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Orthopedic Surgery Disease:Femoral Neck/Trochanteric Fracture

Nearest part of thigh bone is divided as shown as Fig.1, and grouped as below depend on the fracture part;


Fig. 1 Classification of nearest part of Thigh Bone

  1. Femoral Capital Fracture
  2. Femoral Neck Fracture
  3. Femoral Trochanteric Fracture
  4. Femoral Lower Trochanteric Fracture

Here described about Femoral Neck/Trochanteric Fracture.

Fracture is triggered by external injury like tumble.

Fracture is suspicious when having pain on femoral region and get stuck triggered by external injury like tumble, but it is necessary to pay attention for the case of walking is possible even with fracture, or aged person with no epidemic wounds exist.
Firstly, X-ray exam of painful femoral region is conducted. But there is a case where fracture is difficult to diagnose from front image only, so that diagnose it together with side image. When epidemic fracture is not identified with X-ray image, but when fracture is suspicious from severe pain symptom, MRI exam (magnetic resonance imaging method) is conducted so that the existence of fracture is checked in detail.


Fig. 2; Fracture by tumble is common among high-aged person.
The report says that the annual numbers of developing Femoral Neck/Trochanteric Fracture in Japan 2007 is approximately 150 thousand cases, and its developing rate increases from the age of 40s, precipitously increase from the age of 70s. It also says that female’s developing rate is higher than male’s one among the high-aged personnel. 1)
For high-aged person, the most common cause of femoral neck/trochanteric fracture among high-aged person is tumble (Fig.2), but among virile age person, it becomes common that the disease is developed by external injury of traffic accident or severe impact by falling. It is considered that fracture is tending to occur with not so severe impact like tumble, if in case person has osteoporosis by nature.

Recommend having surgery to prevent from complication disease.

In preservation therapy, aching pain relief and bone adhesion (bone is healed up) is expected with keeping up complete rest of bone. But Femoral Neck/Trochanteric Fracture is common as high-aged person injury, so that muscle force is decreased along the stuck state becomes longer and complication disease like pressure ulcer (bedsore), lung inflammation, deep venous thrombosis/pulmonary embolism (economy class syndrome) may be developed. It is therefore, in case if entire body status permits, it is recommended to have surgery operation as early as possible (pain relief is expected with fixing fracture part up in surgery), get mobilized and starts rehabilitation.

Femoral neck fracture is a fracture inside the joint and it is easy to misalign and hard to bone adhere so that osteosynthesis (Fig.3), fixing fractured bone up even with small dislocation (fracture misalignment), is considered. For high-aged person and when dislocation(fracture misalignment) is large enough, it is recommended to take, in consideration of blood vessel supplying blood to femoral head is damaged (Fig.4) and femoral head may likely to be necrotized in future, artifact replacement (hip replacement arthroplasty (Fig.5) for those who has high activation, and femoral head replacement (Fig.6) for those who are in bad shape or who has low mobilization) are recommended. 1)


Fig.3 Bone adhesion

Fig.4 Dislocation is large, and vessel is damaged

Fig. 5, Hip replacement arthroplasty

Fig. 6, Femoral head replacement

For trochanteric fracture, fix it using plates.


Fig. 7 Femoral trochanteric fracture is easy to be displaced pulled by muscle.
Femoral trochanteric fracture is a fracture outside of the joint, and it is easy to be bone adhesion in comparison with femoral neck fracture, but it is easy to be displaced pulled by muscle and is considered as the influence to entire body is large enough due to the amount of bleeding from fracture part. (Fig.7)

Depend on the position and stability of fracture part, metal pieces, like plate + screw type (Fig.8) or intramedullary needle+ screw type (Fig.9), are used to fix fracture part.


Fig.8 Plate + Screw type

Fig.9 Intramedullary Needle + Screw type

Hard to recover to the same level before surgery due to age.

It is reported that the development rate of incomplete healing of bone (fracture part do not heal) after the Osteosynthesis for femoral neck fracture surgery is; 0 to 15% for little displacement case ((non-displacement type), 4 to 40% for large displacement case (displacement type), and development rate of femoral head deformation by necrosis after femoral trochanteric fracture surgery is 0 to 8% in non-displacement type, 26 to 41% in displacement type. Research data says that the development rate of incomplete healing of bone after femoral trochanteric fracture surgery is 0.5 to 2.9%, and development rate of femoral head deformation by necrosis is 0.3 to 1.2% 1). In case necrosis/deformation of femoral head occur due to the incompletion of bone healing then aching pain or functional disorder is onset, artificial bone head insertion surgery or hip replacement arthroplasty is considered.

Regarding the functional prognosis, although appropriate treatment is applied after injury not all person is recovered back to the level before injury, so that report says that the primary factor which influences to the recovery of ambulatory ability is age, ambulatory ability before injury and the degree of dementia. 1)
Regarding the life prognosis, fatality rate in Japan in postoperative one year is 10% for femoral neck fracture and 9.8 to 10.8% for femoral trochanteric fracture. 1)。

Preventive measures by the treatment of osteoporosis and exercise therapy.

It is verified that chemotherapy for osteoporosis is efficacious for the prevention of femoral neck/trochanteric fracture, and exercise therapy is effective for the prevention of tumble which is a major factor of the cause. Importance of trying to prevent femoral neck/trochanteric fracture with using chemotherapy or exercise therapy for the person who has osteoporosis or person who has fracture injury in the past, is pointed out. 2)

Reference
1) Japanese Orthopaedic Surgical Society Guideline Committee. Femoral Neck/Trochanteric Fracture Diagnosis Guideline Formulation Committee, Femoral Neck/trochanteric Fracture Diagnosis Guideline Rev.2, Tokyo Nankodo, 2011
2) Naosi Shiota, Shunichi Kubo, Chapter 4, Traumatic disease, 1. Femoral Neck Fracture, Femoral Trochanteric Fracture, Edited by Shunichi Kubo, Hip Joint Study, Kyoto: Kinhodo Corporation, 2014; 660-678

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