Fractured femoral neck

Traumas are common troubles that can befall us at every step: on the way to work, during rest or at home. One of the most dangerous traumatic injuries is considered to be a violation of the integrity of the femur, which can occur in the form of a complete or partial fracture: the latter refers to a bone crack. For example, what is a femoral neck crack? How serious is it, and what is the essence of such damage?

Epidemiology

Femoral neck injuries, and in particular bone fractures, are more common in older patients and the elderly, and are especially common in postmenopausal women. Young patients with femoral neck fractures are rare.

According to statistics, hip injuries are recorded in 6% of patients who visit a traumatologist. Among these patients, almost 90% are elderly people over 65 years old, and most of them are women. [ 1 ]

Causes femoral neck fractures

A hip fracture can occur in a variety of circumstances, such as a traffic accident, at work or at home, during a fight, while playing sports, or while walking on a slippery or uneven surface. [ 2 ] Additional causes may include:

• incorrectly chosen intensity of sports training;
• exercising too intensely without proper preparation, warming up or stretching;
• wearing uncomfortable shoes or clothing, which increases the risk of falling.

In general, in young and middle-aged patients, femur injuries occur as a result of a strong impact - this can be a car accident, a fall from a height. In old age, the cause is often a direct blow or a hard landing on the hip joint. In old people, femoral neck cracks occur with a banal trip, when transferring the weight of one's own body to a specific limb. [ 3 ], [ 4 ], [ 5 ]

Risk factors

The following conditions and circumstances are considered risk factors:

• lack of vitamin D in the body;
• hypodynamia, low physical activity;
• lack of calcium in the body;
• deficiency of microelements (copper, zinc, manganese), leading to disruption of bone tissue formation;
• vitamin K deficiency;
• protein deficiency;
• age over 50 years.

Pathogenesis

In most cases, femoral neck cracks are a consequence of osteoporosis, bone demineralization, and other pathological processes that increase the fragility of bone tissue.

It is impossible not to take into account the force factor in the development of injury, but sometimes even a slight force impact is enough for a crack to appear. For example, older people, even after a normal fall, can get both a crack and a fracture. [ 6 ]

It is also worth mentioning the so-called pathological secondary damages that occur against the background of other diseases due to unfavorable changes in bone tissue. Thus, we can talk about tumor processes with bone metastases, in which cracks appear without any force influence.

In medical practice, the presence of a specific cause is not always obvious, and many patients initially attribute pain in the hip area to other factors. This significantly complicates both diagnosis and treatment. As a rule, a fall or other injury, after which pain in the groin appears (especially when moving the leg), is a reason for an urgent visit to a traumatologist. [ 7 ]

Symptoms femoral neck fractures

It is not always possible to determine a femoral neck fracture by symptoms, since they are not always specific and can be mistaken for another pathology. The non-specificity of the clinical picture is a problem, since patients delay visiting a doctor, and the injury worsens.

The negative aspect is that a femoral neck fracture sometimes shows practically no signs of itself. This happens especially often with minor injuries in people suffering from arthrosis or osteoporosis.

In general, traumatologists identify the following first signs of partial bone damage:

• Acute pain at the moment of a fall or impact (it may subside later).
• Aching pain when moving the leg or when trying to lean on it.
• The victim is able to walk independently, but it is quite difficult to do so.
• The muscles in the groin become painful and tense.

If a person has previously had problems with hip joints - for example, suffered from arthrosis - then he may mistake a crack in the femoral neck for an exacerbation of a chronic disease. In such a case, it is important to associate the moment of the first signs with an injury, fall, etc. Another important detail: the pain symptoms accompanying a crack in the femoral neck do not go away during the treatment of arthrosis, since conventional anti-inflammatory drugs cannot affect the healing of the damaged bone.

