Basal Neck Fracture Pseudarthrosis

Internal Fixation

Fig. 99. Documentation of a neck fracture on a.-p. films with the limb in internal rotation.

This 45-year-old patient fell from a tree and injured his hip; a. The initial a.-p. film has not been properly taken as the limb had been placed in external rotation. The greater trochanter is projected over the neck and obscures the fracture; b. The fracture becomes only evident with the limb in internal rotation b

Shortening And External Rotation Limb

Fig. 100. Documentation of a neck fracture in a film taken in external rotation.

This 82-year-old woman fell and injured her right hip. After the fall she was able to walk;

a. On the initial a.-p. film correctly taken in internal rotation no fracture was apparent;

b. The fracture became evident two days later when the radiologist recommended a radiograph to be taken in external rotation. An internal fixation with cannulated screws was done b b b a

Fig. 99. Documentation of a neck fracture on a.-p. films with the limb in internal rotation.

This 45-year-old patient fell from a tree and injured his hip; a. The initial a.-p. film has not been properly taken as the limb had been placed in external rotation. The greater trochanter is projected over the neck and obscures the fracture; b. The fracture becomes only evident with the limb in internal rotation

Fig. 100. Documentation of a neck fracture in a film taken in external rotation.

This 82-year-old woman fell and injured her right hip. After the fall she was able to walk;

a. On the initial a.-p. film correctly taken in internal rotation no fracture was apparent;

b. The fracture became evident two days later when the radiologist recommended a radiograph to be taken in external rotation. An internal fixation with cannulated screws was done

Pseudarthrosis Post Fracture Femur Neck

Fig. 101. Radiographs of a patient with a cortication of the proximal fracture surface (Kazar, 1963). 51-year-old patient; a. 10 months after the injury the femoral neck holds the in varus tilted head due to impaction of the calcar femorale; b. 10 years later a tight pseudarthrosis has developed. The head is vascularized, its density is identical with that of the surrounding bony structures, the fracture surface has sealed off. The contour of the head and the coxofemoral joint are almost unchanged. The greater trochanter is high riding. The pseudarthrosis has been caused by the wear of the calcar and the fact that the head is in contact with the lesser trochanter. The patient has used a cane for all these years, but his symptoms have increased over the past year. In the presence of a living femoral head an internal fixation would still have been possible after 10 months after the original injury, at the time when the chance for consolidation of the pseudarthrosis was still good (See Figs. 120. a-d and 140)

Hip Fracture Garden Valgus

Fig. 102. Remote Garden-I fracture.

This 69-year-old woman injured her right hip during a fall 6 weeks ago. She continued walking; a. A specialist interpreted the radiographs taken in an ambulatory facility as being negative; b, c. 6 weeks later the patient was admitted to a hospital on account of increasing pain; d. The fracture was interpreted as being a Garden-I and was fixed with cannulated screws. It is debatable whether the internal fixation after such a long time was still indicated; e. Radiograph of the pelvis shows the right neck in a valgus position when comparing to the left. The lateral film (c) shows a posterior tilt with a posterior step (arrow). Posteriorly the S-shape is interrupted (arrow), becomes crescent shaped. The fracture surfaces and the corners are rounded off. One cannot exclude that this fracture had been older than 6 weeks (For explanations of "S" shapes see Fig. 179)

Fig. 102. Remote Garden-I fracture.

This 69-year-old woman injured her right hip during a fall 6 weeks ago. She continued walking; a. A specialist interpreted the radiographs taken in an ambulatory facility as being negative; b, c. 6 weeks later the patient was admitted to a hospital on account of increasing pain; d. The fracture was interpreted as being a Garden-I and was fixed with cannulated screws. It is debatable whether the internal fixation after such a long time was still indicated; e. Radiograph of the pelvis shows the right neck in a valgus position when comparing to the left. The lateral film (c) shows a posterior tilt with a posterior step (arrow). Posteriorly the S-shape is interrupted (arrow), becomes crescent shaped. The fracture surfaces and the corners are rounded off. One cannot exclude that this fracture had been older than 6 weeks (For explanations of "S" shapes see Fig. 179)

Mid Femoral Neck

Fig. 103. Two separate fractures of the femoral neck.

84-year-old woman, her history could only be given by relatives stating that the patient fell on the day of admission and injured her right hip; a, b. The initial radiographs show two fractures, one mid neck and one basal neck fracture (arrows). The basal fracture is in varus and partly obliterated and caudally remodelled, therefore remote. However, the mid neck fracture is fresh; c. 4 months after internal fixation with cannulated screws the mid neck fracture consolidated

Fig. 103. Two separate fractures of the femoral neck.

