249

THE TREATMENT OF FRACTURES OF THENECK OF THE FEM1UR

By F. P. FITZGERALD, F.R.C.S.I.Honorary Orthopaedic Surgeon, The Royal Northern Hospital

According to Per Linton (i944) in his admirablesurvey of the literature of fractures of the neck ofthe femur, the first ' nailing' operation was per-formed by von Langenbeck in I850. Smith-Petersen in 193i and Sven Johansson in I932,however, really introduced nailing as it is nowunderstood. Since then the subject has been in-vestigated and reported in innumerable articles.The percentage of failures in nailing operations onthe femoral neck has been reported as low as 5per cent. and at the other extreme as high as55 per cent. Probably a figure of 30 per cent.would be accepted as a fair average of failure inthis country. Many theories have been advancedin explanation of non-union. This paper putsforward a theory and a technique, which whenacted upon by the author, considerably increasedthe percentage of bony union in subcapital andtrans-cervical fractures.

A Theory of Non-unionPresupposing that the cause of failure was a

poor blood supply, fibular grafts were used in thehope that these would encourage vascularization.Later, because it was thought that the grafts werenot strong enough (one patient broke the graftcrossing her knees and another turning in bed),they were reinforced by special nails made to fitthe lumen of the fibula (Fitzgerald, I942). Twenty-five cases were treated in this way and in duecourse the results were investigated. There was noincrease in the percentage of bony union. Inthose fractures which united, however, no case ofaseptic necrosis of the head of the femur wasrecorded, but the number of cases was too smallto make this an observation of much value.

Later on, during a nailing operation, it wasnoticed that when a guide wire was inserted, thehead of the femur was rotated by its point; asecond wire rotated it again and a guide and nailwere inserted in a fairly central position only withdifficulty. The fracture failed to unite and led toa closer examination of the anatomy of the femoralneck. This revealed one well-known but perhapsnot fully appreciated fact, that the tendon ofobturator externus lies very close to the femoral

neck and actually grooves its under surface. It waspossible, therefore, that if this tendon slipped inbetween the fragments or invaginated the capsule,the head would be rendered mobile and thus bonyunion would be discouraged. The tendon mightslip in between the bone ends either at the timeof fracture, when the lower fragment movesupwards, or during the usual Leadbetter method ofreduction when the hip is forcibly internallyrotated and abducted. Here then might be onecause of failure.Again Bankart and others have mentioned the

fragmentation and compression of cancellous bonewhich occur on the back of the femoral neck asa result of the external rotation element of theinjury. (This resembles the dorsal compressionseen in a Colles' fracture.) Bankart's finding wasverified and it was noted also that when the femurwas forcibly internally rotated, a wide transversegap developed on the posterior surface of the neck.A nail inserted after forced internal rotation,therefore, would have a grip in the outer fragmentand in the head of the bone, but would be un-covered posteriorly while traversing this ' gap'area.With these two points in mind a large number

of cases was reviewed, including the cases reportedby Eyre-Brooke and Pridie in 94I. It was foundthat a very large number had failed to unite whenoperated upon after forced internal rotation, asshown by the reduced profile of the lesser tro-chanter seen on the antero-posterior radiographtaken on the operating table. On the other hand,when some external rotation deformity wasaccepted, the percentage of success was muchhigher.A large number of patients have now been

treated, taking into consideration these two points,gentle reduction and nailing in slight externalrotation, and the rate of failure has been greatlydiminished.

Types of Fracture and their TreatmentFractures of the neck of the femur are divided

into two large groups, impacted and non-impacted,and the latter are subdivided into subcapital,

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transcervical and basal. Basal fractures do notcome within the province of this article.

I. IMPACTED FRACTURESThese are usually the result of a fall on to the

greater trochanter. The neck breaks- and thelower fragment is impacted into the upper. In thegreat majority of these cases, the force of theviolence abducts the lower fragment on the upper,leading to a coxa valga deformity (Fig. i). Veryoccasionally adduction takes place, and coxa varawith impaction results (Figs. 3 and 4).

TreatmentA. Coxa Valga with Impaction. It is possible to

allow the patient to walk from the first withoutany splintage, and in the majority of these cases,an uneventful recovery follows. Fig. 2 showssuch a case treated without a splint. Two yearslater she fractured the other side and this wasnailed. In a small percentage of cases, however,the impaction is not strong enough and the frag-ments may separate. It is wise therefore to im-mobilize the hip in a closely-fitting plaster spica.After a few days the patient is allowed to walk andthe plaster is retained for two months.

