Treatment of femoral neck fracture with closed nailing (draft)

orthopedic paper V

Treatment of femoral neck fracture with closed nailing

Report of 45 cases

摘要: 45例外伤性股骨颈骨折行闭合复位小切口三棱钉内固定治疗,随访1-3年,骨折延迟愈合1例,迟发性股骨头坏死2例,余均在3-6个月弃拐步行。本疗法具有创伤小、恢复快、安全、适应证宽,以及手术简便和不破坏解剖等特点,易为病人所接受。文中详述手术方法及操作要点,并介绍器具革新。

关键词闭合复位 股骨颈骨折 三棱钉

ABSTRACT

Early manual reduction and closed internal fixation by triangular nail were applied to eight cases of femoral neck fracture from October 1981 to December 1982. Following up six to twenty months, the operators found that the functions of the hip were getting satisfactory in all of them. The indications were discussed and details of operative procedures were presented. This operation, which is emphatically recommended by the authors, is simple and safe, with little injury, fast recovery, and no destruction to anatomy.

Abstract

Forty-five cases of traumatic femoral neck fracture were treated with closed reduction and small incision internal fixation with triangular nail. The patients were followed up for 1 to 3 years. There were one case of delayed fracture healing and two cases of delayed femoral head necrosis. The rest patients abandoned crutch and walked within 3 to 6 months. This therapy has the characteristics of small trauma, rapid recovery, safety, wide indications, and simple operation without destroying the anatomy, which is easily accepted by patients. In this paper, the surgical method and operation points are described in detail, and the appliance innovation is introduced. 

Keywords: closed reduction femoral neck fracture triangular nail   

股骨颈骨折,尤其在老年人,临床上常见。至今仍无规范的治疗方法,探索安全有效而又易于普及的疗法,是骨科界多年努力的目标。1931Smith-Petersen氏创用三棱钉内固定以来,在缩短疗程,降低卧床并发症及病残率,提高连接率等方面,成绩显著。但其开放打钉法,则有损伤大,再次破坏骨膜和血供及招致感染等缺点; 而其闭合复位经皮穿钉 (包括近年来发展的加压螺钉或母子钉),随着放射设备的日臻完善,加之技术改进,器具创新和经验积累,使之大为简化和可行。现就我们近年来开展此项手术并将随访的 45例予以报导。

   

Femoral neck fractures, especially in the elderly, are clinically common. There is still no standardized treatment so far. To explore safe, effective and easy-to-popularize therapies has been the goal of the orthopedic community for many years. Since Smith-Petersen’s invention of internal fixation with triangular nails in 1931, significant achievements have been made in shortening the course of treatment, reducing the rate of complications and disability in bed, and improving the connection rate. However, open nailing has the disadvantages of large injury, secondary destruction of periosteum and blood supply, and infection. However, its closed reduction percutaneous nailing (including compression screws or parent-child screws developed in recent years) is greatly simplified and feasible with the gradual improvement of radiation equipment, coupled with technical improvement, instrument innovation and experience accumulation. Here we report 45 cases in which we performed this procedure in recent years and we will follow up. 

临床资料

    45例都为新鲜骨折。男30例,女15例。年龄40-81岁,平均62岁。左侧32例,右侧13例。外展型6例,余均为内收型。囊内34 (头下7、颈中27),囊外11 (颈基底部)。伤后即入院者14例。皆予早期手术,余均在一周内手术,穿钉成绩佳者术后可不予限制,即可有协助下床上翻动和坐起; 否则,予以下肢牵引2-3周,或穿防旋木板鞋,尔后即可扶双拐下地,全部病例无手术感染。

1 Clinical data 

All 45 cases were fresh fractures. There were 30 males and 15 females. Age ranged from 40 to 81 years, with an average of 62 years. There were 32 cases on the left side and 13 cases on the right side. There were six cases of abduction type, and the others were of adduction type. There were 34 cases within the capsule (7 under the head and 27 in the neck), and 11 cases outside the capsule (basal part of the neck). 14 cases were admitted to hospital immediately after injury. Early operation was performed for all patients, while for others, the operation was performed within one week. Patients with good nailing performance could turn over on the bed and sit up with the help of the unrestricted operation after operation. Otherwise, lower limbs will be towed for 2–3 weeks, or anti-rotation wooden board shoes will be worn, and then both crutches can be lifted to the ground. All cases have no surgical infection. 

