[Definition].
Femoral neck fracture is a fracture between the lower part of the femoral head and the base of the femoral neck. It occurs mostly in the elderly, and the main problems in clinical treatment are non-union of the fracture and ischemic necrosis of the femoral head.
[Diagnostic basis]
I. Medical history
Femoral neck fractures are mostly seen in the elderly, but also in children and young adults, with slightly more women than men. In the elderly, due to osteoporosis and fragility of the femoral neck, even minor trauma such as slipping on a flat surface, landing on the greater trochanter, or sudden twisting of the affected limb can cause fracture. Fractures in young adults are rare, but if they occur, they must be due to strong violence such as car accidents, falls from height, etc., and often combined with other fractures and even internal organ injuries.
Symptoms and signs
After the injury, the affected hip is painful and cannot stand or walk. The symptoms of displaced femoral neck fracture are obvious, the hip is painful, the activity is limited, the affected hip is inward, mildly flexed, the lower limb is externally rotated and shortened. Upward displacement of the greater trochanter with percussion pain, pressure pain in the femoral triangle, dysfunction of the affected limb, refusal to touch and move; percussion heel test (+), reduced bone conduction sounds.
Inclusion fractures and fatigue fractures, the clinical symptoms are not obvious, the affected limb is not deformed, and sometimes the patient can still walk or ride a bicycle, so it is easy to be considered soft tissue injury and missed. For elderly people complaining of hip pain or knee pain after injury, detailed examination and positive and lateral hip films should be taken to exclude fracture.
Special examination
Nelaton’s line, Bryant’s triangle and Schoemaker’s line are positive, and Kaplan’s intersection point is biased towards the healthy side under the umbilicus.
Auxiliary examinations
X-ray examination can clarify the fracture site, type and displacement. It should be noted that some linear undisplaced fractures may not show the fracture on the X-ray taken immediately after the injury.
If the fracture is indeed present, the fracture line can be clearly shown after 2 to 3 weeks of re-examination due to bone resorption at the fracture site. Therefore, if you have clinical suspicion of fracture, you can apply for CT examination or review the film after two weeks of bed rest to make a clear diagnosis.
[Classification of evidence]
Fracture classification according to the degree of fracture dislocation [Garden classification]
Type I Incomplete fracture
Type II Complete fracture without dislocation
Type III Partially dislocated fracture with inward rotational displacement of the femoral head and reduced neck stem angle.
Type IV Complete fracture with separation of the fracture end, rotation of the proximal fracture end, and posterior upward displacement of the distal fracture end.
[Treatment]
The treatment plan should be decided according to the time and type of fracture, the patient’s age and general condition.
I. Non-surgical treatment
(I) Percutaneous internal fixation with hollow compression screws
1. Indications: Garden type I and II fractures.
2. Operation method: Fresh undisplaced femoral neck fracture can be fixed with 2-3 hollow screws directly under G- or C-arm X-ray machine fluoroscopy. First, the assistant will traction and support the injured limb with mild abduction and internal rotation, routine skin disinfection, towel laying, local anesthesia, make 2-3 incisions of about 1cm and 3cm below the greater trochanter, drill 2-3 guide pins into the femoral head via the fracture end in the direction of the femoral neck, see that the fracture is not obviously displaced and the guide pins are well positioned in the positive axial fluoroscopy, select 2-3 hollow compression screws of suitable length to be drilled into the guide pins The fracture was repositioned and the hollow compression screws were well positioned and fixed in a stable position. After one week, the patient can be taken out of bed without weight-bearing functional exercise.
(B) Internal fixation with percutaneous hollow compression screw by manual repositioning
1. Indication: Garden type III and IV fractures.
2, operation method: freshly displaced femoral neck fracture, can be two assistants respectively, the two sides of the homeopathic extraction and traction, and then internal rotation and abduction of the injured limb reset; or flexion of the hip and knee extraction and traction, and then internal rotation and abduction of the injured limb straight reset; or excessive flexion of the hip, knee flexion, extraction and traction of internal rotation and abduction of the injured limb straight reset; can also first bone traction rapid reset, reset satisfactory according to the aforementioned method for fixation.
(C) skin traction
Indications and methods of operation: For femoral neck fractures with combined systemic diseases, it is not appropriate to perform invasive treatment for fixation. If there is no displacement, skin traction with a thong shoe to keep the lower extremity abducted in a neutral traction position is feasible.
