Fracture of the femoral neck

Injuries are common troubles that can await us at every step: on the way to work, during leisure 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: in the latter version, a bone crack is meant. For example, what is a hip fracture? How serious is this, and what is the essence of such damage?

Epidemiology

Injuries to the femoral neck, and, in particular, bone fractures, are more often recorded in elderly patients and the elderly, and especially often in women who have reached the postmenopausal period. Young patients with hip fractures are rare.

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

Causes of the fissures of the femoral neck

A hip fracture can occur under a variety of circumstances - for example, in a traffic accident, at work or at home, during a fight, when playing sports, when walking on a slippery or uneven surface. [2] Additional reasons may be:

• incorrectly chosen intensity of sports training;
• too intense exercise without prior preparation, warming up or stretching;
• wearing uncomfortable shoes or clothing that increases the risk of falling.

In general, in young and middle-aged patients, injuries to the femur occur as a result of a strong blow - this can be a car accident, a fall from a height. In the elderly, the cause is often a direct blow or hard landing on the hip joint. In old people, fractures of the femoral neck occur when banal stumbling, 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 trace elements (copper, zinc, manganese), leading to a violation of the formation of bone tissue;
• lack of vitamin K;
• protein deficiency;
• age over 50 years.

Pathogenesis

In most cases, femoral neck fractures are the result of osteoporosis, bone demineralization, and other pathological processes in which there is an increase in bone fragility.

It is impossible not to take into account the force factor in the development of injury, however, sometimes a completely insignificant force effect is sufficient for the appearance of a crack. For example, older people, even after a normal fall, can get both a crack and a fracture. [6]

It is worth mentioning the so-called pathological secondary injuries that occur against the background of other diseases due to adverse changes in bone tissue. So, 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 hip pain to other factors. This greatly complicates both diagnosis and treatment. As a rule, a fall or other injury, after which there is pain in the groin (especially when moving the leg), is a reason for an urgent appeal to a traumatologist. [7]

Symptoms of the fissures of the femoral neck

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

The negative point is that the fracture of the femoral neck sometimes practically does not manifest itself in any way. Especially often this happens with minor injuries in people suffering from arthrosis or osteoporosis.

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

• Acutely occurring soreness at the time of a fall or impact (subsequently, it may weaken).
• Aching pain on the background of leg movements, or when trying to lean on it.
• The victim is able to walk independently, but it is quite difficult to do this.
• The muscles in the groin become painful and tense.

If a person previously had problems with the hip joints - for example, suffered from arthrosis - then he can take 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 appearance of the first signs with trauma, a fall, etc. Another important detail: the pain symptoms that accompany a hip fracture do not go away during the treatment of arthrosis, since conventional anti-inflammatory drugs cannot affect the healing of the damaged bone. 

If the injury is ignored, then the crack may well transform into a fracture, especially if the victim continues to lead a normal life, exposing the leg to regular stress. In favor of a fracture, the following symptoms speak:

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

In difficult cases, damage is identified using x-rays.

Hip fracture in the elderly

Elderly people who have sustained a hip injury are at additional risk due to:

• The older the patient, the greater the risk of developing complications, both physically and psychologically.
• Elderly people often have reduced immunity, there are chronic pathologies of the cardiovascular and respiratory systems, which can worsen against the background of trauma and a prolonged sedentary state.
• Older people almost always have joint problems, which can adversely affect the healing process of the crack.
• Prolonged bed rest negatively affects the functioning of the cardiovascular and respiratory systems, muscles atrophy, and stagnation occurs.
• Old people can become depressed, neurosis may develop. Lack of motivation and depressed mood of the patient can negatively affect the prognosis of healing.

Stages

The healing of a femoral neck fracture is conditionally divided into several stages - this is directly a bone injury, a restorative and remodeling stage.

So, the first stage is the moment of injury, at which there is a violation of blood supply and a pathological process develops. Various mechanisms are involved - from inflammation to tissue necrosis. The less the circulatory system in the area of damage suffers, the better healing will occur.

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

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 restructuring of the fragment.

The formation of corns occurs as follows: in the area of the crack, new cellular structures begin to actively divide, there is an overabundance of them, which later serves as a corn base. Gradually, the corn changes its structure - from this moment they talk about the beginning of the "fusion" of the crack. The callus of the bone is transformed into a spongy fragment, calcium accumulates in it and strength increases.

Forms

A hip fracture happens:

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

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

Complications and consequences

The period of bone recovery with a fracture of the femoral neck can last up to six months or more. Forced restriction of mobility, lifestyle changes, prolonged inactivity negatively affect the psycho-emotional state of patients: people often become hostages of depression 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, and constipation is observed. The development of vascular thrombosis and congestive pneumonia is also not excluded.

