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Management of displaced femoral neck fractures in young adults (a group at risk)
I,zjury Vol. 29, No. 3, pp. 215-218, 1998 1998 Else&r Science Ltd. All rights reserved
0
Printed
in Great Britain
0020-1383/98
$19.00
+O.OO
ELSEVIER
PII: SOO20-1383(97)00184-8
Management young adults
of displaced femoral (a group at risk)
V. K. Gautam, S. Anand
and B. K. Dhaon
neck fractures
in
Department of Orthopaedics, Maulana Azad Medical College, New Delhi, India
25 youF~g adults (nge 15-50 years) with femoral neck fractures zuere operated on an ordinary operating table, using a WatsonJones npproach. Open reduction of the fracture site through RF1 anterior capsulnr incision was perfOrmed and fixatiorl with three cnncellous screws zms done. Patients were regularly assessed for clinical and radiological evidence of non-uFlioF1 rind azumular necrosis. Azxmge follouw~p was 32 monfhs. Non-uwion ZLXZSseen irl oFle case (4 per cent) and evidence of avascular riecrosis was seen in three cases (12 per cent). The results were compared with available published series of similar fractures, treated by closed and open reduction technique. The comparison showed that in young adults, primary open reduction and internal fixation of femoral neck fractures cnn be recommended as the treatment of choice. 0 1998 Elsezjier Science Ltd. All rights reserved.
Injury,
Vol. 29, No. 3, 215-218,
1998
Introduction Femoral neck fracture in hard bone of young adults is a rare fracture. The high energy leading to this fracture causes comminution at the fracture site; a greater disruption of the blood supply to the femoral head and a higher incidence of associated injuries all adding up to a dismal prognosis. This is manifested in various reportsI showing a very high incidence of avascular necrosis and non-union when treated by conventional closed reduction and fixation (T&e I). Also, complications such as avascular necrosis are more symptomatic in these young adults because of their vigorous lifestyle; salvage procedures such as hip replacement have a higher rate of failure. In this series, we performed open reduction and internal fixation of these fractures in young adults (15-50 years) on an ordinary operating table and advocate this as the primary mode of treatment.
Materials
and methods
From January 1992 to March 1997, 28 cases of displaced (Garden type III and IV) fractures of the
neck of the femur, in patients aged 15-50 years, were operated on. Three cases were lost to follow-up and one patient died of an unrelated cause and has been excluded. One patient had bilateral fractures and has been included as two separate cases. Thus a total of 25 caseswas studied. The operation was performed on an ordinary operating table. The patients were positioned in a supine position, with a sand-bag beneath the lumbar spine on the affected side, causing approximately 20 tilt to the opposite side. The hip was kept flexed throughout the procedure. A standard Watson-Jones approach was used. The capsule was incised through an anterior longitudinal incision stopping short of the intertrochanteric line, thus sparing the ring of vessels at the base of the femoral neck9. The fracture site was exposed and reduction achieved under direct vision. Any rotation of the proximal fragment was controlled by insertion of K-wires (Figure 2). The capsule was left open to prevent development of any later increased intracapsular pressure. Fixation was achieved usually by three 6.5 mm cancellous screws. Post-operatively, patients were kept on a Thomas splint for 6 weeks, on a regimen of quadriceps exercises, following which non-weight bearing crutch
Table I. Incidence of non-union and avascular necrosis in young adults with intracapsular fractures, treated by closed reduction - asseenfrom various published series
Author(s)
Year
MassieZ Zolczer et aL5 Askin and Bryan6 Kuslich and Gustilo’ Protzman and” Burkhalter Kofoed’ Zetterberg et al.4 Tooke and Favero8
1964 1972 1976 1976 1976
Overall *Includes
1982 1982 1985
No. of patients 10
50 19
11
0
26* 19
20 22
25 59
45 86*
17
23
18* 41 33
105 18
6 26
undisplaced
A vascular necrosis (per cent)
27
average some
Non-union (per cent)
fractures.
60
41
216
Injury: International Journal of the Care of the Injured Vol. 29, No. 3,1998
P /‘I
K-WIRE INTO FOR
INSERTED FEMORAL HEAD MANIPULATION
:
FASCIA
LATA
VASTUS LPTERALIS
Figure 1. K-wire inserted into femoral head to control its
movement, so asto achieve optimum reduction. mobilization was started. At 3 months, after confirming union radiologically, full weight bearing was started. Further 3 monthly follow-up was done to look for clinical or radiological evidence of any developing complication. The average age of the patients was 34 years, 68 per cent of them being males. High energy trauma was the cause of injury in 80 per cent of cases.There were associated injuries in 20 per cent of patients and 32 per cent of patients had associated diseases. The average interval between injury and operation was 6.6 days. Fracture site comminution was seen in 68 per cent of cases.Good (in 80 per cent of cases)to acceptable reduction was achieved in 96 per cent of cases(as per Garden’s alignment index). Average follow-up now is of 32 months.
