Eur J Orthop Surg Traumatol

DOI 10.1007/s00590-016-1745-3

EXPERT’S OPINION • HIP - FRACTURES

Tips and tricks for ORIF of displaced femoral neck fractures

in the young adult patient
Stephen C. Stacey1 • Christopher H. Renninger2 • David Hak1 • Cyril Mauffrey1

Received: 22 January 2016 / Accepted: 25 January 2016

 Springer-Verlag France 2016

Abstract Femoral neck fractures in the young adult are a fractures in the young are from repetitive activities, such as
less common, but potentially functionally significant injury athletes and military recruits [7].
commonly occurring after high-energy trauma. The man- As such, femoral neck fractures in the young patient are
agement goals of these injuries are the maintenance of a a distinct clinical entity from those in the elderly requiring
native hip joint absent avascular necrosis and nonunion. different evaluation and management considerations. A
The primary determinant to this end is an anatomic recent meta-analysis describing complications of femoral
reduction in displaced fractures with stable fixation. In this neck fractures in young adult patients found a reoperation
paper, the authors provide a set of technical tips and tricks rate of approximately 18 %, nonunion rate of 9 %, avas-
to aid orthopedic surgeons in the surgical management of cular necrosis rate of 14 %, and an implant failure rate of
these injuries while reviewing the most recent literature nearly 10 % [8]. These rates are consistent with previously
available to inform clinical decision making. The paper published rates in the literature [5, 9–11]. With that in
includes the recommendations of the authors from the mind, clinical decision making, judgment, and surgical
Denver Health Orthopaedic Trauma Service. technique are of utmost importance to reduce those com-
plications. Despite this, timing of surgery, reduction
Keywords Femoral neck
Fracture
Young adult
strategies (open versus closed), implants of choice, and
Techniques
Trauma fixation configuration remain topics of great debate in the
orthopedic trauma literature. The aim of our paper is to
present our surgical strategies in the form of tips and tricks
Introduction so as to strive for anatomic reduction and stable fixation of
such a complex injury.
Intracapsular femoral neck fractures occur in a bimodal
distribution. The most common peak occurs in elderly
patients, generally in their eighth decade [1]. Such an injury Clinical and radiographic evaluation
is typically a fragility fracture [2]. Conversely, femoral neck
fractures in the young adult are less common and frequently The association of femoral neck fractures in the young with
the result of high-energy mechanisms such as motor vehicle high-energy trauma mandates a thorough evaluation for
collisions or falls from height [3–6]. A subset of femoral neck associated injuries and adherence to advanced trauma life
support (ATLS) protocols [5, 11]. Femoral neck fractures
occur in the setting of femoral shaft fractures two to six
& Cyril Mauffrey percent of the time, but are initially missed in as many as
[email protected]; [email protected]
30 % of those combined injuries [12]. Patients present with
1
Department of Orthopaedic Surgery, Denver Health Medical an externally rotated and shortened lower extremity [13].
Center, 777 Bannock St., Denver, CO 80204, USA Radiographic workup consists of full-length plain
2
Department of Orthopaedic Surgery, Naval Medical Center radiographs of the femur in the anteroposterior and lateral
San Diego, San Diego, CA, USA planes [14]. A cross-table lateral is preferable in the setting

