The undisplaced neck fracture GardenI and II
Linton 1944 considered the undisplaced and displaced neck fractures as two phases of the same injury. Most publications, however, make a distinction and also the International Classification of Diseases attributes to them two different code numbers. This is based on the experience that a great percentage Fig. 71. AO ASIF classification of neck fractures Muller, 1990 . a. 31-B1 corresponds essentially to fractures in valgus, without displacement b. 31-B2 slightly displaced transcervical...
Timing for internal fixation of hip fractures
Contrary to the classical orthopedic concepts the diagnosis of emergency cases acute abdomen and the immediate intervention is of cardinal importance in general surgery. These basic principles have not lost their importance in trauma surgery and are the basis of immediate action. Interventions whether performed or missed during the first hour golden hour , or even during the first 30 minutes determine the survival and later the quality of life of the severely injured person, victims of...
Definition and frequency of hip fractures
In the Anglo-American literature and in the colloquial language the fractures of the proximal femur are known as hip fractures on account of their frequency and their medical and socioeconomic impact. This term is imprecise and has therefore not been accepted in other languages. In the pertinent literature one finds terms such as proximal femur fractures, fractures of the upper third of the femur and femoral fractures close to the hip. Two major groups of hip fractures have been recognized in...
Radiographic investigation Special imaging procedures
3.2.1 Standard radiographic examination 3.2.1.1 Conventional radiographs in two planes In instances of fresh fractures a.-p. and lateral radiographs are usually sufficient for a proper diagnosis and planning for emergency surgery B hler, 1963 Williams et al, 1992 . The ultimate fate of the patient depends foremost on the quality of the radiographs. Radiologists and traumato-logists are equally responsible for their correct execution. Therefore both must be familiar with the technique and...
Cannulated screw fixation 199394 in comparison with 199798
We felt compelled to investigate how the above described experiences affected our later results. This seemed to be of particular importance in view of the fact that the developments aimed to solve the problems encountered and to increase the stability had already been done and incorporated into our daily practice. With this in mind, we compared the results of 489 cannulated screw fixations performed between January 1, 1993 and December 31, 1994 with those of 240 cannulated screw fixations...
Technique of percutaneous screw fixation of neck fractures
The great advantage of this method for the patient consists of the precise percutaneous insertion of screws through a small stab incision. Furthermore, thanks to the long instruments the surgeon is not forced to put his hands into the x-ray beam. A disadvantage, however, is the fact that the screws' positioning cannot be followed directly, it is only seen on the monitor and by the position of the instruments. The percutaneous fixation of the femoral neck with cannulated screws differs markedly...
internal fixation with two or three implants
the subchondral anchorage in the femoral head, the support on Adam's arch and lateral cortex, known also as three-point-buttressing, has eliminated this advantage Bout et al, 1997 . The percutaneous approach causes only minimal wound pain allowing the majority of patients to ambulate with a walker and not with crutches the day after surgery. For unstable fractures such as seen in porotic bone stock, Pauwels-III fractures, base of neck fracture and multifragmentary and comminuted fractures, the...
the elderly accident victim
During elective surgery for a chronic condition a detailed examination and meticulous preparation are the basic prerequisites for anesthesia. In emergency conditions, on the other hand, considerations for the patient's life and avoidance of serious complications predominate. An absolute contraindication for surgery must be expediently determined. It is increasingly accepted that the internal fixation of neck fracture is an emergency procedure. From the beginning we realized that delay in...
The progress of emergency surgery in Hungary
The increased utilization of internal fixation of neck fractures gave rise to the first of many questions. Is such an intervention realizable in elderly patients often suffering from serious, preexisting systemic diseases Experience has revealed that such an operation is not only advantageous in respect to the restitution of function it heightens also the survival chances and prevents complications to a greater degree than conservative care. Relatively rare is the case where the general...
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Two Smith-Petersen nails distant plate sliding screw Immediate weight bearing with walker 3 The caudal implant must rest on Adam's arch. Only in this way can the implant prevent a loss of reduction in varus because of the implant's two-arm lever effect. 4 It is important to properly drill the hole in the lateral cortex and to use a buttressing side plate. 5 The dimension of the applied metal implant should be kept at an optimal minimum necessary for a reliable internal fixation. The distance...
Closed reduction of displaced neck fractures
If a spinal anesthesia has been performed, the patient is only transferred to the traction table once the anesthesia has taken effect. While grasping the leg with his hand the surgeon proceeds carefully with the reduction under continuous image intensifica tion. Once the reduction has been achieved the foot is attached to the foot holder. The advantage of the traction table lies in the fact that the limb is fixed in the reduced position and held there for the duration of surgery. The use of the...