Results Early post-operative complications were that the screws were too long in three cases(12 per cent) and superficial wound infection in one case (4 per cent). No deep infection was seen in any of the cases. Union was achieved in all cases by three months, except in one patient (case 20) who had a very small capital fragment in which we were not able to achieve good fixation. There was an early loss of fixation and subsequent revision to THR was done. Thus, we were able to achieve a unidn rate of 96 per cent. Evidence of avascular necrosis was seen in three cases(12 per cent); of these only one case (4 per cent) has segmental collapse so far. In all the three cases, the avascular necrosis was detected between 12 and 18 months after the operation.
Discussion Conventionally closed reduction followed by internal fixation has been done for these fractures in the
young, but the closed reduction technique has many disadvantages. Firstly, intracapsular tamponade cannot be relieved; the intracapsular pressure in femoral neck fractures has been found to exceed arteriolar and venous pressure leading to compromised femoral head circulation“‘-12. This circulation has been found to improve after aspiration of the haematoma’3-15. Also, in the closed reduction and fixation technique, the patient remains on the fracture table with the limb in extension and internal rotation for prolonged periods. This manoeuvre reduces the intracapsular volume, compressing the blood and synovial fluid within the joint by a forceful twist or wringing-out process mediated by the inelastic capsulelz. Furthermore, some authors1h,‘7 have found that in extension and internal rotation of the hip, there is a reduction in the blood supply to the femoral head, as shown by P and oxygen tension studies. Melberg et al.‘* found that patients who had normal circulation of the femoral head pre-operatively, developed decreased circulation post-operatively. He suggested that the prolonged extension and internal rotation position on the fracture table was the probable cause. The repeated forceful manipulation tried in the closed technique may break the remaining retinacular vessels - thus increasing the risk of AVN. Then there is uncertainty of adequacy of reduction as there is no direct look and feel of the fracture. Simon and Wyman” took patients who had satisfactory postoperative AI’ and lateral check films and took more X-rays in various planes of flexion and rotation. They found degrees of malalignment in most. As one deviates from anatomical reduction, the crosssectional area of medullary contact between the two fracture surfaces decreases exponentially, thus providing decreased area for ingrowth of vessels from the distal to the proximal fragment increasing the rates of AVN and non-union dramatically. We believe that open reduction of femoral neck fractures overcomes most disadvantages of closed reduction, while allowing for some advantages. We did open reduction through an anterior capsular
Table II. Incidence of non-union and avascular necrosisin young adults with intracapsular fractures, treated by open reduction as seenfrom various published series No. of patients
Non-union (per cent)
A vascular necrosis (per cent)
0 17 -
10.5 10 18
Author(s)
Year
Swiontkowski et al.” Yamano” Gerber et aLz3 Fehr et al.24
1984 1989 1993 1993
27 19 54 49
1975
17
6
1997
25
4.0
Overall
average
Meyers
et aLzSx
8.5
Our series *Used
posterior
20
approach
with
muscle
pedicle
14.6 0
graft.
12.0
Gautam
et al.: Displaced
femoral
217
neck fractures
AVASCULAR NECROSIS
NON-UNION dosed
m
gf&!g our series
open
Figure 2. A comparisonof average rates of non-union and avascular necrosisthrough open/closedreduction of femoral neck
fractures - as seenfrom various published series.
incision. The anterior capsule is devoid of any major vessel supplying the femoral head2”. Thus, femoral head circulation is not impaired. This also decompressesany intracapsular tamponade. Intracapsular femoral neck fracture is unique in that both proximal and distal fragments are mobile. There is no control over the proximal fragment in closed reduction techniques. In an open reduction, one can put a K-wire in the femoral head and use it to manipulate the femoral head to achieve good reduction (Figure 2). Open reduction allows the surgeon to have a direct look and feel of reduction, without having to depend on an image intensifier, thus saving the surgeon from unnecessary exposure to radiation. Our study from a developing country is unique in that rarely do patients present to us with fresh trauma. Most of the time, they had been referred to us from neighbouring small centres after a delay of a few days. So, out of necessity, we were unable to operate on these patients within the initial few hours. Our average interval between injury and operation was 6.6 days. Yet we were able to achieve excellent results. We feel this was because open reduction allowed us to achieve the best reduction of the fracture with maximum medulla to medulla contact, allowing for optimal conditions for union and revascularization of the femoral head. We feel that the factor of paramount importance for achieving good results in this fracture is a good quality reduction, and open reduction is the only method which ensures this reduction. We were able to achieve good to acceptable reduction in 96 per cent of casesin this study, leading to a union rate of 96 per cent and an AVN rate of only 12 per cent. Thus the bad results of internal fixation are usually the results of bad reduction; open reduction and
fixation can be advocated as the ‘treatment of choice’ in femoral neck fractures in young adults (Tables I and II, Fipw 2).
