The femur, also called the thigh bone, has a spherical femoral head at its upper end, which forms the hip joint with the articular fossa of the hip bone, on which the movement of the thigh depends. Below the femoral head, there is the slender femoral neck, which connects the femoral head to the femoral stem. The femoral neck is the thinnest and weakest of the entire thigh bone, and is also a good place for fractures to occur.
The majority of the femoral neck is within the joint capsule, which is attached to the acetabular rim and the base of the femoral neck. The blood vessels supplying the femoral head and neck come from the internal rotor femoral artery (around the back of the neck), the external rotor femoral artery (around the front of the neck), and the circumflex ligament artery. Both the internal and external rotator femoral arteries enter the femoral neck at the base of the femoral neck from the medullary joint capsule return. Therefore, in the event of a fracture of the femoral neck, the blood supply to the bone tissue above the fracture line is greatly affected, and even ischemic necrosis occurs, affecting the healing connection of the fracture. The blood vessels within the round ligament have a limited blood supply and in old age, most of the vessels here sclerose and lose their blood supply.
Femoral neck fractures are most common in middle-aged and elderly people, especially in elderly women, mainly related to the fact that elderly people tend to have osteoporosis and brittle bones. Most patients only suffer from minor trauma, such as walking and slipping, sudden twisting of the thigh, etc., which causes fractures. Fractures of the femoral neck rarely occur in young adults, and most fractures occur as a result of strong violence, such as vehicle impact, fall from a height, etc.
After a femoral neck fracture, the main symptom is pain in the hip, and any movement of the hip joint will make the pain worse. At the same time, the affected limb cannot move or stand and walk, and swelling and pressure pain appear at the hip joint. However, there are a few patients whose pain is not obvious at the beginning of the fracture and they can still walk, so it is very easy to miss the diagnosis, but the pain worsens after a few days, and they cannot even walk at all. If the fracture is misaligned, there will also be shortening and twisting of the affected leg.
It is easy to diagnose a fracture of the neck of the femur, which can be confirmed with an X-ray, and it is also very clear where the fracture is located and whether there is any misalignment. Minor fractures of the femoral neck may require an MRI scan to confirm the diagnosis.
Most femoral neck fractures are displaced and the flatter the fracture line the more stable it is, called an adductor fracture. The more oblique the fracture line, the more unstable it is, known as an adductor fracture. The fracture line may be located under the femoral head, called subtrochanteric. The subtrochanteric type has severe vascular damage and is more likely to have ischemic necrosis of the femoral head. The fracture line is located in the middle of the femoral neck, which is called trans-neck type, and the possibility of ischemic necrosis of the femoral head is still high. The fracture line at the base of the femoral neck is the basal type, which is mostly stable and easier to fix, and is less likely to have ischemic necrosis of the femoral head.
The types of femoral neck fractures are different, and the treatment methods are also different. The characteristics of the fracture should be carefully analyzed to choose the appropriate treatment method. The patient’s age and physical condition are also an important basis for choosing the treatment method.
I. Conservative treatment
If the fracture is not displaced, or if the patient is in extremely poor physical condition, or if there is a combination of serious heart, lung, kidney and liver dysfunction, conservative treatment, including traction on the affected limb, bed rest, etc., can be adopted. Patients need to rest in bed for 6 to 8 weeks, and during the bed rest period, they should not lie on their sides to avoid displacement of the fracture. 8 weeks later, they can gradually sit up, but they should not sit cross-legged. 3 months later, the fracture starts to heal, and they can gradually walk on the ground with the help of crutches. After 6 months, the fracture has healed very firmly, and only then can you walk without crutches. At the beginning of conservative treatment, X-rays should be taken at the bedside every few days to make sure there is no displacement.
During conservative treatment, the patient is bedridden for a long time, so it often causes complications such as lung infection, urinary tract infection, decubitus ulcer, and deep vein thrombosis of the lower limbs due to prolonged bed rest.
