Feature Article
Displaced Femoral Neck Fractures in Young Adults Treated with Closed Reduction and Internal Fixation
Abstract
This article describes the effect of closed reduction and internal fixation with 3 different screw configurations for acute completely displaced femoral neck fractures in young adults. From 2001 to 2006, 136 patients (age range, 20–50 years) who had acute unilaterally completely displaced femoral neck fractures were evaluated retrospectively. All fractures were managed with closed reduction and internal fixation with 3 cannulated screws. The follow-up period was 55 months on average (range, 36–90 months). One hundred twenty-two patients were available for final evaluation of union condition and late complication. Twenty-three patients (18.9%) had nonunion, 15 (12.3%) had fixation failure, and 21 (17.2%) had avascular necrosis of the femoral head. The average duration from injury to surgery was 18.4 hours in the union group and 23.3 hours in the nonunion group, with no statistical significance (P=.196). The average duration from injury to surgery was 17.3 hours in the avascular necrosis of the femoral head group and 22.3 hours in the non-avascular necrosis of the femoral head group, with no statistical significance (P=.155). Vertical- and separated-type screw configurations resulted in a significantly higher nonunion rate (P=.001 and P=.0017, respectively) than parallel configuration. The complication rate in treating completely displaced femoral neck fractures with internal fixation in young adults is high, and screw configuration may further affect results.
- 1.Caviglia HA, Osorio PQ, Comando D. Classification and diagnosis of intracapsular fractures of the proximal femur. Clin Orthop Relat Res. 2002; (399):17–27.
10.1097/00003086-200206000-00004 Crossref Medline, Google Scholar - 2.Hedlund R, Lindgren U, Ahlbom A. Age- and sex-specific incidence of femoral neck and trochanteric fractures. An analysis based on 20,538 fractures in Stockholm County, Sweden, 1972–1981. Clin Orthop Relat Res. 1987; (222):132–139. Medline, Google Scholar
- 3.Bjørgul K, Reikerås O. Hemiarthroplasty in worst cases is better than internal fixation in best cases of displaced femoral neck fractures: a prospective study of 683 patients treated with hemiarthroplasty or internal fixation. Acta Orthop. 2006; 77(3):368–374.
10.1080/17453670610046271 Crossref Medline, Google Scholar - 4.Bjørgul K, Reikerås O. Outcome of undisplaced and moderately displaced femoral neck fractures. Acta Orthop. 2007; 78(4):498–504.
10.1080/17453670710014149 Crossref Medline, Google Scholar - 5.Raaymakers EL. Fractures of the femoral neck: a review and personal statement. Acta Chir Orthop Trauma Cech. 2006; 73(1):45–59. Medline, Google Scholar
- 6.Aminian A, Gao F, Fedoriw WW, Zhang LQ, Kalainov DM, Merk BR. Vertically oriented femoral neck fractures: mechanical analysis of four fixation techniques. J Orthop Trauma. 2007; 21(8):544–548.
10.1097/BOT.0b013e31814b822e Crossref Medline, Google Scholar - 7.Liporace F, Gaines R, Collinge C, Haidukewych GJ. Results of internal fixation of Pauwels type-3 vertical femoral neck fractures. J Bone Joint Surg Am. 2008; 90(8):1654–1659.
10.2106/JBJS.G.01353 Crossref Medline, Google Scholar - 8.Madsen F, Linde F, Andersen E, Birke H, Hvass I, Poulsen TD. Fixation of displaced femoral neck fractures. A comparison between sliding screw plate and four cancellous bone screws. Acta Orthop Scand. 1987; 58(3):212–216.
10.3109/17453678709146468 Crossref Medline, Google Scholar - 9.Paus A, Gjengedal E, Hareide A, Jørgensen JJ. Dislocated fractures of the femoral neck treated with von Bahr screws or hip compression screw. Results of a prospective, randomized study. J Oslo City Hosp. 1986; 36(5–6):55–61. Medline, Google Scholar
- 10.Rehnberg L, Olerud C. Fixation of femoral neck fractures. Comparison of the Uppsala and von Bahr screws. Acta Orthop Scand. 1989; 60(5):579–584.
