Femoral neck fracture reduction and internal fixation (tri-wing internal fixation)

Femoral neck fractures in addition to the submandibular fracture of the elderly, femoral neck comminuted fracture or pauwel angle gt; 80 ° tend to artificial femoral head replacement, the rest should be early reset internal fixation. In recent years, the internal fixation method has been developed with internal screws such as screw nails, compression screws, and sliding gooseneck nails. Treatment of diseases: femoral neck fracture Indication 1. Intermediate or adductive femoral neck fractures, with displacement or tendency to shift. 2. Abducted femoral neck fracture, the femoral head has a rotational displacement. Contraindications 1. Comminuted fracture of the femoral neck. 2. Older age, important organs have organic lesions, and the general condition is not good. Preoperative preparation 1. Femoral neck fractures are more common in the elderly. The function of each major organ should be thoroughly examined before surgery, especially cardiovascular disease, emphysema, diabetes, etc. Those who find organ diseases should be properly treated. 2. Fresh femoral neck fractures should be followed by tibial tuberosity traction to relieve pain and assist in resetting. 3. If there are no surgical contraindications, every effort should be made to perform the operation within 1 week after admission. Before the operation, under the continuous traction, the neck and the lateral x-ray of the femoral neck were taken at the bedside to observe the fracture reduction. Surgical procedure 1. Position: supine position. 2. Reset: Generally, closed reset is used. There are two methods: (1) Knee flexion, hip flexion 90°, handcuffs, and the other forearm inserted into the armpit, gently rocking to loosen the inserted part of the fracture end. Then pull up and abduct and rotate under continuous traction, and gradually straighten the injured limb [Fig. 2 (1) (2)]. After the reset, the heel can be placed on the palm of the hand to observe, if the reset is perfect, and there is no tendency to external rotation, the injured foot can be tied to the foot support board (or supported by a special person) to maintain the abduction 20 ° ~ 30 ° The foot is rotated 45° to stabilize the fracture end and the greater trochanter, neck and head of the femur at the same level. Then, place the hemostat or barbed wire for positioning, and check the positive and lateral x-rays to check the reset. The reduction should be anatomically aligned in the chamber; if it does not meet the requirements, it should be reset. Violence is strictly prohibited at reset. (2) Traction reset: use orthopedic surgery table. 3. Positioning: The vast majority of the wounded are fixed within the line after manual reduction. In order to ensure the blood supply and healing of the fracture site, do not reveal the fracture end during the operation. The three-wing nail is driven by the guide pin, so the direction and depth of the insertion of the guide pin is one of the keys to the success of the operation. The monitoring of the pin on the TV x-ray machine is most accurate. However, in the absence of this device, in order to make the insertion of the guide pin both ready and fast, two simple positioning methods are described below: (1) Hemostasis method: After the reduction is completed, place the tip of the straight hemostat on the intersection of the inguinal ligament and the femoral artery. The direction of the hemostat should be the same as the direction of the femoral neck. Fix the forceps with tape and then check the film. The relationship between the tip of the hemostat and the femoral head can be observed on the anteroposterior, and the relationship between the direction of the hemostatic forceps and the femoral neck can be observed, and the orientation of the insertion of the guide pin can be performed after correction. This method is simple but not very accurate. (2) Barbed wire method: a piece of iron wire plate of 12×12cm2 is used, the length of the mesh is 0.5-1.0cm, and the center of the mesh plate is made of 2 knots, and the front part of the femur (including the femoral head, neck and large) is fixed with the adhesive tape. Upper part of the rotor and femur). In the x-ray positive position, you can see the overlapping of the upper part of the femur and the barbed wire, so that you can draw the ideal pin line on the x-ray film, and determine the line from the cortical needle under the greater trochanter to the femoral head. The two points of the endpoint, on the x-ray film, count the number of grids of these two points from the wire knot, which can be positioned [Fig. 2 (4)]. According to the positioning, the stencil can be removed by using the gentian purple mark on the patient's skin. After the skin is disinfected, a short needle is inserted at the end of the femoral head, and a long needle is inserted vertically into the distal point, and the needle tip is placed against the cortical bone. Cut the skin, reveal the outside of the femur, close to the periosteal needle as the needle point, and then align the needle pin at the end of the femoral head. This method is more accurate. The positioning is mainly the up and down direction of the insertion of the fixed guide pin. The anteroposterior direction is generally maintained at the horizontal position, because the injured limb is rotated internally, and the greater trochanter, femoral neck and head are horizontal. However, it is still necessary to correct the position of the guide pin displayed on the x-ray side slice. 