Dr. Ebraheim’s educational animated video describes fracture classifications of the femoral neck.
Garden classification
Type I
Incomplete and impacted in valgus
Type II
Fracture is complete and nondisplaced on at least two planes (anterior & lateral).
Type III
Complete fracture and partially displaced
Trabecular pattern of the femoral head does not line up with the acetabular trabecular pattern.
Type IV
Completely displaced with no continuity between the proximal and distal fragments
Pauwel’s classification
There are three fracture types within Pauwel’s classification:
Type I
Type I has an obliquity ranging from 0 to 30 degrees.
Type II
Type II has an obliquity ranging from 30 to 50 degrees
Type III
Type III has an obliquity of 70 or more degrees.
The more vertical orientation of the fracture, the higher the risk of nonunion and osteonecrosis.
The more displaced the fracture, the more disruption of the blood supply and chance of avascular necrosis and nonunion.
Avascular necrosis may occur in 20-25% of displaced fractures.
Nonunion may occur in about 25% of displaced fractures.
Treatment
Nondisplaced fracture
Screw fixation
Nondisplaced fracture may become displaced
Important to fix the fracture emergently in young patients before the fracture becomes displaced.
Displaced fracture-younger patients EMERGENCY
Do closed reduction and screw fixation
If closed reduction fails, do open reduction and screw fixation utilizing the Watson Jones approach.
Displaced fracture older patients
Screw fixation in the elderly has a higher incidence in failure of fixation and reoperation. Do not do screw fixation.
High functional demand patient
Do total hip arthroplasty
Total hip is the procedure of choice especially if there is pre-existing rheumatoid or degenerative arthritis.
Higher dislocation rate.
Elderly low demand patient
Unipolar or bipolar
Cemented or uncemented
In rare cases, excision of the femoral head can provide alternative in high-risk patients.
Nonunion
Do subtrochanteric osteotomy in younger patients.
Do prosthesis in older patients
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