84-year-old woman, her history could only be given by relatives stating that the patient fell on the day of admission and injured her right hip; a, b. The initial radiographs show two fractures, one mid neck and one basal neck fracture (arrows). The basal fracture is in varus and partly obliterated and caudally remodelled, therefore remote. However, the mid neck fracture is fresh; c. 4 months after internal fixation with cannulated screws the mid neck fracture consolidated

Femoral Neck Fracture Mri Falling

Fig. 104. Concomitant femoral neck and pubic ramus fracture.

75-year-old woman had a fall and injured her left hip. 3 months previously she had been treated for a right per-subtrochanteric fracture with a Jewett nail; a. On the basis of the original radiographs a pubic ramus fracture was diagnosed; b, c. At the 6 week follow-up examination the patient was symptom-free and no neck fracture was recorded. 3 weeks later she was admitted being unable to walk; d. Radiographs showed a remote left neck fracture with smooth surfaces (arrow). She was treated with a hemiarthroplasty. Reevaluation of the original a.-p. radiographs (b) raised the suspicion of a fracture in spite of the external rotation: interruption of the cortex medially as well as laterally and varus kinking of the Adam's arch and a flattening of the lateral contour (S) (upper arrow). Also in the lateral film (c) an anterior step (arrow) is visible; it should have led to a suspicion of a fracture. Additional examination would have most probably led to a diagnosis of a fracture. It is possible that the right sided not yet consolidated per-subtrochanteric fracture and a break of the left pubic ramus may have distracted the treating physician. The per-subtrochanteric fracture had rendered difficult a comparison of both hips and the pubic ramus fracture interfered with the assessment of Shenton's line

Fig. 104. Concomitant femoral neck and pubic ramus fracture.

75-year-old woman had a fall and injured her left hip. 3 months previously she had been treated for a right per-subtrochanteric fracture with a Jewett nail; a. On the basis of the original radiographs a pubic ramus fracture was diagnosed; b, c. At the 6 week follow-up examination the patient was symptom-free and no neck fracture was recorded. 3 weeks later she was admitted being unable to walk; d. Radiographs showed a remote left neck fracture with smooth surfaces (arrow). She was treated with a hemiarthroplasty. Reevaluation of the original a.-p. radiographs (b) raised the suspicion of a fracture in spite of the external rotation: interruption of the cortex medially as well as laterally and varus kinking of the Adam's arch and a flattening of the lateral contour (S) (upper arrow). Also in the lateral film (c) an anterior step (arrow) is visible; it should have led to a suspicion of a fracture. Additional examination would have most probably led to a diagnosis of a fracture. It is possible that the right sided not yet consolidated per-subtrochanteric fracture and a break of the left pubic ramus may have distracted the treating physician. The per-subtrochanteric fracture had rendered difficult a comparison of both hips and the pubic ramus fracture interfered with the assessment of Shenton's line

Shenton Line Neck Femur FractureFemur Garden

Fig. 105. Overlooked and incorrectly treated Garden-II fracture.

This 60-year-old woman injured her left hip during a fall; a, b. Based on the radiographs taken at the time of admission the radiologist voiced a suspicion of a neck fracture. This led to additional examinations; c. Only conventional tomograms were done and interpreted as being negative. The patient was mobilized. At the day before discharge (5th day after injury) the hip pain increased considerably; d, e. Radiographs showed a displaced fracture (a.-p.: evident varus position, lateral: slight antecurvature). In retrospect, the original a.-p. film (a) show a slight intraosseous condensation at the cortex. The trabecular structure is interrupted on several places corresponding to the later visible fracture line, particularly cranially; f, g. In spite of the fact that only a displacement in varus was present, a forceful maneuver at reduction was also performed in the sagittal plane. Forced internal rotation led to a recurvatum and a faulty internal fixation was done (screws lie too posterior); h, i. An early loss of reduction was the consequence followed by a septic arthritis. The treatment of the undisplaced fracture ended with a Girdlestone resection!

4 years later the patient was admitted for a different condition; j. During examination necessitated by the symptoms due to the Girdlestone resection, the examiner was able to pull the femur distally under fluoroscopy; k. Based on this finding a THR was done; l. Repeated dislocations occurred in the postoperative period; m. The patient was reoperated (exchange of head component). The septic process recurred; n. At the end all components were removed

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