I. What is a femoral neck fracture?
Femoral neck fracture is a fracture between the lower femoral head and the base of the femoral neck caused by various reasons, and is one of the common hip fractures. The incidence of femoral neck is relatively high in the elderly due to osteoporosis, poor balance and easy falling, while the incidence in young adults is often due to tremendous violence.
2. Do femoral neck fractures require hospitalization?
As the elderly are bedridden for a long time will lead to complications such as decubitus ulcers, crushing pneumonia, urinary tract infections, etc., the nursing workload is high, and the patient’s refusal to move due to pain will further increase the incidence of complications, which can eventually be life-threatening in severe cases. It has been reported that if elderly patients with femoral neck and intertrochanteric fractures are not treated with timely surgery, the survival rate of a significant proportion of the elderly is only 2-3 months due to factors such as improper care and the patient’s own condition. In addition, the risk of fracture non-union and femoral head necrosis is very high in femoral neck fractures. Therefore, patients with femoral neck fractures without obvious contraindications to surgery require inpatient surgery.
Hospitalization cost
The cost of treatment for femoral neck fracture varies depending on the treatment method. For example, the cost of hollow nail fixation is relatively low, and the price of hollow nail fixation varies depending on the nail chosen: domestic hollow nails are generally about six to seven hundred dollars each, and imported ones are about eighteen hundred dollars; while the price of artificial joint replacement varies from ten to twenty thousand to fifty to sixty thousand dollars for domestic ones. In addition, the patient’s pre-injury health condition will affect the post-operative medication, which also largely affects the overall hospitalization cost.
Fourth, choose the appropriate treatment method
At present, the common clinical treatment methods are hollow nail fixation, hollow nail fixation with bone flap graft, artificial total hip replacement, artificial femoral head replacement, and gristle pin fixation. Since the appropriate treatment method directly affects the prognosis, an experienced specialist should select the appropriate treatment method after a comprehensive assessment of the patient’s condition according to the patient’s age, fracture type and general condition. For example, children’s femoral neck fracture should be fixed with a gristle pin after a good repositioning to avoid damaging the epiphysis and affecting the development of children; young adults should avoid artificial joint replacement for femoral neck fracture; elderly people should choose artificial joint according to the situation, etc.
V. Is it better to treat femoral neck fracture as early as possible?
Yes, early treatment is good for releasing the vascular compression or spasm after fracture as soon as possible and restoring the blood supply to the fracture end as soon as possible; meanwhile, long-term bed rest is prone to complications such as decubitus ulcers, blood clots, muscle atrophy, reduced joint mobility and pneumonia. In principle, the operation of femoral neck fracture should not exceed 2 weeks.
Factors affecting the occurrence of femoral head necrosis after femoral neck fracture surgery
The chance of femoral head necrosis occurring after femoral neck fracture surgery is about 20-40%, and the high-risk factors are as follows.
1, fracture site: the closer the femoral neck fracture is to the femoral head, the higher the chance of non-healing and femoral head necrosis, especially the femoral neck head-down fracture, hip dislocation and other injuries can cause impaired blood flow to the femoral head, leading to an increased incidence of ischemic necrosis of the femoral head.
2, age: middle-aged and elderly patients are prone to non-union of femoral neck fractures, while young adults have femoral neck fractures due to high injury-causing violence and greater damage to the blood supply around the femoral neck, and the femoral head may have already undergone trabecular compression and collapse at the time of injury, which increases the intra-capital pressure and further affects the blood supply to the femoral head, thus making femoral head necrosis more likely to occur.
3, weight bearing: premature abandonment of abduction activities causes instability of the fracture end of the femoral neck and relative sliding of the fracture end, which further aggravates vascular injury and is an important cause of femoral head necrosis.
4. degree of dislocation and quality of reset: the rate of femoral head necrosis is 15.7% for mildly dislocated femoral neck fractures, 35.7% for moderately dislocated ones, and 51% for severe ones; the better the quality of reset, the lower the incidence of femoral head necrosis.
