FEMORAL NECK FRACTURE IN A YOUNG PATIENT

The Case for August 2012 is of a 35 year old male who sustained a fracture to his hip during a motorcycle accident.  He sustained a displaced femoral neck fracture.  He was seen by the trauma team and was cleared for operative intervention for his fracture once other injuries had been ruled out.

The fracture had both medial and posterior superior comminution.  There was a retroversion deformity on the lateral view.  This injury carries with it a significant risk of developing avascular necrosis of the femoral head which can lead to early arthritis and disability.  Fracture union can also be problematic as there are significant shear forces across the fracture during healing.

Anatomic reduction in a timely manner is key to maintaining blood flow to the femoral head and allowing for the best chance of fracture healing.  The patient was brought to the operating room when cleared for an open reduction of his fracture.  This was accomplished through a Smith-Peterson anterior approach allowing for direct visualization of the fracture.  With this approach we were able to clean the fracture, clamp it on the anterior tension side to restore anteversion, and restore anatomic alignment under direct visualization.  Also, the hip capsule was incised allowing for decompression of the joint to hopefully improve blood flow to the head.

The fracture reduction was held with a clamp and wire and then guide wires for 7.0 mm cannulated screws were placed through a separate small lateral incision.  We avoided the posterior superior neck region with our fixation so we would not further compromise blood flow to the femoral head.  A screw was placed inferiorly abutting the neck and then two further screws were placed more superiorly with good spread.  Partially threaded screws were used to allow for fracture compression.

Final intraoperative plain films showed an excellent reduction.

The patient was allowed to perform toe-touch weightbearing for three months.  He then progressed to full weight bearing as tolerated.  Serial radiographs were taken throughout his follow-up at six weeks and three months showing no loss of reduction. 

The patient was seen 9 months following surgery.  He walked with a normal gait, had no hip pain, and had returned to all vocational and avocational activities.  Although the patient is still at risk of developing avascular necrosis in the future, radiographs showed a healed fracture with no evidence of avascular necrosis of the femoral head at last follow-up.

A femoral neck fracture in a young patient is a serious injury as it can lead to pain and arthritis secondary to avascular necrosis.  Anatomic reduction with secure fixation contributes to a successful outcome.

Author by Daphne M. Beingessner, MD

Complex Ankle Fracture Dislocation

The Case of the Month for July 2012 is of a 60 year old healthy woman who fell down some stairs and suffered a Complex Ankle Fracture Dislocation

 The Patient was splinted, but not reduced at an outside facility and then transferred to HMC

Plain films confirmed the trimalleolar ankle fracture-dislocation and a CT scan revealed a rather large posterior malleolus fracture, which some might categorize as a posterior pilon fracture

We chose a posterolateral incision to address  the posterior malleolus and fibular components of the injury

We worked on both sides of the peroneal tendons

first posteriorly to address the posterior malleolus

Here we are with the posterior malleolus fracture exposed

We then reduce (put the fragment back into its anatomic position after cleaning it of clot and other debris) and then place small Kirschner wires to hold it provisionally until more definitive fixation is applied

We then place a buttress plate and screws to fix the posterior malleolus of the tibia. Even this provided significant stability

We then worked anteriorly to the peroneals to access access and treat the fibular fracture

Once we fixed the fibula, we turned our attention to the medial or inside part of the ankle to address the medial malleolar fracture

Below are the final radiographs taken in the operative suite at the time of surgery

Author by Robert P. Dunbar, Jr,, M.D.