FRACTURES OF THE NECK OF THE FEMUR

59 this case there was evidence of unusual tension on the thickened denticulate ligament and fibrous nerve-roots, and in addition the theca was adherent to the posterior longitudinal ligament. The ridges due to the spondylosis did not seem, per se, to have compressed the cord. The implications for the treatment of these cases are

discussed. We particularly wish to thank Dr. J. G. Greenfield and Dr. Peter Daniel for all their help with this case, and Miss M. L. Prichard, D.PHIL., for the photomicrographs. REFERENCES

Allen, K. L. (1952) J. Neurol. Neurosurg. Psychiat. 15, 20. Beadle, O. A. (1931) Spec. Rep. Ser. med. Res. Coun., Lond. no. 161. Brain, W. R., Knight, G. C., Bull, J. W. D. (1948) Proc. R. Soc. Med. 41, 509. Epstein, J. A., Davidoff, L. M. (1951) Surg. Gynec. Obstet. 93, 27. Kahn, E. A. (1947) J. Neurosurg. 4, 191. Lindblom, K., Rexed, B. (1948) Ibid, 5, 413. Lund, M. (1945) Acta psychiat. 20, 1. Mettier, S. R., Capp, C. S. (1941) Ann. intern. Med. 14, 1315. Philip, W. M. (1950) Brit. med. J. i, 986. Spillane, J. D., Lloyd, G. H. T. (1951) Lancet, ii, 653. Stookey, B. (1928) Arch. Neurol. Psychiat., Chicago, 20, 275. (1940) Arch. Surg. 40, 417. von Luschka, H. (1858) Die Halbgelenke des menschlichen Körpers. -

Berlin.

FRACTURES OF THE NECK OF THE FEMUR A SIMPLE TECHNIQUE FOR THE INSERTION OF THE SMITH-PETERSEN NAIL

T. T. STAMM M.B. ORTHOPÆDIC

Lond., F.R.C.S.

SURGEON, GUY’S HOSPITAL,

LONDON

ALTHOUGH internal fixation with a Smith-Petersen or one of its modifications, is regarded as the standard method for treating a fracture of the neck of the femur, it should be considered primarily as a method of saving the life of the patient. It is often held that this injury kills elderly people because it confines them to bed. This is not true. Consider the thousands of bedridden old people in infirmaries. It is not being in bed that kills them, but being confined to bed with pain. Abolish the pain, and they will have the best chance of survival. For this reason the primary indication for internal fixation is to relieve the pain. It is in fact a life-saving measure, which incidentally also offers a reasonable chance of obtaining union of the fracture. Age and infirmity of the patient are therefore the most important indications for using this method, provided that the surgical manoeuvres. that it entails do not add too much additional risk. The aim should therefore be to develop a method which causes the minimum of shock and disturbance to the patient, rather than one that will gratify the operator by its technical perfection. At the outbreak of the late war, when all nursing-homes in London were temporarily closed, I was compelled to attempt the operation with the patient in his own bed. To my surprise, an ordinary single bed turned out to be an ideal operating-table for the purpose, and the operation was completed with the minimum of difficulty and very limited assistance. As a result of this experience, a technique of performing the operation without moving the patient from his bed was developed, and has now been used in over a hundred cases. It has proved to be so simple and satisfactory, and so few difficulties have been encountered, that I believe it merits a more general trial. TECHNIQUE The patient lies on his back in the centre of a standard hospital bed 3 ft. wide and remains in this position throughout. The operation can be performed in the patient’s room or ward, or the bed may be wheeled into the operating-theatre. An X-ray cassette holder is slipped