10.3109/17453678909150126 Crossref Medline, Google Scholar - 11.Asnis SE, Wanek-Sgaglione L. Intracapsular fractures of the femoral neck. Results of cannulated screw fixation. J Bone Joint Surg Am. 1994; 76(12):1793–1803. Crossref Medline, Google Scholar
- 12.Lagerby M, Asplund S, Ringqvist I. Cannulated screws for fixation of femoral neck fractures. No difference between Uppsala screws and Richards screws in a randomized prospective study of 268 cases. Acta Orthop Scand. 1998; 69(4):387–391.
10.3109/17453679808999052 Crossref Medline, Google Scholar - 13.Lykke N, Lerud PJ, Strømsøe K, Thorngren KG. Fixation of fractures of the femoral neck. A prospective, randomised trial of three Ullevaal hip screws versus two Hansson hook-pins. J Bone Joint Surg Br. 2003; 85(3):426–430.
10.1302/0301-620X.85B3.13788 Crossref Medline, Google Scholar - 14.Protzman RR, Burkhalter WE. Femoral-neck fractures in young adults. J Bone Joint Surg Am. 1976; 58(5):689–695. Crossref Medline, Google Scholar
- 15.Dedrick DK, Mackenzie JR, Burney RE. Complications of femoral neck fracture in young adults. J Trauma. 1986; 26(10):932–937.
10.1097/00005373-198610000-00013 Crossref Medline, Google Scholar - 16.Zetterberg CH, Irstam L, Andersson GB. Femoral neck fractures in young adults. Acta Orthop Scand. 1982; 53(3):427–435.
10.3109/17453678208992237 Crossref Medline, Google Scholar - 17.Swiontkowski MF, Winquist RA, Hansen ST. Fractures of the femoral neck in patients between the ages of twelve and forty-nine years. J Bone Joint Surg Am. 1984; 66(6):837–846. Crossref Medline, Google Scholar
- 18.Kofoed H. Femoral neck fractures in young adults. Injury. 1982; 14(2):146–150.
10.1016/0020-1383(82)90049-3 Crossref Medline, Google Scholar - 19.Lee CH, Huang GS, Chao KH, Jean JL, Wu SS. Surgical treatment of displaced stress fractures of the femoral neck in military recruits: a report of 42 cases [published online ahead of print September 2, 2003]. Arch Orthop Trauma Surg. 2003; 123(10):527–533.
10.1007/s00402-003-0579-8 Crossref Medline, Google Scholar - 20.Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am. 2004; 86(8):1711–1716. Crossref Medline, Google Scholar
- 21.Upadhyay A, Jain P, Mishra P, Maini L, Gautum VK, Dhaon BK. Delayed internal fixation of fractures of the neck of the femur in young adults. A prospective, randomised study comparing closed and open reduction. J Bone Joint Surg Br. 2004; 86(7):1035–1040.
10.1302/0301-620X.86B7.15047 Crossref Medline, Google Scholar - 22.Zlowodzki M, Weening B, Petrisor B, Bhandari M. The value of washers in cannulated screw fixation of femoral neck fractures. J Trauma. 2005; 59(4):969–975.
10.1097/01.ta.0000188130.99626.8c Crossref Medline, Google Scholar - 23.Oakey JW, Stover MD, Summers HD, Sartori M, Havey RM, Patwardhan AG. Does screw configuration affect subtrochanteric fracture after femoral neck fixation?Clin Orthop Relat Res. 2006; (443):302–306.
10.1097/01.blo.0000188557.65387.fc Crossref Medline, Google Scholar - 24.Selvan VT, Oakley MJ, Rangan A, Al-Lami MK. Optimum configuration of cannulated hip screws for the fixation of intracapsular hip fractures: a biomechanical study. Injury. 2004; 35(2):136–141.
10.1016/S0020-1383(03)00059-7 Crossref Medline, Google Scholar - 25.American Society of Anesthesiologists. New classification of physical status. Anesthesiology. 2009; (24):111. Google Scholar
- 26.Lindequist S. Cortical screw support in femoral neck fractures. A radiographic analysis of 87 fractures with a new mensuration technique. Acta Orthop Scand. 1993; 64(3):289–293.
10.3109/17453679308993627 Crossref Medline, Google Scholar - 27.Gurusamy K, Parker MJ, Rowlands TK. The complications of displaced intracapsular fractures of the hip: the effect of screw positioning and angulation on fracture healing. J Bone Joint Surg Br. 2005; 87(5):632–634.
