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0A NEW APPROACH TO THE TREATMENT OF FEMUR BONE MEDIAL
FRACTURES Mamajonov K.Kh.
Mamajonov Komiljon Khasanboyevich - Associate Professor, Department of Traumatology, Orthopedics and Neurosurgery, Andijan State Medical Institute, Andijan, Republic of Uzbekistan
Abstract: the purpose of this work is to review our experience with the use of plate-screw fixation offemoral fractures via a medial approach, allowing vascular repair from the same approach. Keywords: Femoral fractures, treatment, fractures, procedure, fixation, hip fractures.
UDC 617.616
Femoral fractures with arterial injury requiring vascular repair are uncommon severe injuries, accounting for 0.3-0.4% of fractures. Most common injured vessels are the femoral and the popliteal arteries, due to staying relatively fixed at the Hunter's canal and the trifurcation, respectively. These complex injuries usually include extensive soft-tissue compromise, open fractures and involvement of blood vessels and nerves.
Management of these fractures requires multi-disciplinary approach including orthopedic, vascular and sometimes plastic surgeon. Treatment options include skeletal fixation prior or after vascular repair. High rate of infection can be predicted due to prolonged surgery and nonunion is quite common because of the associated vascular injury and comminution at the fracture site. A number of studies have examined the vascular aspects of such cases, but relatively little attention has been paid to the method of treatment of these fractures. External fixation is the most common recommended method of fixation, while some authors advocate primary internal fixation.
The femoral head and neck are replaced with a reconstruction prosthesis. These procedures typically include hip hemiarthroplasty or total hip arthroplasty (THA). Nondisplaced fractures may be managed with fixation using cannulated screw fixation. Femoral neck fractures are extremely common, demonstrating a bimodal distribution pattern. Intracapsular femoral neck fractures account for approximately 50% of all hip fractures. Intracapsular fractures demonstrate limited healing potential due to the absence of the periosteal layer, so the fracture is only immersed in the surrounding synovial fluid. These injuries occur secondary to low-energy falls in older individuals and higher-energy traumatic mechanisms in younger patients. However, most of these fractures occur in older people with underlying osteoporosis.
This activity for healthcare professionals is designed to enhance learners' competence in determining surgical indications in femoral neck fracture cases. Learners gain a deeper understanding of this condition's intricacies, from its causes and classifications to its diagnostic and treatment modalities. Participants attain proficiency in recognizing the clinical presentations of these injuries and managing them according to evidence-based guidelines, preparing them to work within an interprofessional team caring for affected individuals.
Objectives:
• Determine the surgical indications in a patient with a femoral neck fracture.
• Create a clinically guided diagnostic plan for a patient with a suspected femoral neck fracture.
Hip Joint Anatomy. The hip joint is a ball-and-socket joint formed by femoral head articulation with the pelvic acetabulum of the pelvis. This joint allows for a wide range of motion, including flexion, extension, abduction, adduction, and rotation. The femoral neck is a crucial part of the femur, connecting the femoral head to the femoral shaft. This region is prone to fractures, particularly in the elderly population due to osteoporosis. The iliofemoral, pubofemoral, and ischiofemoral ligaments stabilize the hip joint.
Intracapsular FNFs account for approximately 50% of all hip fractures. Most of these injuries occur in older individuals with underlying osteoporosis.
Distinguishing these injuries is critical. Intracapsular fractures have limited healing potential as they lack a vascular periosteal layer and depend only on the nutrient-depleted synovial fluid for their structural maintenance and metabolic needs. The hip joint capsule attaches to the intertrochanteric line anteriorly and the iliac crest posteriorly. Preserving the hip joint capsule in the context of an intracapsular FNF theoretically poses a risk of compromised blood supply to the femoral head due to elevated intraarticular pressures. A tamponade effect that compromises femoral head perfusion has been demonstrated in previous studies.
The femoral head's arterial supply arises from 3 main sources. The first is the profunda femoris artery, which branches into the medial (MFCA) and lateral circumflex femoral arteries (LFCA). The MFCA is the femoral head's predominant contributor through the lateral epiphyseal artery. The LFCA supplies portions of the anterior and inferior femoral head. Retinacular vessels branching from the circumflex arteries also feed the femoral head.