B. Coxa Vara with Impaction. Two lines oftreatment are available, conservative and operative.

(a) Conservative. The patient is kept in bed ona Braun's splint with 7 to iO lbs. traction, de-pending upon the weight of the patient. Afterthree months she is allowed up with great care.Fig. 3 illustrates a case treated deliberately in thisway. The patient was not old and she has beenback at her full strenuous employment for thepast five years without further trouble. Fig. 4shows a much worse fracture which could not benailed for medical reasons.

(b) Operative. This is probably the bettermethod of treating an adducted impacted fracture.It is nailed without attempting reduction of anykind; traction at the time of operation is strictlyforbidden. In this way impaction is maintainedand the prognosis is very much improved, sinceimpacted fractures nearly always unite. Inaddition, the risk inherent in the unstable adduc-tion deformity is avoided by the presence of thenail. The best advice for adducted impactedfractures therefore is to ' nail them as they lie.'

2. NON-IMPACTED FRACTURESIn these cases operative treatment is the method

of choice. It is proposed to describe in detail onlytwo operative procedures, nailing and a modifiedform of Leadbetter's osteotomy.

Selection of Cases. In the author's view almostevery fresh case should be nailed providing thepatient will stand the operation; osteotomy should

be reserved for old cases and for those in whichnailing has failed.

The Nailing OperationPre-operative Treatment. Most patients who

fracture the neck of the femur are old and are veryliable to develop pulmonary complications if theirmovements and respiratory excursions are im-peded. The pain of the fracture prevents thepatient from moving about in bed, every move-ment being resented even those for nursing pur-poses. If skeletal traction is used, however, thepain ceases and the patient can move with relativefreedom.A Steinmann's pin is driven through the crest

of the tibia. The limb is placed on a Braun's splint,and IO to 12 lbs. traction applied. The foot ofthe bed is raised on io to I2 in. blocks and thepatient is supplied with an overhead sling and afoot rest for the affected limb. In this way she isrendered more independent and is encouragedto move about in bed. Operation is postponed forat least a week.

Reduction. Skates are fitted to the patient'sfeet, and she is then placed upon the orthopaedictable. The perineum is in contact with a specialperineal upright (see below) and the skate on thegood side is fixed to the foot rest. The hip onthe affected side is then flexed to 30 degrees, andthe operator's forearm is placed in the bend of theknee (Fig. 5). Firm but not forcible traction isthen exerted on the limb, while very slight in-ternal and external rotatory movements are carriedout. This simple manoeuvre is sufficient to effectreduction. For reasons which have already beenstated, Leadbetter's method with its full forcedflexion and internal rotation should never beused. b

Position of Fixation on the Table. The firmtraction is maintained by the operator while anassistant fixes the skate to the foot rest. Thetraction is then transferred to the screw or wind-lass (Fig. 6). The limb is abducted 30 degrees, andfixed in a few degrees of external rotation. Forreasons already mentioned internal rotation iscontraindicated.

X-rays. Antero-posterior and lateral picturesare now taken. This is best done by means of aspecial pelvic rest (Fig. 7) which has two ad-vantages. It allows the X-ray plates to be movedin and out without disturbing the patient or thesurgeon. It also avoids the dangerous, potentiallyunsterile and inaccurate method of having acassette held by an assistant. Fig. 6 shows therest and the X-ray sets in position. For taking alateral view, special malleable screens are packedinto the X-ray envelope so that it may be bent tofit the slot in the curved perineal upright (Fig. 7).

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May 1948 FITZGERALD: Treatment of Fractures of the Neck of the Femur

L

FIG. I.--Impacted fracture of abduction type with coxa valga deformity.

.....i

F]C. 2.-Thc right hip shows an old untreated abduction fracture.

C2

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POST GRADUATE MEDICAL JOURNAL May I948

y,;e&-B |B'RSIi|II 10 l I| lI 1S l Il l | l l i i| l --I | I | 11 | I jl;g:I | I | I 1 I L

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FIG. 3.-An impacted adduction type of fracture with coxa vara deformity, treated successfully by traction only.

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MOaY 1948 FITZGERALD: Treatmnent of Fractures oJf the Neck of the Femtur 25

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FIG. 4.-Radiographs from another case of impacted adduction fracture showing union obtained from traction only.

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254 POST GRADUATE MEDICAL JOURNAL May I948

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May I948 FITZGERALD: Treatment of Fractures of the Neck of the Femur 255

A portable dark room and specially heateddeveloper are invaluable.

