Pathophysiology

Skeletal Anatomy

The hip is the largest weight-bearing joint in the body. It’s also a common
place for a fracture after a fall—especially in older people. Hip fractures are
even more likely in people with osteoporosis (a disease that leads to
weakened bones).

The hip is a ball-and-socket joint

where the femur (thighbone) joins
the pelvis. When the hip is healthy,
you can walk, turn, and move
without pain. The head or “ball” of
the femur (thighbone) fits into a
socket in the pelvis. The ball and
socket are each covered with
smooth cartilage. This allows the
ball to glide easily in the socket.
Blood vessels supply oxygen and
nutrients to keep the hip joint
healthy.

The hip can fracture in many

places. Most often, the
fracture occurs in the upper
part of the femur. You can
also have more than one
type of fracture at a time.

• A transcervical fracture is a
break across the neck of the
femur. This type of fracture
can interrupt blood flow to
the joint.
• An intertrochanteric fracture
is a break down through the
top of the femur.
• A subtrochanteric fracture is
a break across the shaft of the femur.
Vascular Supply

The vascular supply to the proximal femur is tenuous and provided largely
by two sources.

Branches of the medial and lateral circumflex femoral arteries, usually

branches of the deep femoral artery, ascend on the posterior aspect of the
femoral neck in the retinacula (reflections of the capsule along the neck of the
femur toward the head). The branches of the medial and lateral circumflex
arteries perforate the bone just distal to the head of the femur where they
anastomose with branches from the foveal artery and with medullary branches
located within the shaft of the femur.

The ligament of the head of the femur usually contains the artery of the
ligament of the head of the femur (foveal artery), a branch of the obturator
artery. The foveal artery enters the head of the femur only when the center of
the ossification has extended to the pit (fovea) for the ligament of the head,
around age 11-13 years. This anastomosis persists even in advanced age but
is never established in 20% of the population.

Femoral neck fractures often disrupt the blood supply to the head of the
femur. The medial circumflex artery supplies most of the blood to the head and
neck of the femur and is often torn in femoral neck fractures. In some cases,
the blood supplied by the foveal artery may be the only blood received by the
proximal fragment of the femoral head. If the blood vessels are ruptured, the
fragment of bone may receive no blood and undergo avascular necrosis (AVN).
• Classification of Fractures

Two broad groups of fractures are recognized in the neck of femur

(1) Intracapsular fractures (2) Extracapsular fractures.

Intracapsular Fractures
This is divided according to the level of the fracture line in the neck as follows.

1) Subcapital
2) Transcervical
3) Basal

Extracapsular Fractures
There are all grouped as Trochanteric fractures of various types.

INTRACAPSULAR FRACTURE NECK OF FEMUR

This is also called a high fracture neck of femur. In this group, the proximal
fragment often loses part of its blood supply and hence, the union of this
fracture is difficult. This is a serious injury in the elderly patient. In the very old
and debilitated person, it can precipitate a crisis in the precarious metabolic
balance. It can become a terminal illness due to uremia, lung infection, bed
sores etc, and be fatal.

Classification (Garden).
This classification relies only upon the appearance of the hip on the AP
radiograph. It is used to determine the appropriate treatment.

• stage I : incomplete fracture of the neck (so-called abducted or impacted)

•
• stage II : complete without displacement
•
• stage III: complete with partial displacement: fragments are still connected
by posterior retinacular attachment; there is malalignment of the femoral
trabeculae

•
• stage IV : this is a complete femoral neck fracture with full displacement:
the proximal fragment is free and lies correctly in the acetabulum so that the
trabeculae appear normally aligned

•
• Pathophysiology

Femoral neck fractures occur most commonly after falls. Factors that
increase the risk of injuries are related to conditions that increase the
probability of falls and those that decrease the intrinsic ability of the person to
with stand the trauma. Physical deconditioning, malnutrition, impaired vision
and balance, neurologic problems, and shower reflexes all increase the risk of
falls. Osteoporosis is the most important risk factor that contributes to hip
fractures. This condition decreases bone strength and, therefore, the bones
ability to resist trauma.
Femoral neck fractures can also be related to chronic stress instead of a
single traumatic event. The resulting stress fractures can be divided into fatigue
fractures and insufficiency fractures. Fatigue fractures are a result of an
increased or abnormal stress placed on a normal bone. Whereas insufficiency
fractures are due to normal stresses placed on diseased bone, such as an
osteoporotic bone.
Trauma sufficient to produce a fracture can result in damage to the blood
supply to an entire bone, e.g., the femoral neck in femoral fracture. With seer
circulatory compromise, avascular (ischemic) necrosis may result. Particularly
vulnerable to the development of ischemic are intracapsular fractures, as occur
in the hip. In this location, blood supply is marginal ad damage to surrounding
soft tissues may be a critical factor since better results are obtained in cases of
hip fracture reduced with in 12 hr. than in those treated after that tine period. In
fractures of the femoral neck, bone scans have been recommended as
diagnostic tools to determine the orability of the femoral need.
• Schematic Diagram

Predisposing Factors: Precipitating Factors:

- Elderly people -Fall
- Trauma - osteoporosis
- Comorbidity -functional disability
- Malnutrition - impaired vision and balance
-neurologic problems
- Obesity
-slower reflexes

Damage to the blood supply to an entire bone.

Severe circulatory compromise

Avascular (ischemic) necrosis may result

Clinical Manifestations:
- Pain (right up)
- Loss of function
- Deformity
- Crepitus
- Swelling and discoloration
- Paresthesia
- Tenderness

Nursing Management: Medical Management:

- Repositioning the patient - Temporary skin traction
- Promoting strengthening exercise - Buck’s extension
- Monitoring and managing complications - Open or closed reduction of the fracture and
- Health promotion internal fixation
- Relieving pain - Replacement of the femoral head with prosthesis
- Promoting physical mobility (hemiarthrmoplasty)
- Promoting positive psychological response to - Closed reduction with pereutaneous stabilization
trauma for an intracapsular fracture.
- Patient teaching
Surgical Intervention:
- Hip Pinning
- Hip Hemiarthroplasty
- Patients with hip osteonecrosis may require Hip
Replacement Surgery
 • Complications of Fracture Neck of Femur

The important complications are:

a) Non-union b) Avascular necrosis of head of femur.

Non-union
Failure of union of this fracture still occurs due to improper reduction of
imperfect internal fixation. When this occurs, the patient complains of pain and
develops instability on walking. The condition is treated by intertrochanteric
osteotomy (McMurray) in the younger age group and replacement arthroplasty
in the elderly.

In the very old patient with poor general condition, the only treatment
possibly may be to keep the leg between sand bags and attend to the general
care of the patient. As soon as the general condition is restored and the local
pain relieved, physiotherapy is started. Movements of the hip are encouraged
and the patient is got up on crutches about three weeks after the injury.
Gradual weight bearing will lead to painless nonunion. This end result is
practicable and is still useful in our country, in places where good surgical and
hospital facilities are not available.

Avascular Necrosis
Avascular necrosis of the head of the femur is an unpredictable complication
met with after any type of internal fixation. The patient presents with pain in the
hip and limping. There is limitation of all movements of the hip with muscle
spasm. Radiography shows patchy areas of increased density in the head of
the femur. Treatment in the early stages is by rest, traction and weight relieving
caliper. When indicated, osteotomy or replacement arthroplasty is done.