Second, surgical treatment
1. Closed internal fixation: At present, hospitals with conditions can perform internal fixation of the fracture without cutting the skin or only a small wound with the cooperation of X-ray machine. After the surgery, the fracture can be repositioned under the surveillance of X-ray machine, and then the guide pin can be inserted under the surveillance of X-ray machine to confirm that the guide pin passes through the fracture line, and then the fracture can be fixed by inserting the screw through the guide pin. This procedure is safe and minimally invasive, and can be done with a catheter delivered through the skin or with a small incision. After the procedure, the patient can reduce the pain of turning in bed. This procedure is suitable for patients with no significant displacement of the fracture, under 60 years of age, and good bone quality. However, this surgery requires a long period of bed rest, about three months before getting out of bed. Of course, it is possible to sit up in bed during this period, etc. Another problem is that the possibility of later femoral head necrosis cannot be completely avoided.
2. Incision and internal fixation: If the hospital does not have conditions for closed fixation, it can only incise the joint capsule to reset and fix the fracture. This surgical method is more damaging and cannot be tolerated by the elderly with poor health condition.
3.Artificial joint replacement: For elderly with serious osteoporosis or poor general condition, or over 60 years old with subtrochanteric fracture or transcervical fracture, or combined with osteoarthritis or femoral head necrosis, choose artificial total hip replacement. For elderly people with combined sequelae of cerebrovascular disease, or those with very poor quality of life before the injury, artificial hemi-hip replacement (femoral head replacement) can be chosen. This surgery removes the broken femoral head and replaces it with an artificial joint. This surgery can get out of bed earlier (usually about a week after surgery) and is very effective, but it is expensive and technically demanding compared to nailing, so it is best to choose a specialist with extensive experience in bone and joint surgery at a municipal tertiary care hospital to perform the surgery.
Health guide for the elderly to prevent femoral neck fracture
Elderly people should not go to places with many people and cars, and do not go out when it is raining, snowing or when the ground is watery or icy to avoid falling and fracture. Do not climb ladders or high activities, and do not walk on steep slopes, because the elderly have weak lower limbs and are slow to respond to falls. When you go out, walk slowly. If you have symptoms such as dizziness, deafness or dizziness, try to go out less. Before going to the toilet at night, sit on the edge of the bed for a few moments to keep the leg muscles in an excited state and to prevent the occurrence of momentary hypotension when the position changes. When taking a shower, prepare a small stool and sit down to put on pants and shoes to prevent falls.
Several misconceptions about the prevention and treatment of femoral neck fractures in middle-aged and elderly people
Osteoporosis has been described as a “silent disease” due to its insidious onset and special diagnostic methods, with a low patient consultation rate and a high rate of missed diagnosis by clinicians. There are still some misconceptions about the treatment and prevention of osteoporotic fractures in middle-aged and elderly people, and it is necessary to re-understand and choose the correct and effective treatment methods.
Myth 1: Disregard for minor trauma
There is a case that impressed me a lot. It was a 79-year-old old woman who sprained her right hip while getting out of bed in the morning and felt some pain but could still walk. He went to the hospital at the urging of his son, and no obvious fracture was found after the X-ray. The doctor cautioned that some minor fractures that are not displaced cannot be detected by early radiographs and can only be revealed by radiographs after a week or so of bone resorption at the fracture end, so he should rest in bed, not stand and walk, and then take a radiograph for review a week later.
However, the old man thought it was fine if no fracture was found and walked home, but the next day the pain started to increase and he could not stand. If the old man had listened to the doctor, the fracture would not have been further displaced so that it could have been treated conservatively or with simple internal fixation.
As the elderly are not very active, most traumatic injuries are sprains or bruises, but do not think that because the injury is light and not very painful, it is not a big deal if the tendon is injured. The elderly mostly have osteoporosis, and the first thing to think about when they receive a trauma is the possibility of a fragility fracture.