Towelling. The towels are so arranged that theoperator's side is completely towelled off from theradiographer on the sound side (Fig. 8). Thisgives that freedom of movement to the radio-grapher which is so essential for rapid work.

Instruments. Apart from the usual set of in-struments, two specially designed by the authorneed description.

The Guide. This consists of a curved piece ofmetal (Fig. 9). It grips the anterior and lateralaspects of the upper end of the shaft of thefemur (Fig. io). Two vertical struts (a) are fixedto the lateral metal piece and the hollow moveabletube (b) can therefore be fixed in any one of alarge series of positions. The position in thecoronal plane is constant, having been worked outexperimentally. It presupposes accurate reduc-tion of the fracture.

Setting the Guide. A guide wire is placed in thesmall moveable tube and the instrument super-imposed upon the antero-posterior radiograph ofthe reduced fracture. The guide wire is thenmoved until it is exactly along the middle of thefemoral neck on the X-ray plate. The guide (b)is locked in this position by the wing nuts and theinstrument is then ready for use.

' Pan's Pipes.' These are simply a series ofhollow tubes fixed together (Fig. i i). If the firstguide wire is not exactly correct, one of these isthreaded over it and another guide is inserted inthe desired position.

The Operation. The skin is sterilized with pureDettol. A s-in. incision is made exactly along thelateral side of the upper end of the femoral shaft,extending downwards from the tip of the greatertrochanter. Any bleeding points are caught andcauterized by diathermy. Skin towels are fixed bymeans of large Michel clips. With a clean knifethe incision is deepened to bone, and bone spikesare passed around the femur. Further bleeding iscontrolled and the spikes replaced by self-retainingretractors.

Ffixing the Guide to the Bone. Two points mustbe verified, firstly the lower border of the greatertrochanter and secondly the gluteal ridge. Thesharp point of the guide is pushed into a smallprominence on the lower border of the greatertrochanter (sometimes called the third trochanter),and the guide is rotated so that its posterior metaledge lies against the gluteal ridge. The point isthen driven home with a hammer and punch, andthe instrument is fixed firmly to the femur (Fig. 12).

Inserting the Guide Wire. The guide wire,attached to a handle, is passed through the guidetube until the point of the wire is in contact withthe bone. With a small chisel, the cortex is

notched at this site to prevent the point fromskidding. The wire is then pushed through thefemoral neck as far as the acetabulum. Antero-posterior and lateral films are taken and theposition and length of the guide checked.

The Length of the Nail. The guide wire shouldbe central and its tip in the acetabulum. Thelength of wire which protrudes is then measuredand subtracted from the total length, giving thedistance from the cortex to the acetabulum. Inchoosing the length of nail, two factors must betaken in consideration. Firstly, that later on thebone fragments must be impacted and secondly,that the joint surface has been traversed. Thisdistance is allowed for and a nail chosenaccordingly.

Inserting the Nail. The three-flanged starteris passed over the guide wire and tapped gentlyinto the cortex. It is then withdrawn and thenail is threaded over the wire, its flanges passinginto the grooves already made. A hollow punchwhich fits over the guide and encloses the headof the nail is used to drive the nail inwards.When it has been driven in about two-thirds of itslength, two more films are taken. If both aresatisfactory the nail is driven home.

Impaction. The traction is released and thebone ends are impacted. The author uses awooden impactor which fits against the bone justbelow the nail. The guide is removed and the nailagain driven home. A small cross pin (Pidcock's)is passed through the hole in the head of the nailinto the bone to prevent it from slipping outwards.The wound is then sutured without drainage.

Dressing. The incision is painted with Dettol,and gauze and wool are held by means of elasto-plast. The latter is applied so as to seal thejunction of wool and skin and prevent infectionfrom without.

After-care. The limb is placed on a Braun'ssplint again. The patient is measured for aweight-relieving caliper, and when this is ready(which takes about six weeks), she is allowed toget up. The caliper by day and the Braun's splintor caliper by night are used for a least six months.With this method of treatment and after-care,

the percentage of failure in a large number ofcases was greatly reduced.

