1.What is a femoral neck fracture?
Fracture of the femoral neck is the most common injury of the hip, which refers to the fracture between the lower femoral head and the base of the femoral neck, and is a very common fracture in the elderly.
Most of the femoral neck fractures in middle-aged and elderly people are caused by twisting, inversion or valgus of the lower limb during walking and falling, and they are mostly caused by landing on the hip when injured. Slippery road, uneven road and going up and down steps are the precipitating factors of fracture, and osteoporosis is the intrinsic factor of fracture.
The chance of fracture increases in the elderly with poor health, important organ diseases such as hypertension, coronary heart disease, hemiplegia; low neuromuscular regulation, inflexible joints and lack of defensive response to trauma are important causes of fracture. Fractures of the femoral neck in young people are mostly caused by strong violence such as car accidents or high falls.
2.Do I need to be hospitalized for a femoral neck fracture?
Most of the femoral neck fractures have more obvious displacement and because of the greater leverage in this area, the fracture is unstable, therefore, most of them require inpatient surgery. In the past, with limited treatment technology and lack of medical equipment, there was often no good way to treat the fracture, and traction + long-term bed rest was mostly used.
However, most of the patients with this disease are elderly, and most of them have combined medical diseases before the injury. Long-term bed rest not only tends to aggravate the original disease, but also can induce serious complications such as pneumonia, decubitus ulcer, urinary system infection, and deep vein thrombosis of lower limbs. Surgical treatment can obtain the early stability of the fracture end and ensure the early bed activity, thus reducing the incidence of bed-ridden complications; more importantly, surgical treatment can obtain satisfactory fracture repositioning which is difficult to achieve with conservative treatment and lay a good foundation for fracture healing. Therefore, it is recommended that patients be hospitalized for surgery as soon as possible.
3.How much does hospitalization cost?
The treatment of femoral neck fracture depends on the treatment method of the fracture, using a relatively conservative nail for fixation, the fixed nail is generally about six or seven hundred dollars domestically, and about eighteen hundred dollars imported; while using artificial joint replacement, the price ranges from eight or nine thousand dollars domestically to fifty or sixty thousand dollars, while the cost of surgery depends on the hospital where the patient is seen, and the charges are set by the state. In addition, the patient’s pre-injury health status and post-operative medication also largely affect the overall hospitalization costs.
4.Is it better to treat the fracture of femoral neck as early as possible?
Yes, early treatment is good for releasing the vascular compression or spasm after the fracture as soon as possible and restoring the blood supply to the fracture end as soon as possible. In principle, surgery for femoral neck fracture should not exceed 2 weeks.
5.What treatments are available for femoral neck fracture?
Early accurate and good repositioning of the fracture is an important condition for bone healing. It is difficult to ensure good repositioning and stability of the fracture end by bedside traction treatment alone. Therefore, the current method of internal fixation is mostly used.
There are four main types of internal fixation devices.
(1) single nail type: three wing nail as the representative, three-blade nail internal fixation for the familiar traditional treatment. This single nail in the mechanical efficiency of the bone can not last, in addition, this nail is also not suitable for adolescents and neck comminuted fracture.
(2) Multi-nailed fixation: including Shih’s pin, triangular pin and multi-threaded nail. This type of fixation is less damaging to the bone and takes advantage of the biomechanical advantages of the multi-staple layout for better efficacy. The disadvantage is that the risk of non-union of the bone increases significantly if the fixed nail withdraws.
(3) Sliding nail plate fixation device: The advantage of this internal fixation device is that it can make the fracture piece firmly embedded and help early weight-bearing. However, it is difficult to operate and surgically invasive.
(4) Pressurized internal fixation: the internal fixation nail with thread, such as hollow pressurized screw, threaded bone round pin and spring pressurized screw, etc.
6.How to choose the most suitable treatment method?
The treatment of fresh femoral neck fracture is mainly based on the fracture site, considering its treatment method.
(1) Fracture of the base of the femoral neck: incomplete fracture and abductor insertion fracture, skin traction or bone traction can be used.
