- Anatomy of the hip
- Causes and mechanism of injury
- Classification of fractures
- Clinical picture
- Treatment tactic
Fracture of the femoral neck is a severe trauma that often develops in the elderly. Age-related changes in bone tissue are associated with osteoporosis, which leads to a decrease in bone strength and a high risk of fracture development. Anatomical features of the femoral neck and its blood supply in elderly patients cause poor healing of the defect without surgical intervention. Surgical treatment of the disease of hip fracture in old age not only allows to restore normal motor activity, but also to save the patient's life.
Anatomy of the hip joint
The hip joint is the largest joint in the human body that performs a supporting function and participates in the movement process. It consists of an acetabulum formed by the bones of the pelvis, and the head of the femur. The hip joint is spherical, limited by the joint bag and strengthened with powerful ligaments and muscles. At the front of the articulation are the muscles of the anterior hip group, and behind - the gluteus muscles.
The head of the thigh is covered with a thick layer of hyaline cartilage, normally its thickness is about 4 mm. The acetabulum is lined with a cartilaginous tissue. When moving in articulation, cartilage prevents friction of bones relative to each other, which causes depreciation and prevents premature destruction of the joint. To strengthen the strength of the joint between the head of the femur and the bottom of the acetabulum, there is a circular ligament.
The head is connected to the body of the femur by means of the neck. This place is a vulnerable site for damage in old age. In young people, the blood supply of the femoral head takes place through vessels that are in the thickness of the bone, penetrate into the joint through its capsule and are located in a circular ligament. From the age of 30 these arteries are gradually obliterated and almost completely closed in the elderly after reaching 60 years of age.
Schematic diagram of fracture in the femoral neck
Insufficient blood supply to the femoral head leads to non-fracture in elderly patients with conservative treatment. Injury of the femoral neck refers to intra-articular fractures, which increases the risk of poor consolidation of damaged bones. Displacement of bone fragments is an indication for surgical intervention at a young age, and trauma in the elderly of any complexity requires an operation. Conservative treatment is prescribed in the detection of absolute contraindications to surgical intervention for health reasons. The operation is not performed with paralysis of the lower extremities, when recovery of the patient's motor activity is not advisable.
Causes and mechanism of injury
Fracture occurs when the bone is exposed to a traumatic force that exceeds the safety margin of bone tissue. The femur is large in size and has high strength. At a young age, lesions in the region of the femoral neck are quite rare and occur as a result of the intensive impact of the traumatic factor - a fall from a high altitude, traffic accidents.
In elderly people, due to the age-related decrease in bone strength, gait unsteadiness due to cerebral circulation disorders and visual acuity reduction, often falls from the height of their own growth. Deformation of bones with the phenomena of osteoporosis occurs when a weak force strikes, especially in the region of the neck of the thigh. After the fracture, the integrity of the arteries feeding the head of the thigh bone is broken, many of which are no longer functioning at the time of injury.
From left to right: subcapital, transcervical, basaltservikalny fracture
After the reposition of bone fragments and immobilization of the leg with a plaster bandage, the fusion of the defect becomes impossible due to a violation of blood supply to the bone tissue. Long-term bed rest leads to fatal consequences for the elderly person. Heart failure develops, stagnant pneumonia appears, and pressure sores are formed.
These complications significantly worsen the general condition, are resistant to medical treatment and cause a fatal outcome within a year after the injury. In addition, the bloodless head of the femur undergoes aseptic necrosis, is completely destroyed, which causes irreversible disturbances in the anatomical structure and functioning of the hip joint. The pathological process permanently rivet the patient to bed, worsens the quality of life and leaves no hope of recovery.
Classification of fractures
Fracture of the femoral neck in the elderly, regardless of the severity of the injury, is considered a serious problem. However, some types of lesions are easier to treat, others are characterized by a long recovery period and often cause the development of complications.
Like other fractures, damage to the neck of the femur can be open and closed. In elderly people, closed injuries are much more common. In this case, bone fragments do not form a wound of the skin and do not communicate with the external environment. Fractures may be accompanied by displacement of bone fragments or trauma does not cause the bone fragments to deviate from the normal axis. The most severe course is damaged, when bone fragments are displaced relative to their physiological axis.
Injuries to the displacement of bone fragments have a more severe course
To determine the tactics of treatment and the forecast of trauma, the location of the fracture line is of great importance. Depending on the localization of the defect of the femoral neck, fractures are identified:
- basaltservikalnye - a defect of bone tissue is located at the base of the neck of the femur, the most distant from the head;
- transcervical - the defect of the bone tissue is located directly in the neck of the thigh;
- subcapital - the defect of the bone tissue is located at the base of the head of the thigh.
The most severe injuries that often cause aseptic necrosis of the head and non-fracture are subcapital hip defects.
In addition to localizing the fracture line, its angle of inclination is of no small importance. According to these characteristics, fractures are distinguished:
- of the first degree - the angle of inclination does not exceed 30 degrees;
- second degree - the angle of inclination is within 30-50 degrees;
- third degree - the angle of inclination is more than 50 degrees.
