The Orthopaedic Enigma: A Simplified Classification

摘要

" The beginning of the end", " The unsolved fracture"- two statements constantly used to describe the most common, yet the most disturbing fracture in the human body -- THE FRACTURE NECK OF FEMUR! This fracture commonly occurs in the elderly, with an increased incidence in women, following a mechanical fall. It is one of the commonest scenarios encountered by junior doctors in training, which is very easily diagnosed clinically by an externally rotated and shortened lower limb on the affected side. It requires immediate attention, as a delay just adds on to an increase in morbidity. The aim of treatment is to get the patient back to that state of mobility which they had prior to the injury. Surgical stabilisation of the fracture along with early mobilisation leads to a decrease in morbidity. This article mainly aims at simplifying the various classifications of this fracture, making it easy for junior doctors to aid in its aggressive treatment as early as possible to prevent morbidity. Fracture Neck Of Femur The femoral neck, as mentioned before is the commonest site of fractures in the elderly. It is therefore very important for us to know how to identify, diagnose and classify them, to decide on the treatment plan. Ever since man discovered this fracture, there have been many classifications put forward. For a classification system to be useful, it must be fairly simple and easily applied. Anatomical Factors The structure of the head and neck of femur is developed for the transmission of body weight efficiently, with minimum bone mass, by appropriate distribution of the bony trabeculae in the neck. The tension trabeculae and the compression trabeculae along with the strong calcar femorale on the medial cortex of the neck of femur, form an efficient system to withstand load bearing and torsion, under normal stresses of locomotion and weight bearing. The Fibrous Capsule The fibrous capsule, is the most important structure, which determines the type of fracture and its outcome. The capsule is strong and dense, and is attached above to the acetabular margin 5 – 6 mm beyond its labrum, in front to the outer labral aspect and near the acetabular notch, to the transverse acetabular ligament and the adjacent rim of the obturator foramen. It surrounds the femoral neck and is attached anteriorly to the intertrochanteric line, superiorly to the base of the femoral neck, posteriorly c.1cm above the intertrochanteric crest, and inferiorly to the femoral neck near the lesser trochanter. The capsule is thicker anterosuperiorly, where maximal stress occurs, particularly in standing, posteroinferiorly it is thin and loosely attached.It is based on this capsular attachment that fractures of the neck of femur are classified as: INTRACAPSULAR: That is within the capsular attachment. EXTRACAPSULAR: That is outside the attachment of the capsule Intracapsular Fracture Neck Of Femur These are classified as: Subcapital : That is below the head of femur. Trans cervical: That is through the neck of the femur. Basal. “GARDEN'S CLASSIFICATION”, is a well known and accepted classification to comment on the stability and displacement of intracapsular fractures. GRADE 1: Incomplete impacted fracture in valgus malalignment. ( Generally stable ) GRADE 2: Complete but undisplaced fracture. GRADE 3: Incompletely displaced fracture in varus malalignment. GRADE 4: Completely displaced fracture with no engagement of 2 fragments.