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of acute trauma to the hip. An anteroposterior view of the stable internal fixation is the most important goals of sur-
pelvis should be included [13]. gical treatment of these injuries. The surgical approach and
The Garden and Pauwels’ classifications are the most choice of implant go hand in hand. Some implants cannot
commonly utilized systems. In the Garden classification, be placed through certain open approaches to the hip;
four types are described by degree of displacement. Type I therefore, the choice of approach and implant must be part
is valgus-impacted or an incomplete fracture. Type II is of a thorough and thoughtful preoperative plan. For
complete and non-displaced. Type III is complete and instance, sliding hip screw (SHS) constructs cannot be
partially displaced. Type IV is completely displaced [15]. placed through a direct anterior (Smith-Petersen) approach,
Pauwels’ classification describes the angle of the frac- so an additional approach to the lateral femur is necessary
ture with respect to the horizontal. Type I is \30; type II for hardware placement if this type of implant is selected.
30–70; and type III [70 [16]. In practice, the inter- and One advantage to the anterolateral (Watson-Jones)
intraobserver reliabilities of both systems are sufficiently approach is that it allows visualization and reduction in
low that fractures are grouped into non-displaced and dis- most basi-cervical and trans-cervical femoral neck frac-
placed variety to help guide treatment decisions [17]. tures as well as access to the lateral femur through the same
Various radiographic findings should be considered. A incision. Some authors believe that visualization of the
high Pauwel’s angle ([50) is associated with posteroin- subcapital region of the femoral neck through the Watson-
ferior comminution in as many as 96 % of cases. They are Jones approach can be limited, but the benefits of a single
also associated with major fracture plane obliquity and loss incision for fracture reduction and hardware placement
of calcar integrity [18]. These fracture patterns present an make this an attractive option for the surgeon comfort-
increased risk of nonunion, malunion, avascular necrosis, able with this approach [9].
and early failure [16, 19–21]. Our preferred approach is the direct anterior (Smith-
Petersen), an internervous approach between the femoral
nerve and superior gluteal nerve territories. This approach
Treatment options and considerations provides excellent visualization of the entire femoral neck
for fracture reduction. The patient is positioned supine on a
Once other life- and limb-threatening injuries have been radiolucent flat-top table after adequate anesthesia has been
addressed, expedient management of femoral neck frac- achieved. A small bump is placed under the affected flank
tures in the young patient should be undertaken. Recent to elevate the operative hip to allow easier visualization
literature has failed to demonstrate that mild delays with fluoroscopy, which comes in from the opposite side of
([48 h) in operative intervention increase the risk of AVN the table. The ipsilateral upper extremity may be secured
or nonunion [9, 22–24]. These findings, however, are in the across the patient’s chest or positioned on an arm board. In
context of previous studies documenting higher rates of this ‘‘bumped’’ position, the femoral anteversion is com-
avascular necrosis with delays in surgical fixation [6, 25]. pensated for by the interna, rotation of the patient’s
Salvage options in the young patient are not tolerated as hemipelvis. That is, a true AP image of the femoral neck is
well as in the elderly population and thus maximizing the obtained when the C-arm is in a vertical position, and a true
probability of maintaining a native hip joint without altered lateral of the proximal femur can be obtained by rolling the
biomechanics is a priority [5, 10]. C-arm under the table 90. If the patient were positioned
In the young patient, internal fixation is the primary flat on the operating table without a bump, the C-arm must
mode of treatment. An anatomic reduction is mandated by ‘‘roll over’’ approximately 15 to account for femoral
either closed or open means. Multiple previous investiga- anteversion in order to get a true AP view of the femoral
tions have demonstrated that a non-anatomic reduction neck, and a lateral view of the proximal femur can be
increases the risk of lower functional outcome, healing obstructed by the contralateral thigh.
complication and reoperation [9, 26–29]. Specifically, A 12- to 15-cm skin incision begins approximately 2 cm
varus malreduction and inferior offset are risks of failure lateral and 1 cm distal to the ASIS and is carried distally
[28, 29]. Minimal valgus alignment has not been shown to toward the lateral aspect of the knee (Figs. 1, 2). The skin
have a deleterious effect on outcome [30]. and subcutaneous tissues are incised sharply, taking care to
identify and protect the fascia. A lap sponge is used to clear
the fascia of any remaining subcutaneous fat (Fig. 3). The
Surgical approach lateral femoral cutaneous nerve is not routinely identified,
but it exits beneath the inguinal ligament and would be
There are many possible surgical tactics for fracture visu- found in the tissues medial to the Smith-Petersen approach.
alization and reduction. We believe that an anatomic The ‘‘blue line’’ is identified in the fascia, which is the
reduction in the femoral neck and subsequent border between tensor fascia lata (TFL) and sartorius. A