Postoperative regimen
A prerequisite for an uneventful healing is a meticulous postoperative surveillance and care. State of consciousness, blood pressure, heart rate, respiration, fluid intake and output and laboratory tests have to be checked. The patient's body temperature usually falls in the air-conditioned operating room in spite of many precautions. The duration of transport from the operating to the recovery room or to the ward should be as short as possible. The postoperative warming up on the ward is often...
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Fig. 25. Distribution of femoral neck fractures by age and sex in the former Trauma Hospital of Budapest the later National Institute of Traumatology, Budapest between 1940 and 1955 1057 patients . Most of the women belonged to the 71- to 80-year-age group and most men to the 51- to 60-year-age group Manninger et al, 1960 Fig. 25. Distribution of femoral neck fractures by age and sex in the former Trauma Hospital of Budapest the later National Institute of Traumatology, Budapest between 1940...
Femoral neck fractures due to primary tumors or metastases
The treatment of fresh femoral neck fractures due to metastases poses many problems Tachdijan et al, 1959 Ehlers and Grimschl, 1960 Poigenfurst et al, 1968 Cotta and Roche, 1984 Berentey, 1989 Mutschler et al, 1989 Friedl, 1995 . In the presence of disseminated metastases a solution must be sought that will facilitate the care of the patient. We recommend internal fixation with two or three cannulated screws, possibly supplemented by bone cement or bone substitute material. If the diagnosis of...
Postoperative hypotension and hypovolemia are usually the consequence of an
Postoperative hypertension is not limited to patients with high blood pressure. Treatment with antihypertensive drugs is indicated once hypoxia, hypercapnia, shivering, pain and urinary retention have been excluded. Cardiac failure can be initiated by limited functional reserves secondary to various causes such as surgery, anesthesia, fluid loss, hypotension, hypoxia, secondary to postoperative hypoventilation, increased need for oxygen when fever is present, pain, shivering and improperly...
Open reduction of a displaced neck fracture
If two or three careful attempts at a closed reduction are unsuccessful, an open reduction is preferable as further manipulations may endanger the circulation in the femoral head. Fortunately this is rarely necessary in elderly patients who constitute the majority of our patients. Due to their osteoporosis in Fig. 178. Anterolateral approach to the femoral neck Marti and Jacob, 1993 . a. Skin incision b. Splitting of the fascia lata, division of the fibers of the tensor fasciae latae muscle and...
Frequent errors of reduction
The majority of errors of reduction are caused by an inadequate positioning either of the injured limb or of the C-arm. This incorrect positioning leads to errors in the interpretation of the images. Incorrect positioning is caused by the following factors The tube was not placed perpendicular to the neck in the a.-p. projection The beam in the a.-p. projection was not centered on the neck The beam in the lateral projection has not been aligned perpendicular to the neck axis the neck is not...
Settling of the fracture leading to shortening of the femoral neck
Already Linton 1944 drew the attention to the fact that backing-out of the nail is a frequent complication of internal fixation. Early on, traumatolo-gists attributed this backing-out to the oblique orientation of the nail's channel and to the forces acting on the femoral head. They attempted to prevent the backing-out by inserting a screw into the lateral cortex perpendicular to the nail, by attaching a plate to the nail or nail plate or even by using a one-piece implant such as the Jewett...
Implants and instruments for cannulated screw fixation of neck fractures
8.2.1 Implants for cannulated screw fixation 1 Material for cannulated screw manufacturing stainless steel Sandvik, ISO 58321 1987, Comp D. or titanium alloy Ti-6Al-4V, ELI ISO 5832-3 1996 . 2 Length of screws between 7.5 and 14.5 cm in increments of 0.5 cm Fig. 188 . 3 Diameter of bore of cannulated screws 2.2 mm. 4 Diameter of screw shank, identical for all screws 7 mm thread diameter 8 mm standard or 9.5 mm. 5 Thread lengths 18 mm, 24 mm standard , 34 mm and 44 mm Type cancellous bone screw...
The incidence of complications after immediate internal fixation is halved when
- The incidence of the most serious complication, the infection, is higher after arthro-plasty - The incidence of complications of THR done for femoral neck fractures in the presence of osteoporosis is many times higher than after arthroplasty for osteoarthri-tis with good bone stock - The incidence of complications after internal fixation can be markedly reduced when problems and errors are analyzed and instruments and techniques are continuously improved. ad 7 In respect to the frequency of...