10.1302/0301-620X.87B5.15237 Crossref Medline, Google Scholar - 28.Scheck M. The significance of posterior comminution in femoral neck fractures. Clin Orthop Relat Res. 1980; (152):138–142. Medline, Google Scholar
- 29.Stiasny J, Dragan S, Kulej M, Martynkiewicz J, Plochowski J, Dragan SL. Comparison analysis of the operative treatment results of the femoral neck fractures using side-plate and compression screw and cannulated AO screws. Orthop Traumatol Rehabil. 2008; 10(4):350–361. Medline, Google Scholar
- 30.Bartonícek J. Pauwels’ classification of femoral neck fractures: correct interpretation of the original. J Orthop Trauma. 2001; 15(5):358–360.
10.1097/00005131-200106000-00009 Crossref Medline, Google Scholar - 31.Alho A, Benterud JG, Solovieva S. Internally fixed femoral neck fractures. Early prediction of failure in 203 elderly patients with displaced fractures. Acta Orthop Scand. 1999; 70(2):141–144.
10.3109/17453679909011252 Crossref Medline, Google Scholar - 32.Damany DS, Parker MJ, Chojnowski A. Complications after intracapsular hip fractures in young adults. A meta-analysis of 18 published studies involving 564 fractures. Injury. 2005; 36(1):131–141.
10.1016/S0020-1383(04)00175-5 Crossref Medline, Google Scholar - 33.Alberts KA, Jervaeus J. Factors predisposing to healing complications after internal fixation of femoral neck fracture. A stepwise logistic regression analysis. Clin Orthop Relat Res. 1990; (257):129–133. Medline, Google Scholar
- 34.Bonnaire F, Schaefer DJ, Kuner EH. Hemarthrosis and hip joint pressure in femoral neck fractures. Clin Orthop Relat Res. 1998; (353):148–155.
10.1097/00003086-199808000-00017 Crossref Medline, Google Scholar - 35.Crawfurd EJ, Emery RJ, Hansell DM, Phelan M, Andrews BG. Capsular distension and intracapsular pressure in subcapital fractures of the femur. J Bone Joint Surg Br. 1988; 70(2):195–198. Crossref Medline, Google Scholar
- 36.Maruenda JI, Barrios C, Gomar-Sancho F. Intracapsular hip pressure after femoral neck fracture. Clin Orthop Relat Res. 1997; (340):172–180.
10.1097/00003086-199707000-00022 Crossref Medline, Google Scholar - 37.Harper WM, Barnes MR, Gregg PJ. Femoral head blood flow in femoral neck fractures. An analysis using intra-osseous pressure measurement. J Bone Joint Surg Br. 1991; 73(1):73–75. Crossref Medline, Google Scholar
- 38.Strömqvist B, Nilsson LT, Egund N, Thorngren KG, Wingstrand H. Intracapsular pressures in undisplaced fractures of the femoral neck. J Bone Joint Surg Br. 1988; 70(2):192–194. Crossref Medline, Google Scholar
- 39.Butt MF, Dhar SA, Gani NU, Delayed fixation of displaced femoral neck fractures in younger adults [published online ahead of print January 31, 2008]. Injury. 2008; 39(2):238–243.
10.1016/j.injury.2007.09.002 Crossref Medline, Google Scholar - 40.Ly TV, Swiontkowski MF. Treatment of femoral neck fractures in young adults. Instr Course Lect. 2009; (58):69–81. Medline, Google Scholar
- 41.Tian W, Cui Z, Kan S. Comparison of cannulated screws fixation with different reduction methods at different time points for displaced femoral neck fractures in terms of fracture healing [in Chinese]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2009; 23(4):440–443. Medline, Google Scholar
- 42.Schmitz MA, Finnegan M, Natarajan R, Champine J. Effect of smoking on tibial shaft fracture healing. Clin Orthop Relat Res. 1999; (365):184–200.