(2) Fracture of the middle femoral neck: single nail, multiple pins or compression internal fixation is feasible.
(3) Subtrochanteric fractures: these fractures are difficult to heal and often necrosis occurs, and artificial joint replacement is often performed in elderly people over 65 years old. For patients under this age, internal fixation with multiple pins or compression nails is preferred.
(4) Femoral neck fracture in children: The main blood supply to the femoral neck in children comes from the intramedullary artery. With four 2-mm Kirschner pins, percutaneous penetration of the pins for internal fixation, there is less injury, and the hip is fixed in a herringbone cast for 12 weeks after surgery. And closely observe whether there is femoral head necrosis occur.
(5) Bone flap grafting: bone traction for 1 week before surgery to release the contracted periprosthetic muscles and correct the fracture displacement. Expose the femoral neck and femoral head, reposition the fracture, cut a bone groove along the long axis of the femoral neck, insert the bone flap into the groove of the femoral neck, and insert a compression nail or multiple pins under direct vision to fix it on the lateral side of the femur below the greater trochanter.
(6) Artificial hip replacement: for those who are over 65-70 years old and have displaced fresh femoral neck head or comminuted fracture, old fracture does not heal or the femoral head is necrotic and there is no osteoarthritis in the acetabulum, artificial hip replacement surgery is feasible.
7.What are the risks in the treatment of femoral neck fracture patients?
There are generally three hurdles to overcome after femoral neck fracture surgery.
(1) Post-operative infection: Most patients can overcome this hurdle, which is usually about 7 days.
(2) The healing hurdle: the femoral neck area has poor blood flow and most patients are middle-aged or elderly, so the healing process is slow, usually taking about 3 months to 1 year, and the older the patient is, the more difficult it is to heal. The first two hurdles are more important to doctors and patients alike.
(3) Femoral head necrosis level: this level is often easy to be ignored. A common clinical situation is that the repositioning, internal fixation and healing of the femoral neck fracture after surgery are smooth, and the doctors and patients are satisfied, so they do not protect and move freely, which eventually causes necrosis of the femoral head and leaves lifelong regret.
8.Is the incidence of femoral head necrosis after femoral neck fracture surgery high? What are the factors that depend on?
The chance of femoral head necrosis after femoral neck fracture 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 subtrochanteric fractures and hip dislocations can cause impaired blood flow to the femoral head, leading to an increased incidence of ischemic necrosis of the femoral head.
(2) Age: Femoral neck fractures in middle-aged and elderly patients are prone to non-healing, while femoral neck fractures in young adults are more prone to femoral head necrosis because of the high injury violence and the 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.
(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, further aggravating vascular injury, which is a common 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 fracture, 35.7% for moderately dislocated and 51% for severely dislocated, the better the quality of reset, the lower the incidence of femoral head necrosis.
9, in order to prevent the femoral head necrosis should pay attention to what aspects?
(1) Diligent review of X-rays: 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 is already a precursor of necrosis, and active measures should be taken to prevent its further development.
(2) Premature weight-bearing is not advisable: Femoral neck fracture is basically weight-bearing after 12 weeks from the perspective of fracture healing, but because of the late onset of femoral head necrosis, reduction of weight-bearing should be adhered to until 1-1.5 years.
10.How to pay attention to the signal of head necrosis after the healing of femoral neck fracture?
After the healing of femoral neck fracture, walking is also painless, and once the pain disease appears later, this is the signal of femoral head necrosis, to take bilateral hip X-ray for comparison. There is no change in the trabeculae on the affected side and the bone density is higher than that on the healthy side.
Or there is uneven bone density, or further ECT examination suggests that the arterial blood supply is reduced, the slope is increased (suggesting bad venous return), the static image presents a large block of ischemia (cold area), a large block of depressed blood (hot area), hot and cold (i.e., uneven), which has been clearly diagnosed as femoral head necrosis (or MRI examination), you have to use back to the double crutch, immediately cast medical treatment to obtain the correct treatment, do not exist fluke delay treatment.