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Fig. 3 Fascia is identified and cleared of subcutaneous fat

Fig. 1 Schematic drawing of the direct anterior (Smith-Petersen)
approach to the hip; ASIS denoted by dashed circle
new knife is used to lightly incise through this fascia just
lateral to the blue line (Fig. 4). An Allis clamp is used to
secure and elevate the medial edge of the fascial incision,
and blunt digital dissection is performed to deepen the
interval between sartorius and TFL. The next step is
identification and protection of the ascending branch of the
lateral femoral circumflex artery. In arthroplasty cases
utilizing the direct anterior approach, this artery is typically
controlled with electrocautery or ligation, but in cases
where viability of the femoral head is of utmost impor-
tance, every attempt should be made to preserve this con-
tribution to the blood supply of the femoral head. It is
typically found in the midportion of the incision (3–4
branches crossing perpendicular to the incision), and blunt
dissection will aid in its identification and preservation.
The internervous plane is then deepened between glu-
teus medius (superior gluteal nerve) and rectus femoris
(femoral nerve) (Fig. 5). Two cobra retractors are placed,
one above and one below the femoral neck (extra capsular).
A Cobb and lap sponge can be used to clear any remaining
tissue off the anterior surface of the joint capsule, which
will be between the two cobra retractors. The reflected
head of the rectus femoris will occasionally obstruct the
surgeon’s view of the capsule, and it can be sharply taken
down from its origin on the AIIS to improve visualization.
Fig. 2 Skin incision begins *2 cm lateral and 1 cm distal to the There is typically a substantial intra-articular hematoma
ASIS and extends distally for 12–15 cm toward the lateral aspect of which can distend the capsule giving it a ‘‘tense’’ feeling. A
the knee

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Fig. 4 Fascia is identified and incised just lateral to the interval Fig. 6 Once the capsulotomy has been made, the cobra retractors can
between sartorius and TFL be placed within the capsule, providing a view of the femoral neck
fracture

capsule–labral junction. The hematoma is evacuated. The

capsule can be tagged with heavy suture to aid with ele-
vation and retraction of the capsule as it is dissected free
from the femoral neck. The 2 cobra retractors are then re-
positioned inside the capsule, one above and one below the
femoral neck, giving an excellent view of the entire
femoral neck and fracture (Fig. 6). External rotation of the
leg can assist with elevation of the capsule along the infero-
medial neck toward the lesser trochanter, which is essential
for placement of a medial buttress plate, if used.
The role of capsulotomy continues to be controversial.
Multiple studies have demonstrated increases in intracap-
sular pressures with femoral neck fractures with improve-
ment after aspiration or capsulotomy and resultant
increases in osseous perfusion pressure [31–33]. However,
in a large series Haidukewych et al. [9] failed to demon-
strate any outcome differences in patients who did or did
not undergo capsulotomy at the time of fixation. Ly and
Swiontkowski [13] reviewed the management of young
femoral neck fractures in 2008 and highlighted that clinical
studies did not readily demonstrate an association between
Fig. 5 Interval between gluteus medius and rectus femoris is capsulotomy and rates of AVN. We do not routinely per-
developed, exposing the anterior joint capsule. Hibbs retractors can
form percutaneous capsulotomies in this injury pattern;
be used for soft tissue retraction
however, in the setting of displaced femoral neck fracture
‘‘T’’- or ‘‘L’’-shaped capsulotomy is made sharply through rarely do we feel comfortable obtaining an anatomic
the anterior capsule, with the long limb of the capsulotomy reduction without an open approach, and thus, a capsulo-
in line with the femoral neck and the other limb along the tomy is generally performed as part of the approach.

