Symptoms

In the foreground of the complaints are strong pains, which are movement-dependent and become even worse with passive hip flexion. Often there is also a malposition of the leg in the hip. This is also a diagnostic sign of the fracture process.

Typically, a completely displaced fracture, for example, results in a shortening of the affected leg and external rotation. If the fracture is not displaced, these malpositions may not occur. In addition, the affected leg can no longer be loaded due to the severe pain.

Diagnostics

In addition to the medical history, if this is still possible due to the pain, the clinical examination and the examination of possible malpositions of the leg serve as an orientation. However, in order to make the final diagnosis, x-rays in two planes are indicated. If the x-rays are taken correctly, they show the fracture gap and allow conclusions to be drawn about the displacement and the necessary therapy.

Fractures of grade Pauwels I can be treated conservatively, due to their stability and because the fracture ends are not displaced. The conservative therapy consists of a partial load with approx. 20 kg of crutches for about 6 weeks.

In order not to overlook a possible tilting of the fractures, regular X-ray checks should be performed after 7, 14 and 21 days. Femoral neck fractures of the classification Pauwels II or III have a significantly increased risk of instability and displacement. For this reason these fractures should always be treated surgically.Depending on the patient’s age and mobility, the therapy is performed either with a prosthesis or with a hip head preserving device:

Surgical treatment of femoral fractures is generally preferable to conservative treatment, for example with a plaster cast.

On the one hand, rehabilitation can generally be started earlier and the leg can be loaded earlier, while on the other hand the complication rate is significantly lower. The surgical treatment of a femur fracture is performed under general anesthesia. The surgery of a femoral shaft fracture itself is usually performed in adults using medullary screws.

However, more complicated fractures, such as comminuted or open fractures, or femoral fractures in polytraumatized patients are first treated with an external fixator, which is replaced by an intramedullary nail when the patient’s condition or the conditions in the wound area improve. Fractures in the femoral neck area pose greater risks to the patient, as good blood supply to the femoral head is often no longer ensured. For patients over 65 years of age, a total endoprosthesis (TEP), i.e. the complete replacement of the joint, is usually the procedure of first choice.

Young patients, on the other hand, usually resort to a hip-head preserving measure, such as dynamic hip screw or lag screw osteosynthesis. The prognosis here is generally quite good. Since the risk of thrombosis is significantly increased by immobilization of the leg, each patient is prescribed heparin.

This is injected subcutaneously, i.e. under the skin. Compression stockings, compression bandages and the earliest possible exercise also help to further reduce the risk of a blood clot (thrombus) forming. Finally, intensive rehabilitative follow-up treatment should be started as early as possible under follow-up X-ray monitoring to ensure mobility and mobility in everyday life and to strengthen the muscles.

Depending on the operation, this is done step-by-step, first with the aid of crutches or under immediate full weight bearing. Additional measures such as cold treatment for the area of operation or ergotherapy can also be applied. As with any other bone, a distinction is made between two types of possible fracture healing in femur fractures; a primary and a secondary.

Primary or direct fracture healing occurs when either the periosteum remains intact (so-called greenwood fracture) or the fracture ends remain in contact (as is the case after surgery, for example). In the course of the fracture healing process, inflammatory cells, hormones and growth factors first enter the fracture gap with the blood. A bruise (haematoma) forms.

This ultimately results in connective tissue that is rich in blood vessels. As the process continues, bone-forming cells attach themselves to the vessels and begin to connect both ends of the bone. After only about 3 weeks, the bone is largely functional again.

If the above-mentioned conditions for primary fracture healing are not met, secondary (indirect) fracture healing begins. Here, too, a bruise is initially formed and, once the inflammation has subsided, vascular connective tissue gradually develops – the so-called soft callus, which is an initial bridging of the fracture gap. Specialized cells begin to break down dead bone tissue and build new bone substance.

This process takes about 4-6 weeks. The decisive difference to primary fracture healing is the mineralization of the callus through the incorporation of calcium, which now takes place. At first, braided bone forms in the gap, the framework of which is still undirected.

It gradually replaces the connective tissue. This takes another 3-4 months in adults. In the months that follow, the bone is remodeled into lamellar bone and its original structure is restored. Bones have a considerable regenerative capacity and, if treated well, heal smoothly and completely without scarring.