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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.