If you ignore the injury, the crack may well transform into a fracture, especially if the victim continues to lead a normal life, subjecting the leg to regular stress. The following symptoms indicate a fracture:

• The foot turns outward unnaturally.
• Bleeding (bruising) or severe redness occurs.
• The leg is shortened somewhat.
• A person in an upright position cannot lift the heel and keep the limb suspended.
• Sometimes the body temperature rises.

In complex cases, damage identification is carried out using X-rays.

Hip fracture in elderly people

Older adults who have suffered a hip injury are at additional risk due to the following:

• The older the patient, the greater the risk of developing complications, both physically and psychologically.
• Elderly people often have weakened immunity and chronic pathologies of the cardiovascular and respiratory systems, which can worsen due to injury and prolonged sedentary status.
• Elderly people almost always have problems with their joints, which can negatively affect the healing process of the crack.
• Prolonged bed rest has a negative impact on the functioning of the cardiovascular and respiratory systems, muscles atrophy, and congestion occurs.
• Old people may become depressed, neuroses may develop. Lack of motivation and depressed mood of the patient may negatively affect the prognosis of healing.

Stages

The healing of a femoral neck fracture is conventionally divided into several stages: the bone injury itself, the recovery stage, and the remodeling stage.

So, the first stage is the moment of injury, when blood supply is disrupted and a pathological process develops. Various mechanisms are activated – from inflammation to tissue necrosis. The less the circulatory system in the area of injury suffers, the better the healing will be.

The recovery stage is accompanied by the processes of ossification of new cellular structures. If osteosynthesis is adequate, the damaged area will be replaced by young tissue: this process is called contact healing.

A bone callus is formed – a significant factor in bone fusion. The new tissue covers the fracture site and acts as a base like a biomatrix. This is necessary for high-quality fusion and reconstruction of the fragment.

The formation of a callus occurs as follows: in the area of the crack, new cellular structures begin to actively divide, their excess is observed, which subsequently serves as a callus base. Gradually, the callus changes its structure - from this moment on, we speak of the beginning of the "fusion" of the crack. The bone callus is transformed into a spongy fragment, calcium accumulates in it and its strength increases.

Forms

A femoral neck fracture can be:

• single;
• multiple;
• through;
• superficial.

Relative to the axis, cracks can be oblique, spiral or longitudinal.

Complications and consequences

The period of bone recovery in case of a femoral neck fracture can last up to six months or more. Forced limitation of mobility, lifestyle changes, prolonged inactivity negatively affect the psycho-emotional state of patients: people often become hostages of depressive states and neuroses. The problem also affects the physical condition of patients: for example, against the background of prolonged bed rest, bedsores develop, blood stagnation in the venous vessels increases, constipation is observed. The development of vascular thrombosis and congestive pneumonia is also possible.

All the above complications are especially characteristic of elderly patients. For them, forced hypodynamia quickly "becomes a habit", the desire for recovery is lost, and the necessary physical exercises are ignored. This, in turn, further aggravates the problem: pulmonary congestion, heart failure develop, and the person may die.

The period during which the patient can fully recover depends entirely on his positive mood, as well as on adequate care, patience and understanding from loved ones. [ 8 ]

Diagnostics femoral neck fractures

The main diagnostic method when a femoral neck fracture is suspected is instrumental diagnostics:

• survey radiography;
• magnetic resonance and computed tomography.

Radiography is performed in the anteroposterior and lateral projections, across the table. When identifying damage to the neck, an X-ray of the entire femur is taken. In some cases, it is quite difficult to examine the injury - for example, if the patient has a severe form of osteoporosis.

If the problem is not visualized on the X-ray, but the clinical picture allows us to suspect a fracture or crack, then magnetic resonance imaging is recommended. This method is considered 100% sensitive and specific.

Laboratory tests are prescribed to assess the general condition of the body. As a rule, general clinical blood and urine tests are performed, and if necessary, a biochemical blood test.

Differential diagnosis

Differential diagnostics are carried out with a fracture of the femoral neck, with a dislocation or contusion of the hip joint, with a subtrochanteric fracture of the upper third of the femur.

