Femoral Neck fractures

Q: Give the range of neck-shaft angle of femur?

The range of neck-shaft angle of femur is 125 o to 155o. In adult average is
135o.
Q: Give the blood supply of femoral head.
Sources of blood supply: The femoral head obtain its blood supply from
three sources
1. Intramedullary vessels in the femoral neck.
2. Ascending cervical or retinacular branches of medial and lateral
circumflex arterial anatomosis, which run in the capsular retinaculum.
3. Vessels of the ligamentum teres.
Pattern/ mode of blood supply:
Extracapsular arterial ring is formed
at the base of the neck by
anastomosis of the branches of
medial
and
lateral
circumflex
femoral arteries. Ascending cervical
or retinacular branches arise from
the ring at regular intervals,
penetrate the capsule and pass
upwards along the femoral neck,
form a subsynovial arterial ring at
the margin of the head. Branches
arise from the second ring to supply
the head and adjacent neck.

Q: What are the changes of femoral head according to advancing

age?
At
1.
2.
3.

the birth: Blood supply of the head is derived from three sources.
Medial ascending cervical (inferior metaphyseal of Tracta) arteries.
Lateral ascending cervical (lateral epiphyseal of Tracta) arteries.
Vessels of the ligamentum teres only a limited area near the fovea.

Infantile (4 months to 4 years): Metaphyseal vessels decrease in size and

number and the lateral epiphyseal vessels assume the major role.
Intermediate (4 7 years): Only sources of epiphyseal supply are from
lateral epiphyseal vessels.

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Preadolescents: Ligamentum teres vessels become more prominent and

anastomose with lateral epiphyseal vessels.
Adolescent period: Lateral epiphyseal vessels provide the major source
and ligamentum teres vessels become increasingly prominent.
Q: What is angle of anteversion of femoral neck? How it is
measured or detected?
The angle of anteversion (also called angle of femoral torsion) is formed
between the transverse axis of the upper end and that of the lower end of
the femur.
Anteversion is detected
1. Radiologically from lateral view X-ray of the hip with proximal femur.
2. Peroperatively putting a guide pin touching the anterior surface of the
neck.
Q: Write short note on calcar femorale.
Calcar femorale is a dense plate of bone forming a buttress to strengthen
the concavity of the neck-shaft angle in front of the lesser trochanter. It
transmits weight from the head of the femur to the linea aspera.
Q: What are the radiological differences between intra- and extracapsular fracture of the proximal femur?
Following radiological differences are
Intracapsular fracture
1.
Location of the fracture is
medial to intertrochanteric
line.
2.
Displacement of the fracture
fragment is less.
3.

seen:
Extracapsular fracture
Through the intertrochanteric line or
lateral to it.

Displacement is more, e.g. proximal

migration and external rotation of
distal fragment is seen.
Soft tissue swelling shadow is Huge soft tissue swelling shadow is
not seen.
seen.

Q: What are the radiological features of the fracture of the

femoral neck?
1.
2.
3.
4.
5.
6.

Breech of continuity of the cortex.

Breakage of Shentons line.
Change of position of greater trochanter (proximal migration).
Shortening of the neck in comparison to the healthy side.
Disorganization of the trabecular pattern may be seen.
No change at all in case of stress fracture.

Q: Why lateral epiphyseal vessels are most vulnerable to damage

in fracture neck femur?
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Lateral epiphyseal vessels run in the postero-superior part of the capsule

which is most vulnerable to be compressed by displaced fracture
fragments or comminuted fragments as displacement usually occur in this
direction.

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Q: What is meant by recent fracture of neck of femur?

Age of fracture up to 48 hours is known as recent femoral neck fracture.
Q: What are the treatment modalities for femoral neck fracture?
Treatment modalities vary according to age of the patient, duration of
fracture, type of fracture and quality of bone. The options are:
1. Internal fixation either after closed or open reduction.
2. Replacement hemiarthroplasty of femoral component cemented or
cementless.
3. Excision arthroplasty Girdle stone operation.
4. McMurrays osteotomy
5. Abduction osteotomy
Q: Which fracture should be fixed first in case of ipsilateral
femoral neck and shaft fracture?
Fracture of the shaft of the femur should be fixed first; otherwise reduction
of the neck will be difficult.
Q: What is Gurgolans sign/ Nathans sign?
Decreased volume of femoral pulse due to compression of femoral artery
from below by the capsular swelling resulting from femoral neck fracture.
Q: What are the differential diagnoses of a pathological fracture
of neck femur in a 20 years old person?
1.
2.
3.
4.

