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Stronger Indications

  1. A fracture that cannot be satisfactorily reduced or fixed with stability, especially with posterior comminution.
  2. Fractures that loose fixation several weeks after operation
  3. An untreated, unreduced, and unimpacted fracture of femoral neck that is more than 3 weeks old
  4. Fracture of neck of femur with complete dislocation of femoral head
  5. A patient who cannot with stand two operations.
  6. Patients with psychoses or mental deterioration eg. Alzheimer’s disease in which protected weight bearing may be unreliable. (i.e. patient is not able to follow instructions).
  7. Neurological disorders such as uncontrolled epileptic seizures, severe uncontrolled parkinsonism.
  8. A patient with a short life expectancy, whether the fracture is pathological (malignancy) or primarily the result of trauma, is best treated with prosthesis so that he can be ambulatory in most of the days of remaining life.
  9. Some preexisting lesions of hip eg AVN, OA rheumatoid rth,itis. Most of these usually require THR.

Selection of Prosthesis

  1. Hemiarthroplasty or Hemi Replacement Arthroplasty (HRA)
  2. In this only femoral side of hip joint is replaced by unipolar or bipolar prosthesis. Cemented Thomsons and uncemented Austin Moore prosthesis are examples of unipolar prosthesis Cemented Unipolar (Thomsons) is indicated in limited household ambulators and who have <2 years expected survival.
  3. Protrusio acetabuli, thigh pain & difficult rivision to total hip arthroplasty are main problems with unipolar prosthesis that precludes their use.
  4. Cemented Modular Bipolar or cemented femoral component of total hip with a bipolar attachment is implant of choice for more active patients because they have lower incidence of protrusio acetabuli, thigh pain and can be easily converted to THR without revision of femoral component, if required.
  5. THR is indicated if the acetabulum side of joint is involved (AVN, OA, RA).

MC- Murray’s

  1. Osteotomy is a biomechanical procedure of subtrochanteric abduction (valgus impaction) osteotomy used in young (< 65 years age) with viable femoral head (No AVN) and minimal collapse of neck.
  2. The purpose of abduction osteotomy is to turn the shaft from adducted to abducted position, which makes fracture line of neck femur more horizontal, so that the shearing stress of weight bearing and muscle retraction becomes an impaction force.
  3. Therefore the operation is applicable to a fracture with delayed union in which final consolidation is prevented by the stresses of adduction deformity, but not to a fracture with established nonunion, or to one in which most of the femoral neck has disappeared.
  4. Meyer’s muscle pedicle (quadratus femoris) bone graft procedure is used in ununited fracture neck femur in younger patients with viable femoral head.

Treatment Plan of Fracture Neck Femur

Fracture neck of femur Overview


< 65 year

>65 year

Fracture neck of femur < 3 weeks


Cannulated cancellous screws

HRA / THR (Pre existing arthritis)



Fracture neck of femur > 3 weeks

Osteotomy / Muscle pedicle graft

<3 weeks

  1. Children
    1. Close reduction & internal fixation (CRlF) by
      1. Austin Moore pins
      2. Knowle’s pin
      3. C.C. screw
  2. Adult with physiological age <65 years
    1. CRIF by multiple cannulated cancellous screws Q (open reduction is only done if close reduction fails as it has more complication rate)
    2. McMurry’s osteotomy is done when reduction is not possible
  3. Adult with physiological age > 65 years
    1. Prosthetic replacement
      1. Otherwise normal hip (i.e. acetabular cartilage is visible)
      2. Hemireplacement arthroplasty
        • Austin Moore prosthesis
        • Thomson’s prosthesis with bone cement (in osteoporotic bone with deficient calcar)
        • Bipolar arthroplasty
    2. Hip with pre-existing arthritis
      • Total hip replacement


  1. <65 years physiological age
    1. McMurry’s displacement or Shanz angulation osteotomy
    2. Meyer’s vascularized muscle pedicle (of quadratus femoris) bone grafting procedure
  2. > 65 years physiological age
    1. Same as that of <3 weeks
  3. Intracapsular Fractrue Neck Femur - Complications
    Avascular necrosis (66 - 84% in some series) > Nonunion (2nd m.c) >arthritis
  4. According to anatomical location of fracture neck femur the chances of AVN & nonunion in decreasing order are:
    1. Subcapital > transcervical > basal > intertrochanteric
    2. Transphyseal > transcervical > cervicotrochanteric > intertrochanteric (in children)
  5. The probable causes of nonunion in fracture neck femur are –
    1. Cambium layer of periosteum which produce callus is missing. Therefore femoral neck must heal via direct endosteal healing only.
    2. There is no contact with soft tissues which could promote callus formation.
    3. Precarious blood supply: by tearing the ascending cervical branches or retinacular vessels the injury deprives head of its main blood supply.
    4. Synovial fluid interfere with fracture healing as it prevents clotting of fracture hematoma and release angiogenic inhibiting factors.
    5. Inadequate reduction and improper immobilization.
    6. Temponade effect of intracapsular hematoma causing floating of both fracture ends and making reduction difficult.
Intertrochanteric of femur

(Fig: 1)

(Fig: 2)
Description: Description: C:\Users\RAMKINKAR JHA\Downloads\PELVIS -Hip AP-17-09-2014-11_21_56 AM-663.JPEG
 (Fig: 3)
  1. Fracture Intertrochanteric of femur
  2. Stable fracture Treatment: Dynamic hip screw (DHS)
  3. Unstable fracture Treatment: Proximal Femoral Nail (PNF).

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