[MUSIC] Proximal femur fractures can cover femoral head fractures, femoral neck fractures, pertrochanteric and subtrochanteric fractures. It is important to consider anatomical basic principles once again. The proximal femur has a callum-caput-diaphyseal angle (CCD) of between 120 and 140°. The femoral neck axis is furthermore rotated to anterior by about 12°, which is designated here as antetorsion. Femoral head fractures. What problems do proximal femoral fractures bring? The main problem is supplying blood to the femur. On the one hand, this enters the femoral head via the capitis femoris artery; while on the other hand, the supply takes place via the two circumflex arteries from anterior and posterior. The capitis femoris artery is obliterated from a certain age onwards. This means that the supply of blood then always streams in solely via the two circumflex arteries. If a fracture is incurred proximal to the in-flowing of these two arteries, then the blood supply to the femoral head is stopped and the threat is present of femoral head necrosis occurring. The number of fractures in the vicinity of the hips is rising at a substantial rate within the Federal Republic of Germany. This is linked to the constant rise in the average life expectancy of the aging population. The key treatment objectives of proximal femoral fractures are to achieve a restoration to the original condition. This means that survival of the patient is to be assured in the first instance, but at the same time their life quality is to be maintained with as little pain as possible and with optimum joint functioning. If the patient’s history of falls and typical relieving posture in external rotation and contraction of the thigh indicates a proximal femoral fracture, then an overview image should be undertaken by means of an anterior-posterior x-ray of the pelvis. Axial images make a lot of sense in clinical terms, but are usually not possible due to the pain endured. Should it not be possible to produce axial images, a cross-table image should be taken. If anything at all is not clear, then the indication should be made for an extensive tomographic imaging examination. Femoral head fractures are distinguished according to the Pipkin classification system. According to this, the fracture line in a Type 1 fracture is below the fovea. In Type 2 fractures, a large fragment of the head is located above the fovea. Type 3 fractures consist of Type 1 or 2 additional to a femoral neck fracture, while Type 4 ones are likewise Type 1 or 2 fractures with dislocation and acetabulum fracture occurring at the same time. Femoral head fractures are usually the result of high speed trauma. The frequently occur after dislocations to the hip joints. Given the role played in supplying blood to the femoral head, a Pipkin fracture is an indication for emergency treatment. Apart from small, non-dislocated Type 1 fractures, treatment must be administered surgically. Under this, Type 1 and Type 2 fractures can be treated by means of cannulated screws, with care being taken to place the heads of the screws below the level of the cartilage. Type 3 fractures either require osteosynthesis by means of dynamic hip screws or a hip replacement. In the case of Type 4 fractures, the femoral head has to be reconstructed whilst simultaneously treating the acetabulum. These x-ray images show a clinical example of a Type 1 fracture with a large fragment and condition following osteosynthesis by means of cannulated screws via an anterior access. The meticulously reconstructed articular surface can be clearly recognised. [NO AUDIO] [NO AUDIO][NOISE] >> Excuse me. The paramedics have just delivered an elderly lady. She fell over in her home. >> Things do not look too good. Her leg is contracted and externally rotated. >> Okay. Where is she, in which bay? >> In the 2nd. >> Okay. >> This is Ms. Müller. She fell over onto her right side at home today. >> Hello! Welcome. >> Hello, doctor. >> What happened? >> Well, I tripped on my own carpet and have hurt myself terribly. >> When did all this happen? >> This morning. >> It's already the afternoon now. >> Yes. >> Do you live alone, or...? >> I live in sheltered housing and nobody visits me that often except my carer who was the one who found me and brought me here. >> Did you fall on your head at all? >> I cannot remember at all if I did or not. Everything happened so quickly when I tripped over, but at the moment I feel as if everything hurts. I am also a bit het up at