The second is the ligamentum teres, a predominant arterial contributor in pediatric patients that loses importance in adult patients. The third is comprised of minimal contributions from the medullary canal and inferior gluteal artery. Besides the tamponade effect potentially compromising femoral head blood flow, patients with FNFs risk developing avascular necrosis (AVN) due to retrograde flow and injury to the retinacular vessels.
The hip joint receives innervation from branches of the femoral, obturator, and sciatic nerves. These nerves provide sensation to the joint and motor function to the surrounding muscles.
Treatment Implications. Displaced intracapsular FNFs in older people are typically managed with hip reconstruction procedures. The femoral head and neck are replaced with a reconstruction prosthesis. These procedures typically include hip hemiarthroplasty or total hip arthroplasty (THA). Nondisplaced fractures may be managed with fixation using cannulated screw fixation.
In contrast, extracapsular fractures rarely compromise the femoral head and neck's arterial circulation. Thus, a broader array of surgical fixation techniques may be used to manage these injuries. Femoral head AVN is very rare following extracapsular fractures.
Hemiarthroplasty and Total Hip Arthroplasty. Hemiarthroplasty, or femoral head replacement, is recommended for displaced intracapsular FNFs, especially in older patients with low activity levels. THA is preferred for patients with intact ambulatory function or evidence of hip pain and degenerative arthritis. Implant design and surgical technique advances have been developed despite the higher risk of hip dislocation associated with THA for FNFs. For active elderly patients with these fractures, using a dual mobility cup during THA reduces dislocation rates and improves functional outcomes without increasing mortality or morbidity compared to hemiarthroplasty.
Consultations. For high-risk fractures that require surgical intervention, consultation with an orthopedic surgeon is necessary.
A health care provider can often diagnose a hip fracture based on symptoms and the abnormal position of the hip and leg. An X-ray usually will confirm the fracture and show where the fracture is.
If your X-ray doesn't show a fracture but you still have hip pain, your provider might order an MRI or bone scan to look for a hairline fracture.
Most hip fractures occur in one of two locations on the long bone that extends from the pelvis to your knee (femur):
• The femoral neck. This area is situated in the upper portion of your femur, just below the ball part (femoral head) of the ball-and-socket joint.
• The intertrochanteric region. This region is a little farther down from the hip joint, in the portion of the upper femur that juts outward.
Types of hip fractures. Most hip fractures occur in one of two locations — at the femoral neck or in the intertrochanteric region. The location of the fracture helps determine the best treatment options.
Treatment for hip fracture usually involves a combination of prompt surgical repair, rehabilitation, and medication to manage pain and to prevent blood clots and infection.
Surgery. The type of surgery generally depends on where and how severe the fracture is, whether the broken bones aren't properly aligned (displaced), and your age and underlying health conditions. Options include:
• Internal repair using screws. Metal screws are inserted into the bone to hold it together while the fracture heals.
• Total hip replacement. The upper femur and the socket in the pelvic bone are replaced with artificial parts (prostheses). Increasingly, studies show total hip replacement to be more cost-effective and associated with better long-term outcomes in otherwise healthy adults who live independently.
• Partial hip replacement. In some situations, the socket part of the hip doesn't need to be replaced. Partial hip replacement might be recommended for adults who have other health conditions or who no longer live independently.
Repair options. A hip fracture can be repaired with the help of metal screws, plates and rods. In some cases, artificial replacements (prostheses) of parts of the hip joint may be necessary.
Surgeons may recommend a full or partial hip replacement if the blood supply to the ball part of the hip joint was damaged during the fracture. That type of injury, which occurs most often in older people with femoral neck fractures, means the bone is less likely to heal properly.
Rehabilitation. Physical therapy will initially focus on range-of-motion and strengthening exercises. Depending on the type of surgery and whether there's help at home, going to an extended care facility might be necessary.
In extended care and at home, an occupational therapist teaches techniques for independence in daily life, such as using the toilet, bathing, dressing and cooking. An occupational therapist will determine if a walker or wheelchair might be needed to regain mobility and independence.
References
1. K. Johansen et al. Objective criteria accurately predict amputation following lower extremity trauma. Jour., Trauma, (1990).
2. R.B. Gustillo et al. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. Jour., Trauma, (1984)
