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Femoral Neck Fractures ORIF with Cannulated Screws

Planning

B

Preoperative Plan

1

Radiographically template the fracture

  • identify fracture pattern

2

Template instrumentation

  • use contralateral side to measure for instrumentation

3

Execute surgical walkthrough

  • verbally describe steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • Two Gelpi retractors
  • Dental Pic
  • Terminally threaded Shantz Pins
  • Small Medium and large Tenaculum Clamps
  • 130 Degree blade plate
  • Mini fragment set

2

Room setup and equipment

  • Fracture table
  • C-arm

3

Patient positioning

  • patient is placed supine with folded sheet placed under the upper buttock on the effected side

Technique

D

Superficial Dissection of Modified Smith Peterson Approach

1

Make the incision

  • from ASIS curve inferiorly in the direction of the lateral patella for 8-10 cm

2

Identify gap between sartorius and tensor fasciae latae

  • dissect through subcutaneous fat
  • identify and avoid lateral femoral cutaneous nerve

3

Incise fascia on medial side of tensor fascia latae

4

Detach origin of tensor fasciae lata on iliac to develop internervous plane

  • ligate the ascending branch of the lateral femoral circumflex artery (crosses gap between sartorius and tensor fascia latae)
E

Deep Disection

1

Identify plane between rectus femoris and gluteus medius

  • detach rectus femoris from both its origins

2

Expose and dislocate the hip

  • retract rectus femoris and iliopsoas medially and gluteus medius laterally
  • expose the hip capsule
  • adduct and externally rotate the hip to place the capsule on stretch
  • incise capsule with a longitudinal or T-shaped capsular incision
  • dislocate hip with external rotation after capsulotomy is complete
F

Fracture Reduction

1

Visual and clear fracture line

  • use a freer elevator and dental pick along with saline irrigation to clear the fracture of infolded soft tissue and clotted blood

2

Obtain reduction

  • use a K wire or 4mm Schantz half pin to manipulate the fracture reduction
  • use traction to manipulate the distal segment of the fracture
G

Provisional Fixation

1

Obtain provisional fixation

  • place a pointed tenaculum or K wire across the fracture for provisional fixation.
  • for comminuted fractures use a small plate with unicortical screws

2

Check reduction with AP/Lateral views with C-arm

H

Cannulated Screw Placement

1

Make a separate lateral incision

  • place incision in line with projected axis of the reduced femoral neck for definitive fixation
  • may be single or three small incision

2

Use C-arm and a parallel drill guide to direct guidepins for the cannulated screws

  • the first screw should directed tangential to and contiguous with the calcar at the level of the fracture on AP view
  • the first screw should bisect the head and the neck on the lateral view
  • starting the screws below the level of the lesser trochanter should be avoided to minimize iatrogenic subtrochanteric fracture

3

Advance screws under fluoroscopic guidance

  • place 3 or 4 parallel cannulated screws directed from the lateral proximal femur into the head to provide good fixation.

4

Confirm position with fluoroscopy

I

Wound Closure

1

Irrigation, hemostasis, and drain

  • copiuosly irrigate the surgical wound

2

Deep closure

  • use 0-vicryl for deep fascia

3

Superficial closure

  • use 3-0 vicryl for subcutaneous tissue
  • use 3-0 nylon for skin

4

Dressing and immediate immobilization

  • place soft dressings over incision

Patient Care

K

Preoperative H & P

1

Obtain basic history and physical exam

  • check neurovascular status
  • compare extremity to uninjured side
  • identify associated injuries and comorbidities
  • identify patient comorbidities and ASA status (predictor of mortality)
  • screen medical studies to identify and contraindications for surgery

2

Order basic imaging studies

  • obtain AP pelvis and cross-table lateral, and full length femur films present of ipsilateral side

3

Perform operative consent including listing potential complications

  • describe complications of surgery including
  • osteonecrosis
  • nonunion
  • infection
  • heterotopic bone formation
  • thigh pain
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • IV fluids
  • prescribe DVT prophylaxis
  • pain control
  • advance diet as tolerated
  • foley out when ambulating
  • check appropriate labs
  • wound care
  • remove dressings POD 2

2

Appropriately orders and interprets basic imaging studies

  • check radiographs of the femur in post op

3

Appropriate medical management and medical consultation

  • foley out when ambulating

4

Initiate Physical Therapy POD 1

  • mobilize with the weight of leg ambulation

5

Discharges patient appropriately

  • pain meds
  • outpatient PT
  • schedule follow up appointment in 2 weeks
M

Intermediate Evaluation and Management

1

Obtains focused history and performs focused exam

  • mechanism of injury
  • check neurovascular status
  • compare extremity to contralateral side
  • impacted and stress fractures
  • no obvious clinical deformity
  • minor discomfort with active or passive hip range of motion, muscle spasms at extremes of motion
  • pain with percussion over greater trochanter
  • displaced fractures
  • leg in external rotation and abduction, with shortening

2

Interpret AP pelvis and cross-table lateral, and full length femur film of ipsilateral side

  • consider obtaining dedicated imaging of uninjured hip to use as template intraop
  • traction-internal rotation AP hip is best for defining fracture type
  • CT scan with 3-D reconstruction recommended with comminution and segmentation

3

Interacts with consultants regarding optimal patient management

  • timing of surgery
  • elderly patients with hip fractures should be brought to surgery as soon as medically optimal
  • medical management
  • the benefits of early mobilization cannot be overemphasized
  • improved outcomes in medically fit patients if surgically treated less than 4 days from injury

4

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 Week postoperative visit
  • wound check
  • diagnose and management of early complications
  • remove sutures
  • check biplanar films of the hip
  • postop: ~ 3 month postoperative visit
  • advance to weightbearing as tolerated
  • check biplanar radiographs
N

Advanced Evaluation and Management

1

Comprehensive assessment of fracture patterns on imaging studies

  • recognize reverse obliquity fractures

2

Garden classification

  • Type I Incomplete, valgus impacted
  • Type II Complete fx. nondisplaced
  • Type III Complete, displaced < 50%
  • Type IV Complete, displaced

3

Pauwels classification

  • Type I < 30 deg from horizontal
  • Type II 30 to 50 deg from horizontal
  • Type III > 50 deg from horizontal (most unstable with highest risk of nonunion and AVN)

4

Interpretation of diagnostic studies for fragility fractures with appropriate management and/or referral

5

Arranges for long term management of geriatric patients

  • management of bone health
  • discharge planning to long term care

6

Completes comprehensive pre-operative planning with alternatives

  • sliding hip screw or cephalomedullary nail
  • hemiarthroplasty
  • total hip arthoplasty

7

Modifies and adjusts post-operative treatment plan as needed

8

Provides prohylaxis and manages thromboemblotic disease

9

Capable of treating intraoperative and postoperative complications

O

Complex Evaluation and Management

1

Develops unique, complex post-operative management plans

 

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