Clinical and diagnostic aspects of postoperative hematomas
During the last decades our approach to the management of postoperative hematomas has become more proactive. If a clinical suspicion exists subfebrile temperatures, swelling, slight secretion at the site of a removed drain and if sonography confirms the presence of larger cavities gt 10 20 ml , we recommend surgical evacuation ubi haema-toma, ibi evacua Fekete et al, 1997a . Aspiration is only successful at early stages when the collection is still in a liquid state. Postoperative hematomas are...
Comparison between SmithPetersen nailing and cannulated screw fixation
The goal of this analysis was to find out possible differences between the two techniques of internal fixation performed in the seventies and eighties. In 1993 1994, treatment of neck fractures with cannulated screws predominated see Fig. 125 . We assume that at that time the technique of screw fixation was mastered by all surgeons involved. We would like to add that in these years no methods to increase stability 9.5 mm screws and DCD plates etc were yet available. The number of patients with...
Reinforcement of the first point of buttressing improvement of the purchase in
5.2.1 Problems of stability concerning the femoral head The inadequacy of the first point of buttressing may have two causes 1 faulty placement of the implant 2 advanced osteoporosis In a publication dealing with our results of the first 1000 femoral neck fractures between 1940 and 1955 we analyzed the importance of the nail position in the femoral neck Manninger et al, 1961a . We noted that the placement of the implant in the cranial part in the head is wrong. We determined the limits of nail...
Selected biomechanical characteristics of the proximal femur
Already in the 19th century the construct of proximal femur has been compared to that of a lamppost or a crane as an example of functional adaptation M ller, 1957 . The forces acting on the femoral head during normal gait are a multiple of the body weight. The abductor muscles of the weight bearing leg must counterbalance the body weight. The vector of the body weight goes through the center of gravity. The femoral head constitutes the center of a two-arm lever system, whereby one arm is the...
Treatment of femoral neck fractures internal fixation versus joint replacement
During the first half of the twentieth century the exclusive treatment of displaced neck fractures consisted of internal fixation. Since the introduction of total joint replacement, this approach became an alternative. In the nineties, in most of the industrialized countries, total joint replacement for femoral neck fractures was the treatment of choice for patients between 60 and 75 years of age in USA recently over 75 years and for older patients hemiarthroplasty. To the contrary, in Sweden...
Treatment of postoperative wound infections
An early superficial wound infection must be immediately exposed and treated in the same way as a hematoma. The approach must be extended in direction of wound pockets. If the wound edges are necrotic, they must be excised. The affected area must be well visible. After repeated swabs for culture and sensitivity the infected hematoma or the abscess are aspirated. All necrotic tissue is excised with a scalpel. Should the infection reach into deeper layers close to bone, the stability of the...
Femoral neck fracture in osteosclerosis
The generalized osteosclerosis is similar to the marble bone disease. The symptoms, however, are less pronounced. The disease usually starts in adulthood Greene and Torre, 1985 and is due to an autosomal dominant transmission. Its course is symptom-free in 40 of patients Figs. 231 and 232 . Both examples illustrate the problems arising during surgical treatment. Even more dramatic were the problems encountered in a tall, young man with a fracture of a markedly sclerotic femoral shaft we...
Internal screw fixation with exposure of the femur
We perform an internal fixation with cannulated screws and exposure of the lateral femoral cortex, when the preoperative analysis of radiographs indicates the need for an increased stability of internal fixation three screws with 2 mm plate or DCD plate or double DCD plate . For the exposure we use the retromuscular approach originally proposed by J. Bohler and modified by us. It resembles the approach for the implantation of a DHS. The straight skin incision runs from the tip of the greater...
Femoral neck fractures after poliomyelitis
After the last great polio epidemic in 1957 58 we treated during the ensuing 15 20 years approximately 20 neck fractures in polio patients in our institute. Since then neck fractures in polio patients have only been observed sporadically only two in 1998 . We would like to submit our experience gained over decades the femoral neck fracture of the atrophic limb is less displaced, most probably due to the muscle weakness. For the same reason a distraction of the fracture often occurs during...
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Fig. 99. Documentation of a neck fracture on a.-p. films with the limb in internal rotation. This 45-year-old patient fell from a tree and injured his hip a. The initial a.-p. film has not been properly taken as the limb had been placed in external rotation. The greater trochanter is projected over the neck and obscures the fracture b. The fracture becomes only evident with the limb in internal rotation Fig. 100. Documentation of a neck fracture in a film taken in external rotation. This...
Migration of the implant
In the following we discuss screw movements that either lead to a perforation of the head or to a backing-out without causing a loss of reduction. When combined, they usually will result in a loss of reduction. The perforation of the head is almost always due to a technical error at the time of internal fixation. At the time of inception of this method we used 4.5 mm DC plates for lateral reinforcement. A jamming of the caudal cannulated screw in the sharp-edged hole of the massive plate...
