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 Table of Contents  
SYMPOSIUM: FRACTURE NECK OF FEMUR
Year : 2018  |  Volume : 1  |  Issue : 1  |  Page : 15-20

Delayed diagnosed femoral neck fractures


Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), Raipur, Chhattisgarh, India

Date of Web Publication28-Dec-2018

Correspondence Address:
Dr. Sandeep K Yadav
Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), Raipur, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.JODP_6_18

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  Abstract 

Treatment of displaced femoral neck fractures includes internal fixation with/without graft supplementation or internal fixation plus osteotomy or arthroplasty. The literature contains conflicting evidence regarding rates of mortality, revision surgery, major postoperative complications, and function in patients with displaced femoral neck fractures who present delayed, treated either by internal fixation or arthroplasty. The purpose of our study was to summarize the management protocol of fracture of neck of femur when they present at different duration and at different stage.

Keywords: Complications, delayed diagnosis, etiology, fracture neck of fracture


How to cite this article:
Kar BK, Agrawal AC, Yadav SK, Sakale H, Sahoo B. Delayed diagnosed femoral neck fractures. J Orthop Dis Traumatol 2018;1:15-20

How to cite this URL:
Kar BK, Agrawal AC, Yadav SK, Sakale H, Sahoo B. Delayed diagnosed femoral neck fractures. J Orthop Dis Traumatol [serial online] 2018 [cited 2019 Apr 22];1:15-20. Available from: http://www.jodt.org/text.asp?2018/1/1/15/248905


  Introduction Top


Intracapsular fractured neck of femur is treated as an emergency in adults (younger than 60 years), and quick efforts are made to restore blood supply of the femoral head.[1] Some advocate that such cases should be regarded as “vascular emergencies” and operative interventions should be rendered within 6–8h.[1],[2]Two major complications threatening the patients with this fracture include nonunion and avascular necrosis (AVN) of the femoral head.[3],[4]Incidence of nonunion and aseptic necrosis of the femoral neck following osteosynthesis is estimated at 10%–30% and 15%–30%, respectively.[3],[4]However, most studies suggest that early fixation with proper reduction is necessary for good results. In some cases, the problem remains hidden and patients with delayed fractures are referred to orthopedic centers.[4] In adults and adolescents, femoral neck fractures usually occur because of high-energy traumas and are accompanied by several multisystem injuries. Therefore, so much time is spent on examining other organs that the golden time is lost for early surgical treatment of femoral neck fractures.[5],[6]Although femoral neck fractures usually occur because of high-energy trauma, they may also result from low-energy trauma.[5],[7]

Also many a times, patients present with fracture neck of femur 2 weeks after the occurrence because of initial management by local bone setters. Just because of negligence or unassessment of severity, they present delay when the golden hour is already lost.

Differences exist between young adults and older patients on the treatment of femoral neck fractures. According to the literature, closed reduction with internal fixation (CRIF) is the best treatment method as it is effective, less invasive, and requires less operation time.[5] Treatment and fear of complications in patients with delayed femoral fractures are important concerns of orthopedic surgeons.

  • Radiographs
    • Recommended views
      • Obtain anterio-posterior (AP) pelvis and cross-table lateral, and full length femur film of ipsilateral side
      • Consider obtaining dedicated imaging of uninjured hip to use as template intraoperatively
      • Traction-internal rotation AP hip is best for defining fracture type
      • Garden classification is based on AP pelvis [Table 1] and [Table 2]
        Table 1: Garden classification

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        ,
        Table 2: Pauwels classification

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  • Computed tomography (CT)
    • Helpful in determining displacement and degree of comminution in some patients
  • Magnetic resonance imaging (MRI)
    • Helpful to rule out occult fracture
    • Helpful in assessing viability of femoral head after fracture
  • Bone scan
    • Helpful to rule out occult fracture
    • Not helpful in reliably assessing viability of femoral head after fracture
  • Duplex scanning
    • Rules out deep venous thrombosis if delayed presentation to hospital after hip fracture


Sandhu et al.[13] have proposed a radiological classification for this injury based on the following variables: (1) fracture site (irregular or smooth), (2) size of proximal fragment (>2.5 or <2.5cm), (3) gap between fragments (<1cm, 1–2.5cm, or >2.5cm), and (4) signs of AVN. This classification involves an MRI for determination. It has not been validated and does not alter management.