All of the above complications are especially characteristic of senile patients. For them, forced physical inactivity quickly "becomes a habit", the desire for recovery is lost, and the necessary physical exercises are ignored. This, in turn, exacerbates the problem even more: lung congestion develops, heart failure develops, and a 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 of the fissures of the femoral neck

The main diagnostic technique for suspected femoral neck fractures is instrumental diagnostics:

• survey radiography;
• magnetic resonance and computed tomography.

Radiography is carried out in the anterior-posterior and lateral projection, 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 consider the injury - for example, if the patient has a severe form of osteoporosis.

If the problem is not visualized on x-ray, but the clinical picture suggests a fracture or crack, then magnetic resonance imaging is recommended. This method is considered to be 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 carried out, if necessary, a biochemical blood test.

Differential diagnosis

Differential diagnosis is 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 thigh.

Treatment of the fissures of the femoral neck

What to do if a person is injured? You cannot know for sure the extent of the injury - for example, it is a crack, a bruise or a fracture. Therefore, it is important to competently provide first aid 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;
• with severe pain, you need to give a tablet of Ibuprofen or Ketoprofen;
• you can not move the injured leg, so it is advisable to fix it with a splint;
• there is no need to remove shoes and clothes from the victim: on the contrary, it is better not to touch the limb until the arrival of medical specialists;
• if a person fell on the street in the cold season, then he must be covered to avoid frostbite;
• if it is required to transfer the victim, then this can be done only after immobilization of the limb, and only on a rigid stretcher;
• it is important to calm the fallen person, not to allow him to panic and move.

Thus, it is necessary to wait for the arrival of the medical team, or take the person to the emergency room on their own, using a stretcher (you can improvise - for example, knocked down boards or plywood).

It is imperative to treat a hip fracture, and sometimes it may be necessary for surgical intervention. Initially, the patient will be placed in a hospital, and the necessary examinations will be carried out. Next, the necessary procedures will be prescribed - in particular, massage, they will evaluate the possibility of moving on crutches. It is forbidden to lean on the injured leg: the attending doctor will decide for himself when the victim will be able to walk on his own again. [10]

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

Medications that a doctor may prescribe

Painkillers
Ibuprofen	The drug is used to quickly eliminate acute pain, since it cannot be taken for a long time, due to the negative effect on the digestive system. The dosage of Ibuprofen is up to 400 mg per dose, but not more than once every 4-6 hours.
Ketanov	Tablets are taken in 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 can be digestive disorders, pain in the head and abdomen. Long-term treatment increases the risk of bleeding.
Solpadein	Pain reliever based on paracetamol, caffeine and codeine. Not allowed for use for more than 3 days in a row. For severe pain, take 1-2 capsules every 5 hours, but not more than eight capsules per day. Side effects are often abdominal pain, nausea with vomiting, allergies, psychomotor agitation or drowsiness, kidney failure.
Diuretics
Veroshpiron	It is prescribed to relieve swelling from the injured area. Take the drug 1-2 times a day, adhering to the daily dosage of 50-100 mg. The course of admission is 2 weeks. Side effects: heart rhythm disturbances, 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
Anesthesia ointment	The agent is applied to the affected area daily, it is possible under a bandage. In the presence of an allergy 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 term of treatment is no more than two weeks. Possible side effects: dermatitis, itching, rashes, erythema.
Indovazin	Gel with analgesic and capillary-stabilizing action. It can be applied externally up to 4 times a day, the term of treatment is no more than 10 days. As a rule, the drug is well tolerated, rarely there is skin irritation in the area of application.
Preparations with chondroitin
Teraflex	The 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). Adverse symptoms are rare and are expressed mainly in dyspeptic disorders or allergic reactions.
Chondroitin complex	The drug accelerates the formation of callus. Capsules are taken orally, one piece three times a day for a month, then they switch to the reception regimen twice a day, for a long time. Side effects can be constipation, diarrhea, dizziness, general weakness, allergic reactions.

Vitamins and minerals

Vitamin and mineral preparations with calcium are a great way to improve bone structure, provide the body with all the necessary substances to accelerate the healing of a femoral neck fracture. For any bone damage, doctors advise taking calcium-containing products. And the absorption of this trace element is significantly increased if taken together with vitamins D and ascorbic acid. The following complex 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 the diet. It is good if the following products are present in the 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);
• marine products, sesame, pumpkin seeds, nuts (sources of zinc);
• fish oil, citrus fruits, kiwi fruit, berries, bell peppers (sources of vitamins D and C).

Physiotherapy treatment

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

• magnetotherapy;
• laser therapy;
• ultrahigh frequency therapy;
• massage;
• reflexology;
• hydrotherapy, balneotherapy.

Any of the proposed methods is applied in courses, from ten to twelve procedures. Treatment is desirable to repeat 3-4 times a year.

Alternative Treatment

Patients are ready to go to great lengths to speed up healing and return to normal life faster. Alternative methods of treatment are also widely used.