随访结果: 全部病例随访1-3年,术后 3月骨性愈合,患髋无痛,无跛形并可持拐步行者占 90% (40/45)。头下型骨折者2例 ,术后半年X线片显示股骨头内侧局限性囊性变、头塌陷,但可步行,一年后略有修复。1例复位欠佳,遗有轻度跛行,另1例术中嵌插不足,术后一年拔钉者25例。

Follow-up results

All cases were followed up for 1–3 years. Bone healing occurred 3 months after operation, and 90% (40/45) of the patients had painless hip, no lame shape and walking with crutch. There were two cases of infrahead fracture. The X-ray film six months after the operation showed localized cystic changes in the medial aspect of the femoral head and head collapse, but the fractures could be walked, and the fractures were slightly repaired one year later. One case had suboptimal reduction with mild claudication, the other one had insufficient insertion during the operation, and 25 cases had their nails removed one year after operation. 

手术指征

    除无移位嵌插骨折无需特殊治疗,粉碎骨折预计穿钉无效外,无论何种骨折均可施此手术。

   

2 Surgical indications This procedure can be performed for any type of fracture, except for non-displaced impaction fractures, which do not require special treatment, and comminuted fractures, for which nailing is not expected to be effective. 

手术方法

    骨折24小时内入院者,全身和局部无特殊手术禁忌症,不预作牵引,尽早给予手术,因此时组织反应不重,肌肉弹性可逆,容易复位; 否则,要预作骨牵引48-72小时,旨在克服骨折移位。根据骨折线方位和变位等病理情况,以估计其剪力,头血供及肌力作用,以确定拟议中的复位方案.

3 Surgical methods Patients admitted within 24 hours of fracture, the whole body and local no special contraindications to surgery, not for traction, to surgery as soon as possible, so the tissue reaction is not heavy, muscle elasticity reversible, easy to reset; Otherwise, bone traction is foreseen for 48 to 72 hours in order to overcome the fracture shift. The shearing force, blood supply to the head and muscular force can be estimated according to the pathological conditions such as the position and displacement of fracture line to determine the proposed reduction plan. 

通常用硬膜外阻滞麻醉,可获 肌肉松弛、复位方便及手术无痛;或者,局麻亦可完成。

Epidural anesthesia is usually used for obtaining muscle relaxation, convenient reduction and painless operation. Or, local anesthesia can also be completed. 

病人仰卧X线诊断台上,行Whitman氏手法复位。注意按先离后合原则,先稍外旋、内收下肢,使骨折面松开,有利牵引下移,待纠正缩短移位,两下等长后再改外展内旋,荧光下检视确定恢复解剖对位并尽力使骨折线靠拢扣紧,使患肢维持内旋15°,以抵消生理前倾角,便于穿针时水平进针。在股骨头中央皮表投影的腹股沟韧带与股动脉交会点上以铅字予以际记。

The patient was supine on the X-ray table and reduction by Whitman’s maneuver was performed. Pay attention to according to the principle of “separation before closing”, first slightly external rotation and adduction of lower limbs, to loosen the fracture surface, which is beneficial to traction down. After the shortening and shifting are corrected, the external rotation and internal rotation are changed after two times of equal length. The anatomy and alignment are confirmed through fluorescence examination and we will try our best to make the fracture line close and fasten, so that the affected limb maintains internal rotation by 15, to offset the physiological anteversion angle, and it is convenient for horizontal needle insertion during needle insertion. The intersection point of the inguinal ligament and the femoral artery projected from the central skin surface of the femoral head was marked with type. 

常规按无菌要求在大粗隆下 3cm 处皮外穿入引针,抵达骨质时需试探其最近点,即股骨外缘切线点上,防止滑前和清后。对准标靶,大致按130°方向水平穿入,直达股骨头缘进针深度可以进针点与标靶间距作为比较,以减少手术人员接触X线量;否则,亦可在荧光下确定。按此规程,熟练术者,几乎均可一次成功。为监测其穿针准确程度,可拍患髋正侧位片,若满意,则另在较上部位横行插入克氏针通过股骨头至髋臼,防止头旋转。注意: 此针勿与导针交扰,并使其间保持三棱钉宽度距离。

According to the aseptic requirements, the introducer needle was routinely inserted through the skin 3cm below the greater trochanter. When the introducer needle reached the bone mass, the closest point, i.e., the tangent point of the outer edge of the femur, should be explored to prevent anterior slip and posterior clear. Aim at that target, and horizontally penetrate the target along the direction of approximately 130 degrees, wherein the penetrate depth reaching to the femoral head margin can be compared with the distance between the penetrating point and the target, so as to reduce the x-ray contact amount of operator; Otherwise, it can also be determined under fluorescence. According to this procedure, skilled operators can almost succeed at one time. To monitor the accuracy of needle insertion, a frontal and lateral radiograph of the affected hip could be taken. If satisfactory, a K-wire was transversely inserted into the upper part of the hip through the femoral head to the acetabulum to prevent the head from rotating. Note: The needle should not be interfered with the guide needle, and the width distance of the triangular nail should be kept there between. 

