fractures without displacement, this frequency is only 0.9%.
Not bone fusion after fracture may be associated with inadequate circulation in the area of the fracture, the inaccurate mapping of the wreckage and failure of osteosynthesis. The latter can be related to the use of outdated methods that do not provide stable fixation of bone fragments, the fixation, low bone density, not allowing stable fixing of the fragments (metal structures “erupt” through the bone, as well as the knife goes through a piece of wet sugar). It is clear that with the death of bone tissue of the head fusion of the fracture can occur in principle.
Sure not to install the fusion of hip fracture through year after fracture, to assume with high probability within six months.
When nonunion of the fracture can be used the following treatment methods:
- Re-osteosynthesis (restaurantes),
- Subtrochanteric osteotomy is the intersection of the femur below her spits to change its geometry and redistribution of loads
- Hip joint replacement – total or only the femoral head 4) the performance of arthrodesis of the hip joint – surgery to eliminate it aimed at the fusion of the femur and pelvis.
Complications after hip replacement surgery
Unfortunately, like any other surgery, knee replacement carries a risk of complications. Thanks to the development of medicine, the risk of these complications has been reduced and will be even less in future with the improvement of methods of prevention.
Common possible complications, such as adverse reaction to anesthesia or the development of a heart attack. The development of modern anesthesia allows us to reduce the risk of such complications to a minimum.
Thromboembolism. To prevent these complications, your doctor may prescribe anticoagulants (Clexane, Fragmin, Warfarin, Arikstra, Xarelto or Pradaxa).
What is an anticoagulant? Anticoagulants or anticoagulant drugs is often presented as medications that thin the blood, but they are not. Rather, they prevent the formation of blood clots (thrombi). Your doctor may prescribe one of these drugs, explaining how long you need to take it. It can be: Clexane, Fragmin, Warfarin,Arikstra, Xarelto or Pradaxa.
Why is it important to prevent blood clots? After the surgery, especially if You are forced to be less active, increasing the risk of blood clots in veins. Most often thrombi formed in the veins of the legs. Sometimes the clots with the blood into the lungs. It is dangerous and can be life threatening. That is why it is so important to the prevention of blood clots.
What is the difference between the anticoagulants? Warfarin is a tablet taken by mouth (oral). The disadvantage of this drug is that the dosage should be selected based on the blood test (assessed international normalized ratio, INR), that it is sometimes quite difficult.
Arikstra, Clexane, Fragmin is injections that make the skin of the abdomen once or twice a day. The advantage is that their dose is determined only by body weight and concomitant diseases, i.e. there is no need to perform laboratory control of dosage blood.
Xarelto or Pradaxa is the pills just like arikstra, Clexane or Fragmin laboratory do not require the selection dosages.
Effectiveness of all these drugs in the prevention of thromboembolic complications when properly receiving the same.
Infectious complications. As we have noted, within two to three days after surgery you will be administered antibiotics. Although infectious complications of hip arthroplasty are rare, is a serious complication that requires urgent surgical treatment. The risk of infectious complications can be significantly reduced. For example, routine dental treatment at the dentist including professional cleaning, may lead to the entry of bacteria into the blood stream and the infection of Your implant. An antibiotic about an hour before these manipulations can greatly reduce or eliminate the risk of infection. The same applies to surgical operations and studies such as colonoscopy. Ask your surgeon to instruct You, if will be scheduled any interference.
Mayhem. After any surgery to replace hip joint there is a risk of dislocation (“popping out”) of the endoprosthesis, especially in the first few days and weeks after surgery. Fortunately, this is a complication, a risk which You can significantly reduce, if you follow the rules and do the rehabilitation, which will strengthen Your muscles.
If You have been the pain medication, first talk to your doctor. Your surgeon will instruct You on how to immediately get help – in the hospital where You were operated on or in the emergency Department duty hospital. Every orthopedic surgeon knows how to set a dislocated prosthesis (back of his head in the Cup).
To reduce the risk of recurrent dislocation of the prosthesis Your surgeon may recommend wearing a special device, a brace that limits motion in the hip joint. Although some risk of dislocation is always, it significantly decreases after restored the soft tissue surrounding the joint, around 3 months.
Always remember the Rule right angle, avoid extreme twisting and bending the hip.
Implant Loosening and wear. After a standard hip replacement, the probability that it will last You over 10 years, is 90-95%. But the implant still is not eternal. After some time you may have signs of wear of the implant, loosening it may require replacement, revision arthroplasty. Ongoing research provides hope for increasing the lifetime of implants and to facilitate their replacement in the future. Feel free to discuss with your doctor the level of technical achievements, discussing the design of the implant.
Damage to blood vessel or nerve. In total, as with any other surgery, there is a risk of damage to nerves or blood vessels, but it is extremely low. If after surgery You suddenly feel a sudden numbness or weakness in Your leg or foot, immediately inform a doctor or nurse.
Different length legs. In patients with chronic, non-United fractures of the femoral neck are often the leg on the affected side appears shorter than the other. Although Your doctor and try to align the length of Your legs, this is not always possible and not always necessary. The vast majority of patients have not noted any significant differences. If You note the difference in leg length, and it makes You uncomfortable, it can easily be corrected with shims under the heel or heels to the heel of the Shoe.