Femoral Neck Frx: Techniques of Closed Reduction

- See: Accetable Reduction Parameters

- Discussion:
    - always attempt closed reduction before open reduction;
    - evaluation of the lateral x-ray after reduction to evaluate posterior comminution of the femoral neck is critical;
    - posterior comminution leads to the loss of a butressing effect posteriorly, w/ subsequent loss of reduction and non-union;
           - majority of patients with non union, have posterior comminution;
           - inferior comminution is also important;
    - as noted by Weinrobe, et al (1998), major relative risk of redisplacement of femoral neck fractures correlates with initial inferior fracture offset and varus angulation;
           - the take home message is that a non anatomic reduction will often lead to postoperative displacement;
           - similar findings were published by Chua, et al (1998), who noted that varus angulation was the biggest predictor of early fixation failure;
 - references:
Predicting the Mechanical Outcome of Femoral Neck Fractures Fixed with Cancellous Screws: an in vivo study.
Predictors of early failure of fixation in the treatment of displaced subcapital hip fractures.

- Leadbetter Technique: (preferred technique)
    - flex the hip to 90 deg, w/ slight adduction, and apply traction in line with the femur;
          - next, while maintaining traction, apply internal rotation to 45 deg;
          - idea is that when the hip is flexed to 90 deg (quadriped position) all muscles about the hip are maximally relaxed;
                 - further internal rotation also relaxes the Y ligament;
                 - by having these structures relaxed, reduction is possible;
                 - finally, full flexion and adduction "books open" the frx site which then allows the reduction to procede;
    - the leg is slowly brought into slight abduction and full extension, while maintaining traction and internal rotation;
    - heel palm test:
          - the surgeon holds both heels in his palms with both legs in abduction and internal rotation;
                 - internal rotation is then released, and the surgeon notes the amount of external rotation of both feet;
                 - if the fractured site has significantly more external rotation than the non injured side, then reduction is probably not satisfactory;
                 - if the injured side, stays in internal rotation, then the reduction is complete;
    - if this maneuver, does not reduce hip satisfactorily, then proceed w/ open reduction rather than repeated attempts with greater force, which may damage blood supply to femoral head;
    - references:
          - A treatment for fractures of the neck of the femur
          - Closed reduction of fractures of the neck of the femur.  

- Closed Reduction of Hip Fracture in Extension:

    - apply a folded sheet around the proximal thigh (as high as possible);
    - apply longitudinal traction as well as lateral traction and then apply internal rotation and abduction;
    - the leg is then brought back into slight abduction and neutral abduciton;
    - it is also useful to apply posteriorly directed to the upper tight;
    - Wellmerling Technique:
           - patient is supine on the frx table w/ the leg in slight external rotation;
           - initially only enough traction is applied to bring the legs out to equal length, and then additional traction is applied to achieve 1-2 cm of frx distraction;
           - the surgeon stands in front of the injured leg and applies a "wrestling hold" with one forearm over anterior thigh near the groin and the other forearm underneath the thigh near the popliteal space,  with the surgeon's hands lock together;
           - reduction is achieved w/ application of slight internal rotation, and by elevation of the knee by the surgeon's forearm (while the other forearm applies downward pressure);
    - references:
           A new treatment for intracapsular fractures of the neck of the femur and Legge-Calve-Perthes disease.    
           Closed operation for intracapsular fracture of the neck of the femur.    
           Critical analysis of the treatment of fractures of the neck of the femur.   

- Closed Reduction of the Hip in Flexion:
    - affected hip is flexed to 90 deg & traction (w/ sl adduction of femoral shaft) is applied along axis of the femur;
          - in this position the thigh is internally rotated;
    - leg is then circumducted into abduction (maintaining internal rotation) and brought down to the table in extension;
    - if reduction is complete, leg will not spontaneously rotate externally;
    - problem head of femur may be rotated on the neck - not apparent on x-ray - which leads to vascular comprimise;

- Open Reduction:
    - indicated fpr failed closed reduction, especially if pt is not candidate for hemiarthroplasty;
          - use Watson Jones approach (Anterior/Anterolateral Approach)
          - or use posterior approach for pedical bone grafting

DSA Observation of Hemodynamic Response of Femoral Head With Femoral Neck Fracture During Traction: A Pilot Study.
Reduction and fixation of subcapital fractures of the femur
Quality of reduction and cortical screw support in femoral neck fractures. An analysis of 72 fractures with a new computerized measuring method.
A new method of reduction of fractures of the neck of the femur based on anatomical studies of the hip joint.   
Femoral neck fractures. A study of the adequacy of reduction.   
Femoral head vitality after preoperative impaction of hip fractures
Predicting the Mechanical Outcome of Femoral Neck Fractures Fixed with Cancellous Screws: an in vivo study.
Predictors of early failure of fixation in the treatment of displaced subcapital hip fractures.  

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Thursday, September 13, 2012 8:41 pm