Scintigraphy may have a role in early postoperative evaluation of AVN before plain radiographic features are identified. Bone scans performed within 2 weeks of operation following 306 non-neglected hip fractures have been shown to determine the healing course with an accuracy of 91% (into categories of uneventful healing, hardware failure, nonunion, and AVN). Broeng et al.[24] showed that decreased uptake noted on a bone scan 1–3 weeks postoperatively and 2 months postoperatively was indicative of eventual loss of reduction or segmental collapse in 50% of patients, whereas normal or increased uptake at those times correlated with uncomplicated healing in 90% of patients.

Factors contributing to nonunion of femoral neck

  1. Inaccurate reduction
  2. Unsound or loss of fixation
  3. Vascular insufficiency
  4. Posterior comminution
  5. No treatment
  6. Osteoporosis
  7. Smoking


Viberg et al.[25] conducted a study and published that low bone bone mineral density (BMD) may be a factor in internal fixation failure. Although not statistically significant, the subgroup analysis for undisplaced fractures showed a hazard ratio of 6 for low BMD as compared to 0.8 for the whole group.

Leighton’s classification of femoral neck nonunion

  1. Type I: Inadequate fixation or nonanatomic reduction[26]
  2. Type II: Loss of fixation with fracture displacement
  3. Type III: Fibrous nonunion with no displacement and intact fixation



  Treatment Top


We searched in MEDLINE database about the management of delayed presentation of fracture neck of femur and reviewed many articles. No single clear-cut schematic, diagrammatic guideline for this unsolved fracture is available.

“The neglected femoral neck fracture in young adults: review of a challenging problem” by Roshan and Ram[12] and another review by Jain et al.[27] were useful [Table 3] and [Table 4], [Figure 1], [Figure 2], [Figure 3].
Table 3: Neglected femoral neck fracture in young adults: a comparison of the literature

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Table 4: : Data on miscellaneous procedures

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Figure 1: Flow chart for management of neglected neck femur fracture

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Figure 2: Fixation with fibular strut grafting

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Figure 3: Transtrochantric osteotomy with fixation

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  Conclusion Top


Fracture neck of femur remains an unsolved fracture from the beginning of orthopedics, even today with advanced tools and infrastructures because of its peculiar anatomy. Not a single definite method of treatment is available. It varies from person to person, age to age, status of head and neck, and depends on patient’s requirement. Sometimes Mcmurray[15] osteotomy also helps the patient to live a life with full weight-bearing with his ability to sit cross-legged on floor, though it produces a bit shortening. Therefore, each case is to be dealt as a different case considering its history, geography, status, and requirement of the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Swiontkowski MF, Winquist RA, Hansen ST Jr. Fractures of the femoral neck in patients between the ages of twelve and forty-nine years. J Bone Joint Surg Am 1984;1:837-46.  Back to cited text no. 1
    
2.
Hou SM, Hang YS, Liu TK. Ununited femoral neck fractures by open reduction and vascularized iliac bone graft. Clin Orthop Relat Res 1993;1:176-80.  Back to cited text no. 2
    
3.
Huang CH. Treatment of neglected femoral neck fractures in young adults. Clin Orthop Relat Res 1986;1:117-126  Back to cited text no. 3
    
4.
Lifeso R, Younge D. The neglected hip fracture. J Orthop Trauma 1990;1:287-92.  Back to cited text no. 4
    
5.
Nagi ON, Dhillon MS, Goni VG. Open reduction, internal fixation and fibular autografting for neglected fracture of the femoral neck. J Bone Joint Surg Br 1998;1:798-804.  Back to cited text no. 5
    
6.
Meyers MH, Harvey JP Jr, Moore TM. Treatment of displaced subcapital and transcervical fractures of the femoral neck by muscle-pedicle-bone graft and internal fixation. A preliminary report on one hundred and fifty cases. J Bone Joint Surg Am 1973;1:257-74.  Back to cited text no. 6
    
7.
Stewart MJ, Wells RE. Osteotomy and osteotomy combined with bone-grafting for non-union following fracture of the femoral neck. J Bone Joint Surg Am 1956;1:33-48; discussion, 48-9.  Back to cited text no. 7
    
