Proximal Femur Fractures
Young-Jo Kim, MD, PhD, MACM
Indications
Unstable proximal femoral fracture (any age)
Nondisplaced femoral neck fracture (age five to skeletal maturity)
Femoral head fractures
Sterile Instruments/Equipment
Fracture table or radiolucent operating table
Open reduction internal fixation set-up
Weber clamps
Deep retractors
Kirschner wires
Implant; age and fracture dependent
4.5 mm or 6.5 mm cannulated screws
Pediatric hip locking plates (3.5 mm/4.5 mm/5.0 mm)
Dynamic hip screw set
Headless compression screws
Patient Positioning
Patient positioning will depend on surgeon preference for free leg technique on the radiolucent table or if placed on the fracture table
A fracture table is preferred for minimally displaced or nondisplaced fractures where reduction is easily obtained by closed means. The patient can be placed with legs scissored and limb in neutral alignment, taking care to make sure complete radiographic visualization is possible
Placement supine on radiolucent table with limb in neutral position and small bump underneath buttock is preferable when an open reduction is needed, as this allows for more manipulation of distal fragment as well as better access for an anterior Smith-Petersen approach
Lateral positioning on a radiolucent table is preferable for femoral head fractures which may be treated with an open surgical hip dislocation or when a Kocher-Langenbeck posterior exposure is needed (Figure 19-1)
Surgical Approaches
Direct lateral
Useful for placement of screws of implant when the fracture is able to be aligned without direct exposure. The skin incision should be directly lateral followed by dissection down to the IT band which may be split longitudinally. Direct elevation of the vastus lateralis is done with the extent depending on the degree of exposure needed for implant placement
Figure 19-1 â–ª Clinical photo showing lateral position for ORIF.
Watson Jones
Useful for femoral neck fracture that requires open reduction and allows placement of implant on the lateral aspect of proximal femur. Skin incision connects the ASIS to the lateral femur with dissection between the tensor fascia and the gluteus maximus superficially and between the gluteus medius and vastus in the deep layer (Figure 19-2).
Anterior Smith-Petersen
Useful for view of the anterior femoral head and neck that may require either
Open fixation (femoral head) or percutaneous fixation (femoral neck). Superficially dissect between the sartorius and tensor. In the deep layer, detach the rectus femoris and elevate the iliocapsularis (Figure 19-3).
Surgical hip dislocation
Useful for fixation of femoral head fractures and displaced femoral neck fractures. Patient is placed in a full lateral approach. The anterior capsule is exposed via a transtrochanteric approach. The femoral head can be anteriorly dislocated without compromising the femoral head blood supply.
Posterior Kocher-Langenbeck
Useful approach to the posterior aspect of the femoral head and acetabular rim. The gluteus maximus is gently split along its fibers to expose the posterior greater trochanter. The medial femoral circumflex artery runs along the obturator externus tendon. Usually the capsular dissection is done between the piriformis tendon and the capsular minimus, which would expose the posterior femoral head and acetabular rim.
Reduction and Fixation Techniques
Fracture Reduction
Closed reduction is usually performed with slight flexion, longitudinal traction, and internal rotation of the leg (Figure 19-4). Circumferential fluoroscopic views are paramount to making sure the reduction is adequate and if so, then fixation can be performed with direct fracture exposure.
Open reduction is performed after adequate exposure using the above approaches. The means of then obtaining reduction can be done in a multitude of ways some together and some in solitudeRelated posts:
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