The fractured neck of femur Fig 466

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Femoral neck fractures are common following falls among the elderly osteoporotic population. Fractures in this region present a considerable risk of avascular necrosis if the fracture line is intracapsular as the retinacula, which carry the main arterial supply, are torn. In contrast, extracapsular femoral neck fractures present no risk of avascular necrosis.

If the fracture components are not impacted the usual clinical presentation is that of shortening and external rotation of the affected limb. This occurs as the adductors, hamstrings and rectus femoris pull upwards on the distal fragment whilst piriformis, the gemelli, obturators, gluteus maximus and gravity produce lateral rotation.

The gluteal region (Figs 46.3 and 46.4)

The gluteal region is limited above by the iliac crest and below by the transverse skin crease—the gluteal fold. The fold occurs as the overlying skin is bound to the underlying deep fascia and not, as is often thought, by the contour of gluteus maximus. The greater and lesser sciatic foramina are formed by the pelvis and sacrotuberous and sacrospinous ligaments (Fig. 46.5). Through these, structures pass from the pelvis to the gluteal region.

Contents of the gluteal region (Fig. 46.4)

• Muscles: of the gluteal region include: gluteus maximus, gluteus medius, gluteus minimis, tensor fasciae latae, piriformis, gemellus superior, gemellus inferior, obturator internus and quadratus femoris (see Muscle index, p. 164).

• Nerves: of the gluteal region include the: sciatic nerve (L4,5,S1-3), posterior cutaneous nerve of the thigh, superior (L4,5,S1,2) and inferior gluteal (L5,S1,2) nerves, nerve to quadratus femoris (L4,5,S1) and the pudendal nerve (S2-4).

• Arteries: of the gluteal region include the: superior and inferior gluteal arteries. These anastomose with the medial and lateral femoral circumflex arteries, and the first perforating branch of the profunda, to form the trochanteric and cruciate anastomoses, respectively.

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