8.
Henderson MS. Ununited fractures of the neck of the femur treated by aid of the bone graft. J Bone Joint Surg 1940;1:97-106.  Back to cited text no. 8
    
9.
Inclan A. Late complications in fracture of the neck of the femur treated by nailing, bone grafting or both. J Int Coll Surg 1946;1:36-50.  Back to cited text no. 9
    
10.
Patrick J. Intracapsular fractures of the femur treated with a combined Smith-Petersen nail and fibular graft. J Bone Joint Surg Am 1949;1:67-80.  Back to cited text no. 10
    
11.
Bonfiglio M, Voke EM. Aseptic necrosis of the femoral head and non-union of the femoral neck: Effect of treatment by drilling and bone graft (Phemister technique). J Bone Joint Surg 1968;1:48-66.  Back to cited text no. 11
    
12.
Dooley BJ, Hooper J. Fibular bone grafting for non union of fracture of the neck of the femur. Aust N Z J Surg 1982;1:134-40.  Back to cited text no. 12
    
13.
Sandhu HS, Sandhu PS, Kapoor A. Neglected fractured neck of the femur: A predictive classification and treatment by osteosynthesis. Clin Orthop Relat Res 2005;1:14-20.  Back to cited text no. 13
    
14.
Roshan A, Ram S. Early return to function in young adults with neglected femoral neck fractures. Clin Orthop Relat Res 2006;1:152-7.  Back to cited text no. 14
    
15.
McMurray TP. Ununited fractures of the neck of the femur. J Bone Joint Surg 1936;1:319-27.  Back to cited text no. 15
    
16.
Kalra M, Anand S. Valgus intertrochanteric osteotomy for neglected femoral neck fractures in young adults. Int Orthop 2001;1:363-6.  Back to cited text no. 16
    
17.
Zinghi GF, Specchia L, Ruggieri N, Galli G. The role of osteotomy in the treatment of pseudarthrosis of the neck of the femur in younger patients. Ital J Orthop Traumatol 1985;1:341-8.  Back to cited text no. 17
    
18.
Baksi DP. Internal fixation of ununited femoral neck fractures combined with muscle-pedicle bone grafting. J Bone Joint Surg Br 1986;1:239-45.  Back to cited text no. 18
    
19.
Leung PC, Shen WY. Fracture of the femoral neck in younger adults. A new method of treatment for delayed and nonunions. Clin Orthop Relat Res 1993;(295):156-60.  Back to cited text no. 19
    
20.
Nagi ON, Dhillon MS, Gill SS. Fibular osteosynthesis for delayed type II and type III femoral neck fractures in children. J Orthop Trauma 1992;1:306-13.  Back to cited text no. 20
    
21.
Mishra D. Femoral neck fracture open reduction Asnis screw fixation and fibular grafting. Ind J Orthop 1998;1:32-35.  Back to cited text no. 21
    
22.
Snyder SJ, Sherman OH, Hattendorf K. Nine-year functional nonunion of a femoral neck stress fracture: Treatment with internal fixation and fibular graft. A case report. Orthopedics 1986;1:1553-7.  Back to cited text no. 22
    
23.
Slater RN, Gore R, Slater GJ. Free fibular bone grafting for femoral neck fractures: Precise graft placement using a ‘cannulated screw’ technique. J R Coll Surg Edinb 1993;1:376-7.  Back to cited text no. 23
    
24.
Broeng L, Bergholdt-Hansen L, Sperling K. Predicting results of rehabilitation after hip fracture. A ten-year follow-up study. Clin Orthop Relat Res 1993;1:76.  Back to cited text no. 24
    
25.
Viberg B, Ryg J, Overgaard S, Lauritsen J, Ovesen O. Low bone mineral density is not related to failure in femoral neck fracture patients treated with internal fixation. Acta Orthop 2014;1:60-5.  Back to cited text no. 25
    
26.
Leighton RK. Fractures of the neck of femur. In: Bucholz RW, Heckman JD, Court-Brown C, editors. Rockwood and Green’s fractures in adults. 6th ed. Vol. 2. Philadelphia, PA: Lippincott Williams and Wilkins; 2006: 1753-91.  Back to cited text no. 26
    
27.
Jain AK, Mukunth R, Srivastava A. Treatment of neglected femoral neck fracture. Indian J Orthop 2015;1:17-27.  Back to cited text no. 27
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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