Treatment femoral neck fractures

What to do if a person is injured? You cannot know for sure the extent of the injury – for example, whether it is a crack, a bruise or a fracture. Therefore, it is important to provide first aid correctly so as not to harm the victim. [ 9 ] And this must be done before the arrival of doctors:

• the injured person should be laid on his back;
• in case of severe pain, you should give a tablet of Ibuprofen or Ketoprofen;
• you cannot move the injured leg, so it is advisable to fix it with a splint;
• there is no need to remove the victim’s shoes and clothes: on the contrary, it is better not to touch the limb until medical specialists arrive;
• If a person falls on the street during the cold season, he must be covered to avoid frostbite;
• if it is necessary to move the victim, this can only be done after immobilizing the limb, and only on a hard stretcher;
• It is important to calm the fallen person down, not to allow him to panic and move.

Therefore, it is necessary to wait for the medical team to arrive, or take the person to the emergency room yourself, using a stretcher (it can be improvised - for example, knocked down boards or plywood).

It is necessary to treat a hip fracture, and sometimes there may be a need for surgical intervention. At first, the patient will be hospitalized, and the necessary examinations will be carried out. Then, the necessary procedures will be prescribed - in particular, massage, and the possibility of moving on crutches will be assessed. Leaning on the injured leg is prohibited: the attending physician will decide when the victim will be able to walk independently again. [ 10 ]

To speed up healing and to make the patient feel better, certain medications are prescribed.

Medicines that a doctor may prescribe

Painkillers
Ibuprofen	The drug is used to quickly relieve acute pain, since it cannot be taken for a long time due to its negative impact on the digestive system. The dosage of Ibuprofen is up to 400 mg per dose, but not more often than once every 4-6 hours.
Ketanov	Tablets are taken 1 pc. 3-4 times a day, but not more than five days. Injections are performed intramuscularly, in an individually selected dosage, also not more than five days. Side effects may include digestive disorders, headache and abdominal pain. With long-term treatment, the risk of bleeding increases.
Solpadeine	A painkiller based on paracetamol, caffeine and codeine. Not approved for use for more than 3 days in a row. For severe pain, take 1-2 capsules every 5 hours, but no more than eight capsules per day. Side effects often include abdominal pain, nausea and vomiting, allergies, psychomotor agitation or drowsiness, and renal failure.
Diuretics
Veroshpiron	Prescribed to relieve swelling in the injured area. The drug is taken 1-2 times a day, adhering to a daily dosage of 50-100 mg. The course of administration is 2 weeks. Side effects: cardiac arrhythmia, nausea, menstrual irregularities or metrorrhagia in women.
Furosemide	Take before meals, taking into account the maximum daily dose of 1500 mg. Side effects: metabolic disorders, dehydration, hypercholesterolemia, allergies, arrhythmia, loss of appetite, general weakness, visual impairment.
External ointments and gels
Anesthetic ointment	The product is applied to the affected area daily, possibly under a bandage. If you are allergic to anesthesin, the ointment is not used.
Diclofenac	Diclofenac ointment or gel is often used for inflammation and pain associated with injuries. Apply to the painful area up to 4 times a day, rubbing gently. The treatment period is no more than two weeks. Possible side effects: dermatitis, itching, rashes, erythema.
Indovazin	Gel with an analgesic and capillary stabilizing effect. Can be applied externally up to 4 times a day, the treatment period is no more than 10 days. As a rule, the drug is well tolerated, skin irritation in the area of application rarely occurs.
Preparations with chondroitin
Teraflex	A combined preparation of D-glucosamine and chondroitin, stimulates the regeneration of cartilage tissue. Teraflex is taken orally, 1 capsule three times a day, for a long period (minimum - 8 weeks). Side effects occur rarely and are expressed mainly in dyspeptic disorders or allergic reactions.
Chondroitin complex	The drug accelerates the formation of bone callus. The capsules are taken orally, one piece three times a day for a month, then switch to twice a day for a long time. Side effects may include constipation, diarrhea, dizziness, general weakness, allergic reactions.

