Neck of femur fractures are one of the commonest fractures in the population as bone density in the thigh area drops in elderly women after the menopause, with large numbers of hospital beds dedicated to this group. Abnormal stresses repeatedly applied to the neck of femur such as by long distance runners or military trainees can result in stress fractures of the femoral neck in this much fitter and younger group. Direct trauma to the area such as a fall on the side of the hip can cause fracture at any age as can fractures secondary to pathological changes such as neoplasm.
Orthopaedic practitioners have long recognised the importance of promptly restoring the anatomical alignment of the femoral neck fracture so that avascular necrosis (AVN) of the femoral head could be avoided. In AVN the blood supply is lost to the head of the femur, causing death of the bone and the head then degenerates and collapses, necessitating replacement operation. Immobilisation in a hip spica was initially used, with internal fixation developed in the 1930s by Smith-Petersen. Later developments such as the Richards Screw Plate use a form of sliding fixation which allows surgical impaction of the fracture site.
Walking puts both shearing and compression forces across the neck of femur in normal life but these forces are greatly magnified by activities such as sports involving jumping, sprinting or running. A typical increase in force of five to six times the bodyweight occurs across the femoral neck in normal activities such as climbing stairs. Hip pain refers commonly to the front of the thigh, side of the hip and the groin in a number of hip syndromes including a stress fracture, which can develop into a complete fracture plus displacement with the attendant risks.
In younger healthy people who exert abnormally high demands on normal bone the bone structures can fail mechanically due to the excessive stresses imposed on them. In older people, especially post menopausal women, normal stresses are imposed on bone which is not able to cope with them, bone with pathological changes due to insufficiency of the bone from osteoporosis or other metabolic abnormality. Oestrogen maintains the turnover and health of bone strength and without it bones become more brittle, either in older women or female athletes in high intensity training.
A specialist will consider stress fracture in the differential diagnosis of an athlete who, after an increase in training, presents with a new hip pain problem. The pain is generally worse with the sport and better with resting. Bone scanning is a more sensitive investigation than x-rays in this case. The vast majority of these fractures occur in elderly persons who fall or twist, fracturing the femoral neck. Diagnosis is established by noting an inability to stand on the leg, a laterally rotated leg, a shortened limb and pain in the side of the hip and the groin.
Transverse fractures of the femoral neck have approximately a 10-15 percent risk of displacement with its accompanying possibilities of avascular necrosis. These fractures need operative fixation and the question arises about the correct surgical management. Joint replacement or internal fixation is the choice and this depends on the anatomical placement of the fracture. If the fracture is sub-capital, directly under the head, then the blood supply is potentially affected especially if the fracture is displaced, making a Thompson hemi-arthroplasty or total hip replacement a better option.
In many cases the fall fractures the bone and compacts the fracture fragments together, forming a compression system which resists displacement and can bear weight. This type of fracture may not need operation as it is stable and can be managed conservatively. If the fracture is in a different area then it may be unstable as tension forces are acting on it, so must be managed by insertion of one of a large choice of fixation devices. Sub-trochanteric, trochanteric and lower neck fractures may fall into this category.
Once the fracture is replaced or fixed the patient is allowed 24 hours to recover medically then the physiotherapist and an assistant will check the operative instructions, review the patient's observations and get the patient up weight bearing with a frame or crutches. - 14130
Orthopaedic practitioners have long recognised the importance of promptly restoring the anatomical alignment of the femoral neck fracture so that avascular necrosis (AVN) of the femoral head could be avoided. In AVN the blood supply is lost to the head of the femur, causing death of the bone and the head then degenerates and collapses, necessitating replacement operation. Immobilisation in a hip spica was initially used, with internal fixation developed in the 1930s by Smith-Petersen. Later developments such as the Richards Screw Plate use a form of sliding fixation which allows surgical impaction of the fracture site.
Walking puts both shearing and compression forces across the neck of femur in normal life but these forces are greatly magnified by activities such as sports involving jumping, sprinting or running. A typical increase in force of five to six times the bodyweight occurs across the femoral neck in normal activities such as climbing stairs. Hip pain refers commonly to the front of the thigh, side of the hip and the groin in a number of hip syndromes including a stress fracture, which can develop into a complete fracture plus displacement with the attendant risks.
In younger healthy people who exert abnormally high demands on normal bone the bone structures can fail mechanically due to the excessive stresses imposed on them. In older people, especially post menopausal women, normal stresses are imposed on bone which is not able to cope with them, bone with pathological changes due to insufficiency of the bone from osteoporosis or other metabolic abnormality. Oestrogen maintains the turnover and health of bone strength and without it bones become more brittle, either in older women or female athletes in high intensity training.
A specialist will consider stress fracture in the differential diagnosis of an athlete who, after an increase in training, presents with a new hip pain problem. The pain is generally worse with the sport and better with resting. Bone scanning is a more sensitive investigation than x-rays in this case. The vast majority of these fractures occur in elderly persons who fall or twist, fracturing the femoral neck. Diagnosis is established by noting an inability to stand on the leg, a laterally rotated leg, a shortened limb and pain in the side of the hip and the groin.
Transverse fractures of the femoral neck have approximately a 10-15 percent risk of displacement with its accompanying possibilities of avascular necrosis. These fractures need operative fixation and the question arises about the correct surgical management. Joint replacement or internal fixation is the choice and this depends on the anatomical placement of the fracture. If the fracture is sub-capital, directly under the head, then the blood supply is potentially affected especially if the fracture is displaced, making a Thompson hemi-arthroplasty or total hip replacement a better option.
In many cases the fall fractures the bone and compacts the fracture fragments together, forming a compression system which resists displacement and can bear weight. This type of fracture may not need operation as it is stable and can be managed conservatively. If the fracture is in a different area then it may be unstable as tension forces are acting on it, so must be managed by insertion of one of a large choice of fixation devices. Sub-trochanteric, trochanteric and lower neck fractures may fall into this category.
Once the fracture is replaced or fixed the patient is allowed 24 hours to recover medically then the physiotherapist and an assistant will check the operative instructions, review the patient's observations and get the patient up weight bearing with a frame or crutches. - 14130
About the Author:
Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, physiotherapists in Glasgow, back pain, musculo-skeletal conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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