References 1 Kuslich S. D. and Gustilo R. B. Fractures of the femoral neck in young adults. J. Bone Joint Stq. 1976; 58A: 724. 2 Massie W. K. Fractures of the hip. I. Bme loid Szrrg. 1964; 46A: 658. 3 Protzman R. R. and Burkhalter W. E. Femoral neck fractures in young adults. J. Bone Joiwf Surg. 1976; 58A: 689. 4 Zetterberg C. H., Instam L. and Andersson G. B. J.
Femoral neck fractures in young adults. Actn Scund.
Orfhop.
1982; 53: 427.
5 Zolczer L., Kazar G., Manninger J. and Nagy E. Fractures of the femoral neck in adolescence.Injury 1972; 4: 41. 6 Askin S. R. and Bryan R. S. Femoral neck fractures in young adults. Clin. Orthop. 1976; 114: 259.
7 Kofoed H. Femoral neck fractures in young adults. lnjuty 1982;14: 146. 8 Tooke S. M. T. and Favero K. J. Femoral neck fractures in skeletally mature patients, fifty years old or less. J. Bone Joint Surg. 1985; 67A: 1255. 9 Nagi 0. N., Gautam V. K. and Marya S. K. S. Treatment
of femoral neck fractures with a cancellousscrew and fibular graft. I. Bone Joint Surg. 1986; 68B(3): 387. 10 Crawford E. J. I’., Emery R. J. H., Hausell D. M., Phelan M. and Andrews B. G. Capsular distension capsular pressure in subcapital fractures of J. Bone Joint Surg. 1988; 708: 195. 11 Soto-Hall R. Alterations in the intra-articular trans-cervical fractures of the hip. J. Bo,le 1963; 45A: 662.
and intrathe femur. pressure in Joint Surg.
218
Injury:
International
12 Soto-Hall R., Johnson L. H. and Johnson R. A. Variations in the intra-articular pressure of the hip joint in injury and disease. J. Bone Joint Surg. 1964; GA: 509. 13 Bauer G., Weber D. A., Ceder L., Dart L., Egund N., Hansson L. I. and Stromqvist B. Dynamics of technitium-99m methylene diphosphonate imaging of the femoral head after hip fractures. Clin. Orthop. 1981; 15: 85. 14 Stromqvist B. Femoral head vitality after intracapsular hip fracture - 490 cases studied by intravital tetracycline labelling and Tc-MDP radionuclide imaging. Acta Orthop. Stand. 1983; 54(suppl.): 200. 15 Wingstrand H., Stomqvist B., Egund N., Gustafson T., Nilsson L. T. and Thorngren K. G. Haemarthrosis in undisplaced cervical fractures. Acta Orthop. Stand. 1986; 57: 305. 16 Boyd H. B., Zilversmit D. B. and Calandruccio R. A. The use of radioactive phosphorus P to determine the viability of the head of the femur. 1. Bone Joint Surg. 1955; 37A: 260. C. F. An instrument for the measurement 17 Woodhouse of oxygen tension in bone. A preliminary report. J. Bone Joint Surg. 1961; 43A: 119. 18 Melberg I’. E., Korner L. and Lansinger 0. Hip joint pressure after femoral neck fractures. Acta Orthop. Stand. 1986; 57: 501. 19 Simon W. and Wyman T. E. Femoral neck fractures - a study of adequacy of reduction. C/in. Orthop. 1970; 70: 152.
Journal
of the Care of the Injured
Vol. 29, No. 3,1998
20 Trueta J. and Harrison M. H. M. The normal vascular anatomy of the human femoral head in adult man. J. Bone Joirzt Surg. 1953; 358(3): 442. 21 Swiontkowski M. F., Winquist R. A. and Hansen S. T. Fractures of the femoral neck in patients between the ages of twelve and forty nine years. J. Bone Joint Surg. 1984; 66A(6): 837. 22 Yamano Y. Prong plate fixation for displaced intracapsular fractures of the femoral neck. J. Booze Joint Surg. 1989; 71B: 598. 23 Gerber C., Stehle J. and Ganz R. The treatment of fractures of the femoral neck. Clin. Orthop. 1993; 292: 77. 24 Fehr H. R., Steiner W. and Moesberger B. Osteosynthesis in dislocated femoral neck fractures (Garden III and IV) - long term results and treatment concept. Helu. Chir. Acta 1993; 59(4): 539. 25 Meyers M. M., Moore T. M. and Harvey J. I’. Displaced fractures of the femoral neck treated with muscle pedicle graft: with emphasis on the treatment of these fractures in young adults. J. Bone Joint Sztrg. 1975; 57A: 718.