Treatment of pathologic femoral neck fractures
9.5.1 Treatment of pathologic neck fractures due to bone cysts Our subsequent discussion will be directed towards Our treatment approach is documented by clinical the treatment of various pathologic fractures and examples Figs. 226-228 . our surgical treatment aiming at the preservation of the femoral head in a sequence outlined in Sect. 2.3. Fig. 226. Pathologic fracture caused by a juvenile bone cyst. This 10-year-old boy fell during a soccer game his right leg was in external rotation, he...
postoperative soft tissue and joint infection
In general, the risk of infection after cannulated screw fixation is lower than after conventional surgery exposing the femur. The duration of potential contamination is markedly reduced and the surface of the wound less extensive. More frequent occurrences are hematomas due to an inadequate hemostasis or an insufficient drainage as well as an untreated or delayedly treated hematoma. Bleeding may also be the consequence of absent soft tissue protection or of too tight sutures causing a tissue...
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I . M. C. L VOB DR UHGKR f 1 21.m I93S 21 I POWER V I HtVE Ml MAL Y MiY.H. 3135t Scan 7VQf gt SI E 14 Pn 5. S Ulj I ' I r I . M. C. L VOB DR UHGKR f 1 21.m I93S 21 I POWER 45. 1x45. H m 9Sx3B6 C 1523 S Hmm W 4B S El - ENHANCED J I I SE Standard TE M uv i-0 SVta3,PEtVtC 45. 1x45. H m 9Sx3B6 C 1523 S Hmm W 4B S El - ENHANCED J I I SE Standard TE M uv i-0 SVta3,PEtVtC Fig. 83. Transient ischemia of the hip as seen in MRI. a. This 55-year-old patient was sent for assessment of possible avascular...
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The level of walking ability was significantly better in patients with cannulated screw fixation than those who underwent nailing. The majority of patients with cannulated screw fixation were able to ambulate either without a walking aid or with only one cane in the same group the incidence of patients confined to bed was lower, they also complained less about strong hip pain. On the other hand, the number of patients who were free from pain was greater after nailing. It can be assumed that...
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Fig. 214. Yearly distribution of frequency of 122 conservatively treated and 125 operated patients with undisplaced femoral neck fractures during the years 1985 to 1990. allowed us to collect reliable data of three-fourth of the 247 patients 184 247 74.5 . At the time of this study, 101 patients - 39 conservatively treated and 62 operated were still alive 101 247 40.9 . As the number of operated patients increased in later years, it does not seem to be correct to compare the overall mortality...
Femoral neck fractures in osteogenesis imperfecta
Osteogenesis imperfecta is a connective tissue disease that is usually characterized by autosomal dominant transmission the autosomal recessive type leads to death in early childhood . Similar to osteopetrosis a congenital and a later appearing form are known. The congenital form can be recognized by intrauterine fractures and by bone deformities already apparent at birth. Typical for this disease is the absence of periosteal bone formation. Symptoms include a transparent blue sclera, deafness,...
Treatment of stress fractures of the femoral neck
Many authors have elaborated on the conservative treatment of stress fractures of the neck and discussed the prerequisites based on clinical and radiologic findings Jeffery, 1962 Ernest, 1964 Devas, 1965 Erne and Burckhardt, 1980 Kaltsas, 1981 Menoman et al, 1981 Sloan and Holloway, 1981 Ochy and Vogt, 1985 Tountas and Waddell, 1986 Meine, 1991 Kerr and Johnson, 1995 Bucinto et al, 1997 Parker and Tremlow, 1997 . - Complete passive range of motion - Good impaction in both projections We believe...
dSubtrochanteric fracture
Undisplaced femoral neck fractures Overall term for Garden-I and -II fractures. Previously, the Garden-I fracture was known as impacted valgus or abduction fracture of the femoral neck. Overall terms for Garden-III and -IV fractures. Previously, they were known as varus or adduction Garden alignment angle, measured in the a.-p. projection Normally, a line along the medial cortex of the femoral shaft and a line going through the center of the compression trabeculae of the femoral head form an...
Reinforcement of the second buttressing point Adams arch and calcar femorale
5.3.1 Problems of stability at the second buttressing point Following the principle of the two-arm lever the greater the part of the Adam's arch and the calcar femorale remaining attached to the caudal fragment the more stable will be the internal fixation. If the buttressing point of the caudal screw that is the pivot of the lever lies more cranial, the length of the lever arm to which force is applied increases distance between pivot and lateral cortex . To compensate for the body weight...
