- 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 (Jan 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;
- 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. GW. Leadbetter. JBJS 15-A: 931. 1933.
- Closed reductiton of fractures of the neck of the femur. GW Leadbetter. JBJS Vol 20: 108, 1938.
- 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 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 leg. JE Bozan. Vol 16: 75, 1934.
Closed operation for intracapsular fracture of the neck of the femur. T King. British Journal of Surgeon. Vol 26:721. 1939.
Critical analysis of the treatment of fractures of the neck of the femur. R. Whitman. Annals of Surg. Vol 60: 485, 1914.
- 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;
Reduction and fixation of subcapital fractures of the femur. Garden RS. Orthopedic Clinics of North America. 5(4):683-712, 1974 Oct.
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. Flynn M. Injury. 5(4):309-17, 1974 May.
Femoral neck fractures. A study of the adequacy of reduction. Simon WH. Wyman ET Jr. CORR. 70:152-60, 1970 May-Jun.
An evaluation of closed reduction techniques for femoral neck fractures.
Femoral head vitality after preoperative impaction of hip fractures. B Jacobsson and N Dalen. Acta Orthop. Scan. 1985. Aug. 56(4) p 312-313.
Predicting the Mechanical Outcome of Femoral Neck Fractures Fixed with Cancellous Screws: An in vivo study.
W. Weinrobe et al. J. Orthop. Trauma. Vol 12. No 1. p 27-37.
Predictors of early failure of fixation in the treatment of displaced subcapital hip fractures. D Chua et al. J Orthop Trauma. Vol 12. No 4. p 230-234. 1998.
