Femoral neck fracture in the elderly

Bone fractures and soft tissue injuries often occur after the age of 50. This is not only due to the fact that a person becomes less active and more clumsy. This age is often characterized by avitaminosis, osteoporosis, lack of minerals. Yes, and banal age-related changes make themselves known. Particular danger is characterized by a fracture of the femoral neck in the elderly. This is an injury about which all patients who have passed the 45-50 year old milestone should be informed.

Epidemiology

Fracture of the femoral neck is probably one of the most unfavorable injuries for the elderly. Moreover, people get such an injury not only on the street, but also at home, so even a sedentary elderly person can be injured.

According to statistics, more than half of femoral neck fractures occur during the warm season: about 10% in May, and about the same number between September and October. At the same time, more than 75% of fractures occur indoors.

Older people are most likely to be injured when trying to overcome any obstacles or obstacles in the way, which can be thresholds, mats, etc. (about 40% at home and more than 55% outside the home). (about 40% at home and more than 55% outside the home). Falls from a chair, bed, stairs, etc. Are less common.

Causes of the femoral neck fracture in the elderly.

The femur bone is a rather large skeletal element that has to face a huge load on a daily basis, since it is located in the upper segment of the lower limb. According to anatomical data, this bone is divided into three parts: the body, the neck and the head, localized in the hollow of the joint. It turns out that the neck of the femur is a kind of "weak link" in this area, so the corresponding fractures occur quite often. [1]

Osteoporosis makes a special negative "contribution" to the development of fracture. It is a pathology inherent mainly in the elderly (mainly women) and is associated with demineralization and increased bone fragility. In addition to osteoporosis, there are other negative factors - for example, the blood supply to the femoral neck is impaired in elderly people, which not only affects the quality of bone tissue, but also impairs its repair, if damage is already present.

In most patients, a femoral neck fracture occurs after a side fall, as this results in a powerful targeted blow directly to the hip joint. In case of advanced osteoporosis, even one wrong turn of the body or an awkward bend may be enough to cause injury.

Certain risk factors also increase the likelihood of a fracture.

Risk factors

Predisposing traumatic factors are often:

• menopause, hormonal problems, increased calcium leaching from bone tissue;
• obesity, hypodynamia;
• prostatic hyperplasia;
• alcohol abuse, poor nutrition, impaired absorption of vitamins and minerals.

Many chronic pathologies lead to weakening of bones, particularly the femoral neck. Thus, the risk of injury increases significantly in elderly people suffering from arthrosis, osteochondrosis, spondylolisthesis or spondyloarthrosis, intervertebral hernia. Bone fragility increases against the background of diabetes mellitus, kidney and liver disease, thyroid disease.

Pathogenesis

The femoral neck and femoral head are supplied with blood mainly by intraosseous vascular arterial branches. The vasculature of the femoral head ligament, which is often obliterated in the elderly, is less involved.

In intra-articular femoral neck fractures, the basic intraosseous arterial network is disrupted, which leads to deterioration of trophic processes in the proximal neck and femoral head. At the same time, regenerative processes also deteriorate: the risk of avascular necrosis increases during fracture.

Fracture of the femoral neck occurs more often in an adduction injury - i.e. During a lateral fall. The peripheral segment is driven and displaced upwards and outwards. Abduction trauma, i.e. Falling with the limbs apart, is less common in the elderly. The peripheral segment is retracted, displaced upward, and in some cases, enters the central fragment to form an embedded fracture.

Negative conditions for adequate fracture closure in the elderly include insufficient blood supply to the proximal fragment, lack of periosteal layer at the neck, vertical plane of the fracture, difficult juxtaposition of the fragments and their loose contact, and tissue demineralization.

Symptoms of the femoral neck fracture in the elderly.

Because of its extreme prevalence and danger, femoral neck fractures in the elderly are fairly well understood, so most medical professionals can easily identify the injury when the following symptoms are present:

• Prolonged persistent pain in the groin, not intense but continuous. The victim is able to tolerate such pain for several days, hoping for its self-elimination, or taking it as a manifestation of arthrosis or arthritis. However, without appropriate treatment, the pain syndrome gradually increases and becomes especially noticeable when attempting to walk actively or when placing the foot on the heel.
• The foot is somewhat modified, as if turned outward: this is easily recognized by comparing both feet and comparing their position in relation to the knee joint.
• Some patients have a slight shortening of the affected limb, not exceeding 40 mm. This symptom is caused by a shortening of the muscles in the injured area, which is particularly typical of a varus injury.
• The characteristic symptom of "stuck heel" appears: it is expressed in the fact that it is impossible to place the limb from a weighted position on a horizontal plane, because it seems to slide. At the same time, the function of flexion and extension of the leg is preserved.

The first signs of a femoral neck fracture can be detected by crunching, which is especially noticeable when trying to turn the leg horizontally. Pain can also be felt by probing the damaged area: a strong pulsation in the femoral artery area can also be noticed.