If the fracture, but also continue to move or stand and walk, may cause fracture displacement, aggravate the soft tissue injury or cause secondary vascular nerve injury. Therefore, the best emergency treatment for the elderly after trauma, regardless of the severity of the injury and whether there is severe pain, is to stay in place to keep the injured part stable and inactive, while calling for help and waiting for rescue, and only after the doctor’s examination to exclude fracture standing or walking.
Myth #2: Calcium is fine for osteoporosis
The cause of osteoporosis is still unclear, but the medical community believes that the following factors are related to.
1, aging: as the body ages, the metabolic function of bone will slow down, calcium absorption capacity decreases, and calcium in the bones will be gradually lost;
2, estrogen decline: estrogen will stimulate the formation of bone and inhibit the breakdown of bone, women due to ovarian removal or menopause, estrogen to stop or reduce secretion, will accelerate osteoporosis;
3, nutritional disorders: calcium intake is insufficient or often eat high-protein, high-salt food, or addicted to smoking, alcohol;
4, abnormal life: lack of exercise, less sunshine;
5, disease: suffering from kidney disease, liver disease, diabetes, hypertension, hyperthyroidism, rheumatoid arthritis, rigid spondylitis or certain cancers;
6, drugs: long-term use of steroids, anti-cancer drugs, diuretics, etc.;
7, genetic: osteoporosis has a certain degree of heredity.
Therefore, osteoporosis is not equal to calcium deficiency, and simple calcium supplementation cannot prevent osteoporosis and osteoporotic fractures. To prevent osteoporosis, you should have balanced nutrition and moderate exercise. The diet should contain sufficient calcium, vitamin D and other nutrients. Calcium and vitamin D are essential nutrients that are indispensable for increasing and maintaining bone quality, while protein and other nutrients such as phosphorus, sodium, magnesium and other minerals also play an important role in maintaining bone health. Exercise can significantly accelerate blood circulation throughout the body and bones, and muscle contraction and diastole have a direct stimulating effect on bones, all of which can stop and slow down the process of osteoporosis.
Myth 3: You can’t move around after fracture
Most people think that the elderly hip fracture, to take good care of the disease, to rest in bed as far as possible can not be active. I do not know that the elderly can not recuperate after fracture, the more they recuperate, the more disease.
After an osteoporotic fracture, if the elderly are bedridden for a long time, in addition to local complications such as decubitus ulcers, complications such as deep vein thrombosis (DVT) of the lower limbs, fat embolism syndrome, crushing pneumonia and urinary tract infection may occur. Meanwhile, bone loss is accelerated during bed rest, osteoporosis is aggravated, and re-fracture is highly likely to occur.
Therefore, during treatment, it is important to closely observe changes in the condition and take comprehensive measures to prevent and treat complications such as respiratory and urinary system infections and decubitus ulcers. Emphasis is placed on early active and passive muscle exercises, early movement of unfixed joints, and minimizing the time spent in bed when possible. This will restore function as soon as possible, effectively prevent complications, improve function and enhance quality of life.
In what cases can internal fixation be used?
For fracture patients under 59 years old, regardless of whether the fracture is misaligned or not, as long as the bone condition is good and they are relatively healthy, in principle, they can take internal fixation treatment. It is an international consensus that the more severe the fracture misalignment, the higher the incidence of non-union and later femoral head necrosis. The higher the location of the fracture (near the top of the femoral head), the higher the rate of non-healing and necrosis. The longer the delay in treatment after the fracture, the higher the rate of non-union and necrosis. Therefore, surgery should be performed as soon as possible after a femoral neck fracture if it is eligible for internal fixation.
The healing time after fracture fixation is 3-6 months, and necrosis of the femoral head can occur up to 5 years after the injury, but the chance of necrosis is highest in the first year and decreases year by year thereafter, and the possibility of necrosis of the femoral head beyond 5 years is very low. If a femoral neck fracture does not heal, necrosis is basically inevitable. Necrosis can still occur after a femoral neck fracture heals, so the chance of osteonecrosis after a femoral neck fracture is greater than the rate of non-healing fractures.