The more horizontally the line of the defect of the bone is located, the greater the chances of fusion fracture. At the third degree, the infection of the area of bone tissue damage is the least likely.
Thus, the prognosis for recovery after a fracture of the femoral neck worsens with the age of the patient, with the vertical location of the bone defect line in the region of the femoral head.
Clinical picture of
Fracture of the femoral neck in elderly people can occur when falling from a height of their own growth or hitting a hip against a hard surface. To form a bone defect, a minor traumatic force is sufficient. During an injury, an elderly person may experience pain of varying degrees of intensity. Sometimes the pain syndrome is rather weak and does not cause a worsening of the general condition. The pain is worse when trying to move a damaged leg. At rest, patients do not feel discomfort in the area of trauma.
Foot rotation outside with femoral neck fracture
Clinical manifestations of fracture in the femoral neck:
- pain during movement in the injured hip joint;
- inability to lean on the foot on the side of the damage;
- shortening of the leg as a result of displacement of bone fragments;
- external rotation( turning the foot out) in the supine position;
- inability to lift the heel of a sore leg( a symptom of a stitched heel);
- crunching in the fracture site when feeling the hip joint or trying to move with the foot.
In the elderly, there is rarely edema in the fracture site and subcutaneous hematoma does not form.
After the onset of a thigh injury, the injured person should be taken to a traumatology unit to diagnose damage and perform therapy. To do this, urgently need to call the ambulance. Physicians will carry out anesthesia, immobilize the injured limb with a pneumatic tire or Dieterichs bus. Transport immobilization prevents injuries with bone fragments of soft tissues on the way to a medical institution.
On the roentgenogram determine the nature of the injury and the location of bone fragments
In the emergency room, the doctor examines the site of the fracture, assesses the severity of the injury, clinical manifestations and the general condition of the patient. To confirm the diagnosis, an X-ray examination of the hip joint is performed, which reveals the character of the fracture, the displacement of the bone fragments, and the location of the defect line of the bone tissue. In severe diagnostic cases, magnetic resonance imaging( abbreviated MRI) is prescribed, which allows to detect bone defect and disruption of the integrity of soft tissues( muscles, ligaments, nerves, vessels).
Treatment of a fracture in the neck of the femur in old age is performed surgically. If any contraindications to the operation are identified, conservative therapy is prescribed. Surgical intervention is impossible with severe cardiovascular, renal, hepatic insufficiency, complicated course of diabetes mellitus, a recently transferred myocardial infarction. The operation is not indicated for paralysis of the lower extremities that occurred before the injury due to a stroke.
Conservative methods of treatment are ineffective in old age and are prescribed if surgery is not possible. On the damaged hip joint, a plaster bandage is applied after repositioning the bone fragments. The goal of repositioning is not so much the restoration of the former anatomical position of the neck of the hip, but rather the fracture of the bone to the optimal position for the formation of bone callus. In this case, fracture lines attach a horizontal position, which improves the fusion of bones. In severe cases, skeletal traction is used.
Conservative methods of therapy are associated with prolonged bed rest, which negatively affects the health of elderly patients. Immobilization for a long time( 3-6 months) causes the development of complications:
- disruption of the cardiovascular system;
- formation of thrombi in deep veins and thromboembolism of the pulmonary artery system;
- formation of pressure sores;
- congestion in the lungs( congestive pneumonia);
- atrophy of the muscles of the lower limb;
- ankylosis( immobility) of the hip, knee joint.
Hip joint prosthesis improves the prognosis of injury in the femoral neck region
In modern traumatology, the "gold standard" of hip fracture therapy in elderly patients is hip arthroplasty. After surgical intervention, the terms of the recovery period are significantly reduced, motor activity and self-service capability remain.
In elderly age, a single-pole prosthesis is more common, which consists in replacing the prosthesis with the head and neck of the thigh. In this case, the acetabulum is not subjected to surgical intervention. The disadvantage of this operation is the friction of the implant about the cartilaginous interlayer of the acetabulum and the rapid abrasion of the hyaline cartilage. From the positive side, we can note a small trauma and duration of surgical intervention, which is important in the elderly. Strength and life of a single-pole prosthesis usually corresponds to the motor activity and lifestyle of elderly patients.
In connection with the development of age-related osteoporosis, the endoprosthesis is fixed with the help of polymer cement. This makes it possible to better fix the implant and prevents the prosthesis from penetrating the bone tissue of the femur. In normal condition, the bones are placed with an implant with a porous coating, which eventually grows out with bone tissue and is thus fixed in the thigh. This technique is called cementless and does not require additional fixation of the prosthesis by polymers.
Tissue healing after surgery and recovery of motor activity takes 1-2 months. To increase the effectiveness of therapy after surgery, physiotherapy, massage and exercise gymnastics are prescribed. The rehabilitation period helps to return to the usual motor activity in the shortest possible time.
Fracture of the femoral neck in the elderly refers to a serious trauma, which in most clinical cases requires surgical treatment - hip joint prosthetics. The performed operation prevents the non-elimination of bone defect and other severe complications, helps to return to motor activity, avoid disability and early mortality.