it is a severe injury that is more common in older people. Age-related changes in bone tissue are associated with osteoporosis, which leads to decreased bone strength and a high risk of fractures. The anatomical features of the femoral neck and its blood supply in elderly patients cause poor healing of the defect without surgical intervention. Surgical treatment of femoral neck fracture in old age not only allows one to restore normal motor activity, but also saves the patient’s life.
Anatomy of the hip joint
The hip joint is the largest joint in the human body, which performs a supporting function and participates in the process of movement. It consists of the acetabulum, formed by the pelvic bones, and the head of the femur. The hip joint has a spherical shape, is limited by the articular capsule and is strengthened by powerful ligaments and muscles. In front of the joint are the muscles of the anterior thigh, and behind are the gluteal muscles.
The head of the femur is covered with a thick layer of hyaline cartilage, normally its thickness is about 4 mm. The acetabulum is lined with cartilage tissue. When moving in a joint, cartilage prevents friction between the bones relative to each other, which causes shock absorption and prevents premature destruction of the joint. To enhance the strength of the articulation, there is a round ligament between the femoral head and the bottom of the acetabulum.
The head is connected to the body of the femur through the neck. This area is a vulnerable area for damage in old age. In young people, the blood supply to the femoral head occurs through vessels that are located deep in the bone, penetrate the joint through its capsule and are located in the round ligament. From the age of 30, these arteries gradually become obliterated and almost completely close in older people after reaching 60 years of age.
Schematic representation of a fracture in the femoral neck.
Insufficient blood supply to the femoral head leads to non-union of fractures in elderly patients during conservative treatment. Femoral neck injury is an intra-articular fracture, which increases the risk of poor consolidation of the damaged bones. Displacement of bone fragments is an indication for surgery at a young age, and trauma in older people of any complexity requires surgery. Conservative treatment is prescribed when absolute contraindications to surgery are identified for health reasons. The operation is not performed for paraplegics of the lower extremities, when restoring the patient’s motor activity is not advisable.
Causes and mechanism of injury
A fracture occurs when a bone is exposed to a traumatic force that exceeds the strength of the bone tissue. The femur is large and highly durable. At a young age, injuries in the femoral neck are quite rare and occur as a result of intense exposure to a traumatic factor - a fall from a great height, road traffic accidents.
In older people, due to age-related decreases in bone strength, unsteady gait due to impaired cerebral circulation and decreased visual acuity, falls from their own height often occur. Bone deformation with symptoms of osteoporosis occurs when there is a weak impact, especially in the area of the femoral neck. After a fracture, the integrity of the arteries supplying the head of the femur is disrupted, many of which are no longer functioning by the time of injury
From left to right: subcapital, transcervical, basicervical fracture
After repositioning the bone fragments and immobilizing the leg with a plaster cast, healing of the defect becomes impossible due to impaired blood supply to the bone tissue. Prolonged bed rest leads to fatal consequences for an elderly person. Heart failure develops, congestive pneumonia appears, and bedsores form.
These complications significantly worsen the general condition, are resistant to treatment and cause death within a year after the injury. In addition, the femoral head, deprived of blood supply, undergoes aseptic necrosis and is completely destroyed, which causes irreversible disturbances in the anatomical structure and functioning of the hip joint. The pathological process forever confines the patient to bed, worsens the quality of life and leaves no hope for recovery.
Classification of fractures
A hip fracture in older people, regardless of the severity of the injury, is considered a serious problem. However, some types of injuries are easier to treat, others are characterized by a long recovery period and often cause complications.
Like other fractures, femoral neck injuries can be open or closed. Closed injuries are much more common in older people. In this case, bone fragments do not form a wound to the skin and do not communicate with the external environment. Fractures may be accompanied by displacement of bone fragments or the injury does not cause deviation of bone fragments from the normal axis. The most severe damage occurs when bone fragments are displaced relative to their physiological axis
injuries with displacement of bone fragments have a more severe course.