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Reduction technique are placed for provisional stabilization. Additionally, a

bone hook or similar instrument may be placed over the
Once the fracture has been exposed, the fracture edges are anterior portion of the femoral neck to provide a laterally
cleared of fracture hematoma. Often, high-energy femoral directed counter force against the ball-spiked pusher. A
neck fractures in young adults will have a high Pauwels more direct reduction technique may be utilized which
angle, making them particularly unstable to shear forces involves the use of two 3.5-mm cortex screws and the
(Fig. 7). Depending on the level and obliquity of the Farabeuf reduction clamp. The two screws are placed bi-
fracture, a Schanz pin or large K-wire may be placed just cortically on either side of the fracture and measured long
lateral to the articular cartilage (Fig. 8). A combination of to allow *5 mm of the screw head to sit prominently such
internal rotation of this K-wire in conjunction with external that it can be grasped by the Farabeuf clamp (Fig. 9).
rotation of the leg will book open the fracture sufficiently Securing the clamp to both screw heads allows varying
to allow all debris to be cleared from the fracture site. This degrees of compression as well as rotation to be applied
maneuver can be reversed (external rotation of the K-wire across the fracture. Once an anatomic reduction has been
and internal rotation of the leg) to affect a provisional achieved and confirmed under direct vision and fluoro-
reduction. Fractures with minimal comminution will have scopically, the fracture can be provisionally held in the
good cortical read of the reduction along the inferior reduced position with multiple K-wires.
margin of the femoral neck. If additional reduction
maneuvers need to be employed, a small incision over the
lateral aspect of the greater trochanter will allow a ball- Fixation strategies
spiked pusher to be introduced in a percutaneous fashion
against the lateral cortex of the proximal femur (Fig. 8). The choice of internal fixation will determine the next steps
This tool can hold the reduction, while additional K-wires in the case. If cannulated lag screw fixation is chosen, the
guide wires can be placed through a small incision over the
lateral aspect of the proximal femur without a formal
approach. To minimize stress riser formation, care should
be taken to avoid placing the starting point of these screws
below the level of the lesser trochanter [34]. Partially
threaded 6.5- or 7.3-mm cannulated screws are typically
placed in an inverted triangle configuration, with the
screws abutting the endosteal cortex to provide the most
stable fixation possible [35–37]. A divergent or parallel
pattern has been shown to be biomechanically superior to a
convergent pattern [37]. Inverted triangle pattern may also
reduce the risk of subtrochanteric fracture after fixation
[38]. Other biomechanical studies have suggested that the
addition of a fourth screw may improve fixation strength in
cases with posterior comminution [39]. Similarly, in high-
risk patterns (i.e., Pauwels type III), utilizing a trochanteric
lag screw (Fig. 10) has been shown to be biomechanically
superior when compared to an inverted triangle pattern
[40]. The use of washers in the setting of cancellous screws
improves compression forces [41].
If a sliding hip screw construct is chosen, a direct lateral
approach to the proximal femur is performed for hardware
placement. A separate screw placed above the sliding hip
screw can serve as an anti-rotation device and confer
additional fracture stability from improved biomechanical
strength [20]. Increased torsional stress may contribute to
higher rates of avascular necrosis after SHS fixation in
some studies, highlighting the importance of de-rotation
Fig. 7 Determination of the Pauwels angle. The long axis of the
pin and/or screw use [42]. From a technical standpoint, the
femur is marked, and a perpendicular line to this is drawn. The angle
formed by the fracture and this perpendicular line is the Pauwels surgeon should strive for a tip–apex distance of less than
angle 25 mm to prevent screw cutout and placement of the lag

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Fig. 8 Intraoperative fluoroscopic view demonstrating a Schanz pin in the proximal fragment and a ball-spiked pusher placed in a percutaneous
fashion to affect a reduction in the femoral neck. A K-wire can be placed for provisional stabilization

