CHAPTER 21 Steven H. Stern 1. Intertrochanteric hip fracture (Fig. 21–1A) 2. Low femoral neck fracture (“base of neck” fracture) 1. Impacted femoral neck fracture (Fig. 21–B) 2. Displaced femoral neck fracture (in younger patient after “satisfactory” reduction) 1. Medical contraindications 2. Nonambulatory patient (relative–must individualize) 1. Hip radiographs 2. Appropriate medical and anesthetic evaluation 3. Document status of preoperative neurovascular examination 1. The patient is placed supine on the fracture table (Fig. 21–2). 2. All pressure points should be padded. 3. The procedure can be done with general, spinal or epidural anesthesia. 1. Assess the adequacy of the fracture reduction after positioning the patient on the fracture table, but prior to prepping and draping. Use fluoroscopy in two planes to evaluate the reduction. 2. Most intertrochanteric fractures can be reduced with longitudinal traction and internal rotation. 3. Femoral neck fractures may require live fluoroscopy to aid reduction. 4. Administer intravenous antibiotics appropriate for the hospital’s bacterial flora prior to skin incision. 5.Take care to ensure adequate padding of the feet and lower extremities. 6. Position the noninjured extremities so they do not interfere with the fluoroscopy. Commonly, the contralateral lower extremity is positioned in a flexed and abducted position. The ispilateral upper extremity is taped across the anterior chest wall. 1. If possible, avoid a varus hip reduction. 2. For intertrochanteric fractures, attempt to avoid medial displacement of the proximal fragment and concurrent lateral displacement of the femoral shaft. 3. For impacted femoral neck fractures, avoid excessive traction, which could serve to disimpact the fracture fragments. 5. Avoid allowing the guidepin to penetrate through the femoral head into the soft tissues of the pelvis. 1. When medically possible, attempt to mobilize the patient in the postoperative period. If the medical condition permits, the patient should be placed in a sitting position as expeditiously as possible. 2. Consider utilizing some form of deep-vein thrombosis prophylaxis. Options include warfarin, low-molecular weight heparin, and intermittent pneumatic compression. 3. Depending on the fracture stability, adequacy of the reduction and the patient’s bone quality, ambulation can commence either with non-weight bearing (NWB), toe-touch weight bearing (TTWB) or weight bearing as tolerated (WBAT). 4. Reassessment of the distal neurovascular examination should be done after surgery. 1. Position the patient supine on the fracture table. The patient should be positioned directly against the groin post. Pad the extremities. Most fractures can be reduced with a combination of traction and internal rotation. The degree of internal rotation can be assessed by evaluating knee rotation (Fig. 21–2). 2. Prior to prepping and draping the patient, evaluate the fracture using biplanar fluoroscopy. It is important prior to draping to assess the patient’s position to ensure that the fluoroscopic C-arm adequately obtains satisfactory AP and lateral hip images. Optimize the fracture reduction at this time. 3. Prepare and drape the patient and extremity per the hospital’s standard sterile protocol. Commonly, a large plastic drape (“shower curtain”) is utilized. 4. Obtain an AP hip fluoroscopic image to assist in positioning the skin incision. Place a metal clamp or Steinman pin on the anterior thigh so it serves as a visible landmark on the fluoroscopic image. 5. Make a skin incision along the lateral aspect of the thigh. Palpate the femur to ensure that the incision is positioned in the femur’s AP mid-point. The skin incision should be approximately 15 cm in length. The incision’s proximal pole should extend 1 to 2 cm proximal to the lesser trochanter (Fig. 21–3). 6. Carry the dissection directly through the subcutaneous tissue. Maintain adequate hemostasis. Identify the tensor fascia lata (Fig. 21–4). 7. Sharply incise the tensor fascia lata longitudinally. Place retractors deep to the tensor fascia lata. Identify the vastus lateralis. 8. Retract the vastus lateralis anteriorly. Sharply incise the fascia of the vastus lateralis longitudinally. This incision is positioned to allow dissection through the posterior one-third of the vastus lateralis. Take care to incise only the fascia and not the muscle (Fig. 21–5). 9. Use a periosteal elevator to bluntly dissect through the muscle fibers of the vastus lateralis. Carry the dissection down to the femur. Place a Bennett retractor over the anterior femur so it lies against the medial femoral cortex. Use it to retract the soft tissues medially to enhance visualization (Fig. 21–6). 10. Use a medium- (~3.5 mm—commonly, the drill bit that will be used later in the procedure for the cortical screws is used) size drill bit to locate the optimal starting point on the lateral femoral cortex for the compression screw. Optimize the superior-inferior starting hole position by evaluating AP fluoroscopic hip images. Generally, the starting hole should be at or below the level of the lesser trochanter. Palpate the femur to ensure that the starting hole is midway between the anterior and posterior femoral cortex (Fig. 21–6). 11. Drill the hole through the lateral femoral cortex. First start drilling perpendicular to the bone’s long axis to gain purchase in the lateral femoral cortex. Then drill a “sloppy” hole by aiming the drill at the approximate angle desired for the compression screw. The “sloppy” hole enhances accurate placement of the guidepin in the next step.
Internal Fixation of Hip Fracture
Indications
Compression screw and side plate
Multiple cannulated screws
Contraindications
Preoperative Preparation
Special Instruments, Position, and Anesthesia
Tips and Pearls
What To Avoid
Postoperative Care Issues
Operative Technique
Compression screw and side plate
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