orthopedic paper V
Treatment of femoral neck fracture with closed nailing
Report of 45 cases
Abstract The paper discusses treating 45 cases of traumatic femoral neck fractures using closed reduction and percutaneous triangular pinning. Follow-up conducted over 1-3 years showed delayed healing in one case and avascular necrosis of the femoral head in two cases. The rest of the patients were able to walk without crutches within 3-6 months. The treatment method is characterized by minimal trauma, quick recovery, safety, broad indications, and the preservation of anatomical structures. Keywords: Closed Reduction, Femoral Neck Fracture, Triangular Pin
Introduction
Femoral neck fractures are clinically common, especially among the elderly. To date, there is still no standardized treatment method, making the search for a safe, effective, and easily disseminated approach a long-standing goal in the field of orthopedics. Since Smith-Petersen first introduced the use of triangular nails for internal fixation in 1931, there have been notable achievements in shortening the duration of treatment, reducing complications related to bed rest, and lowering disability rates, among other aspects. However, the method of open nailing has its disadvantages, such as causing significant trauma, further damaging the periosteum and blood supply, and increasing the risk of infection. On the other hand, closed reduction and percutaneous nailing, including recent developments like compression screws or cannulated screws, have become much simpler and more feasible with the continuous improvement of radiological equipment, technical advancements, innovative tools, and accumulated experience. The text concludes by stating that the authors have recently conducted this type of surgery and have followed up on 45 cases, which will be reported.
Clinical Data
All 45 cases are fresh fractures. There are 30 males and 15 females. Ages range from 40 to 81 years, with an average age of 62. There are 32 cases on the left side and 13 on the right. Six are of the eversion type, while the rest are inversion. There are 34 intracapsular cases (7 subcapital and 27 in the neck) and 11 extracapsular ones (at the base of the neck). Fourteen patients were admitted immediately after the injury. All received early surgery, and the rest underwent surgery within a week. For those with successful nailing, postoperative movement was unrestricted, and they could move around and sit up with assistance. Otherwise, patients received lower limb traction for 2-3 weeks or wore a rotational support shoe. Afterward, they could move with crutches. No surgical infections were reported in any cases.
Follow-Up Results: All cases were followed up for 1-3 years. Three months post-op, 90% (40/45) of patients had bone union, pain-free hips, and could walk without limping, using crutches. In two cases with subcapital fractures, X-rays six months post-op showed localized cystic changes and collapse within the femoral head, but walking was still possible, and slight repair was observed after a year. One case had poor repositioning and resulted in mild limping, while another case had insufficient implant insertion. One year post-op, 25 cases had the nails removed.
Surgical Indications
Apart from non-displaced impacted fractures that do not require special treatment, and comminuted fractures where nailing is expected to be ineffective, this surgical procedure can be applied to all types of fractures.
Surgical Method
For patients admitted within 24 hours of the fracture, who have no specific contraindications for surgery, traction is not pre-arranged and surgery is carried out as soon as possible. At this point, tissue reaction is mild, and muscle elasticity is reversible, making reduction easier. Otherwise, preoperative skeletal traction is applied for 48-72 hours to correct fracture displacement. The proposed reduction plan is determined based on factors such as the direction of the fracture line, the shear force, blood supply to the head, and muscle action.
Epidural blockade anesthesia is usually used to achieve muscle relaxation, facilitate reduction, and make surgery painless. Alternatively, local anesthesia can also be used.
The patient lies supine on the X-ray diagnostic table for reduction using Whitman's method. The principle of "first separation, then joining" is followed. Initially, the leg is slightly externally rotated and adducted to loosen the fracture surface, making it easier to apply traction and correct shortening. The fluoroscope is used to confirm anatomical alignment and to tighten the fracture line. The affected limb is kept in 15° internal rotation to counteract the natural forward tilt, facilitating horizontal needle insertion. A lead marker is used to mark the intersection point between the inguinal ligament and the femoral artery at the surface projection of the center of the femoral head.