• To improve the "binding" of the bone, a powerful magnet is used, which is driven over the injury site 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 can be tumors, blood diseases, recent heart attacks or strokes.
• The use of onion broth inside helps a lot (a couple of medium onions are fried and then boiled in 1 liter of water for ten minutes). The drug is not filtered, consumed between meals, 200 ml three times a day.
• Every day, the damaged area is treated with fir oil, and they also eat ½ tsp. Crushed eggshell (twice a day, before breakfast and dinner).
• Eat 2-3 walnuts daily. They often include jelly (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, an essential component for healing bone fractures. To prepare the medicine, take 1 tbsp. L. Dry plant, pour 250 ml of boiling water, insist under the lid for 15-25 minutes. The infusion is filtered and taken three times a day for a third of a glass.
• A mixture of ground valerian root, St. John's wort and chamomile not only soothes, but also prevents the development of the inflammatory process in the damaged area. Take 1 tbsp. L. 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 each.

In addition, you can put lotions based on herbal mixtures:

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

If you add lard to these decoctions, then you can use the funds 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 medicines. Homeopathic medicines can be used for injuries in children and the elderly, they reduce the need for taking excessive doses of analgesics, shorten the healing period for bone fractures, and do not have side effects.

Homeopathic experts advise to pay attention to such remedies:

• Symphytum (Comfrey officinalis) - heals cracks and fractures, prevents problems with bone tissue fusion, relieves boring pain.
• Arnica - eliminates pain, significantly reduces the period of healing and recovery.
• Evpatorium - acts as a homeopathic analogue of Arnica, eliminates pain and bone "ache".
• Calcium Phosphoricum - is prescribed in a low potency (3d or 6d), allows you to absorb calcium, directing it to strengthen bone tissue. Accelerates the healing process of the femoral neck fracture.
• Ruta - suitable as a first aid drug for hip injuries, as well as for the treatment of poorly healing painful cracks.

There are not only those listed, but also other drugs that can alleviate the condition of the victim and speed up 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 injury. However, the above homeopathic remedies will prove to be effective for most patients who have received a hip fracture.

Surgery

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

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

Depending on the type of crack, specific structures are introduced into the bone - like spokes, pins or rods. Also, according to the indications, it may be recommended to replace the joint with a prosthesis - in partial or complete execution. [12]

With fractures of the femoral neck, the intervention is most often performed under X-ray observation: the articular capsule is not opened. Endoprosthetics is recommended only if there is an increased risk of complications.

Recovery after a hip fracture

After carrying out all the necessary therapeutic measures, a patient with a femoral neck fracture is sent to a rehabilitation center, where he will be offered the following recovery methods:

• Pain-relieving procedures - a combination of taking analgesics with physiotherapy and manual therapy. If necessary, it is recommended to wear a fixing orthosis - a device to reduce the degree of pain.
• The fight against physical inactivity - various preventive methods are practiced to prevent trophic disorders, cardiovascular pathologies, respiratory and digestive disorders. A special role is played by massage, hygiene procedures.
• Special physical education - this restorative method becomes relevant when the patient begins to feel an improvement in his condition. 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 the restoration of an adequate emotional state of the patient, which is especially important in relation to elderly patients.
• Changes in nutrition involve the saturation of the diet with mineral and vitamin substances - for example, calcium, silicon, which is necessary to speed up recovery and strengthen bone tissue.

All of these activities contribute to a significant reduction in the recovery period, which passes faster, and the patient has every chance to return to the normal rhythm of life.

Prevention

You can prevent the appearance of a crack in the femoral neck if you listen to the following recommendations:

• monitor nutrition, use high-quality and healthy products;
• competently organize the regime of work and rest;
• avoid hypodynamia and excessive overloads;
• avoid lifting too heavy objects;
• avoid smoking, drinking alcohol;
• fight overweight;
• adhere to safety regulations, both at work and at home;
• after 40 years, additionally take calcium-containing drugs, chondroprotectors;
• choose for yourself such clothes and shoes in which it would be convenient and safe to move around.

In old age, it is very important to minimize the risk of injury. It is desirable that the house does not have high thresholds, tucked-in carpets and rugs, for which a person can catch and stumble. Be sure to put a non-slip rubber mat on the bathroom floor, as well as attach handrails to the wall so that the old man can hold himself up from the toilet or bath.

Forecast

The femoral neck does not have a layer of periosteum. The blood supply to this bone section is not complete enough, so injuries here do not heal well. Insufficient nutrition often leads to defective bone fusion. After a while, the place of the crack is fixed by a dense scar from the connective tissue: this is called fibrous fusion. [13] The prognosis depends on many factors: the age and state of health of the patient, the location of the damage line, its depth and length. [14] In some adverse cases, a crack can cause disability.