Bone cyst simple or aneurismal

Fibrous dysplasia
Chondroblastoma
Giant cell tumor

Q: Which vessel is important in healing of fracture neck of femur?

Lateral epiphyseal vessels.
Q: What is the prognosis of basal neck fracture?
Prognosis is good as it is an extra-capsular
fracture and blood supply remains intact.
Q: What is Wards triangle? What is its
importance?
The triangular area of the femoral neck that
is bounded by the primary compressive and
tensile trabeculae and the secondary
compressive trabeculae is called Wards
triangle.
This
triangle
has
minimal
trabecular bone and provides extremely
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poor purchase for internal fixation devises. So, the tip of the fixation
devise should not lie in this area and must cross this triangle.
Q: What is the significance of fracture neck of femur in young
people?
Femoral neck fracture in young people is either (a) Result of high energy
trauma or, (b) Pathological fractures e.g. fibrous dysplasia or tumours.
Q: Give classification of fracture neck of femur in children.
Delberts classification of femoral neck fracture in children:
Type I Transepiphyseal separations, with or without dislocation of
femoral head from the acetabulum.
Type II Transcervical fractures, displaced or nondisplaced.
Type III - Cervicotrochanteric fractures, displaced or nondisplaced.
Type IV - Intertrochanteric fractures.
Q: What is Pauwels angle and Parlingtons angle?
The angle of the fracture line of the neck of the femur that forms with
respect to horizontal line is known as Pauwels angle and the angle formed
with respect to vertical line is Parlingtons angle. Various degrees of these
angles indicate the amount of displacement of fracture fragments and
thus the progress.
Q: What are the differences between transcervical and basal neck
fractures?
1.
2.
3.
4.
5.

Transcervical fractures
Fracture line passes through the
middle of the neck.
Intracapsular.
Reduction
and
fixation
comparatively difficult.
Fixation
device
used

cancellous screws.
Prognosis usually poor as it is
intracapsular.

Basal neck fractures

At the junction of the neck and
shaft.
Extracapsular posteriorly.
Comparatively easier.
Fixation device used DHS can be
used.
Prognosis
good
as
it
is
extracapsular.

Q: What are the various procedures of reduction of fracture

femoral neck?
(A) Closed reduction 1. Hip in extension:
(a) Whitmans method (b) Classic (c) Deyerle (d) Mc Elevnny
2. Hip in flexion:
(a) Leadbetter (b) Flynn (c) Smith Peterson
(B) Open reduction
[Whitmans method:
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The fractured extremity is tied to the footplate of fracture table in an

externally rotated position. With the extremity externally rotated, it is
abducted approximately 20 degrees, and enough traction is applied to
regain slightly more than normal length. The extremity is internally
rotated until the patella is internally rotated 20 to 30 degrees.
Leadbetter technique: (Satisfactory when the Whitman technique is
unsuccessful).
The affected limb is flexed at the hip to 90 degrees, and the thigh is
slightly internally rotated; traction is applied in line with the femur. The
limb is circumducted into abduction, maintaining the internal rotation, and
is brought down to table level in extension]
Q: What is heel-palm test?
It is a clinical test to assess the accuracy of reduction of fracture neck
femur. The heel of the affected limb should remain in neutral in the palm
of the surgeons outstretched hand and not lie externally rotated after
reduction.
Q: How fracture neck femur differ from that of adult and children?
It is a clinical test to assess the accuracy of reduction of fracture neck
femur. The
Fracture NOF in children
Fracture NOF in adult
1. Bone quality is stronger
Weak bone
2. Blood supply is different and easily Blood supply less damaged.
damaged. AVN of femoral head is more
common.
3. Transepiphyseal fracture can occur.
Cannot occur.
4. Premature physeal closure may cause Shortening of the limb is
shortening of the affected limb.
not seen.
5. Child can tolerate immobilization much Adult
tolerate
more readily than an adult. So, more immobilization badly. So,
choice of treatment is available; e.g. operative treatment is the
traction, spica cast, bed rest are treatment of choice.
additional to operation.
6. Internal fixation should be done by Threaded pins (screws) are
smooth pins if physis is to be crossed.
used in adults.
Q: What are the factors that determine the prognosis of fixation
of femoral neck fracture?
The factors that influence the prognosis are:
1. Age of the patient
2. Age (duration) of fracture
3. Type of fracture
4. Time and type of fixation
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5. Bone quality
6. Socioeconomic condition of the patient
7. General physical condition of the patient