在导针进皮处作软组织切开2cm许直达骨质,用自制的皮质开口器 (三棱钉作成齿状递进阶梯) 套钉击穿皮质预作隧道,旋即拔出,检视导针无移动后,根据其刻度,选用适宜三棱钉,再套钉对槽,徐徐打入,防止偏位、卡壳和穿出头缘,拔除引针和壳氏针,用自制小园钢筒予以嵌插使骨折面加紧,创口一层缝合,加压包扎,术毕。

A soft tissue incision was made for 2cm at the site where the guide needle entered the skin so as to reach the bone mass. The self-made cortical opener (the triangular nail was made into a toothed progressive step) was used to set the nail to puncture the cortical prefabricated tunnel and it was pulled out immediately. After checking that the guide needle did not move, the appropriate triangular nail was selected according to its scale, and the nail was set into the groove and then it was driven in slowly to prevent misalignment, shell sticking and threading edge. The guide needle and the Shell needle were pulled out, and the fracture surface was tightened by embedding with the self-made small round steel cylinder. The layer of the wound was sutured, pressure-wrapped, and the surgery was completed. 

4 讨论

    髋关节周围肌肉丰富,肌力强大,加之干颈头不在一个轴线上,股骨颈骨折后剪式应力极易造成缩短变位; 还由于这是一个杵臼关节头,失去干的连续和控制,在臼内易于旋转,造成畸形连接,而影响日后该关节某个方位的运动幅度; 再者,一个硕大的下肢要去长期维持对合一个极易转动的头,也是十分不易的。这些解剖和病理的因素,决定了很多保守疗法的不良后果。为此,及时复位,有效的内固定,对维待良好的对位和及早解脱卧床,以及提高治愈率,十分必要。

4 discussion 

The muscles around the hip joint are rich and the muscle strength is strong. In addition, the head of the dry neck is not on a single axis, so the shearing stress after the femoral neck fracture is very easy to cause shortening and displacement. Also because this is a pestle mortar joint head, loss of dry continuous and control, easy to rotate in the mortar, cause deformity connection, and affect the joint movement amplitude of a certain position in the future; Furthermore, it is not easy to maintain a large lower limb with a very easy-to-rotate head for a long time. These anatomic and pathological factors determine the adverse consequences of many conservative therapies. Therefore, timely reduction and effective internal fixation are necessary for good alignment and early bed rest removal as well as improving the cure rate. 

 股骨颈骨折的闭式穿钉治疗,临床资料证明,它具有创伤小,手术简便,固定有效,恢复快,花费少,有利骨折愈合,适应症宽等优点。它不但使患者尽早离床,消除全身并发症的威胁,而且为病人保留一个自身股骨头,不破坏髋关节解剖,并大多恢复伤前功能。本组功能恢复达90% (40/45)

The closed nailing treatment for femoral neck fracture has been proved by clinical data, which has the advantages of less trauma, simple operation, effective fixation, rapid recovery, less cost, favorable fracture healing, and wide indications. It not only enables the patient to leave the bed as soon as possible and eliminates the threat of systemic complications, but also preserves one’s own femoral head for the patient without damaging the hip joint anatomy, and mostly recovers the pre-injury function. The functional recovery in this group was 90% (40/45). 

  放射设备和技术细节是该术式实施的两个要素,在有放射电视和双球管设备的条件下则更为方便。技术要领是恢复生理干颈角、前倾角及股骨颈的解剖长度,防止髋内、外翻。穿针正确和骨折面紧扣是技术关键。基此,术后即可床上活动,有利机体恢复。

Radiological equipment and technical details are two elements of the operation, which are more convenient in the presence of radiotelevision and double-balloon equipment. The technical essentials are to restore the physiological dry neck angle, anterior inclination angle and the anatomical length of the femoral neck, and prevent hip varus and varus. The key technology is to correctly thread the needle and fasten the fracture surface. On this basis, you can move on the bed after surgery, which is beneficial to the body recovery. 