For the choice of treatment tactics and prognosis of injury, the location of the fracture line is of significant importance. Depending on the location of the femoral neck defect, fractures are distinguished:
- basiscervical - the bone tissue defect is located at the base of the femoral neck, farthest from the head;
- transcervical - the bone tissue defect is located directly in the femoral neck;
- subcapital - the bone tissue defect is located at the base of the femoral head.
The most severe injuries, which often cause aseptic necrosis of the head and nonunion of the fracture, are considered to be subcapital defects of the femur.
In addition to the location of the fracture line, its angle of inclination is of no small importance. According to these characteristics, fractures are distinguished:
- first degree - the angle of inclination does not exceed 30 degrees;
- second degree - the angle of inclination is within 30-50 degrees;
- third degree - the angle of inclination is more than 50 degrees.
The more horizontal the bone defect line is, the greater the chance of fracture healing. In the third degree, healing of the area of bone tissue damage is least likely.
Thus, the prognosis for recovery after a fracture of the femoral neck worsens with increasing age of the patient, with a vertical location of the bone defect line in the area of the femoral head
Hip fracture in old people: you can do without surgery
However, surgery is not suitable for everyone. A hip fracture in old people aged 60 to 80 years can be cured surgically, but much depends on the condition of the patient himself. There are many contraindications to surgery, primarily diseases of the cardiovascular system.
But what if a person has suffered a hip fracture; 85 years old is his age, which makes him fear for the outcome of the operation? There is also a conservative treatment method, which, with proper care and compliance with all instructions, has a fairly favorable prognosis. This method is used for impacted and lateral fractures.
Clinical picture
A femoral neck fracture in older people can occur when they fall from their own height or hit their hip on a hard surface. A minor traumatic force is sufficient to form a bone defect. During an injury, an older person may experience pain of varying degrees of intensity. Sometimes the pain syndrome is quite mild and does not cause a deterioration in the general condition. The pain intensifies when you try to move the injured leg. At rest, patients do not feel discomfort in the area of injury.
External rotation of the foot with a fracture of the femoral neck
Rehabilitation during conservative treatment of a femoral neck fracture
Gavrilkina Oksana Sergeevna Chief rehabilitation doctor, physical therapy and sports medicine doctor,
More about the doctor
For a fracture of the femur of any type, surgical treatment is indicated. However, there are a number of contraindications to surgery for a hip fracture - a history of myocardial infarction stroke (local hemorrhage in the brain), mental disorders (schizophrenia), liver and kidney failure during an exacerbation, arterial hypertension that cannot be corrected with medications. In the presence of the above contraindications, conservative treatment methods are used.
Conservative treatment methods
The main condition for successful conservative treatment is immobilization of the damaged joint . Immobilization is carried out using various methods - they cover the injured leg with sandbags, apply a splint, place the leg in a derotational boot, or a regular plaster cast can be applied to the lower leg.
After immobilizing the leg in order to keep the joint in the correct position, in some cases cutaneous, skeletal traction is recommended. It can be attached simply to the shin or using a knitting needle inserted into the tibia. The weight of traction varies: with cutaneous traction it ranges from 2-4 kg, with skeletal traction it ranges from 4-9 kg. The period of bone fusion is very long, it is about 8 months . All this time, the patient must carry out rehabilitation measures, otherwise the fracture will result in necrosis of the femoral head and complete loss of physical activity.
Particular attention should be paid to the prevention of complications associated with impaired motor activity and threatening not only the health, but also the life of the patient. Bedsores , deep vein thrombosis of the legs and thighs , congestive pneumonia, impaired intestinal motility and constipation , and depression are the most common problems that can be encountered during the rehabilitation process.
Types of rehabilitation measures
Rehabilitation measures can be divided into two types:
- Exercises aimed at stabilizing blood circulation in a broken femoral neck.
- General measures designed to protect the patient from bedsores, bowel movements, congestion in the lungs, and depression.
Normalization of blood circulation is achieved by warming up all joints except the damaged one. Over time, under the guidance of an instructor, you can do simple exercises with the joint of the injured leg. In the first 2-3 weeks you need to perform the following exercises:
- Neck rotation;
- Rapid rotational movements of the hands, arms at the elbow and shoulder joints;
- Raising the body above the bed;
- Raising your healthy leg off the bed about 45 degrees.