nail,

under the patient’s buttocks ; this is a flat wooden box, 15 in. square and 1 in. deep, open at one side so that the X-ray cassette can be slipped in for the anteroposterior view without disturbing the patient. It may be constructed from two pieces of plywood held 1 in. apart by slats on three sides. Correct anaesthesia is important. It is necessary to have complete relaxation at the commencement but only for a very short time to allow the reduction to be accomplished easily and without trauma. After that, deep anaesthesia is unnecessary. The initial short and deep anaesthesia is obtained by the intravenous administration of sodium thiopentone 0-5 g. or less. The smallest dose that will be effective, given rapidly, is the ideal to be aimed at. Subsequent maintenance is with gas-andassisted by ether if necessary. oxygen, The surgeon " scrubs up " and arranges the sterile towels over the patient so that the affected leg is free though wrapped in a towel. Anaesthesia is not induced until this has been done. Thus the surgeon is ready to reduce the fracture while the patient is completely relaxed under the thiopentone ; the limb does not have to be disturbed after reduction to put towels round it, and the pinning can be started immediately. With very nervous patients a screen may be used so that they do not see these signs of the coming operation. Reduction is effected by the Leadbetter (1938) method : the knee and thigh are flexed to a right angle, and the thigh is then rotated externally and internally alternately, while upward traction is exerted with counter-pressure on the pelvis. This disimpacts the broken bone ; and, when full internal rotation has been achieved, it is maintained while the thigh is brought down into a position of extension and abduction. The leg now hangs over the edge of the bed, and will be found to lie naturally in a position of full abduction and internal rotation. As the cassette holder compensates for the sag in the middle of the bed, the hip will also be in a position of full extension. Thus a constant and correct position for the leg is secured automatically. A vertical incision 4 in. long is made on the outer side of the thigh, starting above at the level of the lowest part of the greater trochanter. The vastus lateralis muscle is split vertically, and two bone spikes are passed, one in front of and one behind the shaft of the femur, the handles being then separated to expose the bone. A blunt dissector is passed up along the bone deep to the muscle until it will go no further. This indicates that the dissector has reached the line of attachment of the muscle to the ridge on the lowest part of the trochanter, which provides a constant and easily identifiable landmark. At a point 1 in. below this level a hole 3/16 in. in diameter is drilled through the cortex of the bone. If the fracture has been properly reduced, this hole will be in line with the centre of the inguinal ligament on the same side of the body and the anterior superior spine on the opposite side of the body. The point of a Watson-Jones calibrated guide (Watson-Jones 1936) is inserted into the hole and aimed in this line while being held horizontally. It is slowly pushed along through the bone until the increasing resistance of the head of the femur is felt. Anteroposterior and lateral radiographs are now taken. For the lateral radiograph the cassette is wrapped in a sterile towel and propped up vertically at right angles to the inguinal ligament and with one edge resting against the iliac crest. The opposite leg is raised out of the way, and the X-ray tube is placed approximately where the knee of this leg lay on the bed. It is aimed so that the rays pass parallel to the inguinal ligament. The radiographs first of all check the reduction : if this is incomplete, which only happens very occasionally, the guide is partially withdrawn, the reduction is corrected by further manipulation, and the guide is pushed home again. Secondly, the radiographs check the position of the guide :z

60 if this is incorrect, a second hole is drilled in the bone, and another guide is inserted before the first one is withdrawn. The desired length of nail is estimated from the position of the point of the guide and the calibration mark visible where the guide emerges from the bone, 1/4 in. being allowed for impaction when the nail is driven home. The selected nail is threaded on to the guide wire, and oriented so that one fin points directly down the shaft of the femur, before it is hammered in. A further radiograph may then be taken, though this is usually unnecessary. In any event, the wound is closed while the X-ray film is being developed ; this saves valuable time, and it is a simple matter to remove the stitches in the unlikely event of this being necessary. ADVANTAGES OF THE METHOD

The chief

advantages of this method are its extreme and the minimal degree of disturbance and shock to the patient. The only special instruments simplicity

are an ordinary Smith-Petersen set, consisting of a set of nails, cannulated for the Watson-Jones guide, two guides, cannulated punch, impactor, a bone drill, and, for peace of mind, a nail extractor. The operation can be performed anywhere, even in the patient’s own bedroom, and the whole procedure does not take more than half an hour, including ten minutes for taking

required

radiographs.

