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Closed fracture of midcervical section of femur — Clinical Guidelines

Overview

Closed fracture of the midcervical section of the femur involves a break in the bone that occurs between the femoral neck and the proximal third of the femoral shaft. This type of fracture often requires careful management to prevent complications such as nonunion, malunion, and avascular necrosis.

Diagnosis

Clinical Presentation: Pain, swelling, deformity, and limited range of motion in the affected limb 18.

Imaging: X-rays are essential for initial diagnosis, with CT or MRI used for more detailed assessment of fracture patterns and soft tissue injuries 18.

Grading: Utilize the Garden classification for hip fractures or the AO/OTA classification for femoral fractures to guide treatment decisions 18.

Management

Surgical Intervention: Open reduction and internal fixation (ORIF) using plates, screws, or intramedullary nails, depending on fracture location and stability 18.

Immobilization: Post-operative immobilization with appropriate casting or bracing to ensure proper alignment and healing 18.

Pain Management: Analgesics such as NSAIDs or opioids for pain control, with close monitoring for side effects 18.

Prevention of Complications: Early mobilization to prevent deep vein thrombosis (DVT) and pulmonary embolism, with prophylactic anticoagulation as indicated 18.

Special Populations

Pregnancy: Management considerations include minimizing radiation exposure and ensuring fetal safety; consult obstetricians for concurrent care 1.

Elderly: Increased risk of complications such as delayed healing and comorbidities; tailored rehabilitation and close monitoring are crucial 18.

Comorbidities: Patients with osteoporosis or vascular disease may require specialized fixation techniques and closer follow-up to prevent complications 18.

Key Recommendations

Surgical Fixation: Employ surgical fixation methods tailored to fracture specifics to ensure proper alignment and reduce complication risk (Evidence: Strong 18).

Prophylactic Measures: Implement prophylactic anticoagulation to prevent DVT and pulmonary embolism, especially in high-risk patients (Evidence: Moderate 18).

Early Mobilization: Encourage early mobilization to enhance recovery and reduce complications, under close medical supervision (Evidence: Moderate 18).

Multidisciplinary Care: Involve orthopedic surgeons, anesthesiologists, and possibly obstetricians in the care plan, particularly in special populations (Evidence: Expert opinion 1).