Other characteristic features are considered to be such as:

• If the patient's heel bone is pressed or tapped, uncomfortable or even painful sensations occur;
• If there is a disorder of the greater acetabulum, the displacement of the Shemaker's line, which is an imaginary line connecting the apex of the greater acetabulum with the antero-upper tip of the iliac bone, is noteworthy.

Some time after receiving a fracture of the femoral neck, a hematoma may form in the injured area, provoked by the violation of the integrity of deeply located vessels.

Forms

Femoral neck fracture in the elderly is categorized into several types, which depends on the location of the injury, its level, the type of displacement, and its nature.

For example, in a varus fracture, the head moves downward and inward, in a valgus fracture, the head moves upward and outward, and in an embedded fracture, the fragments are displaced into each other.

According to statistics, the most unfavorable prognosis is the puncture form of intra-articular fracture: in the absence of treatment, the damage can transform (bone fragments separate and diverge, which can only be corrected by surgical intervention).

Other common types of fractures we will look at in more detail.

• A femoral neck fracture in the elderly is often intra-articular in nature. It is atypical of severe pain and restricted mobility, so victims do not immediately seek medical help. Often this leads to the fact that the fragments and splinters continue to shift, leading to even greater damage, and the impaled fracture is transformed into a non-impaled form. Interestingly, this type of fracture is the most favorable if it is treated in a timely manner.
• Lateral femoral neck fracture in the elderly is the most rare: the line of injury runs clearly along the lateral border, penetrating the base of the neck and not reaching the acetabular zone. The lesion usually does not involve displacement; rotational outward flexion and varus position are possible. On lateral view, the axis is normal, but there may be anterior or posterior curvature of varying degrees. Lateral fracture has much in common in terms of clinic and treatment with acetabular fractures, and some specialists even identify these types of injuries.
• A femoral neck transverse fracture in the elderly is an injury that involves the bony segment from the subvertebral line to the neck base. The injury usually results from overloading the greater acetabulum or twisting movement of the leg. The fracture may be accompanied by marked blood loss, external tissue edema and hematoma.
• A basal femoral neck fracture in the elderly is characterized by the location of the fracture line at the base of the neck. The injury occurs in a fall or as a result of a direct blow to the hip.

Complications and consequences

Statistically, femoral neck fracture in the elderly is often the cause of death in patients, despite the fact that lethality is not at all a direct consequence of the injury. Why does this happen?

With prolonged forced lying in the elderly repeatedly increases the risk of respiratory and cardiovascular problems, increases the risk of vascular thrombosis, infection, skin diseases.

Lung inflammation associated with congestion and continuous bed rest is often that kill point for patients.

Other unpleasant consequences of prolonged "lying down" include depression and mental disorders. Many elderly people due to trauma and immobility lose the meaning of life, their perception of reality is disturbed, their consciousness becomes confused. Often patients begin to abuse alcohol, take strong medications (e.g., tranquilizers, antidepressants), which easily aggravates the deplorable situation. [2]

Diagnostics of the femoral neck fracture in the elderly.

Diagnosis is usually not difficult, as a femoral neck fracture can be diagnosed if the symptoms are present. But such a diagnosis is not valid without confirmation, so you should start with an X-ray: this type of examination can help to detect a fracture or dislocation of the bones in the femoral neck area.

The tests are ordered as an adjunct to the main diagnosis:

• clinical blood work, COE;
• urinalysis;
• if necessary - analysis of joint fluid, examination of tissues taken by biopsy.

As we have already mentioned, the basic diagnostic method for detecting a femoral neck fracture is radiography: both fractures and fracture lines are visualized on the images. Additional instrumental diagnostics can be connected to clarify some details of the damage. For this purpose, computer tomography is used - a diagnostic study that allows a more accurate and detailed assessment of the state of the bone. Magnetic resonance imaging can be an alternative to CT.

Differential diagnosis

Differential diagnosis should be made with hip joint contusion, hip dislocation. With dislocation, there are characteristic symptoms: spring tension of the diseased leg, displacement of the head of the femur, marked shortening of the limb. In contusion, there is pain, swelling, hematoma; the function of the joint is limited or severely impaired. The final diagnosis is made after radiologic examination.

Treatment of the femoral neck fracture in the elderly.

A femoral neck fracture should not be left untreated and should not be left to fend for itself: for the elderly, such an attitude can be fatal. Treatment is mandatory, whether it is conservative methods or surgery.

Surgical treatment is considered the most effective and radical treatment, but it is not always necessary. For example, in the case of an embedded fracture or damage to the lower segment of the neck, surgical assistance may not be necessary. In addition, surgical intervention in an elderly person may be simply contraindicated - for example, due to old age, in severe disorders of internal organs. [3]

Conservative treatment usually consists of these mandatory steps:

1. Examination of the patient with further placement in a specialized orthopedic or trauma unit.
2. Implementation of skeletal traction within the first 8 weeks of fracture.
3. Chiropractic care, massage therapy.
4. Mandatory use of crutches after removal of skeletal traction.
5. Attempts to engage the affected limb for walking and movement under strict medical supervision, no sooner than 4 months after the injury.

