Intracapsular Hip Fractures



Carlos J. Meheux, Luis F. Pulido-Sierra

10 Intracapsular Hip Fractures



Femoral Head Fractures



Introduction




  • I. Associated with hip dislocations 1 4 :




    1. True orthopaedic emergency.



    2. Shear type fractures.



    3. Indentation or crush type. 5



  • II. Anatomy and blood supply to the femoral head 6 :




    1. Medial femoral circumflex artery (MFCA).



    2. The MFCA branches from the deep femoral artery:




      1. Five constant branches: superficial, ascending, acetabular, descending, deep.



    3. The deep branch supplies the blood to the femoral head:




      1. Perforates the posterior capsule.



      2. Proximal to the superior gemellus.



      3. Distal to the tendon of the piriformis.



    4. Terminates in the posterolateral retinacular branches:




      1. Covered by synovium.



      2. Enters the femoral head: 2 to 4 mm lateral to the bone–cartilage junction.



    5. Anastomosis of the inferior gluteal artery and the MFCA:




      1. Inferior border of the piriformis.



      2. Constant anastomosis.



      3. Must be preserved with surgical approaches.



Mechanism




  • I. High-energy motor vehicle collision (84%) 7 :




    1. Posterior hip dislocation:




      1. Twelve percent are associated with femoral head fractures.



      2. Axial load with hip flexed and adducted.



      3. Knee to dashboard. 8



    2. Associated injuries in hip dislocation and femoral head fractures:




      1. Acetabular fracture. 8



      2. Femoral neck fracture.



      3. Femoral shaft fracture.



      4. Ipsilateral knee injuries (25%) 8 :




        1. Meniscus tear (22%).



        2. Bone marrow edema (33%).



        3. Knee effusion (37%).



        4. Cruciate ligament injury (25%).



        5. Collateral ligament injury (21%).



        6. Periarticular knee fracture (15%).



      5. Sciatic nerve injury (10–23%) 9 12 :




        1. Peroneal division.



        2. Sixty to 70% recover. 13



      6. Pelvis, abdomen, chest, head, and spine injuries.



Diagnosis




  • I. History:




    1. Limited.



    2. High-energy trauma.



  • II. Physical examination:




    1. ATLS (Advanced Trauma Life Support):




      1. Prioritize (life, limb, function).



      2. Primary survey:




        1. Airway and cervical spine control.



        2. Breathing and ventilation.



        3. Circulation and hemorrhage.



        4. Disability.



        5. Exposure.



      3. Secondary survey:




        1. History.



        2. Head to toe examination.



        3. Extremity:




          • i. Posterior dislocation: Hip position 14 : Flexed, adducted, and internally rotated.



          • ii. Anterior dislocation: Hip position 15 : abducted, externally rotatated, flexed (inferior or obturator, and extended – superior or pubic), vascular examination. neurologic examination: motor and sensory to lower extremity and always before and after reduction attempts.



  • III. Imaging:




    1. Plain radiographs:




      1. Supine anteroposterior (AP) pelvis:




        1. Routine imaging in polytrauma.



        2. Symmetric femoral heads.



        3. Femoral head fragment in acetabular fossa.



        4. Femoral neck.



        5. Limb position.



        6. Pelvic ring injury:




          • i. Inlet and outlet views.



          • ii. CT scan.



        7. Acetabular fractures:




          • i. Judet’s views (iliac and obturator oblique).



          • ii. CT scan.



      2. Cross-table lateral:




        • Orthogonal imaging.



    2. CT:




      1. Frequently performed in polytrauma patients:




        1. Chest, abdomen, pelvis.



        2. Cervical, thoracic, and lumbar spine.



      2. Prereduction CT:




        1. Should not delay hip reduction.



        2. Indicated in irreducible dislocation.



      3. Postreduction evaluation:




        1. Always CT scan following closed reduction.



        2. Multicut detector, high-collimation, 1- to 2-mm cuts.



        3. Evaluation:




          • i. Concentric reduction.



          • ii. Intra-articular loose bodies.



          • iii. Femoral head fracture: size and location.



          • iv. Acetabular fractures:




            1. Posterior wall fracture.



          • v. Femoral neck.



Classifications




  • I. Pipkin 17 ( Fig. 10.1 ):




    1. Femoral head fracture with posterior hip dislocations:




      1. Type I:




        1. Fracture below the fovea.



        2. Fracture outside the weight-bearing joint area.



      2. Type II:




        1. Fracture cranial to the fovea.



        2. Fracture within the weight-bearing joint area.

          Fig. 10.1 The Pipkin classification system of femoral head fractures with posterior hip dislocations. The relationship to the fovea determines the type of fractures in types I and II (a, b). Type I fractures are caudal to the fovea. Type II fractures are cranial to the fovea and are usually in the weight-bearing zone. Type III (c) fractures are associated with a femoral neck fracture. Type IV (d) fractures are associated with additional acetabular fractures.


