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Femoral Neck Fractures in the Young & Old
Lisa K. Cannada Associate Professor Saint Louis University
Disclosures
- No pertinent disclosures
- Member:
– AAOS Board of Directors – MAOA Board of Directors – OTA Committee Member
Femoral Neck Fractures in the Young & Old Lisa K. Cannada - - PowerPoint PPT Presentation
Femoral Neck Fractures in the Young & Old Lisa K. Cannada - - PowerPoint PPT Presentation
Femoral Neck Fractures in the Young & Old Lisa K. Cannada Associate Professor Saint Louis University Disclosures No pertinent disclosures Member: AAOS Board of Directors MAOA Board of Directors OTA Committee Member
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First….Define Young
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On Call
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Define Young
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Reality: How to Keep Your 35 yo patient from getting a THA…which is the answer for the old
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Tip #1: Pre op Planning
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Decision Making Variables: Patient Factors
- Young
– High energy injuries
- Often High Pauwels
Angle (shear)
- Comminution
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Pauwels Classification
stable Less stable unstable
Images from: Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Tip #2: Limit AVN
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Pre-operative Considerations: Timing of ORIF in Young
- Surgical Urgency?
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- During open reduction
- r percutaneously
– Reduces intracapsular pressure from fracture hematoma?
- Increased capsular
pressure not clinically associated with AVN
– Maruenda et al, CORR 1997
Capsulotomy?
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Tip #3: Reduction Matters (most)
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- Closed versus open reduction does not
seem to affect nonunion or AVN rates but data is very limited
- MAIN GOAL: GOOD REDUCTION
Closed versus Open Reduction
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Closed Reduction
- Flexion, slight
adduction, slight traction
- Apply traction,
internally rotate to 45 degrees, followed by full extension, slight abduction
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Open approach
- Smith-Peterson
– Direct access to fracture – Between TFL and sartorius – Second approach needed for fixation
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Open approach
- Watson-Jones
– anterolateral – Between TFL and gluteus medius – Same approach for fixation – Best for basicervical
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- Fracture table or flat jackson
- Use schanz pins, weber clamps, or
jungbluth clamp for reduction
Open Reduction Technique
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Tip #4 Stable Fixation
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Fixation Constructs
- 3 Screws
- 4 Screws
- Dynamic hip
screw
- Blade plate
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Fixation Concepts
- Reduction makes
it stable
– Avoid ANY varus – Avoid inferior
- ffset
- Malreduction
likely to fail
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Fixation Concepts: What Matters?
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Fixation Concepts: Screw Fixation
Good Bad
Posterior Anterior Lateral Epiphyseal Artery
- Good spread
- Hugging Calcar and
posterior cortex
- Posterior and inferior
screws are most important
- Clustered together
- Nothing on calcar
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This Matters
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Fixation Concepts
- Sliding hip screw
– May help with comminution – Basicervical – Accessory screw for rotation
- Can use small frag
plate for reduction as well
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TAD Matters!
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- Femoral neck fractures in < 60
– take physiology and activity into account
- Ideally, fix within 24 hours
- Reduction is likely more important
than:
– Capsulotomy – Type of approach – Method of fixation
- Follow closely for shortening, AVN
and nonunion
YOUNG FNF Summary
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Thank You!
Lcannada@slu.edu