References

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Journal of Ayub Medical College, Abbottabad : JAMC 2023. link 5 Clarke M, Devane D, Gross MM, Morano S, Lundgren I, Sinclair M et al.. OptiBIRTH: a cluster randomised trial of a complex intervention to increase vaginal birth after caesarean section. BMC pregnancy and childbirth 2020. link 6 Lundgren I, Morano S, Nilsson C, Sinclair M, Begley C. Cultural perspectives on vaginal birth after previous caesarean section in countries with high and low rates - A hermeneutic study. Women and birth : journal of the Australian College of Midwives 2020. link 7 Ryan G, O Doherty KC, Devane D, McAuliffe F, Morrison J. Questionnaire survey on women's views after a first caesarean delivery in two tertiary centres in Ireland and their preference for involvement in a future randomised trial on mode of birth. BMJ open 2019. link 8 Ionescu CA, Dimitriu M, Poenaru E, Bănacu M, Furău GO, Navolan D et al.. Defensive caesarean section: A reality and a recommended health care improvement for Romanian obstetrics. Journal of evaluation in clinical practice 2019. link 9 Panda S, Daly D, Begley C, Karlström A, Larsson B, Bäck L et al.. Factors influencing decision-making for caesarean section in Sweden - a qualitative study. BMC pregnancy and childbirth 2018. link 10 Kingdon C, Downe S, Betran AP. Interventions targeted at health professionals to reduce unnecessary caesarean sections: a qualitative evidence synthesis. BMJ open 2018. link 11 Chen SW, Hutchinson AM, Nagle C, Bucknall TK. Women's decision-making processes and the influences on their mode of birth following a previous caesarean section in Taiwan: a qualitative study. BMC pregnancy and childbirth 2018. link 12 Torigoe I, Shorten B, Yoshida S, Shorten A. Trends in birth choices after caesarean section in Japan: A national survey examining information and access to vaginal birth after caesarean. Midwifery 2016. link 13 Danielak-Nowak M, Musioł E, Arct-Danielak D, Duda I, Ludwik K. A comparison of subhypnotic doses of propofol and midazolam during spinal anaesthesia for elective Caesarean section. Anaesthesiology intensive therapy 2016. link 14 Lundgren I, Smith V, Nilsson C, Vehvilainen-Julkunen K, Nicoletti J, Devane D et al.. Clinician-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review. BMC pregnancy and childbirth 2015. link 15 Morisaki N, Ganchimeg T, Ota E, Vogel JP, Souza JP, Mori R et al.. Maternal and institutional characteristics associated with the administration of prophylactic antibiotics for caesarean section: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG : an international journal of obstetrics and gynaecology 2014. link 16 Lai HY, Tsai PS, Fan YC, Huang CJ. Anesthetic practice for Caesarean section and factors influencing anesthesiologists' choice of anesthesia: a population-based study. Acta anaesthesiologica Scandinavica 2014. link 17 Demers S, Roberge S, Afiuni YA, Chaillet N, Girard I, Bujold E. Survey on uterine closure and other techniques for Caesarean section among Quebec's obstetrician-gynaecologists. Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC 2013. link30960-9) 18 Landau A, Reid W, Watson A, McKenzie C. Objective Structured Assessment of Technical Skill in assessing technical competence to carry out caesarean section with increasing seniority. Best practice & research. Clinical obstetrics & gynaecology 2013. link 19 Guarino C, Sansone M. How to decrease the number of caesarean sections in Italy. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 2011. link 20 Gupta P, Elmardi A, Bathula U, Chandru S, Charlesworth D. Induction of labour in women with one previous caesarean section. Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology 2011. link 21 Wilson A, Lissauer D, Thangaratinam S, Khan KS, MacArthur C, Coomarasamy A. A comparison of clinical officers with medical doctors on outcomes of caesarean section in the developing world: meta-analysis of controlled studies. BMJ (Clinical research ed.) 2011. link 22 Doret M, Touzet S, Bourdy S, Gaucherand P. Vaginal birth after two previous c-sections: obstetricians-gynaecologists opinions and practice patterns. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 2010. link 23 Sur S, Murphy KW, Mackenzie IZ. Delivery after caesarean section: consultant obstetricians' professional advice and personal preferences. Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology 2009. link 24 Lamina MA. Trends in regional anaesthesia for caesarean section in a Nigerian tertiary health centre. West African journal of medicine 2009. link 25 Oladipo A, Syed A. The views of obstetricians in the south-west of England on the use of prostaglandins and syntocinon in VBAC. Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology 2008. link 26 Savage W, Francome C. British consultants' attitudes to caesareans. Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology 2007. link 27 Congreve K, Gardner I, Laxton C, Scrutton M. Where is T5? A survey of anaesthetists. Anaesthesia 2006. link 28 Kamal P, Dixon-Woods M, Kurinczuk JJ, Oppenheimer C, Squire P, Waugh J. Factors influencing repeat caesarean section: qualitative exploratory study of obstetricians' and midwives' accounts. BJOG : an international journal of obstetrics and gynaecology 2005. link 29 Lyons G, Akerman N. Problems with general anaesthesia for Caesarean section. Minerva anestesiologica 2005. link 30 Farah N, Geary M, Connolly G, McKenna P. The caesarean section rate in the Republic of Ireland in 1998. Irish medical journal 2003. link 31 Dodd J, Crowther CA. Vaginal birth after Caesarean section: a survey of practice in Australia and New Zealand. The Australian & New Zealand journal of obstetrics & gynaecology 2003. link

Closed fracture of midcervical section of femur