the moment. >> Hm. Are you taking any medication of any kind? >> Yes, I have to take Marcumar. That is something to do with “backyard fibrillation” or such like, isn’t it? >> Atrial fibrillation, yes, that’s right. >> Oh, that's right - atrial fibrillation. Oh dear, I’m getting things mixed up. >> Have you been taking it for a long time, the Marcumar? >> Yes, for about two years. >> OK, then we need to take a look now. You said your hip hurts? >> Yes, my hip, that’s right. >> I have already fitted a splint. >> Yes, that's enough for now. Well, it looks as if it is shortened and externally rotated. Can you still move your toes? >> Yes, that's OK. Can you feel everything OK? >> Yes. >> Can you still lift your leg up? >> That hurts. Good. I’ll now check on the pulses. >> Mhm. >> Okay. Can I now just take a look if I can see anything, such as a bruise? Yes, good, nothing is open. Okay. How about your head? >> No, I cannot remember being unconscious at all; I have..., I cannot..., no, I don’t recall any more. >> Look at me, please. Is everything OK in terms of your vision? >> Yes. >> Ok? >> Yes. >> One finger, OK? Everything fine? >> Yes. >> Does that hurt, up here? >> It's OK. >> Can you turn your neck? Is that OK? >> Yes. Yes. I can move that OK. >> Good. Let's have a look at your clavicle. Shoulder What about the ribs? >> Yes. >> Does that also...? >> Yes, it does hurt a bit. >> And what about the abdomen? >> Oh, yes. >> Good. OK. We will certainly need to take a CT due to the danger of cerebral haemorrhaging with Marcumar, an ultrasound of the abdomen and also an x-ray of the hip. >> Is all that really necessary? >> Yes, I am afraid so. We'll do the ultrasound here right away and then the x-ray examination straight afterwards. That’s right. Can I just have another look at your abdomen? There, is that OK? >> Yes, that’s OK. >> Here? >> Ow. Yes, it does hurt a little. >> Then we’ll have a quick look at what is happening. This can be a bit cold. Don’t be frightened. Now let's go a bit higher here. Like this. Hmm. - Nothing to be found here. OK and we need to cover the spleen as well. Just a moment. No, nothing there either. Well, we've been lucky once again. At least there is no severe abdominal haemorrhaging occurring. Oh. That’s good. >> It certainly is. OK, we’re now going to take a CT of the head and an x-ray image here of the hip. >> Oh, doctor, we’ve done a lot, haven’t we? >> Yes and I’ll be back in half an hour. >> Thank you, thank you. Oh dear. [NO AUDIO] Femoral neck fractures. Femoral neck fractures essentially affect three groups of people: on the one hand, young, healthy patients following high speed trauma, then what are termed Golden Agers with high functional demands aged between 65 and 75 and elderly patients with considerable accompanying illnesses aged over 75. Femoral neck fractures are defined as fracture lines between the femoral head and the trochanter major. These fractures are classified either according to Pauwels or Garden. Falling onto the hip usually comes into consideration as the cause of the accident. Femoral neck fractures are further sub-divided into medial and lateral. The further to medial, the higher is the risk of necrosis of the femoral head. Medial femoral neck fractures can either result in valgus or varus deformities. A contracted leg in a position of external rotation is typical for such fractures. This slide shows in diagrammatic form the classification according to Pauwels. Within this, a horizontal line is placed parallel to both ischial tuberosities. A line is then drawn through the fracture and the angle between both these straight lines is then measured. [NO_AUDIO] At 30°, a Pauwels I fracture is present, between 30 and 50°, a Pauwels II and everything exceeding 50° is a Pauwels III. Please note that these angular degrees can fluctuate between 50 and 70°, depending on the literature. [NO_AUDIO] This slide shows the classification according to Garden. The Garden classification also takes axial dislocation into account. Type I is fully impacted, Type II is completely fractured, but not dislocated, Type III is completely fractured and partially dislocated and Type IV is completely, fully dislocated. [NO_AUDIO] [NO_AUDIO] [NO_AUDIO] [NOISE] >> Hello, here I am again. >> Hello, doctor. Hello. >> Unfortunately, though, I have some bad news. >> Really? Mhm. >> Yes, the femoral neck is broken. >> Oh dear. >> The upper femoral neck. >> [NOISE] >> Yes, as was to be expected, I’m afraid, seeing you cannot move