Outline:
Fracture of neck of femur is a kind of fracture occurring in the region from under the head of femur to the base of neck of femur. It is mostly seen in old people from 60 to 70 years of age, occasionally seen in the middle aged and juvenile. The old people's fracture may be caused even by minor injury due to osteoporosis and fragile neck of the femur. The typical gesture of injury is a fall down with the hip joint rotated and adducted, and the buttock first touching the ground. As for the youth and the middle aged, the fracture is mostly caused by violent force. According to different locations, the fracture can be classified into the fracture beneath the head, in the middle neck and at the base of the neck. The former two fractures are intracapsular type and the latter is extracapsular type.

According to the patterns of violence and the roentgenogram, fractures can be further divided into abduction and adduction types. The fracture line of the former is usually located in the middle neck or at the base with minor displacement or impaction of the fracture end. The collodiaphyseal angle becomes greater, and the inclination angle formed by the fracture line and the vertical line of longitudinal axis of femoral shaft is often less than 30°. The local shears force is smaller. It is of stability with little disturbance of blood supply and of higher healing rate.

So, the abduction type is of favorable prognosis. As for adduction type, the fracture line is commonly located beneath the head or in the middle neck with marked displacement of the fracture end. The collodiaphyseal angle becomes smaller, and the inclination angle formed by the fracture line and the vertical line of longitudinal axis of femoral shaft is often more than50°. There is little impaction in this kind of fracture, but in most cases there are displacement, and the distal end of fracture adducts and moves upward. The blood supply is seriously disturbed with lower healing rate and higher rate of ischemic necrosis of femoral neck. It is of an unfavorable prognosis.

Major points for diagnosis  
1. The first diagnosis is the fracture of the neck of the femur if an old person who experienced a fall complains of painful hip and inability to stand and walk.
 
2. A pain is in the deep part of hip aggravated on exertion and may radiate to the medial side of the thigh and the knee.
 
3. There is tenderness at the midpoint of groin with no evident local swelling. And there is percussion pain in great tuberosity and sole of the foot. The patient is unable to raise his diseased limb horizontally and stand up. For the fracture with marked displacement there may appear obvious deformities of flexion, adduction, extorsion and shortening. Extorsion deformity for intracapsular fracture is about 45° to 60° and for extracapsular fracture usually goes to 90°. Patients with minor fissure fracture can still walk or even ride a bicycle.   

4. Radiographic examination is regarded as a routine for patients with traumatic hip. The roentgenogram can confirm the location and type of fractures.

Treatment:  
For fresh fracture with no displacement or impacted fracture, reduction is not needed, but any movement should be strictly controlled for the injured limb. Fresh fracture with displacement should be treated with reduction and fixation as early as possible. For the old fracture, internal fixation with three-wing nail, or osteotomy for changing the line of weight carrying and artificial femoral head replacement may be applied. Children patients with fracture of neck of femur should be treated with steel pin or spiral nail fixation after reduction.
     
Reduction:    
The patient with fresh adduction fracture should receive gentle manual reduction under effective analgesia or anesthesia if the general condition permits. The patient lies on his back with one assistant fixing the patient's pelvis, the operator holds popliteal fossa with one elbow and holds the ankle of the injured limb with the other hand to flex the patient's hip and knee to 90°. The operator keeps lifting up with great force. As the fracture end is supposed to be drawn off by traction, the operator abducts and rotates internally the injured limb, then straightens the lower limb and fixes it in a position of 30°abduction while the traction is continued. After reduction the palmar test may be performed. If the extortion deformity of the injured limb disappears, it shows that the reduction has been gained (see Fig. 15). A gradual reduction through skeletal traction of tibia tubercle may also be used.

Fixation:     
Fracture without displacement or impacted fracture is treated with restriction of motion with T-shape shoes or skin traction for 6 to 8 weeks. Fracture with displacement may be fixed with longer splints on the lateral side of the diseased limb or fixed with continuous traction, or three-wing nail, or steel pins, with the diseased limb in an abduction and neutral position or in an abduction and slight extortion position.