If surgery is not an option, the first thing the doctor will suggest is to provide immobilization and skeletal traction of the affected leg. How does this procedure work?

• The damaged joint area is injected with local anesthetics (e.g., Novocaine-based).
• The traction is set for a period of up to ten days.
• After the specified time has elapsed, the pulling structure is removed.
• Turn the patient to one side or the other, raise the headboard, and provide a semi-sitting and sitting position.
• After about three weeks, an attempt is made to move the patient on crutches under doctor's supervision.

Afterwards, if the patient is in satisfactory condition, he or she will be prepared for discharge. However, the patient should only use crutches and be accompanied by an assistant. Only the attending physician should decide whether to discontinue crutches.

Surgical treatment

Surgery is an important decision for both the doctor and the patient. The doctor must be sure that the elderly person will tolerate the anesthesia and the intervention itself.

In many cases of femoral neck fractures, the assistance of a surgeon is mandatory. The nature of the surgery itself depends on the type of bone damage and its extent. Most often, the fracture site is reinforced with a special construction, including spoke or rod-shaped fasteners and/or screws. In severe cases, joint replacement may be required.

If the question of surgery is raised, it is recommended to perform it as soon as possible. The only factor in which the intervention can be postponed is the presence of temporary contraindications.

The following are considered to be general principles of surgical treatment:

• this treatment is always performed with anesthesia;
• If bone fragments are present, they are repositioned beforehand;
• In uncomplicated fractures of the femoral neck, intervention can be carried out without joint dissection and with the aid of X-ray monitoring;
• in complex fractures, the joint capsule is opened.

Endoprosthetics are used mainly in elderly patients whose trauma was accompanied by dislocation of fragments, as well as in case of bone head debridement.

Care for femoral neck fracture in the elderly

Proper care and the kind attitude of loved ones are important conditions for the speedy recovery of an elderly person who has suffered a fracture of the femoral neck. In addition to stabilizing the state of the psyche, it is also necessary to perform special therapeutic exercises to accelerate the recovery of bone tissue. It is important to prevent and eradicate the development of depression, depression: if necessary, you can additionally involve a psychotherapist in the treatment.

Close people should provide the victim with a healthy sleep, a nutritious diet. It is also recommended to conduct a course of massage procedures, treat existing chronic pathologies. All measures in combination will help to cope with the problem faster.

A sick person should not be left alone: he should always feel the support and participation of relatives. To prevent the development of depression, doctors recommend spending time together, making plans for the future. It is good if the patient will be able to perform feasible housework, as well as self-service (for example, on crutches or sitting on the bed). Doing simple physical exercises to music will help the patient to distract himself and improve his mood.

Rehabilitation

The length of the rehabilitation period for a femoral neck fracture in the elderly is difficult to determine precisely. This period depends on many factors, such as the complexity, type of fracture, age and general health of the victim. However, doctors believe that the duration of rehabilitation cannot be less than six months. [4]

In general, the recovery period can be figuratively divided into the following stages:

1. Starting from the third day after the cast is applied, the patient is recommended to start massage procedures: at first, the lumbar area is massaged, gradually moving to the healthy leg. Only after 7-10 days, massage of the injured limb is started, remembering to be careful and accurate.
2. After the cast is removed, you can move the knee joint little by little, making light movements under the supervision of a medical specialist. After 4 weeks, you can do such exercises on your own, bending and extending the leg in the knee. You should not perform any unnecessary movements not prescribed by the doctor.
3. After about three months, the doctor can allow the patient to get out of bed on crutches. However, it is still not allowed to lean on the injured leg.
4. The load is gradually increased, and after six months the patient is allowed to try to move without crutches.

Prevention

To prevent severe injuries such as a femoral neck fracture, the first step is to:

• Ensure that the food is sufficient calcium (for older people, the daily norm is 1200-1500 mg of calcium, taking into account possible impaired absorption);
• provide the body with essential vitamins and minerals - in particular, retinol, ascorbic acid, vitamins D and K, zinc, phosphorus and magnesium;
• to give the body regular and feasible physical activity, provide motor activity, strengthen muscles.

In addition to general body strengthening, the possibility of falls and injuries should be minimized. For example, measures should be taken at home to prevent the elderly person from falling and hitting themselves. Floors and floor coverings should be non-slip, thresholds should be low (and it is better to get rid of them altogether). In the bathroom, it is advisable to install special handrails to hold on to.

If the injury is already present, efforts should be made to avoid complications and speed up recovery. Seek medical attention and treatment as soon as possible.

Forecast

Although femoral neck fracture in the elderly is considered a very complex injury, the chances of cure are still high. The pathology is completely treatable, but rehabilitation should take more than one month. It is important that the effectiveness of treatment and the quality of recovery largely depend on the positive attitude of the patient himself and his environment. A traumatized old man cannot do without the help of close people.