Fracture of the femoral head
[Definition].
Fracture of the femoral head is the loss of integrity or continuity of the femoral head or its cartilage. Fractures of the femoral head in children are rare and may be related to the toughness of the femoral head in children.
[Diagnostic basis]
I. Medical history
Pipkin believes that when the hip joint is flexed at about 60°, the thigh and hip joint are in an unnatural inward or outward position, and strong violence is transmitted upward along the axis of the femoral stem, forcing the femoral head to shift upward toward the posterior aspect of the hard acetabulum, and when the femoral head slides to the posterior superior edge of the acetabulum, the femoral head is cut, resulting in femoral head fracture and posterior dislocation of the hip joint. Fractures of the femoral head rarely occur in anterior hip dislocation. It is believed that the traumatic force that caused the femoral head fracture was strong and combined with the traumatic mechanics of the joint, resulting in a lamellar cut and scrape of the femoral head.
Symptoms and signs
Pain in the affected hip after the injury, loss of active movement, and severe pain when moving passively.
The affected hip is painful, showing flexion, inversion, internal rotation and shortening deformity; the greater trochanter is displaced posteriorly and superiorly, or the raised femoral head is touched at the hip; the lower limb is shortened and floating when the femoral neck is fractured. The active flexion and extension of the hip joint is lost, and the pain of the hip is aggravated when moving passively. Positive and lateral X-ray of the hip joint can confirm the diagnosis.
Third, auxiliary examination
X-ray examination: it shows that the hip joint is dislocated and fractured, and the femoral head is dislocated from the acetabulum, or partially displaced, or completely dislocated. Partial dislocation refers to the fracture fragment of the femoral head embedded in the acetabulum, and the distance between the head and socket increases or the femoral head moves upward. Sometimes combined with the posterior edge of the acetabulum, posterior wall, posterior wall posterior column fracture, X-ray can show, need to carry out CT examination to clarify the diagnosis.
Differential diagnosis
It should be distinguished from posterior hip dislocation, posterior hip dislocation combined with posterior acetabular rim fracture, posterior hip dislocation combined with femoral neck fracture, etc.
[Classification of evidence]
Pipkin subdivided the fifth type of posterior hip dislocation with femoral head fracture by Thampson and Epstein into four types, which are called Pipkin’s femoral head fracture subtypes.
Type I: posterior hip dislocation with incomplete fracture of the femoral head distal to the round ligament fossa.
Type II: Posterior dislocation of the hip joint with fracture of the femoral head on the proximal side of the round ligament fossa.
Type III: Type I or II fracture with femoral neck fracture.
Type IV: Type I, II, or III fracture with acetabular fracture.
This typing takes into account the characteristics of femoral head fractures and also takes care of the concomitant injuries of hip dislocation and acetabular fractures, which is important for diagnosis, treatment and prognosis.
The most frequent clinical type is Pipkin type I, and the other types decrease in order, with type IV being the least.
[Treatment].
The treatment of patients with this type of injury should be timely and accurately performed hip dislocation repositioning. For Pipkin type I and II femoral head fractures, hip repositioning should be tried first, and if the femoral head is repositioned and the femoral head fracture fragment also reaches anatomical repositioning, then non-surgical treatment is appropriate. If the femoral head is repositioned, but the femoral fracture fragment is not satisfactorily repositioned, or one or more bone fragments are embedded between the head and socket, it is an indication for surgical incision and repositioning. Regardless of the treatment, it is important not to neglect other parts of the patient’s injury, such as cranial, abdominal visceral and thoracic visceral injuries and their bleeding and infection. It is advisable to wait for these injuries to stabilize before considering surgical treatment of the affected hip. It is a wise choice to resuscitate while rescuing the shock.
I. Non-surgical treatment
Closed repositioning traction method
1. Indications: Pipkin type I and II. The following conditions should be considered: the center of the dislocated femoral head should be in the acetabulum after the correction; satisfactory alignment with the femoral head fracture fragment; the shape of the femoral head bone fragment; the reset and stable condition between the head socket and the bone fragment.
2, operation method: the same as posterior hip dislocation, if the fracture piece is not rotated in the acetabulum, the femoral head can often be well aligned with the fracture piece after resetting, if it has been confirmed that the resetting is good after taking the film again, then tibial tuberosity bone traction should be used to maintain the affected limb abduction 30° position traction for 6 weeks, wait for the fracture to heal and then walk with weight.
Surgical treatment
(A) Incisional internal fixation or fracture fragment removal method
1. Indications: In young patients, although the head of the femur is repositioned, the head of the femur is not satisfactorily repositioned, or one or more pieces of bone are embedded between the head and socket.
2. Operation method: The operation is mostly performed with an anterior or lateral incision to facilitate fixation and resection of the fracture fragment. The fracture fragment is fixed with absorbable nails, screws, wires and other internal fixation materials, the tail of the nail should be deep under the cartilage, and the wire suture is fixed under the greater trochanter or percutaneously, which is easy to wear and easy to remove. If the fracture fragment is very small, less than 1/4 of the circumference of the femoral head and no longer in the weight-bearing area, the fracture fragment can be removed.
(B) Arthroplasty, artificial femoral head replacement or artificial total hip arthroplasty
1. Indications: Pipkin type III and IV, elderly patients, old cases, or patients with original hip joint damage, such as osteoarthritis or other cartilage and subchondral bone disorders, it is appropriate to choose arthroplasty, artificial femoral head replacement or artificial total hip replacement according to the type of fracture and the extent of acetabular fracture and its displacement.
2. Operation method: the same as arthroplasty for old hip dislocation and artificial hip replacement for femoral neck fracture.
Three, drug treatment
(A) Chinese medicine treatment
The medicine should be used according to the three stages of identification of injury. In the early stage of swelling and pain, it is advisable to activate blood circulation, eliminate blood stasis, reduce swelling and relieve pain, and use Peach Red Four Elements Tang with reduction or San Qi Bone Pill; in the middle stage of pain reduction and swelling, it is advisable to activate blood circulation, activate blood circulation and nourish blood, and use Live Blood Spirit Soup or Shu Tendon and Blood Soup; in the late stage, it is advisable to nourish liver and kidney, strengthen tendons and bones, and use Special Bone Pill. For local and distal limb swelling, it is advisable to benefit the qi, activate the blood, and use the Plus Flavor Beneficial Qi Pill; for muscle wasting and hardening, and dysfunction, it is advisable to nourish the blood, promote the joints, and use the Nourishing Blood Pain Pill.
(II) Western medicine treatment
If surgical treatment, apply antibacterial drugs prophylactically half an hour before surgery, usually for three days, and give symptomatic drug treatment if combined with other internal diseases.
IV. Rehabilitation treatment
Functional exercise (active and passive)
(a) After repositioning and fixation, perform quadriceps muscle stretching and functional activities of knee and ankle joints.
(2) After two weeks, support double crutches to get out of bed without weight-bearing activities, and pay attention to keep the external booth; Pipkin type III and IV fractures can delay the time of getting out of bed appropriately; after 8 weeks, support double crutches for light weight-bearing activities; after six months, support single crutches for light weight-bearing activities depending on the condition; after one year, abandon crutches for functional exercises and pay attention to regular review.
(c) The main problem of femoral head fracture treatment is to prevent fracture non-union, ischemic necrosis of the femoral head and traumatic osteoarthritis, so medication, functional exercise and regular review are especially important in the middle and late stages. Once ischemic necrosis of the femoral head appears, weight bearing and activity time should be delayed.