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Q: What are the preconditions of getting union in fracture neck of

the femur?
1. Anatomical reduction
2. Secured fixation as early as possible
3. Good postoperative management
Q: What are the criteria of ideal reduction of femoral neck
fracture?
Acceptable reduction is determined by Garden index in radiography. In A/P
view normal alignment index is 155 o to 180o between proximal and distal
fragments postreduction. In lateral view it is 160 o to 180o. If the angle is
less than 155o or more than 180o in either of the views, then the reduction
is not acceptable.
Q: Give the algorithm of management of femoral neck fracture?
Gustilo Vol-2, page 800, Fig- 23-16

Q: What are steps of close reduction of fracture neck of the

femur?
Steps of reduction vary according to the type of maneuver. The most
popular is the Leadbetter maneuver. The steps in this technique is
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 Traction in leg with hip flexed at 90o and femoral shaft in slight
abduction in the long axis of femur to cause disimpaction.
The leg is then brought into abduction, internal rotation and extension.
Q: When full weight bearing is allowed after internal fixation of
femoral neck fracture?
Full weight bearing is allowed after radiological evidence of union.
Q: What are the advantages of cannulated hip screws?
1. Screws can be inserted over a guide pin which is introduced previously
in correct position, checked by radiography.
2. Decompression of the intracapsular tamponade can occur through the
cannulated screws, thus helps in healing by improving circulation.
Q: What are the complications of femoral neck fracture?
Complications are
1. Nonunion
2. Malunion e.g. varus or valgus
3. Avascular necrosis of femoral head
4. Infection
5. Thromboembolism
Q: Why AVN is so high in type-III and IV femoral neck fractures?
Due to displacement of fracture fragments there is more damage to
retinacular vessels and second trauma also during reduction and
internal fixation.
Anatomical reduction is not possible most of the times in these types of
fractures.
Q: How many times close reduction can be tried in femoral neck
fracture?
Attempts of close reduction should not be tried more than twice. If such
attempts are tried more than twice, there will be more damage to
vascularity and AVN or nonunion will develop later on.
Q: What is Girdle-Stone operation? What is its another name?
Excision of the femoral head is known as Girdle-Stone operation. It is also
known as excision hemiarthroplasty.
Q: Why pain is relieved following Girdle-Stone operation?
Pain producing nerve endings are destroyed by cutting the capsule.
No friction between the fracture fragments.
Q: What are the disadvantages of Girdle-Stone operation?
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 Shortening of the affected limb.

Unstable joint.
Q: What is the principle of McMurrays osteotomy?
Shearing force is converted into compressive force.
Osteotomy increases circulation of fracture site.
Q: What are the implants that can be used to fix femoral neck
fracture?
1. Screws Cannulated, non-cannulated, ASIS, Knowles pin, Moore pin
etc.
2. Fixed angle nail
3. Sliding or telescoping nails (Dynamic hip screws)
Q: What are the muscles that can be taken as muscle pedicle
bone graft in nonunion of fracture neck of the femur?
1. Gluteus medius
3. Tensor fascia lata
5. Vastus lateralis

2. Gluteus minimus
4. Quadratus femoris
6. Sartorius

Q: Write short note on Knowles pin?

Knowles pins are used to fix femoral neck fracture in children. This screw
has a pointed beveled tip which is self cutting, threaded part with
minimum pitch distance and thread length 16mm and 32mm, shank or
shaft, quadrangular or hexagonal head and a stack for attachment with
drill. After insertion the stack is broken out. Various lengths are available
according to the need.

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