10.1097/00003086-199908000-00024 Crossref Medline, Google Scholar - 43.Kyrö A, Usenius JP, Aarnio M, Kunnamo I, Avikainen V. Are smokers a risk group for delayed healing of tibial shaft fractures?Ann Chir Gynaecol. 1993; 82(4):254–262. Medline, Google Scholar
- 44.Ly TV, Swiontkowski MF. Treatment of femoral neck fractures in young adults. J Bone Joint Surg Am. 2008; 90(10):2254–2266. Medline, Google Scholar
- 45.Pape HC, Krettek C, Friedrich A, Pohlemann T, Simon R, Tscherne H. Long-term outcome in children with fractures of the proximal femur after high-energy trauma. J Trauma. 1999; 46(1):58–64.
10.1097/00005373-199901000-00010 Crossref Medline, Google Scholar - 46.Castillo RC, Bosse MJ, MacKenzie EJ, Patterson BMLEAP Study Group. Impact of smoking on fracture healing and risk of complications in limb-threatening open tibia fractures. J Orthop Trauma. 2005; 19(3):151–157.
10.1097/00005131-200503000-00001 Crossref Medline, Google Scholar - 47.Chen F, Osterman AL, Mahony K. Smoking and bony union after ulna-shortening osteotomy. Am J Orthop (Belle Mead NJ). 2001; 30(6):486–489. Medline, Google Scholar
- 48.Wosje KS, Kalkwarf HJ. Bone density in relation to alcohol intake among men and women in the United States [published online ahead of print November 8, 2006]. Osteoporos Int. 2007; 18(3):391–400.
10.1007/s00198-006-0249-0 Crossref Medline, Google Scholar - 49.Hodges DL, Kumar VN, Redford JB. Effects of alcohol on bone, muscle and nerve. Am Fam Physician. 1986; 34(5):149–156. Medline, Google Scholar
- 50.Matsuo K, Hirohata T, Sugioka Y, Ikeda M, Fukuda A. Influence of alcohol intake, cigarette smoking, and occupational status on idiopathic osteonecrosis of the femoral head. Clin Orthop Relat Res. 1988; (234):115–123. Medline, Google Scholar
- 51.Kauffman JI, Simon JA, Kummer FJ, Pearlman CJ, Zuckerman JD, Koval KJ. Internal fixation of femoral neck fractures with posterior comminution: a biomechanical study. J Orthop Trauma. 1999; 13(3):155–159.
10.1097/00005131-199903000-00001 Crossref Medline, Google Scholar - 52.Baitner AC, Maurer SG, Hickey DG, Vertical shear fractures of the femoral neck. A biomechanical study. Clin Orthop Relat Res. 1999; (367):300–305. Medline, Google Scholar
- 53.Stankewich CJ, Chapman J, Muthusamy R, Relationship of mechanical factors to the strength of proximal femur fractures fixed with cancellous screws. J Orthop Trauma. 1996; 10(4):248–257.
10.1097/00005131-199605000-00005 Crossref Medline, Google Scholar - 54.Elmerson S, Andersson GB, Pope MH, Zetterberg C. Stability of fixation in femoral neck fractures. Comparison of four fixation devices in vivo and in cadavers. Acta Orthop Scand. 1987; 58(2):109–112.
10.3109/17453678709146451 Crossref Medline, Google Scholar - 55.Parker MJ, Porter KM, Eastwood DM, Schembi Wismayer M, Bernard AA. Intracapsular fractures of the neck of femur. Parallel or crossed garden screws?J Bone Joint Surg Br. 1991; 73(5):826–827. Crossref Medline, Google Scholar
- 56.Martens M, Van Audekercke R, Mulier JC, Stuyck J. Clinical study on internal fixation of femoral neck fractures. Clin Orthop Relat Res. 1979; (141):199–202. Medline, Google Scholar
- 57.Rubin R, Trent P, Arnold W, Burstein A. Knowles pinning of experimental femoral neck fractures: biomechanical study. J Trauma. 1981; 21(12):1036–1039.
10.1097/00005373-198112000-00006 Crossref Medline, Google Scholar - 58.Shih CH, Wang KC. Femoral neck fractures. 121 cases treated by Knowles pinning. Clin Orthop Relat Res. 1991; (271):195–200. Medline, Google Scholar
- 59.Clark DI, Crofts CE, Saleh M. Femoral neck fracture fixation. Comparison of a sliding screw with lag screws. J Bone Joint Surg Br. 1990; 72(5):797–800. Crossref Medline, Google Scholar