Seven, how to avoid femoral head necrosis after femoral neck fracture surgery
1. Do not bear weight prematurely. Femoral neck fracture can be weight-bearing after 12 weeks simply from the perspective of fracture healing, but because of the late onset of femoral head necrosis, walking with crutches is best until 1~1.5 years after surgery;
2. Review regularly. Even if the fracture heals, it should be tracked for 3~5 years. Studies have shown that about 85% of femoral head necrosis occurs within 3 years after the fracture, and 98% occurs within 5 years. For the evaluation of the treatment and efficacy of femoral neck fractures, the fracture should not be observed only to heal, but should be followed up to 5 years after the injury. If nail marks, diminishing height of the femoral head and sclerotic hyaline zone are found on the X-ray, it indicates that the femoral head has a precursor of necrosis, and active measures should be taken to prevent its further development.
Postoperative exercise methods
According to the different surgical methods, different exercise methods should be used in different postoperative periods.
1.Postoperative exercise methods after hollow nail fixation.
(1) healing period
3-5 days after surgery, start to sit in the prone position for health care gymnastic exercises, 1-2 times a day, mainly including active exercises of toe and ankle, static contraction of quadriceps and gluteus maximus; in the second week, with the support of medical staff, do not make the femur rotate and retract, do hip and knee active flexion and extension exercises, gentle movements, small amplitude, few repetitions, in order not to cause obvious pain; at the same time, upper limb resistance exercises of supporting muscles, including pectoralis major and latissimus dorsi. In the same period, resistance exercises for the supporting muscles of the upper limbs, including the pectoralis major, latissimus dorsi, triceps brachii, etc. In the second month after surgery, sit on the bedside with the lower legs hanging down and the knees close to the edge of the bed, and perform active flexion and extension exercises for the affected limbs, so that the lower limbs are not swollen and the knees are actively straightened to more than 60°; after 6 weeks after surgery, active hip flexion and knee extension exercises can be performed in the sitting position. It is not advisable to sit on the bed in a coiled position to avoid the external rotation of the hip joint affecting the stability of the femoral neck fracture. Sitting on the edge of the bed with both lower legs on the footstool, practice propping up the upper body with both arms and supporting both arms and lifting the hip upward to the back.
Three months after surgery, the following exercises may be added.
① supine position with the affected limb straightened to do active lower limb inversion and abduction exercises, as well as prone position with the affected limb straightened and raised to do hip extension muscle strength exercises.
②Sitting exercises for resisting quadriceps, and if necessary, exercises to restore the range of motion of knee flexion and extension. Patients who are younger and stronger can walk with a double tuck stick at two points without weight bearing on the affected limb.
(2) Recovery period
The fracture healing enters the recovery period, during which the exercises of the hip, knee and ankle should be strengthened and the affected limb should gradually resume weight-bearing in order to restore the joint range of motion of the hip and knee, restore mobility and strengthen the stability of the lower limb.
Increase the following exercises in the first month: joint range of motion distraction of hip flexion and extension. Stand on the pole with both feet to do active ankle joint flexion and extension, inversion and valgus movements and squatting and standing. After another 1 week, add standing on the pole to do alternate step exercises of both lower limbs. Walk inside the parallel bars and do four-point walk with double tucked canes.
In the second month, walking with a single crutch on the healthy upper limb can be practiced, and after 2 weeks, the crutch can be changed to be held by the upper limb of the affected limb.
In the third month, the walking can be changed to walking with the cane by the upper limb on the healthy side. After 2 weeks, walk with the cane on the affected upper limb.
Later on, gradually improve the weight-bearing ability, endurance and mobility of the lower limb and ADL function, including walking with variable speed, crossing obstacles, picking up fallen objects, going up and down stairs, using the toilet, bathing, etc. This process can take up to 1-1.5 years, during which regular review, including X-ray film review, should be conducted to check the functional recovery and observe the tendency of femoral head necrosis.
