Foreign pathology fractured femoral neck

2021-01-30 12:00 AM

If treatment is good, it can avoid systemic complications, bone healing after 3, 4 months, no sequelae, if treatment is not good, it will leave many complications.

Outline

The femoral neck fractures are fractures in which the line of fracture is between the cusp and the axon mass.

Common in the elderly, even a minor injury (such as a fall in the buttocks).

Very rare in young people and children.

The prognosis for healing is complicated by prosthetics and resorption.

Often life-threatening due to complications such as pneumonia, urinary tract infection, heart failure, and long bed ulcers.

Recall important anatomical factors

Weakness

Located between two skeletal systems: Fan base system and pointed arch system.

About X-rays

Essence points

1 year old: There is bone marrow.

5 years old: Appeared to add more essence to the big turning point.

8 years of age: Strongly develop osteoclasts and large nodules.

10 years old: Appeared to add baby transformation points.

13 years: The bone is fully developed, but the nodules stick firmly to the bone from 16-18 weeks and the bone tip is firmly attached to the thigh from 18-20 years old.

The ancient bowline is closed

Is the continuous arc connecting the femoral neck and the ridge on the hole?

Neck angle

The angle is created by the axis of the femur neck and of the femur body. Normally the angle is about 1300.

About circulatory nurturing the cap

Upper group: is formed from 3-4 small branches separated from the posterior ciliary artery, connecting with the anterior capillary branches, the bundled branches, and the branches going in the bursae to nurture the upper apical artery. 

The inferior-inner group: Separated from the posterior capillary artery nourishes the lower quarter of the cap. 

Circular ligament artery: Separated from the occlusion artery, has a very small role to nourish only a part of the cap. 

Classify

The Garden

Based on the existing correlation of the longitudinal fibres. If the correlation is maintained, the displacement is of little importance and the cusp nourishment will be good thanks to the intact joint. The prognosis is good.

Grade I: Interlocking fracture, bone straight. 

Grade II: Fracture does not move, the bone fibres remain straight, but are pressed between broken bones. 

Grade III: Fracture closed displacement, horizontal bone fibres. 

Grade IV: Fracture is very displaced, the bone is free in the cavity, the fracture is in contact with the circular ligament, the parallel but separated bone fibres. The encephalopathy threatens necrosis. 

Theo Pauwels

Pauwels I: Fracture line created with horizontal line at an angle of 300, easy to heal. 

Pauwels II: This angle is equivalent to 500, the prognosis is difficult. 

Pauwels III: This angle is equivalent to 700, the risk of cap necrosis is high. 

Clinical symptoms

Depending on the type of fracture (closed fracture or type), the manifestation of clinical symptoms varies.

Right neck fracture as a closed fracture

Most often, the fractures are separated by muscle tension. Lower fracture in the closed position and outer rotation.

Pathology

Location

Subprotoid fracture: This type of treatment is complicated because only the tip of the bone is small. The poorly nourished tip is only round ligament artery, so it is difficult to heal, easily lead to prosthetic joints or capillary.

Cross-neck fracture: The prognosis is better than the above type because there is a part of the bone attached to the cap, better nutrition.

The direction of fracture: Usually from bottom to top from inside out. 

Deviation: The broken segments are not interlocking.

The distal segment moved upwards due to the gluteus muscle pull, the two bones are angled, at the lower angle and back.

clinical

Pain: Often, most painful when trying to move the groin.

Complete loss of muscle function: Missing unable to lift her leg off the bed surface.

Deformation:

Short broken legs, thighs closed, feet turned outwards.

Feel the big wheel is pulled up.

There is a change in the line of the Nélaton Roser, normally the anterior pelvic spine on the large cavity, the mound sits on the same line. When broken, the big chuck is pulled up high, on the line connecting the anterior pelvic spine and the mound.

There may be an effusion of the knee joint in the fracture.

X-ray

Need to shoot straight and tilt the hip fracture. Can see:

The fracture line on the inner edge of the neck crossed downwards and inward, or the fracture line between the neck is perpendicular to the axis of the neck bone.

On the displacement, the outer section was pulled up on the rotating cap, causing the neck and bone to fall down. On the slant film, there are 2 broken segments that are not interlocking, which is the main sign. After checking to determine a fracture, it is necessary to assess the state of the whole body for appropriate indications and treatment.

Genuinely broken neck fracture shape

Less common than closed fracture because the two segments intersect.

Clinical

After a fall, the block is moved to the ground, the bone breaks and the bone is locked. Clinical symptoms are often ambiguous, incomplete loss of muscle function, the patient may lift his heel from the bed and in some cases still stand up, then the fracture may be separated into a closed fracture.

X-ray

The cervical or cross-neck fracture line is almost horizontal. Two interlocking fractures widen the neck and body angle.

