Internal fixation with triangular nails

Femoral neck fractures are more common in older women. Because the old man is weak, he has been bedridden after a fracture, and is prone to pneumonia, hemorrhoids, heart failure, thrombosis, pyelonephritis and so on. After the femoral neck fracture, the local shear stress is large and difficult to stabilize. It can also cause ischemic femoral head necrosis, femoral neck absorption and nonunion, which brings difficulties and complexity to the treatment. The anatomical features of the femoral neck are closely related to injury and treatment. The femoral neck and the trunk constitute the neck dry angle, and the normal femoral neck long axis and the femoral frontal plane form a anteversion angle of normal 125° to 130°, and the normal angle is 10° to 15°. After the fracture, the angle may change and the treatment needs to be restored to normal. The blood supply to the femoral neck has the following sources: 1 The central artery of the ligament of the femoral head gradually degenerates with age, and may disappear after adulthood; 2 The trophoblastic ascending branch supplies the base of the femoral neck; 3 The branch of the inner and outer arteries of the circumflex femur is supplied to the joint capsule; Synovial fluid. This type of blood vessel distribution and blood supply indicates that the closer the blood supply is to the femoral head, the less it will affect healing. The hip joint is surrounded by the joint capsule and ligament. The upper and posterior sides are covered by the joint capsule and the sacral ligament. The posterior and posterior femoral neck are outside the capsule. Therefore, the lower head and the middle neck fracture are intracapsular type, and the basement of the neck is fractured. It is an extracapsular type. Intracapsular type is also affected by blood supply due to poorer capsule appearance. Due to muscle traction and stress, after the femoral neck fracture, the affected limb is shortened and externally rotated, which will cause difficulty in repair and fixation. The femoral neck fracture is generally divided into the head, the neck (neck) and the base fracture according to the fracture site. The first two types of blood damage are large, unstable, and difficult to heal. According to the posture and external force direction of the injury, it is divided into two types: abduction and adduction. The former has no displacement or embedding. The latter has displacement, the external rotation of the affected limb, the blood damage is great, the healing is difficult, and the femoral head is difficult. Easy to necrosis. Abdominal and extracapsular fractures are more stable, less displacement, and feasible non-surgical treatment. However, endogenous and intracapsular fractures are prone to nonunion and avascular necrosis of the femoral head due to displacement and blood flow disorders. Long-term bed rest is also prone to complications. Therefore, if there is no serious osteoporosis, internal fixation is not easy to maintain firm, neurological lesions and other contraindications, it is advisable to open the internal fixation and open fixation treatment for early surgery, and strive for anatomical alignment to promote bone healing. Treatment of diseases: femoral head fractures of the subtrochanteric fracture Indication Triangular nail fixation is suitable for: 1. Adult adduction type, intracapsular fracture. 2. Adult abduction fracture, femoral head backward tilt > 30 °. 3. Femoral head fracture, head rotation and difficulty in resetting. Contraindications 1. Osteoporosis, comminuted or neurological disorders, etc., the triangular nails are not strong or can not maintain the head lice. 2. Physical conditions are not suitable for surgery. Preoperative preparation 1. Take X-rays and select the appropriate length of the triangular nails. 2. First skin traction, reduce pain and prevent shortening. 3. Generally, the operation should be performed as soon as possible within 3 to 5 days after the injury, so as to prevent the bone hematoma from becoming mechanized and the neck bones being absorbed, which affects the recovery and stability. Surgical procedure If there are conditions, as far as possible under the X-ray control of the TV or under the X-ray film, the closed reset and the triangular nail internal fixation can be used. If there is no equipment condition, the reset internal fixation can still be cut. Open method (1) Incision: The hip joint is exposed by the incision in front of the patellofemoral. About 2cm from the anterior superior iliac spine. The inner edge is downward, and an arc-shaped incision is made to the front of the strand, which is about 12 cm long. Cut the skin and fascia, separate and retract between the sartorius muscle and the tensor fascia, and protect the lateral femoral cutaneous nerve. The rectus femoris and sartorius muscles were pulled inward, and the gluteus medius and tensor fascia lata were pulled outward to reveal the joint capsule. The switch capsule was cut along the long axis of the femoral neck and was about 2.5 cm long. Clear blood and blood clots in the joints. External rotation of the lower extremities can see the fracture. It can also be used as a lateral incision and extended to the anterior superior iliac spine. The upper end of the femur and the hip joint capsule can be simultaneously revealed. The joint capsule is exposed along the fascia lata or between the rectus femoris. Cut along the longitudinal axis of the femoral neck to show the fracture line. The lateral femoral muscle is cut under the large trochanter, which reveals the femur. (2) Drilling the guide needle: drill a guide needle with a scale from 1.5 to 2 cm below the lower edge of the large trochanter, 45° to the backbone, toward the center of the femoral head (equivalent to the midpoint of the groin), needle and stock The lateral axis is in a plane, and after drilling into the cortical bone, it is forced to the resistance (ie, the proximal side of the fracture). At this time, the thigh is externally rotated to check whether the guide needle is drilled from the center of the distal end. If you are not satisfied, adjust the position and direction and drill into the second guide pin. The direct rotation of the internal rotation is performed under direct vision, and the guide needle is continuously drilled into the femoral head. (3) Insert the triangular nail: put the appropriate length of the triangular nail on the well-positioned guide pin, first use a small bone knife to cut a three-ribbed groove at the femoral needle to correspond to the three wings of the nail, so as to avoid It splits the bone when it is shot. Connect the driver and gradually insert the triangular nails in the direction of the guide pins. To prevent the guide pin from being driven in, when the drive is 0.5 to 1 cm, remove the driver and check the exposed length of the guide pin. If it is entered together, the adjustment correction needs to be pulled out. Under direct vision, the final check of the position of the fracture, the degree of stability and affect the joint activity or not. Finally, each incision is sutured in layers 2. Closed Performed under TV X-ray surveillance. After the fracture is repaired, the affected limb is rotated in the abduction. Only the lateral femoral incision of the femur was performed to reveal the femoral trochanter. The lateral longitudinal incision of the lower margin of the large trochanter is about 6 cm long. The skin and the fascia, the lateral femoral muscle and the periosteum are cut open, that is, the large femoral trochanter and the lateral part of the femur are exposed. Drill the guide pin under fluoroscopy and insert the triangular nail. The specific method of operation is the same as the open method.