A guide needle is inserted 3 cm below the greater trochanter, following aseptic requirements. When it reaches the bone, its closest point, i.e., the tangential point on the outer edge of the femur, is probed to prevent sliding forward or backward. It is inserted horizontally at approximately a 130° angle, using the distance between the insertion point and the target for comparison to reduce X-ray exposure for the surgeon. Skilled surgeons can achieve this almost every time on their first try. A Kirschner wire is inserted transversely from the upper part through the femoral head to the acetabulum to prevent head rotation. Note: This wire should not interfere with the guide wire and should maintain a triangular nail width distance.
A 2 cm incision is made at the skin entry point of the guide wire to reach the bone cortex. A self-made cortical opener (triangular nail with a serrated progressive step) is used to pierce the cortex and pre-make a tunnel. After confirming that the guide wire has not moved, a suitable triangular nail is chosen based on its scale. The nail is carefully driven in to prevent misalignment, jamming, or breaching the head edge. The guide wire and Kirschner wire are then removed. A self-made small round steel tube is used to embed and tighten the fracture surface. The incision is sutured in one layer, followed by compression bandaging. Surgery is then completed.
Discussion
The hip joint is surrounded by abundant muscle tissue and is very strong. Additionally, the shaft and head are not aligned, making it easy for shear stress to cause shortening and dislocation after a femoral neck fracture. The joint also tends to rotate easily within the socket, causing deformities that affect the range of motion in the joint later on. These anatomical and pathological factors often lead to poor outcomes with conservative treatments. Therefore, timely reduction and effective internal fixation, which help maintain proper alignment and allow the patient to get out of bed as soon as possible, are crucial.
Clinical data shows that closed nailing treatment for femoral neck fractures has several advantages: minimal trauma, simplicity, effective fixation, fast recovery, and cost-effectiveness. It not only allows the patient to get up quickly but also retains the patient’s own femoral head, without damaging the anatomy of the hip joint, and largely restores pre-injury function. In our study, functional recovery was achieved in 90% of cases (40/45).
Radiological equipment and technical details are two key elements in this surgical method. Advanced radiological facilities make the procedure even more convenient. The technique focuses on restoring physiological angles and preventing inward and outward rotation of the hip. Accurate needle placement and tight bone fracture contact are essential. With these in place, the patient can move in bed shortly after surgery, aiding overall recovery.
Considering the complex anatomy and mechanics of the hip joint, surgeons must understand the fundamental theories and master the pathology of fractures. Improvements in equipment, traction methods, and positioning can further refine the surgical procedure. Recent years have seen advancements like pressure screws for better insertion, traction frames for effective traction and stable positioning during surgery, and cortical openers for accurate cortical bone chipping, which significantly simplify the surgical process and improve medical outcomes.
Regarding bone non-union and head necrosis, the general rate is between 15%-25%. It's observed that necrosis is generally determined at the time of fracture but only manifests later. Factors such as the degree of dislocation, location of the fracture, timing, and method of reduction, as well as weight-bearing time on the affected limb, are relevant. Preventing iatrogenic re-injury is crucial. Even if this treatment fails due to poor reduction, needle error, or other complications, salvage methods like osteotomy or artificial femoral head replacement are still available.
References
- Liu Shijie, Chinese journal of surgery 1980 18: 125
- Ouyang Jia, Chinese journal of surgery 1978 16: 123
- Wu Zuyao, Chinese journal of surgery 1959 7: 135
- Wang Yongchang, Chinese journal of surgery 1982 20:289
This article was originally published in the 1994 supplemental issue of the Journal of Southern Anhui Medical College, pages 37-38 Nanling Hospital, Li Mingjie,Zhang Jianmin, Xu jianzhong Sept. 1, 1988
from 闭式穿钉治疗股骨颈骨折45例