2.Post-operative exercise methods after artificial hip replacement.
(1) Pre-operative rehabilitation education
Explain the operation to the patient, introduce the postoperative rehabilitation program, teach the patient to perform long contractions of ankle pump contraction, quadriceps, N cord muscle and gluteus, and enhance the muscle strength training of lower and upper limbs. Practice position change and instruct the patient to walk with a 3-point or 4-point gait while holding the crutches. Introduce postoperative movements and positions to be avoided. Psychological guidance to eliminate the patient’s fear of surgery and the fear of disease recovery.
(2) Pre-operative assessment
Pre-operative assessment of gait, muscle strength of the limbs and range of motion of the hip joint.
(3) Postoperative rehabilitation
①Movements and positions to be avoided during the 2-3 months after surgery
a. Avoid internal retraction, as it is easy to dislocate the artificial joint after surgery. When lying on the side, put a pillow or quilt between the legs to prevent inversion.
b. Avoid “stretched legs”, squatting and putting on shoes, squatting and urinating and defecating, etc.
② Muscle strength training
On the first postoperative day, ankle pump exercises, isometric contraction exercises for the quadriceps, N-flexor and gluteus muscles of the affected limbs were started. Muscle strength training of both upper limbs and the healthy lower limbs, deep breathing exercises were started as early as possible and continued.
On the 3rd postoperative day, hip flexion and knee extension exercises, abduction of the affected limb, and hip elevation (bridge exercise) exercises were started.
On the 7th postoperative day, resistance muscle strength exercises for the gluteal muscles were started.
The muscle strength exercises should be performed in a pain-free or patient tolerable range, and the frequency and intensity of the exercises should be continuously increased according to the patient’s condition as appropriate.
(iii) Joint mobility exercises
Active joint mobility exercises were performed 3-4 times a day for 5-10 minutes each time for both upper and lower limbs. Passive joint mobility exercises for the affected hip were started on the third day after surgery, and active knee flexion and hip abduction exercises were started on the seventh day after surgery. However, hip flexion should not exceed 90°, and avoid internal retraction, internal rotation and semi-flexion movements.
④Weight-bearing and position change
On the 2nd-3rd postoperative day, train the transition from lying to sitting position. On postoperative day 5-6, transfer from bed to chair. On postoperative day 7, stand with two crutches and practice walking with two crutches or walking aids.
⑤ Pre-discharge evaluation and education
Before discharge, muscle strength, joint mobility and walking ability should be evaluated. Teach the patient the home training program and emphasize the postoperative movements and positions to be avoided.
IX. Precautions for daily life after discharge
One postoperative patient did not pay attention to the correct socks after artificial joint surgery, and put on the socks by rotating the leg externally and using a shoe lifting posture, which resulted in joint dislocation. Some people also put on socks in a sitting position with their legs stretched out. This is not correct. The correct posture for putting on socks is: sitting on a bed or a high stool, flexing the hip and knee, and slightly closing the knee joint to the inside of the calf.
It is also important to use a bidet when going to the toilet, to sleep in the supine position, and to visit the hospital regularly for postoperative follow-up. It is also important to have regular postoperative reviews at the hospital. The first, third, sixth and twelfth months after surgery, and then annually.
Post-operative osteoporosis prevention, osteoporosis in middle-aged and elderly patients, if not controlled, will likely ‘bury’ artificial joints, this is not an alarmist statement. The danger of osteoporosis is that the skeletal muscles cannot grow together with the joint prosthesis, which can easily lead to loosening of the joint prosthesis or fracture around the prosthesis. More sunshine, moderate exercise, diet attention to calcium intake, if necessary, calcium supplements. Some patients drink bone broth every day after surgery, this is a misconception, in fact, usually drinking milk can already provide enough calcium. If you drink too much bone broth, it may not be absorbed, and it will hinder the function of the spleen and stomach.