Fig. 9 Lateral view showing a Farabeuf reduction clamp placed over two 3.5-mm screws for a direct reduction in the femoral neck fracture. AP
view demonstrates final fixation with partially threaded lag screws

screw in the inferior portion of the neck to abut the cortex primary fixation. External rotation of the hip will allow
[43]. dissection along the inferior femoral neck toward the lesser
When considering the implant selection, the specific trochanter. A 1/3 tubular plate is then contoured to fit and
fracture pattern must be considered. Biomechanical studies secured with 3.5-mm cortical screws (Figs. 10, 11). The
have suggested that for highly unstable fracture patterns addition of an infero-medial plate has been shown to result
(Pauwels type III, basi-cervical and highly comminuted in a biomechanically stiffer and stronger construct than
fractures), a SHS construct may confer greater stability to either cannulated screws or a SHS alone [49, 50].
resist shear forces than cancellous screws [19, 44–46].
However, recently Stockton et al. [47] noted an increase in
femoral neck shortening after fixation with SHS when Discussion
compared to cancellous screw fixation. The functional
impact in that study was unclear, though shortening has Femoral neck fractures in the young adult represent a high-
been shown in older patients to decrease functional out- risk injury with the potential for significant complications.
comes and alter biomechanics [48]. Supplementary fixation There remains a paucity of high-level prospective literature
such as an infero-medial buttress plate may be placed after guiding the management of these injuries. Specifically,

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Fig. 10 Intraoperative fluoroscopic views demonstrating placement of a trochanteric lag screw placed perpendicular to the fracture plane. An
infero-medial buttress plate was placed as supplementary fixation

Fig. 11 Once the fracture has been reduced and stabilized, external rotation of the hip can be performed for placement of an infero-medial
buttress plate

prospective comparative literature is lacking regarding (1) and avascular necrosis while maximizing functional out-
open versus closed reduction, (2) SHS versus cannulated come, an anatomic reduction must be obtained with
screws, (3) the timing of operative intervention, and (4) the stable fixation [9, 26–29]. High-risk fractures (i.e., vertical
role of capsulotomy. The Fixation using Alternative shear or comminuted) carry a higher risk of complication,
Implants for the Treatment of Hip Fractures (FAITH) trial and supplemental fixation should be considered in these
is currently ongoing as a multicenter prospective, ran- patterns [16, 18, 20, 21, 40, 49].
domized study comparing cancellous screw fixation to SHS Patients should be counseled on the nature of these
fixation, adding to the body of literature on this topic. injuries. Meta-analyses and multiple studies have demon-
Despite these limitations, several patterns emerge from strated consistent complication rates: an avascular necrosis
the available literature. To reduce the risk of both nonunion rate of *15–25 %, nonunion rate just under 10 %, and a

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Ethical statement Dr. Hak reports personal fees from Globus, neck fractures: are they reliable and reproducible? Med Glas
personal fees from Merck, personal fees from Invibio, outside the (Zenica) 9:5
submitted work. Dr. Mauffrey reports personal fees from Springer, 18. Collinge C, Mir H, Reddix R (2014) Fracture morphology of high
personal fees from Slack, personal fees from Elsevier, and institu- shear angle ‘‘vertical’’ femoral neck fractures in young adult
tional support from Striker, institutional support from Synthes, patients. J Orthop Trauma 28(5):6
institutional support from Abbott, institutional support from AO 19. Baitner AC, Maurer SG, Hickey DG, Jazrawi LM, Kummer FJ,
organization, and institutional grant support from Hebei province and Jamal J, Goldman S, Koval KJ (1999) Vertical shear fractures of
CoI, all outside the submitted work. the femoral neck: a biomechanical study. Clin Orth Rel Res 367:6
20. Bonnaire FA, Weber AT (2002) Analysis of fracture gap changes,
Conflict of interest Dr. Renninger and Dr. Stacey have nothing to dynamic and static stability of different osteosynthetic procedures
disclose. in the femoral neck. Injury 33(Suppl 3):9
21. Stankewich CJ, Chapman J, Muthusamy R, Quaid G, Schemitsch
Human and animal rights This article does not contain any studies E, Tencer AF, Ching RP (1996) Relationship of mechanical
with human participants performed by any of the authors. factors to the strength of proximal femur fractures fixed with
cancellous screws. J Orthop Trauma 10:10
22. Damany DS, Parker MJ, Chojnowski A (2005) Complications
after intracapsular hip fractures in young adults: a meta-analysis
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