There are various factors that can cause or accelerate femoral head necrosis or lead to non-healing fractures.
1. High fracture line position and severe misalignment;
2, osteoporosis and low healing capacity;
3, poor surgical quality;
4, further damage to residual blood supply during surgery;
5.Postoperative internal fixation failure;
6, Premature activity, interference with fracture healing and reconstruction;
7, malnutrition;
8, infection, etc.
It is because of these factors that it is the responsibility of the physician to explain clearly to the patient when choosing a treatment modality that internal fixation of the fracture is not the same as healing the fracture and that there are many follow-up problems. For elderly people older than 60 years old, or even 70 years old, if they are eligible for internal fixation, they can choose internal fixation of fracture. You can sit up early after surgery to avoid prolonged bed rest. However, it is important to follow the principles of treatment and regular follow-up review. As a physician, it takes long-term efforts to improve the surgical technique and increase the rate of one-stage fracture healing. For the time being, the quality of the surgeon’s surgery is one of the most important factors affecting the fracture healing rate.
Once fracture non-union or femoral head necrosis occurs after internal fixation, most of them eventually require artificial joint replacement to save the joint function.
Artificial total hip arthroplasty – the best choice of treatment for elderly femoral neck fractures
Due to the characteristics of femoral neck fracture, it is decided that even if the fracture is treated with internal fixation, it is not possible to fully achieve fracture healing, and it is not possible to achieve the purpose of not having post-fracture femoral head necrosis (femoral neck fracture is one of the several parts of the human body where fractures are least likely to heal).
Therefore, for femoral neck fractures in middle-aged and elderly people, the following principles should be followed.
1.If the fracture location is low and the misalignment is not large, especially if the patient is young (under 60 years old), internal fixation surgery is preferred for treatment;
2.If the patient is older than 65 years old, the fracture dislocation is serious, the fracture position is high, and the osteoporosis is not heavy, biological fixation type artificial total hip replacement surgery is preferred;
3.If the patient is older than 75 years old, the fracture is obviously misaligned and the bone is osteoporotic, the artificial total hip joint replacement surgery with bone cement fixation can be adopted;
4.For patients older than 60 or even 70 years old, the fracture dislocation is not large, as long as the fracture position is low and the bone quality is good, the internal fixation surgery can be implemented;
5. For whether to use artificial femoral head replacement or artificial total hip replacement, whether to use biological fixation joint, bone cement fixation joint or mixed fixation joint, we can consider the patient’s age, mobility before fracture, bone quality condition of fracture site, general condition and doctor’s experience. Artificial femoral head replacement surgery is simple and quick to recover, but some patients may experience hip discomfort or even pain after surgery, which is more suitable for older people with low mobility, poor general condition or combined with sequelae of cerebrovascular disease.
Artificial total hip replacement surgery is suitable for patients who are younger, in good physical condition, with high mobility and long life expectancy. Compared with internal fracture fixation surgery, the artificial joint replacement does not require long-term bed rest after surgery, and generally one week after surgery, the patient can go to the ground and move around, so there is no concern of non-healing fracture and femoral head necrosis after surgery, and it can be a “radical” treatment for elderly patients with femoral neck fracture.
However, despite the fact that the surgical technique is much more advanced than 10 years ago, and that there are reports of 30 years of normal use after the initial replacement, and that the majority of patients have recovered well after the surgery, the quality of the surgery is much higher, and if the surgery fails, it needs to be revised and redone afterwards. Therefore, it is recommended to the elderly that once a femoral neck fracture occurs and your doctor recommends surgery, you and your family should clarify the need for surgery and the specific method of surgery. For patients who need artificial joint replacement, it is recommended that they go to a large tertiary care hospital, especially an orthopedic surgeon with extensive experience in the field, to perform the surgery.