Delay in Bony UnionDespite this rather elaborate care the rate at

which bony union took place remained slow. Inan attempt to overcome this, a series of cases wasoperated upon, using bone chips as well as anail.Method of Obtaining Iliac Bone Chips. A 4-in.

incision is made below the anterior end of theiliac crest. A thin layer of bone is raised upwards

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256 POST GRADUATE MEDICAL JOURNAL May 1948

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May 1948 FITZGERALD: Treatment of Fractures of the Neck of the Femur

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FIG. 13.-The chip-graft gun. (a) The cannulated drill. (b) Brace or handle to fit the drill. (c) The cannula withhopper for iliac chips. (d) The blunt-ended trochar to fit the cannula.

and inwards from the upper surface of the crest;the muscles attached to the lateral surface of theblade are stripped off with a rougine. The cortexis then incised as far anteriorly, posteriorly andinferiorly as possible, and the incision deepenedas far as the deep cortex. A thin osteotome is theninserted between the inner cortex and the can-cellous bone from above, and the mapped outpiece of bone is removed. The muscles are thenreattached and the wound sewn.The cortex is carefully separated from the piece

of bone removed and the remaining cancellousbone is cut up into very fine chips.

Chip Grafts in the Femoral Neck. Two guidewires are inserted into the neck of the femur, thefirst below, by means of the guide, and the otherabove and parallel, by means of the set of littleparallel tubes (' Pan's pipes '). A nail is insertedover the upper guide as described above andthe chip graft gun is directed by the lowerone.

Chip Graft Gun. This consists of a cannula

with a special hollow drill to fit (Fig. 13). Thehollow drill, which is turned with either a brace ora handle, is passed into the cannula. It is threadedover the lower guide wire, and is bored into thefemoral neck across the fracture. The drill isthen removed, leaving the cannula in situ. At theouter end of the cannula is a small funnel or hopperplaced at an angle.

Inserting the Chips. The blunt-ended trocharis inserted almost to the hopper level. The chipsare now ' poured ' into the hopper, and reach thecannula, whence they are driven into the femoralneck by the trochar. As the chips are packedhome, the gun is gradually withdrawn, leaving inits place a solid tube of chips which may possiblyspread out at the fracture level. The fracture isthen impacted and the wound treated as before.

Theoretically, this method should shorten thetime for bony union and perhaps discourageaseptic necrosis of the head of the femur. In theauthor's series the results are promising, but it istoo early vet to assess them finally.

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258 POST GRADUATE MEDICAL JOURNAL Maiy 1948

/A WI'

FIG. I4.

Old-Standing Fractures of the Neck of theFemurIn these cases nailing of grafting is not ad-

visable on account of sclerosis of the bone ends.Also many of these cases have failed to uniteafter nailing. An osteotomy is the method ofchoice, and the one to be described here is amodification of the one by Leadbetter. Thisoperation resembles McMurray's osteotomy, butit has some features which seem to be an improve-ment on the older method.

Modified Leadbetter's Osteotomy. The fractureis reduced and the patient fixed to the ortho-paedic table as before. The lateral surface of thefemur is exposed as above. (Leadbetter em-ploys an anterior approach and cuts the boneunder direct vision.)

Level of Osteotomy. A guide wire is inserted intothe femoral neck as far as the fracture and at thejunction of the upper two-thirds with the lowerone-third of the neck (Fig. 14a). An osteotome isthen used to divide the outer fragment only at thislevel. The new lower fragment is then pushedfirmly inwards and rotates the head until thefreshly-cut upper surface lies in contact with thelower fracture surface of the head. The greatertrochanter is displaced laterally; this preserves

the length of the gluteus medius and thus preventsa dip or positive Trendelenburg's sign. The cutsurface of the lower fragment opposes the brokenarea of the head in its new position (Fig. I4b).A double plaster spica is then applied. Care

is taken not to move the patient from the ortho-paedic table until the plaster has set, as the bonesare very easily displaced. The results in thefew cases treated by this method have beenexcellent.

SummarySome causes of non-union in fractures of the

neck of the femur are mentioned and means dis-cussed for obviating them. These methods havedecreased the percentage of non-union.A method of chip grafting in an effort to in-

crease the rate of bony union is described.Finally, a modification of Leadbetter's osteo-

tomy for cases of established non-union isdescribed.

BIBLIOGRAPHY

BANKART, A. S. B. B. (1942), Lancet, I, 249.EYRE-BROOK, A. L., and PRIDIE, K. If. (I94I), Brit. Jnl.

Surg.; 29, 1 I5.FITZGERALD, F. P. (1942), Lancet, 2, 183.FITZGERALD, F. P. ( 946), Brit. Med. Jnl., 2, 86 i.LINTON,.P. (i944), Acta Chir. Scand., 90, Supplement 86.

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