Open reduction of a displaced neck fracture

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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

Femur Neck Fracture Open Reduction

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 detachment of the gluteus medius with a cautery knife; c. The greater trochanter and the insertion of the gluteus minimus are shown, the latter is divided between two stay sutures to exposes the joint capsule; d. Insertion of the retractors: 1. caudal, 2. cranial to the neck, 3. at the anterior acetabular rim. The joint capsule is open in an inverted T-shaped fashion to expose the fracture

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 detachment of the gluteus medius with a cautery knife; c. The greater trochanter and the insertion of the gluteus minimus are shown, the latter is divided between two stay sutures to exposes the joint capsule; d. Insertion of the retractors: 1. caudal, 2. cranial to the neck, 3. at the anterior acetabular rim. The joint capsule is open in an inverted T-shaped fashion to expose the fracture creasing proportionally with age, the fragments can usually be easily moved as compression and fragmentation of bony spikes occur more often. Contrar-ily, in younger patients the jagged fracture surfaces prevent a reduction as described above.

If a large anterior spike exists, a small lateral incision, particularly in slim patients, should be made. With the help of a periosteal elevator advanced to the anterior surface of the neck fracture exerting a pressure on the spike the desired position of the femoral head can be obtained; the fracture is stabilized by a Kirschner wire.

The posterolateral approach according to Gibson or Kocher has only been used in hospitals where in addition to an internal fixation a pedicled bone-muscle transfer has been done.

An anterior approach according to Smith-Petersen (Smith-Petersen et al, 1931; Parker, 1993; Marti and Jacobs, 1993) is traditionally used for exposure of the neck. Through a 10 cm long longitudinal incision at the anterocranial third of the thigh along the anterosuperior iliac spine the anterior surface of the joint capsule is reached lateral to the rectus femoris. The joint is open through a T-shaped incision and the capsular flaps are held by stay sutures. Retractors keep the wound open exposing the joint. The fracture can now be reduced with a periosteal elevator and gentle manipulations.

The advantage of the anterior approach lies in the fact that the important vessels in the posterior retinaculum are not damaged. The disadvantage of this approach is the impossibility to perform the internal fixation through the same approach. Therefore nowadays we use it primarily in revasculariza-tion surgery for implantation of the pedicled bone graft into the head.

More commonly used is the modified antero-lateral approach according to Watson-Jones.

This approach makes it possible to insert the implants through the same incision (Fig. 178).

In Watson-Jones' original description the center of the skin incision was placed over the tip of the greater trochanter. It extended caudally in a 7 cm long line and cranially it curved to the anterosupe-rior iliac spine. Today, we prefer a straight incision. We split the fascia lata in the same direction as the skin incision posterior to the muscle belly of the tensor fasciae latae. The insertion of the gluteus medius is seen in the cranial part of the wound, whereas the muscle belly of the vastus lateralis is found caudally. The muscle fibers of the gluteus medius originating close to the capsule are detached with a cautery knife. The tendon of the subjacent gluteus minimus is divided 1 cm caudal to the tip of the greater trochanter between two stay sutures. At the level of the lesser trochanter one retractor is inserted medial to the neck and one at the anterior rim of the acetabulum or posterior to the neck. Thus the capsule is visualized and incised in a T-shaped fashion exposing the fracture.

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