Vitamins and minerals

Vitamin and mineral preparations with calcium are an excellent way to improve bone structure, provide the body with all the necessary substances to speed up the healing of a hip fracture. In case of any bone damage, doctors recommend taking calcium-containing products. And the absorption of this microelement is significantly increased if taken together with vitamin D and ascorbic acid. The following combination preparations may be recommended:

• Calcemin Advance;
• Feminex calcium;
• Calcemin Silver;
• Calcium D ₃ Nycomed;
• Marine calcium Biobalance with vitamins C and D ₃.

In addition to taking pharmaceutical products, it is necessary to make adjustments to your diet. It is good if the following products are present in your daily diet:

• dairy products, nuts and seeds, white cabbage (sources of calcium);
• greens, bananas, seafood, sprouted wheat grains (sources of magnesium);
• legumes, hard cheese, buckwheat and oatmeal, eggs (sources of phosphorus);
• seafood, sesame, pumpkin seeds, nuts (sources of zinc);
• fish oil, citrus fruits, kiwi, berries, bell peppers (sources of vitamins D and C).

Physiotherapy treatment

Physiotherapy is only included at the stage of recovery after a hip fracture. The following procedures are recommended:

• magnetic therapy;
• laser therapy;
• ultra-high frequency therapy;
• massage;
• reflexology;
• hydrotherapy, balneotherapy.

Any of the proposed methods is used in courses of ten to twelve procedures. It is advisable to repeat the treatment 3-4 times a year.

Folk remedies

Patients are ready to do a lot to speed up the healing and return to their normal life faster. Traditional methods of treatment are also used everywhere.

• To improve the "binding" of the bone, a powerful magnet is used, which is moved over the damaged area clockwise for 20 minutes daily. The number of procedures is up to 20. After 6 weeks, such treatment is allowed to be repeated. Contraindications to the use of a magnet may be tumors, blood diseases, recent heart attacks or strokes.
• Drinking onion broth internally helps well (fry a couple of medium onions, then boil in 1 liter of water for ten minutes). The potion is not strained, but consumed between meals, 200 ml three times a day.
• Treat the damaged area daily with fir oil and also eat ½ teaspoon of crushed eggshell (twice a day, before breakfast and dinner).
• Eat 2-3 walnuts daily. Often include aspic (jelly, but without salt and sugar) in the diet, at least 2 times a week, for a long time.

Herbal treatment

• Horsetail is a well-known diuretic plant, but few people know that it is rich in silicon, a necessary component for healing bone cracks. To prepare the medicine, take 1 tbsp. of dry plant, pour 250 ml of boiling water, insist under the lid for 15-25 minutes. Filter the infusion and take three times a day, one third of a glass.
• A mixture of ground valerian root, St. John's wort and chamomile flowers not only soothes, but also prevents the development of the inflammatory process in the area of damage. Take 1 tbsp. of the same mixture of plants, pour 250 ml of boiling water, keep under the lid for twenty minutes. Then filter and drink in the morning, before lunch and before dinner 100 ml.

In addition, you can apply compresses based on herbal mixtures:

• comfrey rhizome is boiled for twenty minutes, cooled and ground;
• The rhizome of comfrey is boiled in 500 ml of water until it becomes thick.

If you add lard to the above decoctions, you can use the product as an ointment, rubbing the affected area twice a day.

Homeopathy

Not all patients and doctors trust homeopathy, but these remedies are considered safer and no less effective than traditional medications. Homeopathic preparations can be used for injuries in children and the elderly, they reduce the need for taking excessive doses of analgesics, shorten the healing period of bone cracks, and have no side effects.