         鉴于髋关节的解剖生理及力学关系的复杂,欲在闭合的情况下复位满意,并使针准确地穿在头颈部中央轴上并有效地抗剪力,就要求术者在熟悉有关基础理论和掌握骨折病理的基础上,具有一个立体概念而不致顾此失彼。改革器具,改良牵引及固定体位的方法,可使该手术更臻完善。近年来我们改用加压螺钉获得更佳成绩 ,它可使骨折面更形嵌插 (2); 足蹬会阴部牵引架可保证有效牵引和术中体位稳定; 皮质开口器使之准确凿开骨皮质而防止坚质骨医源性劈裂; 小钢筒嵌插器有利于小切口的术末嵌插等等,是近年来的新进展,大大简化了手术程序,提高了医疗效果。

In view of the complexity of anatomical, physiological and mechanical relations of the hip joint, to restore satisfaction under the condition of closure, and to make the needle accurately penetrate on the central axis of head and neck and effectively resist shearing force, the operator is required to have a stereoscopic concept on the basis of being familiar with relevant basic theories and mastering fracture pathology without paying attention to either one. The operation can be further perfected by reforming the apparatus and improving the methods of traction and fixation of body position. In recent years, we have obtained better results by using compression screws, which can make the fracture surface more shape insertion [2]; Pedal perineum traction frame can ensure effective traction and stable position during the operation. The cortical ostium was used to accurately cut the bone cortex to prevent iatrogenic splitting of the hard bone. The small steel cylinder impactor is beneficial to the intraoperation insertion of a small incision and the like, and is a new progress in recent years, greatly simplifies the operation procedure and improves the medical effect. 

 关于骨不连接和头坏死,一般为15% -25%,据吴祖尧氏观察: 头坏死的发生早在骨折时即已决定,只不过晚后才出现征象。Meyes氏资料中股骨头坏死出现在伤后一年至一年半,早期却无可靠征象。它的发生与错位程度、骨折部位、复位时间和方法对位情况、穿针成绩以及患肢支重时间等因素有关。尤其要防止医源性再损伤,这就说明了开放复位内固定的弊端,Steinberg 通过组织学观察,伤后几周股骨头坏死率达 65%~85%但其中不少病例后来又有血管再生,说明头坏死有可逆变化及修复过程,对此,应予耐心追踪观察,不必急于再处理。

Regarding bone nonunion and head necrosis, the average figure is 15% to 25%. According to Wu Zuyao’s observation, the occurrence of head necrosis was decided as early as the time of fracture, and it only appeared after late. In Meyes’s data, femoral head necrosis occurred one to one and a half years after the injury, but there were no reliable signs in the early stage. Its occurrence is related to such factors as the degree of dislocation, fracture site, reduction time and method, para-position, needle insertion result, and the time for the affected limb to become heavy. In particular, iatrogenic re-injury should be prevented, which illustrates the disadvantages of open reduction and internal fixation. According to Steinberg’s histological observation, the femoral head necrosis rate reached 65%–85% in the weeks after injury. However, in many cases, vascular regeneration occurred later, indicating that there were reversible changes in head necrosis and the process of repair. Therefore, Steinberg should be patient in follow-up observation and it is unnecessary to rush to further treatment. 

       本疗法即使失败,如复位不良、穿针错误,术中卡壳、骨质劈裂以及坏死、骨不连等,还可以截骨术或人工股骨头位置换等办法予以补救。

Even if the therapy fails, such as poor reduction, wrong needle insertion, intraoperative shell sticking, bone splitting, necrosis, and bone nonunion, it can also be remedied by osteotomy or replacement of the artificial femoral head position.   

References 

  1. Liu Shijie Chinese journal of surgery 1980 18: 125 
  2. Ouyang first-class Chinese journal of surgery 1978 16: 123 
  3. Wu Zuyao Chinese journal of surgery 1959 7: 135 
  4. Wang Yongchang Chinese journal of surgery 1982 20:289

参 考 资 料

[1] 刘世杰 中华外科杂志 1980 18:125[2] 欧阳甲等 中华外科杂志 1978 16:123[3] 吴祖尧 中华外科杂志 1959 7:135[4] 王永畅 中华外科杂志 1982 20:289

Application of Closed Inserting with Triangular Nail in the Treatment of Femoral Neck Fracture

By Ming-jie Li, Jian-min Zhang, Jianzhong Xu, Nanling Hospital, Anhui

Sept. 1, 1988

李名杰 (芜潮长航医院)

原载《皖南医学院学报》1994年第13卷增刊,1994;37-38

发布者

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