FEMORAL NECK FRACTURE IN A YOUNG PATIENT

The Case for August 2012 is of a 35 year old male who sustained a fracture to his hip during a motorcycle accident.  He sustained a displaced femoral neck fracture.  He was seen by the trauma team and was cleared for operative intervention for his fracture once other injuries had been ruled out.

The fracture had both medial and posterior superior comminution.  There was a retroversion deformity on the lateral view.  This injury carries with it a significant risk of developing avascular necrosis of the femoral head which can lead to early arthritis and disability.  Fracture union can also be problematic as there are significant shear forces across the fracture during healing.

Anatomic reduction in a timely manner is key to maintaining blood flow to the femoral head and allowing for the best chance of fracture healing.  The patient was brought to the operating room when cleared for an open reduction of his fracture.  This was accomplished through a Smith-Peterson anterior approach allowing for direct visualization of the fracture.  With this approach we were able to clean the fracture, clamp it on the anterior tension side to restore anteversion, and restore anatomic alignment under direct visualization.  Also, the hip capsule was incised allowing for decompression of the joint to hopefully improve blood flow to the head.

The fracture reduction was held with a clamp and wire and then guide wires for 7.0 mm cannulated screws were placed through a separate small lateral incision.  We avoided the posterior superior neck region with our fixation so we would not further compromise blood flow to the femoral head.  A screw was placed inferiorly abutting the neck and then two further screws were placed more superiorly with good spread.  Partially threaded screws were used to allow for fracture compression.

Final intraoperative plain films showed an excellent reduction.

The patient was allowed to perform toe-touch weightbearing for three months.  He then progressed to full weight bearing as tolerated.  Serial radiographs were taken throughout his follow-up at six weeks and three months showing no loss of reduction. 

The patient was seen 9 months following surgery.  He walked with a normal gait, had no hip pain, and had returned to all vocational and avocational activities.  Although the patient is still at risk of developing avascular necrosis in the future, radiographs showed a healed fracture with no evidence of avascular necrosis of the femoral head at last follow-up.

A femoral neck fracture in a young patient is a serious injury as it can lead to pain and arthritis secondary to avascular necrosis.  Anatomic reduction with secure fixation contributes to a successful outcome.

Author by Daphne M. Beingessner, MD

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Minimally Invasive Manipulative Reduction and Fixation of Pelvic (Pubic & Sacral) Fractures

This month's case features a 19 years old male who was injured in a high-speed automobile accident. He was the driver of the vehicle and medics at the scene noted significant intrusion of the driver’s side of the car. He was extracted from the vehicle, complained of pelvic and back pain. On presentation to the emergency department, he was awake and alert, and continued to complain of severe left sided low back and hip area pain. He was initially hemodynamically unstable but responded to routine volume resuscitation. His physical examination revealed left pelvic and back pain with any attempted passive movement. Compressive pelvic exam identified pelvic mechanical instability and related exacerbation of his complaints. There was no pelvic deformity or abnormal other findings. The lower extremity neurological and vascular examinations were within normal limits, excepting muscle power limitations due to pain.

Plain pelvic radiographs and a computed tomography scan demonstrated displaced left sided pubic ramus and sacral fractures. The axial CT images demonstrated the fracture and deformity details. The left hemipelvis was flexed and internally rotated relative to the uninjured right side.  The patient was fully resuscitated and evaluated. He and his parents were counseled regarding the various non-operative and operative treatment options, as well as the risks and benefits of each. They opted for attempted manipulative reduction and percutaneous fixation if possible, and agreed to open reduction and internal fixation if needed.

On the day after injury, the patient was medically stable and cleared for surgery. He was anesthetized, positioned supine on the radiolucent operating table, elevated on a soft lumbo-sacral support, and the entire abdomen and bilateral flanks were included in the sterile operating field. After the preoperative patient/procedure verification was completed and antibiotic prophylaxis administered, a simple 2 pin anterior oblique pelvic external fixation device was applied using bilateral 5mm pins inserted into the right iliac crest and left supra-acetabular areas. The single bar oblique frame was oriented to correct the left hemipelvic flexion and internal rotation deformities. The compression-distraction device was applied to the bar remote from the injured areas so to not obstruct pelvic fluoroscopic imaging.  The manipulative reduction was assessed using fluoroscopy until satisfactory ramus and sacral re-alignment reductions were achieved.  Then antegrade superior pubic ramus medullary screw and iliosacral screw fixations were placed percutaneously through small stab wounds under multiplanar fluoroscopic guidance. The postoperative imaging confirmed the reduction accuracy, deformity correction, and screw safety. On the day after surgery, he was comfortable and began his rehabilitation including weight of limb protected weight bearing using crutches, and isometric exercises for the subsequent 6 weeks. He returned for follow up evaluation with no complaints, radiographic union of his fractures, and was released to his normal activities 3 months after injury.

Authored By: M.L. Chip Routt, Jr.,M.D

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