Femoral Neck Fractures ORIF with Cannulated Screws

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Preoperative Patient Care
Operative Techniques
E

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
F

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
G

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)
H

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
I

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
J

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

K

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

L

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
Postoperative Patient Care
 

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