open method is indicated in non-impacted cases in which the fragments cannot otherwise be brought back into satisfactory apposition. Nailing and pegging the neck in place have been practiced for some years past but, because of the internal structure of the upper end of the femur, the end results have not been as encouraging as might be desired. The cancellous tissue, through 'which the screw passes, crushes so readily that displacement following the operation is prone to occur. <Callout type="risk" title="Risk of Displacement">To avoid this result two screws or nails, placed at different angles have been used but the results following this method have been almost as uniforml}^ inefficient as when a single screw is employed.</Callout> A much more satisfactory method is that devised by the author in Fig. 619. Fig. 617. — Diagram of femur showing the common sites of fracture of the femoral neck. (Surg., Gynecol, and Obstet., Feb. 1914.) Fig. 618. — Diagram showing the manner in which the cancellous tissue crushes when the neck is subjected to the displacing actiorf of the thigh and hip muscles, following operation with a simple screw or nail. (Surg., Gynecol, and Obstet., Feb., 1914.) Fig. 619. — Diagram showing the author's screw-plate in position. Angulation of the screw portion is prevented by the plate portion which secures a firm hold on the only available compact tissue in this region. (Surg., Gynecol, and Obstet., Feb., 1914.) which a modified Lane plate is employed, as shown in Fig. 619. By means of this screw-plate the compact tissue below^ the great trochanter is utilized to prevent the inner end of the screw portion of the appliance from being displaced downward. The head of the bone is thus hung on the end of the screw portion much as a hat is hung on a peg, the plate securing its hold on compact tissue.
552 FRACTURES AND DISLOCATIONS Before drilling through the trochanter the surgeon should make sure of the proper alignment of the head and neck. This can usually be accomplished by dull dissection along the neck outside the capsule. Following operation, external fixation apparatus should be employed to relieve the bone of as much strain as possible. Simple extension and counter-extension with the long side splint may be used, or the plaster cast applied. The cast is, as a rule, preferable following operation on the hip or thigh and should be applied before the patient comes out of the anesthetic.
Within forty-eight hours of the operation a window should be cut through the plaster to expose the region of incision. In operating on the neck of the femur the parts may be exposed by a vertical incision over the trochanter or an incision of the U-type may be employed. The best time for operation is at the end of a week or ten days following the accident.
When the open method is selected early in the condition because it offers better reduction and apposition of the fractured surfaces the results are usually satisfactory. When, however, operation is performed as a last resort when other methods have resulted in non-union or deformity the results are not nearly as good. In operating for non-union the fibrous tissue must be cut away and the fractured surfaces freshened and secured in apposition, preferably by the screw-plate just described. This procedure necessarily results in some loss of tissue and shortening of the neck.
If the fracture is through the inner end of the neck and the head is comminuted, it may be advisable to remove the fragments, round off the end of the femoral neck and rely on the formation of a new articular surface. Remarkably good results have followed resection of the femoral head.
Murphy has demonstrated the possibility of making a new femoral head and articular surface from a transplanted portion of the great trochanter, and of reestablishing the function of the joint following ankylosis. These operations, however, are rarely called for as a result of fracture of the femoral neck.
Operative intervention offers little in the aged and is seldom called for in children. It offers most in the healthy adult, and is indicated in cases in which good reduction cannot otherwise be obtained, and in instances in w^hich deformity or non-union with considerable loss of function has followed non-operative methods.
After-Treatment. — The fact that the fragments have been placed in good apposition does not necessarily mean that they will remain 553 so and it should be the surgeon's greatest care during the after-treatment to see that the fixation apparatus employed is properly performing its function. Numerous adjustments will be needed during the process of repair.
A weight of fifteen or twenty pounds may be necessary during the first few days but at the end of a week it may be entirely too much. If the patient is confined to bed the back and heels should be watched for signs of skin irritation, and if they develop special care must be taken to keep the parts dry and relieved of pressure.
The sheets should be clean, smooth and free from wrinkles and the patient should be frequently splinted. 620. — Diagrams illustrating the principles of tlie single and double Thomas hip sponged and rubbed with alcohol especially in regions subjected to pressure. If a metal splint or cast is used the points of pressure should be similarly watched and treated if irritation develops.
If the cast is employed it may be necessary to cut a window in it, if the patient complains of persistent cutaneous pain in a given region. The duration of the after-treatment depends on the progress of repair at the seat of fracture. It may be impossible to secure bony union in the aged and fixation may, in some cases, be prolonged indefinitely without result.
In this type of case it is better to get the patient up and about after sufficient time has elapsed to give the fragments a fair chance to unite. Function will, of course, be 554 FRACTURES AND DISLOCATIONS imperfect but the patient will be better off than if a prolonged, futile immobilization is carried out.
The older the patient the less the probability of bony union and the slower it will be in forming, if it does occur. In a middle aged person union should be well advanced at the end of eight or ten weeks but no weight should be borne on the injured member inside of three months. During the first eight weeks the hip should be immobilized, after this period gentle passive motion is advisable up to the third month, though all strain should be guarded against.
Because of the varying rapidity in the process of repair seen at different ages and the different types of fracture encountered, no hard and fast rule can FRACTURES OF UPPER END OF FEMUR 555 be laid do^Yn regarding the length of fixation. The most reliable information concerning the progress of union is to be obtained through the X-ray.
Rontgenograms taken at the end of, say, eight, ten, and twelve weeks will show the condition of the fragments and the progress of repair, and will constitute the very best guide in the resumption of function. The patient's comfort during the after-treatment deserves much consideration, especially in elderly persons.