      3. Type III:




        1. Associated ipsilateral femoral neck fracture.



      4. Type IV:




        1. Associated ipsilateral acetabular fracture.



  • II. Orthopaedic Trauma Association (OTA):




    1. 31-C, articular fracture head 18 :




      1. 31-C1, split fracture (Pipkin types I–II):



      2. 31-C2, with depression.



      3. 31-C3, with femoral neck fracture.



Treatment




  • I. Nonoperative 15 , 19 :




    1. Emergent closed reduction.



    2. Touchdown weight bearing for 4 weeks.



    3. Knee immobilizer or hip abduction brace.



    4. Indications:




      1. Pipkin type I with articular incongruity of 1 mm or less.



      2. Pipkin type II without articular incongruity.



      3. No interposed fragment.



      4. Concentrically reduced joint.



      5. Patients that are unable to tolerate surgery.



  • II. Surgical treatment:




    1. Open reduction and internal fixation (ORIF) 19 :




      1. Indications:




        1. Pipkin type I with greater than 1 mm articular incongruity.



        2. Pipkin type II with any displacement.



        3. Pipkin types III and IV.



        4. Interposed fragment.



        5. Nonconcentrically reduced joint.



      2. Surgical approaches:




        1. Smith–Peterson approach.



        2. Trochanteric flip osteotomy.



        3. Surgical hip dislocation.



        4. Transgluteal approaches.



        5. Arthroscopic-assisted percutaneous fixation.



      3. Method of fixation:




        1. Mini or small fragment screws 20 :




          • i. Cancellous biosabsorble.



          • ii. Herbert screw fixation.



          • iii. Countersunk screws.



        2. Pelvis reconstruction plate.



      4. Pipkin type III fractures:




        1. Femoral head and neck ORIF.



        2. Hip arthroplasty:




          • i. Elderly.



          • ii. Comminution.



      5. Pipkin type IV:




        1. Femoral head and acetabulum ORIF.



        2. Restore acetabular stability.



      6. Rehabilitation:




        1. Immediate mobilization.



        2. Touchdown weight bearing with two crutches:




          • i. Six to 8 weeks: isolated femoral head fixation.



          • ii. Eight to 12 weeks: femoral neck or acetabulum.



    2. Prosthetic replacement 19 :




      1. Total hip arthroplasty:




        1. Active.



        2. Longer life expectancy.



      2. Hemiarthroplasty:




        1. Older patient.



        2. Limited mobility.



      3. Indications:




        1. Pipkin type III in the elderly.



        2. Evidence of advanced hip arthritis.



Complications




  • I. Posttraumatic arthritis (20%) 21 :




    1. Osteochondral lesion:




      1. Larger size.



      2. Weight-bearing location.



      3. Comminution.



    2. Acetabulum or femoral head bone loss.



    3. Incongruent reduction:




      1. Soft-tissue interposition.



      2. Incarcerated bone fragment.



  • II. Avascular necrosis (AVN; 12%) 22 :




    1. Hip dislocations with associated femoral head fractures:




      1. High-energy trauma disrupts vascular supply.



      2. Delay in treatment.



      3. Iatrogenic injury:




        1. Closed reduction.



        2. Surgical approaches:




          • i. Preferable anterior or trochanteric flip.



  • III. Heterotopic ossification (6–64%) 9 , 11 , 12 , 23 25 :




    1. Muscle and soft-tissue injury:




      1. Mechanism of trauma.



      2. Surgical exposure.



    2. Acetabular fracture (Pipkin type IV):



    3. Associated head injury.



  • IV. Malunion. 26



  • V. Hip instability.



Femoral Neck Fractures



Introduction




  • I. Epidemiology:




    1. Higher in patients older than 70 years. 27



    2. Common in the elderly patients.



    3. Uncommon in young patients.



    4. Osteoporosis major risk factor:




      1. Risks increases with decreasing bone mass.



      2. More common in women.



      3. Bone density in the proximal femur declines with age.



      4. Low bone mineral density:




        1. Chronic diseases:




          • i. Hypothyroidism.



          • ii. Rheumatoid arthritis.



        2. Menopause.



        3. Tobacco use.



        4. Alcohol use.



        5. Medications:




          • i. Corticosteroids.



          • ii. Seizure medications.



  • II. Anatomy:




    1. Osseous 28 , 29 :




      1. Femoral neck shaft angle is approximately 130 ± 7 degrees.



      2. Femoral neck anteversion is approximately 10 ± 7 degrees.



      3. Femoral head diameter varies between 40 and 60 mm.



    2. Vascular 6 :




      1. MFCA:




        1. Lateral epiphyseal branch.



        2. Main blood supply to the femoral head.



      2. Lateral femoral circumflex:




        1. Inferior metaphyseal branch.

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Dec 29, 2020 | Posted by in ORTHOPEDIC | Comments Off on Intracapsular Hip Fractures
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