11.After surgery, is it just waiting for the fracture to heal?
Surgery is only one part of the whole treatment process, post-operative rehabilitation is the follow-up treatment. The correct exercise method is a very important factor to ensure the success of the surgery.
12.What are the post-operative exercise methods?
The exercise method should be combined with the patient’s general condition and surgery, and the rehabilitation program should be implemented according to the patient’s specific situation.
Postoperative exercise methods after hollow nail fixation.
(1) rehabilitation exercises during the healing period
3-5 days after the operation, start to sit in the prone position, 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 personnel, do not make the femur rotate and inward, do hip and knee active flexion and extension exercises, gentle movements, small amplitude, few repetitions, in order not to cause obvious pain.
During the same period, resistance exercises for the supporting muscles of the upper limbs were performed, including the pectoralis major, latissimus dorsi and triceps brachii. In the second month after surgery, sit on the bedside with both lower legs hanging down and knees close to the edge of the bed, and perform active flexion and extension exercises for the affected limbs, so that both lower limbs are not swollen and the knees are actively straightened to more than 60°. 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.
At 3 months postoperatively, 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.
The 2nd month: you can practice walking with single crutch with the upper limb of the healthy side, and after 2 weeks, you can switch to crutch support by the upper limb of the affected limb.
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.
Then 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 time regular review, including X-ray review, should be conducted to check the recovery of function and observe whether there is any tendency of femoral head necrosis.
Post-operative exercise methods after artificial hip arthroplasty.
(1) Pre-operative rehabilitation education
Explain the surgery to the patient, introduce the postoperative rehabilitation program, teach the patient to perform long contraction movements 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. Internal retraction After surgery, the affected hip may easily dislocate the artificial joint by internal retraction. The postoperative bed position should be kept in an external booth, with a pillow placed between the legs and a pillow on the outside of the affected limb to prevent external rotation of the hip joint.
b. “Stretching the legs”, squatting and putting on shoes, squatting and urinating and defecating, etc. are actions that can easily lead to dislocation of the artificial hip joint.
c. Lying on the affected side Lying on the affected side puts the artificial hip joint under greater force of backward dislocation, which easily leads to joint dislocation and fracture around the prosthesis.
② Muscle strength training
On the first postoperative day, ankle pump exercises, isometric contraction exercises for the quadriceps, N cord and gluteus muscles of the affected limb were started. Muscle strength training of both upper extremities and the healthy lower extremities, 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 should be performed 3~4 times a day for 5~10 minutes each time for both upper and lower limb joints. 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. Non-cemented 20% weight-bearing, gradually increase to 100% weight-bearing after 6 weeks; cemented 100% weight-bearing; mixed weight-bearing according to the patient’s pain condition. In the second week after surgery, practice walking up and down the stairs as appropriate, and perform single-leg half-squat exercises for cemented type.
⑤ Pre-discharge evaluation and education
Muscle strength, joint mobility and walking ability should be evaluated before discharge. Teach the patient the home training program, emphasize the movements and positions to be avoided after surgery, and come to the hospital for rehabilitation 1-2 times a week within 3 months.
13.What do I need to pay attention to in my daily life after discharge?
One post-operative patient did not pay attention to the correct socks after artificial joint surgery and put on the socks by rotating the leg outward and using a shoe lifting posture, which resulted in joint dislocation. Some people also put on socks while sitting in a stilted position. 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. Bone soup is not necessarily absorbed, but also hinder the function of the spleen and stomach, if you want to drink, once or twice a week can be.
14.Do I need to take medication, and do I need to take medication after discharge?
After the surgery to preserve the femoral neck fracture, you need to continue to take medication after discharge to promote fracture healing and reduce the risk of femoral head necrosis.
The artificial joint is compatible with the human body and will not be rejected, so there is no need to take medication after surgery. However, if the patient has rheumatoid arthritis, psoriasis or other primary diseases, long-term medication is required because these systemic diseases can affect the “peaceful coexistence” of the joint and the body.