The surroundings should be as bright and cheerful as possible. His friends should visit him frequently but should not be encouraged to stay long enough to weary him. Prognosis. — Fracture of the neck of the femur is a serious injury even under the most favorable circumstances. In the aged it is particularly dangerous because of the low vitality of the patient.
They not infrequently suffer greatly from shock and confinement and are subject to complications which, in their asthenic state, may produce death. Bony union has for years been considered as dependent on whether or not the fracture was within the joint cavity. The correct conditions, however, are probably whether or not the fractured surfaces are in firm apposition.
Under proper treatment union is to be expected in a healthy adult but in the aged it may or may not be obtained regardless of the treatment followed. Fibrous union means some impairment of function, yet a surprisingly useful hip may result even when there has been failure in bony union and some deformity exists.
The surgeon should never, even under seemingly favorable circumstances, promise bony union.
Injuries to the Feynoral Neck in Children. — The epiphysis of the head joins the neck at about the eighteenth year, and the bony tissue of the neck is tougher and less brittle than in adult or ad- vanced life. These anatomical variations account for the clinical picture accompanying injury of the femoral neck in childhood.
A green-stick fracture of the neck of the femur or an epiphyseal separation of the head of the bone (incomplete as it usually is) is pathologically and mechanically quite different from fracture of the femoral neck as seen in the adult or the patient advanced in years. Accordingly the symptoms and course of the case are different.
In an incomplete fracture of the femoral neck the head of the bone is depressed and the neck approaches more nearly a right angle. This change in the angle of the neck increases the strain on it and further bending of the neck follows unless all weight- bearing, jar and strain are removed. In 'starting' of tlie epiphysis the pathology is somewhat different, though the result is practically the same.
When the epiphysis is 'started' it is displaced downward, and the fractured surface is only partially contacted with the end of the diaphysis. This downward displacement of the head is equivalent to a downward bending of the neck seen in green-stick fractures of the neck, and if the patient continues to use the member the result will be the same ; namely coxa vara.
Either of these injuries usually follows severe trauma and after being confined for a short time in bed the patient is up and about although limping. The limp is thought little of at first, but- when this symptom increases instead of improving the surgeon's advice is sought. In some instances apparent immediate recovery takes place, and months or even years later coxa vara develops with progressive bending of the femoral neck and corresponding impairment of function.
The immediate symptoms are slight, as a rule, and the condition may go unrecognized by the surgeon as well as the family. The apparent insignificance of the initial injury and the disastrous late consequences point out the necessity of the most careful examination following injuries of the hip in children.
If the lower extremities are carefully measured it will usually be found that the injured member is from one half to one inch shorter than its fellow, and there may be slight eversion of the thigh. The X-ray should be employed when there is a history of injury to the hip, even if only for the purpose of exclusion.
If the case is seen soon after the initial injury it should be treated by rest in bed with Buck's extension applied and sand bags about the injured member, or the long side splint employed. If deformity exists after the acute traumatic stage has passed the plaster cast should be employed with the lower extremity in abduction according to the principles laid down by Whitman.
(See Fig. 614.) At the end of a month this dressing may be replaced by an ambulatory hip splint with traction which is to be worn for a number of months, until union is solid and the danger of coxa vara passed.
After this splint is removed the hip should be frequently examined by the X-ray to determine whether the strain incurred by use of the member is causing any change in the angle of the neck. If such is found to be the case the splint should be resumed with increased traction.
If the case is seen only after the development of the secondary symptoms and coxa vara is present the traction ambulatory splint should be employed and worn for a number of months.
If the deformity and disturbance in function are pronounced it is well to consider the advisability of an osteotomy to restore the angle of the neck.
Key Takeaways
- Use screw-plates for better alignment and apposition of bone fragments in upper femur fractures.
- Employ external fixation apparatus to relieve strain on the bone during recovery.
- X-rays are crucial for monitoring progress and ensuring proper healing.
Practical Tips
- Always ensure proper alignment before applying any fixation methods, as misalignment can lead to poor healing outcomes.
- Use gentle passive motion after the initial immobilization period to prevent stiffness and maintain some range of motion in the hip joint.
- Regularly monitor the patient's comfort and adjust the weight-bearing restrictions accordingly.
Warnings & Risks
- Be cautious when operating on elderly patients, as they may not heal properly or suffer complications from prolonged immobilization.
- Avoid making promises about bony union to patients, as outcomes can vary greatly depending on age and overall health.
Modern Application
While the surgical techniques described in this chapter are historical, the principles of proper alignment, external fixation, and X-ray monitoring still apply today. Modern advancements have improved materials and methods for fixation, but the importance of accurate diagnosis and careful after-treatment remains critical.
Frequently Asked Questions
Q: What is the best time to perform surgery on a fractured upper femur?
The best time for operation is at the end of a week or ten days following the accident. Early intervention can offer better reduction and apposition of the fractured surfaces, leading to more satisfactory results.
Q: How does the author suggest dealing with non-union after an initial fracture?
For non-union cases, the fibrous tissue must be cut away and the fractured surfaces freshened. The screw-plate method is recommended for securing the fragments in apposition, though this procedure may result in some loss of tissue and shortening of the neck.
Q: What are the risks associated with operating on elderly patients?
Elderly patients have a lower probability of bony union and slower healing. They are also more susceptible to complications from shock and prolonged immobilization, which can lead to death in some cases.