Homeopathic specialists advise paying attention to the following remedies:

• Symphytum (Comfrey) – heals cracks and fractures, prevents problems with bone tissue fusion, and eliminates the boring pain.
• Arnica – eliminates pain, significantly reduces the healing and recovery period.
• Eupatorium – acts as a homeopathic analogue of Arnica, eliminates pain and bone aches.
• Calcium phosphoricum - prescribed in low potency (3d or 6d), allows calcium to be absorbed, directing it to strengthening bone tissue. Accelerates the process of fusion of the femoral neck crack.
• Rue - is suitable as a first aid remedy for hip joint injuries, as well as for the treatment of poorly healing painful cracks.

There are not only the listed, but also other drugs that can alleviate the condition of the victim and speed up the healing. To choose the most optimal remedy, it is necessary to take into account all the signs of pathology, evaluate the reaction of a particular organism to the injury. Nevertheless, the above homeopathic drugs will be effective for most patients who have received a femoral neck crack.

Surgical treatment

The need for surgical intervention is determined after a thorough diagnosis, using X-ray, computed tomography or magnetic resonance imaging. [ 11 ]

In some cases, a femoral neck fracture does not require surgery, but in some cases it cannot be avoided - for example, with deep bone damage, with a high risk of complications (necrosis, etc.).

Depending on the type of crack, specific structures are inserted into the bone – such as spokes, pins or rods. Also, according to indications, replacement of the joint with a prosthesis may be recommended – in partial or complete execution. [ 12 ]

In case of femoral neck cracks, the intervention is most often performed under X-ray observation: the joint capsule is not opened. Endoprosthetics is recommended only in case of increased risk of complications.

Recovery from a hip fracture

After all necessary treatment measures have been carried out, the patient with a hip fracture is sent to a rehabilitation center, where he will be offered the following recovery methods:

• Pain-relieving procedures – a combination of analgesics with physiotherapy and manual therapy. If necessary, wearing a fixing orthosis is recommended – a device to reduce the degree of pain.
• Combating physical inactivity – various preventive methods are used to prevent trophic disorders, cardiovascular pathologies, respiratory and digestive disorders. Massage and hygiene procedures play a special role.
• Special physical training – this rehabilitation method becomes relevant when the patient begins to feel an improvement in his condition. The loads are selected individually, with a gradual increase in the frequency and duration of classes. At the initial stages, exercises are performed using bandage support.
• Psychotherapy – this method involves restoring the adequate emotional state of the patient, which is especially important in relation to elderly patients.
• Changes in nutrition involve saturating the diet with minerals and vitamins, such as calcium and silicon, which are necessary to speed up recovery and strengthen bone tissue.

All of the above measures help to significantly reduce the recovery period, which passes more quickly, and the patient has every chance to return to his normal rhythm of life.

Prevention

You can prevent the occurrence of a hip fracture if you follow these recommendations:

• monitor your diet, eat high-quality and healthy foods;
• properly organize the work and rest schedule;
• avoid physical inactivity and excessive overload;
• avoid lifting objects that are too heavy;
• avoid smoking and drinking alcohol;
• fight excess weight;
• adhere to safety precautions both at work and at home;
• after 40 years, additionally take calcium-containing drugs and chondroprotectors;
• choose clothes and shoes for yourself that will make it comfortable and safe to move around in.

In old age, it is very important to minimize the risk of injury. It is desirable that the house does not have high thresholds, folded carpets and rugs that a person can catch on and trip over. It is necessary to put a non-slip rubber mat on the bathroom floor, and also attach handrails to the wall so that the elderly person can hold on when getting up from the toilet or bathtub.

Forecast

The femoral neck does not have a periosteum layer. The blood supply to this bone section is insufficient, so injuries here heal poorly. Insufficient nutrition often leads to inadequate bone fusion. Over time, the crack site is fixed with a dense scar of connective tissue: this is called fibrous fusion. [ 13 ] The prognosis depends on many factors: the patient's age and health, the location of the injury line, its depth and length. [ 14 ] In some unfavorable cases, the crack can cause disability.