The need for open reduction in acute femoral fractures of patients < 65 years is controversial. It has been shown that the quality of reduction is linked to the outcome (AVN and revision surgery). But these studies assess reduction by radiography - as done after closed reduction is performed.
Do we always need open reduction if closed reduction achieves good alignment?
Closed reduction is the gold standard. Open reduction for femoral neck fractures is an exception. But the main problem with this injury is the fracture fixation. Reduction without internal fixation should not be discussed at all.
On many occasions,these fractures can be reduced successfully by closed reduction followed by osteosynthesis using multiple cancellous screws.Thus, the incidence of femoral head developing AVN is reduced,which is of major concern with open reduction.However,proper intra-operative (Image intensifier)and post-operative(check X-rays) assessment is required to ensure anatomical reduction of the fracture treated by closed method.
The easiness of reduction is linked with fracture personality, and it correlates with prognosis in a high number of cases the closed reduction es enough, but in some cases open reduction my be necessary for gross displacement.
and example is the Fragmetation of the posterior neck wall that is correlated with dificult reduction and higher rates of necrosis
Dear Dr. Parsa,
Femoral neck fractures in children is a rare injury. In similar cases close reduction usually succeeds. But do you mean traumatic femoral head epiphysiolysis ? This is something else, although in fresh cases close reduction is usually also successful. On the contrary, in cases of inveterate or malunited cases open reduction or neck osteotomy is needed.
I do agree with regard to femoral neck fractures in children which is a rarity.Undisplaced/successfully reduced fractures can be treated conservatively.Children do tolerate hip spica/traction extremely well with least complications as compared to adults.However,like in young adults,displaced fractures in paediatric age group, necessitate open reduction at the earliest.
There are 2 main factors that give a poor outcome after intracapsular hip fractures, in order of importance:
My hip colleagues try very hard for closed reduction, using a Steinman pin on a T-handle in the proximal femur to disimpact and manipulate the fracture, rather than using a Leadbetter manoeuvre. The quality of the intra-operative fluoroscopy is key. Fixation is usually with 2 or 3 cannulated screws (better than spinning the head round on a DHS lag screw!)
Femoral neck fractures in children are very rare, but the level of complications is high. Closed reduction and internal fixation is a priority, but in some cases we are facing with difficulties of anatomic closed reduction, specially in high energy trauma cases. According Delbet classification type I and II have very high level of AVN. Early capsular decompression may be useful in reducing the risk for AVN.
Closed reduction in femoral neck fractures of young people is the best option as long as the surgeon performs a true anatomical reduction. Closed reduction is the best but anatomical reduction and stable internal fixation is a must. Anyway, some surgeons aspirate the intracapsular hematoma after closed reduction and internal fixation to decrease intracapsular pressure. Increased intracapsular hematoma may block the microcirculation in the articular cartilage and leads to AVN. What do you think about this?
Always closed reduction and internal fixation , but too young children need an open reduction sometimes
Dear Dr. Ciftdemir,
I agree entirely with you as far as closed reduction and internal fixation are concerned. I do not see a lot of sense in aspirating the intracapsular hematoma. Usually, it is not of such a big amount, and on the other hand, the blood cells are important in the very early stage of fracture healing.
I understood your answer. Thank you, Dr. Parsa. I think you are right.
closed reduction and internal fixatio ( cannulated screws), possobly within fisrt 24 h
minimal displaced by closed reduction, totally displaced by open reduction
Dear Dr.Ismail Hadisoebroto Dilogo,what is the criterion to differentiate 'minimally' displaced and 'totally' displaced fracture neck of femur?Is it arbitrary or based on any classification you follow?
Closed reduction for sure, but anatomical reduction with stable and solid percutaneous fixation... I deeply believe that there is no reason, as mentioned before, to open this joint and add injury to the injury. I've been experiencing GAMMA Nails since a few years for these fractures with really good results and early physiotherapy and full weight bearing. There is no comparison with what we got with simple screwing... Regarding classifications used to treat these fractures, I still use GARDEN and PAUWELLS and added LAMARE classification for vertical displacements. This gives a good idea of head vascular prognosis. The delay before reduction remains probably the most important factor for the future and these fractures should be treated - on my opinion - as real emergencies, if possible before 6 hours...
Once again the gold standard is closed reduction and stable fixation as soon as possible. Even on emergency base if the facility has experienced surgeons at disposal any time. Open reduction is an exception, and it should be done only if the closed reduction fails.
This adds more oil to the fire:
http://www.injuryjournal.com/article/S0020-1383%2814%2900614-7/abstract
Dr. Osterhoff,
The survey cited tackles in the first line the techniques of fracture fixation, and then the method of reduction. I think the conclusions coincide with the opinions posted above. There is a bigger discordance in the techniques of fixation than in the methods of fracture reduction.
Regards
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