it any more. >> Yes, hmm. >> Fortunately, however, there is no bleeding in the head. >> Mhm. >> The CT images show everything as being very good. >> Mhm. >> The results from the abdominal ultrasound examination are also basically very good. >> Mhm. >> That's >> Mhm. >> good to hear. >> That’s good news. >> Mhm. Yes, what is not so good, though, I have to tell you, >> Mhm. >> is that the femoral neck is broken and an operation always had to be carried out in such cases. >> Mhm. >> Otherwise, it would mean you would not be able to walk again. >> In that case, an operation has to take place. Mhm. [NO_AUDIO] >> In treating femoral neck fractures, the first critical question to be considered is whether treatment to retain the head makes sense. The answer to this question is derived on the one hand from the biological age of the patient, the potential perioperative risk, individual functional demands and the degree of mobility prior to the accident. Treatment of Pauwels I fractures can be conducted non-operatively, with the patient being informed about a potential prophylactic screw fixation. Pauwels II and III fractures must always be treated surgically due to the instability involved. If the patient is younger than 65, this treatment can be undertaken by means of plate and screw osteosynthesis. If the patient is older than 65, the joint should be replaced by means of primary fracture prosthesis. The head-retaining operation can either be undertaken by means of three cannulated compression screws or a dynamic hip screw. Endoprosthetic treatment can provide either for total joint replacement, that is to say socket and shaft, or just for bipolar femoral head prosthesis. [NO_AUDIO] These slides show examples of lateral and anterolateral access for the surgical treatment of a femoral neck fracture. The dashed line on the right slide marks the incision if opening of the capsule is required. This slide shows how locking of the femoral neck can be undone. In this process, a bone hook is inserted into the distal fragment and the head is manipulated by means of two Kirschner wires. [NO_AUDIO] >> Mhm. >> And for someone of your age, that is always done by using an artificial joint, a prosthesis. >> What? A prosthesis? >> Yes. we have to insert one >> Aha. >> as the screws will no longer keep in place in the bone and the probability then arises of the bone dying, what is called necrosis of the head >> Oh dear! >> of the hip. >> Mm. >> That is why such fractures are always treated with prosthesis. >> Mhm. [NO_AUDIO] >> These illustrations show typical implants for treating femoral neck fractures. A dynamic hip screw can be recognised on the left side. The term “dynamism” is derived from the ability of the femoral neck screw to move within the location of the plate. Three cannulated screws can be recognised on the right side. [NO_AUDIO] These x-ray images show examples of how a femoral neck fracture can be treated by means of three cannulated screws. [NO_AUDIO] Another clinical example shows a femoral neck fracture on the left side and on the right side a condition following treatment by means of dynamic hip screw. [NO_AUDIO] This clinical example shows a femoral neck fracture in an elderly male patient. The important thing to note is that the bipolar femoral head prosthesis shown can only be used if the acetabulum is intact. If pre-existing symptoms of coxarthrosis are present, the socket must also be replaced, as is shown in this example. As the patient has obviously been ill beforehand, the shaft has been cemented. [NO_AUDIO] This algorithm shows the therapeutic procedure to be followed following a femoral neck fracture. If the fracture is dislocated, then the next question has to be: How old is the patient? If the patient is young and has a high level of muscular activity, then osteosynthesis should be undertaken instead. [NOISE] If the patient is older and has previously been ill, then hip replacement should be preferred. [NO_AUDIO] Please now allow me to summarise how femoral neck fractures are treated: young patients should be treated with osteosynthesis within six hours. Older patients with high functional requirements achieve optimum results after total joint replacement, whilst restoration to the original condition can be achieved in even older patients following bipolar hemiprosthesis. [NO_AUDIO] Pertrochanteric femoral fractures. [KEIN_AUDIO] [GERÄUSCH} Pertrochanteric femoral fractures usually affect older patients whose bones have previously been