FemoralNeckFractures-achangingparadigmDepartment of Orthopaedics-Mangmang Chenl Definitionl 1 one of the most commonly treated orthopaedic injuries,3.58%l 2 increasing number of femoral neck fractures.l Longer lifespan of patientsl Increased activity of patientsl Osteoporosis3(這里可以放一些圖片 )Demographics:Most 75y Over 1 million femoral neck fractures were treated in the 65 year old population in the US Between 1991-2008.(有一張圖片最好，地圖分布圖 )Hip Fractures:DemographicsVery heterogeneous patient populationCan ranger from independent mobile,healthy elderly patientsVary degress of dementia(1分 38的時候看不懂 )110140，average127。140coxavalgus50unstableclassificationthedegreeofdisplacementoffractureType :incomplete fracture 5Type II： complete fracture,Not displaced 18Type III： complete fracture ， partially displaced 28Type IV： complete fracture ,completely displaced 38 -1994Generally,the greater the displacement,the greater risk ofGardenclassificationClinicalmanifestationanddiagnoseMedical history： history of traumaPhysicalsign： 1.malformation： extorsiondeformity-45 60。2.pain： localtenderness;theaxialtapspain-positive。3.limbshortening： thegreatertrochanter,shiftuplimbshorteningBryanttriangle； bottommargin-shortenHorizontalpositionTheapexofthegreatertrochanter,abovetheNelatonslineLateralpositionImageologicalexaminationlX-ray： Pelvis AP， hip joint AP,Ll3-dimensional CTlMRI： incipient fractureX-ray： hardenedzone(bottomofthefemoralneck)MRI： weakersignalFemoral Neck Fracture Differentialdiagnosisneck F Trochanteric FExtorsion deformity 45 60 90 Local swelling rare obviousecchymosis rare commonHipfracturesmanagement:Goalsl1 restore function to preopertive state(if possible)l2 one operation for lifel3 lowest complication ratel （放幾張并發癥的圖片，舉例）Hipfracturesmanagement:optionsl1 open reduction and internal fixationl2 close reduction and internal fixationl3hemiarthroplastyl Unipolarl Bipolar(可以放一些圖片 )l4Total hip arthroplasty etc.TreatmentThe therapeutic regime depend on1.which part2.the degree of displacement3.age4.etcOTHER:1what was their prior activity level2what co-morbidities do they have3will they be compliant with rehab protocol(such dislocation precautions)Conservationtreatment： notdisplaced;impactedfracture;intoleranceofoperationl Traction/anti-rotation shoe： lie in bed 812wl 3m partial weight-bearing walking， 6m total weight-bearing walkingConservationtreatmentl Reexamine the X-ray(bedside);l Ifoperationl Deep venous thrombosisl Attach importance to nursing work-prevention measures:decubitus ulcer、 hypostatic pneumonia、 urinary tract infection,depressive disorder;ect(complication)。Operativetreatment:displaced;unstablel IF： stable condition;no chronic disease;high functional requirements;bone quality;younger;minimally displaced fracturesl THA： 65;chronic disease;Osteoporosis;subcapital;poor patient complianceIF：X-ray:close/open,reductionIF;percutanousl X-ray:anatomicalreductionl BenefitsofIF:l Disadvantages:Whatsthedefiniteconstraindications:PresenceofarthritisDisplacedfractureinelderlypeople1slidinginternalfixation2compressiveinternalfixation1flexjoint90， tractalongtheaxisofthefemur2internalrotation,abduction3keepinternalrotation,abduction， straightleg4adduction,keepinternalrotationHowtoReductslidinginternalfixationSlidebear load-compression。 Smith-Petersen nailDestruct the blood supply aseptic necrosisNo compression ununioncompressiveinternalfixationlReliable fixation， slight injury to soft tissue， less damage to blood supply（ DHS)dynamichipscrewcompressiveinternalfixationcompressiveinternalfixationBonegrafting IFv free bone graftv pedicle bone graft：vSartorius musculoskeletal flapquadratus femoris muscle pedicle bone graftHipjointreplacementl Subcapital in elderly people、 old fracture、 nonunion/AVN(avascular necrosis of femoral head)l Total hip arthroplastyl Hemiarthroplastyl Unipolarl Bipolarl Historically,higher dislocation ratel More invasiveHemiarthroplastyTotal hip arthroplastyExpectation20-30% patient will