Functional exercise:     
After reduction and fixation, the patient should be encouraged to practice functional activities of upper limbs and the normal lower limb in an appropriate range. But he should avoid turning over on bed, taking lateral recumbent position or cross-legged sitting position. The patient should be encouraged to do deep breathing, especially deep abdominal breathing, to pat himself on the chest actively to promote expectoration, to put air cushion or foam rubber cushion for prevention of complication due to long term bed rest. Slight movement of the ankle and the joints of the affected limb are advisable, then contractile activities of quadriceps muscle of thigh can be carried out gradually.

As soon as the fracture is healed, the fixation should be removed, and the patient may practice movements of the hip and knee joints, mainly the flexion and extension of the joints on the bed, but the excessive adduction or rotation should be avoided. When the fracture is very well healed through confirmation of X-ray photographs, the patient will be asked to practice walking and bearing load. Within 2 to 3 years, excessive weight bearing on the affected hip is forbidden. Periodical roentgenogram should be done to help to determine whether the ischemic necrosis of femoral hand is present or not.

Herbal therapy:  
Internal treatment based on syndrome differentiation
 
1. In the early stage
Main symptoms and signs:
Pain in the hip, abdominal distension and fullness, nausea and vomiting, difficulty in urination and defecation, mental irritability and insomnia.

Therapeutic methods:
Promoting blood flow to remove stasis, reducing heat by purgation.
 
Recipe and herbs:
Modified Fuyuan Huoxue Decoction and Dacheng Decoction. Specifically, Zhidahuang  (Radix et Rhizoma Rhei Praeparata )20 g, Zhike (Fructus Citri Aurantii )20 g, Dangguiwei ( Extremitas Radix Angelicae Sinensis )15 g, Chaihu (Radix Bupleuri)12 g, Tianhuafen (Radix Trichosanthis)12 g, Poxiao (Sat Glauberis) (to be taken following its infusion with the hot decoction )10 g, Sumu (Lignum Sappan)10 g, Chenpi (Pericarpium Citri Reticutatae)10 g, Houpo (Cortex Magnoliae Officinalis)10 g, Honghua ( Flos Carthmi )10 g, Taoren (Semen Persicae)10 g and Gancao (Radix Glycyrrhizae )3 g.

 2. In the middle stage
Main symptoms and signs:
Alleviated pain in the hip, muscular atrophy, and failure of the bone in union.

Therapeutic methods:
Strengthening tendons and muscles and reuniting the bone.

Recipe and herbs:
Modified Zhuangjin Xugu Pillet. Specifically, Shudihuang (Radix Rehmanniae Praeparata)15g, Gusuibu (Rhizoma Drynarii)15g, Danggui (Radix Angelicae Sinensis)10 g, Buguzhi (Fructus Psoraleae Corylifoliae)15 g, Tusizi (Semen Cuscutae)10 g, Dangshen (Radix Codonopsitis Pilosulae)10 g, Liujinu (Herba Artemisiae Anomalae)10 g, Xuduan (Radix Dipsaci)15 g, Wujiapi (Cortex Acanthopanacis Gracilistyli Radicis)15 g, Chuanxiong (Rhizoma Ligustici Chuanxiong)10 g, Baishaoyao (Radix Paeoniae Alba )10 g, Duzhong ( Cortex Eucommiaeulmoidis )10 g, Guizhi (Ramulus Cinnamomi Cassiae )6 g and Gancao (Radix Glycyrrhizae )5 g.

3. In the late stage
Main symptoms and signs:
Rigidity of the joint, weakness of the limbs, osteoporosis and emaciation.

Therapeutic methods:
Replenishing qi and blood, relaxing tendons and activating collaterals.

Recipe and herbs:
Modified Shiquan Dabu Decoction. Specifically, Renshen (Radix Ginseng)10 g, Huangqi (Radix Astragali seu Hedysari)15 g, Baizhu (Rhizoma Atractylodis Macrocephalae)10 g, Fuling (Poriae) l0 g, Danggui ( Radix Angelicae Sinensis ),10 g, Baishaoyao (Radix Paeoniae Alba)10 g, Shudihuang (Radix Rehmanniae Praeparata)12 g, Rougui (Cortex Cinnamomi Cassiae)9 g, Chuanxiong ( Rhizoma Ligustici Chuanxiong)10 g and Gancao (Radix Glycyrrhizae)6g.