All exercises need to be done 8-10 times in 2-3 approaches. This simple exercise will help maintain muscle tone and stabilize blood circulation throughout the body.
After about a month, you can try to get out of bed, leaning on 2 crutches or a walker. It is not recommended to put much weight on the injured leg. Support on the injured leg is allowed after 5-6 months. All terms depend on the condition of the individual patient. Usually the doctor prescribes short walks within the room (no longer than 20 minutes), followed by walks in the fresh air lasting up to an hour.
A special place during the recovery period is occupied by massage (regular and hydromassage), which is prescribed from the first days. It improves tissue metabolism, stimulates blood circulation, normalizes muscle tone, and prevents the appearance of bedsores. Hydromassage improves skin condition and stimulates metabolic processes. Physiotherapy starts from 10 days.
Maintaining the general health of the patient
To avoid the occurrence of pneumonia , the patient must perform breathing exercises, which consists of alternate deep inhalations and exhalations, holding the breath for a few seconds, and inflating a balloon. These exercises will prevent fluid stagnation in the bronchi.
Your diet should include foods high in fiber to normalize stools and prevent constipation. Also useful are foods rich in calcium - cottage cheese, parsley, etc.; iron – liver; fat-soluble vitamins (A, E) – red fish, seafood.
To prevent the development of depression, if necessary, you should invite a psychologist or psychiatrist for consultation.
Subsequently, for a long time, the patient who has suffered a hip fracture must follow the so-called “Four NOT” rules :
- Do not lean forward more than 90°;
- Do not raise your knee above hip level;
- Do not cross your legs at the knee joints or ankle area;
- Do not make any rotational movements with the injured leg.
Clinical manifestations of a fracture in the femoral neck:
- pain during movement in the damaged hip joint;
- inability to lean on the leg on the side of the injury;
- shortening of the leg as a result of displacement of bone fragments;
- external rotation (turning the foot outward) while lying on your back;
- inability to lift the heel of the affected leg (symptom of stuck heel);
- a crunching sound at the fracture site when feeling the hip joint or trying to move the leg.
In old age, edema rarely develops at the fracture site and a subcutaneous hematoma does not form.
Leg traction for a hip fracture and other non-surgical methods
The non-surgical treatment plan is approximately as follows:
- Skeletal leg traction for a femoral neck fracture is used for 2-3 months, and weights are also applied. If the fracture is lateral and not displaced, the patient lies in traction for about 10 days.
- After the traction is removed, the patient is allowed to stand on crutches and learn to walk, but should not lean on the sore leg for some time. If an experienced caregiver is nearby, this process is much easier and more effective.
- Exercise therapy after a hip fracture is prescribed literally from the first days of placing the patient on traction. This lesson is usually carried out by a hospital nurse, but a visiting nurse invited to provide care will do the gymnastics more carefully and carefully, since there is only one patient in her care.
Special exercises for a hip fracture without surgery are prescribed; the complex depends on the type of injury, and it must be performed slowly and carefully. The patient himself is still capable of little and is weakened, so during this period the support of a qualified nurse is especially important.
Diagnostics
After a hip injury occurs, the victim should be taken to the trauma department for diagnosis of the injury and treatment. To do this, you must urgently call an ambulance. Doctors will administer pain relief and immobilize the injured limb with a pneumatic splint or Dieterichs splint. Transport immobilization prevents injury from bone fragments to soft tissues on the way to a medical institution.
An x-ray determines the nature of the injury and the location of bone fragments.
In a medical institution, the doctor examines the site of the fracture, assesses the severity of the injury, clinical manifestations and general condition of the patient. To confirm the diagnosis, an X-ray examination of the hip joint is performed, which reveals the nature of the fracture, the displacement of bone fragments, and the location of the bone tissue defect line. In severe diagnostic cases, computed or magnetic resonance imaging (abbreviated MRI) is prescribed, which can detect a bone defect and a violation of the integrity of soft tissues (muscles, ligaments, nerves, blood vessels)