(iv) For smaller children, fine kerf pins are used to fix the fracture, and for larger children, hollow screws are used to fix the fracture.
II. Surgical treatment
(I) Hollow compression screw fixation
1, indications: closed reduction failure or poorly displaced fractures.
2. Operation method: take the lateral hip incision, expose the fracture end to make the fracture reach anatomical repositioning or slight over-repositioning, the technique of hollow compression screw fixation is the same as above.
(B) Sliding nail plate internal fixation
1. Indications: Fracture of the base of the femoral neck with closed repositioning failure or femoral upper end with lateral cortical comminution. Operation method: take the lateral hip incision, the pressurized hip screws should be placed along the middle axis of the femoral neck or inferiorly.
The lateral plate screws should be more than 3. To prevent rotational deformity of the femoral neck fracture, 1 additional screw can be fixed through the femoral neck into the femoral head.
(C) Internal fixation and bone grafting
1. Indications: old femoral neck fracture that does not heal, or ischemic necrosis of the femoral head without significant deformation, or displaced femoral neck fracture in young adults.
2. Operation method: the femoral condylar traction can be performed first, and after the fracture end is retracted, a percutaneous internal fixation with a hollow compression screw is performed (or internal fixation can be performed during surgery), and then a transposition graft with a deep iliac artery tip, an iliac flap with a sutures muscle tip or a bone flap with a femoral square muscle tip is performed depending on the condition.
(D) Osteotomy
1. Indications: old femoral neck fractures that do not heal or heal malformed may be osteotomized to improve function.
2, operation method: femoral inter-rotor internal displacement osteotomy (Mai), Meng’s osteotomy, femoral sub-rotor abduction osteotomy, Bey’s surgery, etc.. However, we must strictly grasp the indications and weigh the considerations.
(E) Artificial hip arthroplasty
1. Indications: It is mainly applicable to those who are over 60 years old and have old femoral neck fractures that do not heal, failed internal fixation or malignant tumors, fractures that are significantly displaced and cannot be satisfactorily repositioned and stabilized internally, those with mental diseases or mental injuries and ischemic necrosis of the femoral head, etc. Artificial hip arthroplasty is feasible.
2.Operation method: general anesthesia or epidural block anesthesia. The anterolateral approach to the hip (S-P approach), lateral approach, posterolateral approach, etc. can be used, and the corresponding position should be adopted according to the different approaches. Elderly patients should always put life protection in the first place and be carefully observed to prevent and treat complications.
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 and eliminate blood stasis, eliminate swelling and relieve pain, using Tao Hong Si Wu Tang with addition and reduction; in the middle stage of pain reduction and swelling, it is advisable to activate blood circulation, activate blood circulation and nourish blood, using Wu Guo Ling Tang or Shu Shu Tendon and Blood Soup; in the late stage, it is advisable to nourish liver and kidney, strengthen tendons and bones, using San Qi Jian Wan. For local and distal limb swelling, it is advisable to benefit the Qi and activate the Blood, using Plus Flavor Beneficial Qi Pill. For muscle wasting and hardening, and dysfunction, it is advisable to nourish the Blood and facilitate the joints, using Nourishing Blood and Relieving Pain Pill.
(II) Western medicine treatment
If surgical treatment, prophylactic application of antibacterial drugs should be given half an hour before surgery, usually for three days. Combined with other internal diseases, symptomatic drug treatment should be given.
IV. Rehabilitation treatment
Functional exercise (active, passive)
(a) After repositioning and fixation, perform quadriceps muscle stretching and functional activities of knee and ankle joints.
(2) After 1 week, support double crutches to get out of bed without weight-bearing activities, and pay attention to keep the external booth; Garden III and IV fractures may delay the time of getting out of bed; after 8 weeks, support double crutches for light weight-bearing activities; after 6 months, support single crutches for light weight-bearing activities depending on the condition; after 1 year, abandon crutches for functional exercises and pay attention to regular review.
(c) The main problem of femoral neck fracture treatment is to prevent fracture non-healing and ischemic necrosis of the femoral head, so the medication and regular review are especially important in the middle and late stages. Patients should be instructed not to lie on their sides, not to cross their legs, and not to internalize the injured limb. Once ischemic necrosis of the femoral head appears, weight bearing and activity time should be delayed.