Progression and complications

If good treatment can avoid complications of the whole body, bone healed after 3-4 months, no sequelae. If the treatment is not good, it will leave many complications.

Early complications

Injury: Rarely.

Combination injury: Joint injury or femoral fracture.

Late complications

Body

Skin ulcer, buttock, sacral heel.

Heart and lung damage: Bronchitis, pneumonia, risk of heart failure.

Urinary complications: Urinary tract infections.

Stroke: Phlebitis and pulmonary thrombosis.

In place

Can deviation: In the closed groin position, the limb short fracture 4-5cm and can be compensated with hip flexion, spine, high heel sandals.

Bad Can: Easily at risk of osteoarthritis, especially the hip joints, spine.

Joint prostheses: Due to lack of treatment such as poor immobility, early exercise practice.

Suggested clinical symptoms are walking pain, walking with difficulty as a missing step, requiring x-rays to confirm.

 The principles of treatment

Orthopaedic method

Apply to braces: This is the case with good prognosis, patients do not have to lie still in bed. The patient can lift the heel and, if possible, walk. X-rays must be checked to track fractures. However, the risk of secondary deviation is very important, requiring surgical intervention. Therefore, it is necessary to prevent secondary deviation.

Some surgeons treat it with bed rest and gentle foot movement. Other authors like to cast thigh pelvis to practice walking gradually and help quickly heal bones.

According to the classical treatment, people treat with a Whitman cast, which is based on the sternum, close to the toes, down the armpits. When the dough dries, let the patient practice standing, walking and leaving the dough for 3-4 months. However heavy powder is only applicable to healthy people.

Continuous pull: If the cast cannot be cast, one pierces the nail through the head under the femur and pulls continuously on the Braun truss with groin shape, the foot rotates inward. However, by dragging the patient to lie for a long time, it is easy to have systemic complications, so it is less applicable.

Surgical methods

Indicated for all displacement fractures. These cases can naturally heal bones and progress to lose prosthetic joints with short limbs and poor support on the limbs. The aim of treatment is to avoid long bed lying so either incorporating strong bones to allow walking with crutches and leg support gradually on the broken side and early rehabilitation exercise, or hip replacement surgery. to allow immediate foot movement.

Bone association: First, it is necessary to manipulate the orthopaedic table with general anaesthesia and X-ray examination.

There are many surgical methods such as using nails, simple screws, DHS compression screws (Dynamique Hip Scew), braces, L braces ... after surgery must allow early movement and gradual leaning on the broken limb. Full leg support when there is a visible healing on radiograph, usually 2 months after surgery. Surgical methods often depend on each school as well as the habits of the surgeon.

Hip replacement: There are 3 types: cap prosthesis, prosthetic joint and complete.

Cap prosthesis: Used since 1952, it replaced only the femur with a metal cap connected to a long body plugged in the body of the femur. Surgery is very quick and has little effect on people in poor condition. The steps after surgery are very simple, the patient can get up the next day.

This type of cap-prosthetic joint has 2 inconveniences: it is easy to fracture and wear out the alveolar cartilage and easily sink the body of the prosthesis into the canal.

To overcome the second disadvantage, people use cement to plug the prosthetic body into the canal or replace it with a stem corresponding to the diameter of the canal. The size fit of the prosthetic joint with the canal is very favourable whether cement is used or not. To avoid the first disadvantage, an intermediate prosthetic joint has been improved and used, which is the bearing protected by a movable cusp located between the false cusp and the jar. Therefore, the rear part is protected and the wear time is longer.

Protheses total: Apply in cases where the axillary cartilage is not good, especially in cases of neck fracture on a groin that has previously degenerated.

An entire hip joint was replaced with two separate pieces that were inserted directly into the mortar and femur body.

Problems indicated for the treatment

Depends on age:

In children and young people: Assign to combine bones for all types of fractures, with simple screwdrivers or press screws (DHS).

In the elderly: Indicated depends on the patient's condition, old age or too old, mental status, living status, and other medical conditions.

If <60 years old, then combine bone.

65 - 70 years old can combine bones, but most of them replace joints and allow immediate movement and should be used for full joint replacement at this age.

75 - 80 years old: using a semi-joint.

> 80 years old: using a prosthetic joint.

Prognosis

Cap necrosis can occur during bone fusion for up to 2 years, especially in highly displaced fractures.

Joint prosthesis after bone fusion

Mortar inflammation due to false caps, cement liquid in the body and joints.

Preventive

Propaganda and education in the community about traffic and labour laws.

It is necessary to educate the community of good local first aid in fracture cases to limit complications in fractures.

For grassroots health facilities, it is necessary to early diagnose, handle properly and refer to specialized medical level for early treatment to minimize complications caused by femoral neck fracture.

Educate patients on rehabilitation exercises after treatment.