4. Incision, exposure: routinely disinfect the skin, spread the surgical towel, and fix it on the skin with suture (do not use the towel clamp to avoid affecting the intraoperative film). An arc-shaped incision is made on the side of the greater trochanter, about 8 to 10 cm long, starting from the front of the greater trochanter, and bypassing its side to the upper and middle 1/3 of the joint. Cut the bundle and pull it away from the sides. Under the greater trochanter, the starting point of the lateral femoral strand is traversed, and cut along its posterior edge, and pulled forward. Then, the periosteum i-shaped is cut and peeled under the rotor to reveal the lateral cortical bone of the upper femur. A longitudinal incision can also be made on the outside of the greater trochanter to directly separate the lateral femoral strands, and the periosteum is cut to reveal the outer side of the upper femur. Although this method is direct and simple, it has more bleeding. 5. Insert the scale guide needle: first drill a hole in the cortical bone insertion point under the greater trochanter (more than 2cm under the greater trochanter), then manually hold the guide needle by hand, and align the directional hemostatic forceps or femoral head. The injection needle at the end is drilled along the horizontal position. Generally insert 2 to 3 guide pins, then take the positive and lateral x-ray films and observe the position of the guide pins. The ideal location is through the center of the femoral neck and head. Leave the guide pin in the best position and continue to drill under the femoral head to remove the other guide pins. Then, the other guide needle is drilled in parallel at a distance of about 1 cm from the original guide needle by hand, preferably to the acetabulum, to prevent the femoral head from rotating when the three-wing nail is nailed. The depth of the drill can be calculated by using the length of the inner guide pin displayed on the x-ray film against the scale of the guide pin, and the length required for the three-wing nail can also be accurately calculated. 6. Stud into the three-wing nail: the length of the three-wing nail should be selected at the top of the joint surface, and the tail is just tightly embedded in the lateral cortical bone of the femur. First, with the guide needle as the center, some cortical bones are removed from the femur to make it correspond to the three wings of the nail, so as to avoid nail fracture and avoid changing the nailing direction due to the resistance of the cortical bone. The three-wing nail is inserted into the guide pin, and the nail is inserted outside the guide pin, screwed into the tail of the three-wing nail, and gradually inserted into the direction of the guide pin. The direction of the sniper should be the same as the direction of the guide pin, and the slamming force should be light and stable. At the time of the sniper, the assistant should press the palm of the hand appropriately to press the back to prevent the head from rotating. The length of the guide needle outside the bone should be measured every 1 cm of the three-wing nail. Under normal circumstances, the extra-bone length should be kept constant. When the tail of the three-winged nail enters the cortical bone, the cortical bone corresponding to the tail should be removed, so that the tail is tightly embedded in the bone, and no cleft palate fracture occurs to enhance the fixation effect. Then, using the inserter to slam the number in the greater trochanter, the crack at the fracture end that may be caused when the nail is inserted is eliminated, so that the fracture end is closely embedded. Take the positive, lateral x-ray film again, check the position of the trilobes, and adjust to the desired depth with an extractor or a nailer. Finally, pull out the two guide pins, rinse the wound, and suture them layer by layer. 7. Cut and reset, three-wing nails are fixed inside. If the manual reset is failed or reset after resetting, or the guide pin is inserted multiple times, if the position is not satisfactory, you can consider using the open reset when you have to. Extend the incision to the anterior superior iliac spine, that is, similar to the lateral aspect of the hip joint, open the tensor fascia and gluteus medius, visible joint capsule, cut the switch capsule, then reset under direct vision, and then insert according to the above method Place 2 needles. After inserting a certain length (equivalent to the length of the needle insertion point to the fracture line), the injured limb is adducted and externally rotated to expose the distal fracture surface. The guide needle should have a center at the fracture surface and the other one is 1 cm away from it. . Then the injured limb was pulled and the abduction and internal rotation were reset. After direct vision and finger exploration confirmed that the reduction was satisfactory, the two guide needles were inserted into the proximal end to the required length. The positive and lateral x-ray films confirmed that the guide needle was in the correct position. After that, nail into the three-wing nail. How much this method can affect the blood supply of the femoral head, the intraoperative joint should be minimized to reduce blood damage. complication infection.