suffering from osteoporosis. A direct fall onto the hip frequently forms the basis for the accident mechanism. The leg is contracted and externally rotated. [NO_AUDIO] The AO classification system has asserted itself when it comes to pertrochanteric fractures. A1 is used to designate a closed fracture, A2 a multifragment fracture, with the fracture line being at 90° to the strength transmission line, while an A3 fracture reveals a fracture line parallel to the strength transmission line. This is of great importance in terms of assessing the degree of stability. [NO_AUDIO] These criteria of stability are then conclusive in determining the form of treatment. A1 fractures can be treated by means of dynamic hip screws. A2 and A3 fractures should be surgically stabilised by means of a cephalomedullary system, such as a proximal femoral nail or a gamma nail. [NO_AUDIO] >> And when will the operation take place? >> We’ll need to check, due to the thinning of the blood. >> I see. >> You will probably need to stay here so that we can monitor >> I see. >> your head and abdomen >> I see. >> so as to ensure no blood is entering these >> I see. >> and we also need to increase the clotting screen level. When we have done all this, we can proceed and this will probably be this afternoon. >> This afternoon? That soon? OK. Well, if it has to be, it has to be. >> I can show you the prosthesis we will be using once again. >> Oh, yes please. Definitely. I thought you might like to and so I brought one with me, so that we can see what will be being inserted. This is what it looks like; it has two parts, one which fits into the pelvis, >> Mhm. >> the socket, and another, the replacement head, >> Mhm. >> which is anchored >> Mhm. >> in the femoral shaft, >> Mhm. >> that is to say in the thigh bone, >> Mhm. >> and this will mean that you can basically walk >> Mhm. >> again relatively well. >> What, that heavy part has to be inserted into me? >> Yes. >> Yes. >> it has been tried and tested very many times. >> [LOUD] >> An artificial hip joint. >> And what is it made of? >> This is titanium. >> This is titanium and this... It will be well accepted and grows in well. >> And how long will that last for? [LAUGH] >> Forever. >> [LAUGH] >> [LAUGH] >> Oh well, there’s nothing else for it. It will need to be done then? >> Then we’ll arrange for it to be done this afternoon. >> Thank you, doctor. [TALKING] >> Everything clear? Or have you still got any questions? >> No, I think everything has been covered. >> Then that’s it for the moment, OK. >> Yes, everything is clear now. >> OK, then >> Thank you, doctor. [TALKING] >> then we’ll meet up again later. Goodbye. >> See you later. See you later. Mm. Mm. [NO_AUDIO] These x-ray images show examples of how a 31A1 fracture is treated by means of dynamic hip screws and anti-rotation screws. [NO_AUDIO] This clinical example shows a 31A2 fracture. As this fracture is of a multifragment nature, it has a tendency towards being unstable and therefore requires treatment by means of a cephalomedullary system. [NO_AUDIO] Subtrochanteric fractures. [NO_AUDIO] Subtrochanteric fractures are not defined in any uniform manner in the international literature. It should be noted that reference is made to a subtrochanteric fracture in the case of a fracture line 5 cm beneath the trochanter minor. Younger people are usually affected following high speed trauma. If elderly patients suffer this fracture, the bone has been affected by osteoporotic illness beforehand. Varus deformity of the thigh bone is typical in such cases. Subtrochanteric fractures are either classified according to the AO, Russell-Taylor, Seinsheimer or other systems. [ON_AUDIO] Treatment of subtrochanteric fractures usually has to be undertaken surgically, as these fractures are very unstable due to the muscular traction exerted by various muscles on the points of the epiphysis of the bone. A complicated repositioning manoeuvre is frequently required and cephalomedullary systems, such as PFN or gamma nails, should be implanted. [NO_AUDIO] This clinical example shows a subtrochanteric fracture of a young patient following high speed trauma which has been treated by means of closed reposition and long PFN. [NO_AUDIO] Allow me to summarise: Proximal femoral fractures are one of the most frequently encountered forms of injury in trauma surgery. Treatment must be undertaken in accordance with anatomical localisation and the individual circumstances of the patient. [NO_AUDIO] [MUSIC] [MUSIC]