-

practice with this method it is justifiable to operate, if necessary, without radiographic control. I have done the operation several times without the aid of X rays, and the average time taken from the start of anaesthesia to the bandaging of the wound was twelve minutes. Although in such cases the nail may not be sited perfectly, it is almost impossible to miss the head of the femur, and it should always be possible to obtain fixation firm enough to relieve pain and make the patient comfortable. After

some

DIFFICULTIES AND FAILURES

surgical operations, difficulties and failures occasionally encountered. Since some of these are avoidable, it may be of advantage to consider those that have been experienced, and the precautions now observed to guard against them. Difficulty in Reducing the fracture As in all

are

Reduction may be difficult where the fracture is or the operation is undertaken a long time after the accident. Impaction most commonly occurs in abduction fractures, and as a rule no attempt at reduction should be made. In late cases, where there is much upward displacement of the femur, a short preliminary period of traction is sometimes advisable. If the fracture is reduced during the stage of complete relaxation, which occurs immediately after the intravenous injection of sodium thiopentone, there will rarely be difficulty. In my experience incomplete reduction can usually be traced to a failure to secure and maintain full internal rotation of the femur. Difficulty in Passing the Guide The resistance to the passage of the guide should steadily increase until the articular surface of the head of the femur is reached. If the firm resistance of cortical bone is felt before the guide has been inserted for 3 in., it usually means that the guide has caught on the calcar femorale and must therefore be withdrawn and reinserted with a rather greater upward inclination. Apart from this, difficulty in passing the guide is usually due to incorrect reduction of the fracture, and it is therefore better to check the reduction again by further manipulation rather than to continue trying to insert the guide in different directions. Jamming of the Nail on the Guide Wire This very trying accident is due to the nail catching on one of the grooved calibrations of a guide which is

impacted

slightly bent. Unless the mishap is noticed, the guide will be carried in with the nail. While the nail is being hammered in, the punch should be withdrawn repeatedly to make sure that this is not happening. Guides can now be obtained which are calibrated without grooves, and this minimises the possibility of such an accident. It may still happen, however, if the guide is slightly out of true. If it happens, both guide and nail must be extracted together. Attempts to extract the guide only may lead to breaking off the portion extruding from the nail, which may then be left embedded somewhere in the joint. Wrong Length of Nail If a second guide has had to be inserted, and the length of nail required has been determined from the X-ray plate showing the first guide, a wrong length of nail may be selected. The only safe method is to feel the point of the guide impinge upon the cortical bone of the head of the femur, and to choose a nail a full 1/4 in. shorter than the length shown on the guide where it .

emerges from the femur. Loosening and Extrusion of the Nail It is debatable whether any precautions should be taken to prevent the possibility of the nail being gradually extruded. If some of the bone in the neck of the femur is being absorbed, this extrusion may be beneficiaifor it will prevent the nail from being protruded through the head of the femur into the joint cavity. On the whole, therefore, I prefer not to use any additional form of fixation of the nail.

Non-union

Though some cases of non-union must be expected, the technique described here helps to reduce this number to a minimum. First, the method of reduction and the position used encourage slight over-reduction of the fracture, thus impacting the upper margins of the fracture and rendering the fracture line more horizontal. Secondly, the method is so straightforward and simple that it is not necessary to transfix the head with several guide wires passing in different directions, a manoeuvre which can do no good to the precarious blood-supply that remains to the upper fragment. SUMMARY

A simple technique is described for the insertion of the Smith-Petersen nail for fractures of the neck of the femur, the essential feature being the use of the patient’s own bed as the operating-table ; in fact, the patient remains in his own bed throughout. The method not only enables the operation to be performed anywhere without special apparatus, but also considerably reduces its length and also the disturbance and shock to the patient. REFERENCES

Leadbetter, G. W. (1938) J. Bone Jt Surg. 20, 108. Watson-Jones, R. (1936) Brit. J. Surg. 23, 787. " It is quite customary to ask the psychologist to predict of a group of people without specifying the exact nature of the situation in which success or failure will be decided. Thus the subjects who passed successfully through the O.S.S. assessment programme might be detailed to do one of a large number of very dissimilar jobs, ranging all the way from putting on propaganda shows in oriental countries to being dropped as secret agents into enemy-occupied territory. This situation would find an analogue in the physicist’s being asked which of a large number of metal bars were likely to fracture, but without his being given any information as to the precise stress which would be applied to each of these bars.... Until those who pose the questions gain some insight into the methods of science, and learn to provide suitable conditions for an experimental determination of the answer, psychology will continue to operate at a low level of scientific respectability."-H. J. ESSENCE, PH.D., The Scientific Study of Personality, London, 1952, p. 292. success