Femoral neck fractures in children and adolescents
A neck fracture in persons under 18 years of age is even more seldom. For every 100 to 300 neck fractures in adults one accounts for one infantile neck fracture Ratcliff, 1962 Zolczer et al, 1972 Bohler, 1981 Fornaro et al, 1982 Niethardt, 1982 Ruter and Krenczer, 1982 Schlickewei and Paul, 1993 Canale and Tolo, 1995 . These fractures are caused by a great force and therefore often occur during a major trauma or polytrauma. The serious complications may lead to a life long incapacity. This...
Even a tall person can have a narrow medullary canal
A more careful clinical examination and a proper analysis of the radiographs could have avoided such a difficult operation and also the serious complications. Meticulous history taking will furnish a reliable clue. Special attention should be paid to a marked radiodensity of the neck, a pathologic thickening of the cortices, a narrowing of the medullary Fig. 232. Femoral neck fracture in osteosclerosis Patient 2 . 37-year-old woman with generalized osteosclerosis a. Right, vertical neck...
Guidelines for the assessment of internal fixation
Already during the analysis of the first 1000 patients with femoral neck fractures seen at our institute between 1940 and 1955 our team paid special attention to the early and late complications arising from the position of the implant Manninger et al, 1961b . During the subsequent half century osteoporosis has led to major changes in bone quality of the proximal femur. Due to the ever increasing mean age of the population osteoporosis has become a national concern. The trabecular bone stock of...
Mobilization followup care
Our views in respect to the cardinal importance of early mobilization in the prevention of complications are in full agreement with those of other authors Abrami and Stevens, 1964 Ainsworth, 1981 Parker et al, 1991b Koval et al, 1995 Day et al, 1997 Koval et al, 1998a Koval et al, 1998b . A cooperative patient can begin respiratory exercises already hours after surgery. Once the anesthetic agent has worn off, all four limbs should be moved. If the elderly patient is unable to do so due to his...
The blood supply to the proximal femur
1.6.1 Anatomy of the arterial supply For hundred years the idea prevailed that fractures of the femoral neck and their complications were foremost due to already inadequate vascularization of femoral head and neck that worsened with age Cordasco, 1938 . Nowadays, we are of the opinion that the vulnerability of the supplying vessels is the deciding factor it is due to the intraarticu-lar position of the 7 cm long portion of head and neck. During childhood this vulnerability is already present...
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Threads up to the tip, little self-cutting Fig. 127. Magnified views of the experimentally tested cannulated screws. 1 Olmed 2 Sanatmetal 1 3 Sanatmetal 2. The tip of the 9.5 mm screw Sanatmetal 3 is identical to the tip of screws still used today of the type Sanatmetal 2 Fig. 127. Magnified views of the experimentally tested cannulated screws. 1 Olmed 2 Sanatmetal 1 3 Sanatmetal 2. The tip of the 9.5 mm screw Sanatmetal 3 is identical to the tip of screws still used today of the type...
Preparation for surgery
8.1.1 Preparation for immediate internal fixation To meet the requirements for emergency surgery the preparations should be as succinct as possible. With the exception of evidently absolute contraindications and remote fractures all patients with femoral neck fractures should undergo an examination relevant for an emergency situation. This includes patients in whom the interval between trauma and admission exceeds six hours. Therefore we divide the patients rather speedily into the following...
The importance of threepoint buttressing
In Sects. 1.3 and 1.5, we have discussed the anatomical and biomechanical characteristics of the proximal femur that determine the optimal position of the stabilizing implants during internal fixation three-point buttressing lateral cortex, Adam's arch calcar femorale and subchondral bone in the femoral head . In Sect. 4.2.2, we summarized the fundamental biomechanical principles as they are related to the design of the implant in respect to the internal fixation with two Smith-Petersen nails....
Classification Garden
sis for surgical indications in various countries, particularly in German-speaking areas. Today it has lost almost completely its importance Kazar et al, 1960 Dynan and Parker, 1998 . On the one hand, it became evident that fracture surfaces are not smooth, they are almost always jagged and fragmented modifying considerably the interaction between the fragments. On the other hand, the stability of internal fixation has been considerably improved over the years. Therefore, it is nowadays...
History of the treatment of hip fractures 411 The beginnings
The first proper description of proximal femur fractures was done by Ambroise Par in the 16th century. Up to this time they were thought to be dislocations cited by Cordasco, 1938 . During the ensuing centuries many unsuccessful treatment attempts have been described. Cooper 1822 distinguished between extracapsu-lar fractures having a favorable prognosis and in-tracapsular fractures that failed to consolidate he attributed this failure to the poor blood supply to the femoral head. This...