Paper
accepted
20 October
1997.
Requests for reprints should be addressed to: Dr V. K. Gautam, Department of Orthopaedics, Maulana Azad Medical College, New Delhi, India. Fax: +Oll-3235574.
0
Printed
in Great Britain
0020-1383/98
$19.00
+O.OO
ELSEVIER
PII: SOO20-1383(97)00184-8
Management young adults
of displaced femoral (a group at risk)
V. K. Gautam, S. Anand
and B. K. Dhaon
neck fractures
in
Department of Orthopaedics, Maulana Azad Medical College, New Delhi, India
25 youF~g adults (nge 15-50 years) with femoral neck fractures zuere operated on an ordinary operating table, using a WatsonJones npproach. Open reduction of the fracture site through RF1 anterior capsulnr incision was perfOrmed and fixatiorl with three cnncellous screws zms done. Patients were regularly assessed for clinical and radiological evidence of non-uFlioF1 rind azumular necrosis. Azxmge follouw~p was 32 monfhs. Non-uwion ZLXZSseen irl oFle case (4 per cent) and evidence of avascular riecrosis was seen in three cases (12 per cent). The results were compared with available published series of similar fractures, treated by closed and open reduction technique. The comparison showed that in young adults, primary open reduction and internal fixation of femoral neck fractures cnn be recommended as the treatment of choice. 0 1998 Elsezjier Science Ltd. All rights reserved.
Injury,
Vol. 29, No. 3, 215-218,
1998
Introduction Femoral neck fracture in hard bone of young adults is a rare fracture. The high energy leading to this fracture causes comminution at the fracture site; a greater disruption of the blood supply to the femoral head and a higher incidence of associated injuries all adding up to a dismal prognosis. This is manifested in various reportsI showing a very high incidence of avascular necrosis and non-union when treated by conventional closed reduction and fixation (T&e I). Also, complications such as avascular necrosis are more symptomatic in these young adults because of their vigorous lifestyle; salvage procedures such as hip replacement have a higher rate of failure. In this series, we performed open reduction and internal fixation of these fractures in young adults (15-50 years) on an ordinary operating table and advocate this as the primary mode of treatment.
Materials
and methods
From January 1992 to March 1997, 28 cases of displaced (Garden type III and IV) fractures of the
neck of the femur, in patients aged 15-50 years, were operated on. Three cases were lost to follow-up and one patient died of an unrelated cause and has been excluded. One patient had bilateral fractures and has been included as two separate cases. Thus a total of 25 caseswas studied. The operation was performed on an ordinary operating table. The patients were positioned in a supine position, with a sand-bag beneath the lumbar spine on the affected side, causing approximately 20 tilt to the opposite side. The hip was kept flexed throughout the procedure. A standard Watson-Jones approach was used. The capsule was incised through an anterior longitudinal incision stopping short of the intertrochanteric line, thus sparing the ring of vessels at the base of the femoral neck9. The fracture site was exposed and reduction achieved under direct vision. Any rotation of the proximal fragment was controlled by insertion of K-wires (Figure 2). The capsule was left open to prevent development of any later increased intracapsular pressure. Fixation was achieved usually by three 6.5 mm cancellous screws. Post-operatively, patients were kept on a Thomas splint for 6 weeks, on a regimen of quadriceps exercises, following which non-weight bearing crutch
Table I. Incidence of non-union and avascular necrosis in young adults with intracapsular fractures, treated by closed reduction - asseenfrom various published series
Author(s)
Year
MassieZ Zolczer et aL5 Askin and Bryan6 Kuslich and Gustilo’ Protzman and” Burkhalter Kofoed’ Zetterberg et al.4 Tooke and Favero8
1964 1972 1976 1976 1976
Overall *Includes
1982 1982 1985
No. of patients 10
50 19
11
0
26* 19
20 22
25 59
45 86*
17
23
18* 41 33
105 18
6 26
undisplaced
A vascular necrosis (per cent)
27
average some
Non-union (per cent)
fractures.
60
41
216
Injury: International Journal of the Care of the Injured Vol. 29, No. 3,1998
P /‘I
K-WIRE INTO FOR
INSERTED FEMORAL HEAD MANIPULATION
:
FASCIA
LATA
VASTUS LPTERALIS
Figure 1. K-wire inserted into femoral head to control its
movement, so asto achieve optimum reduction. mobilization was started. At 3 months, after confirming union radiologically, full weight bearing was started. Further 3 monthly follow-up was done to look for clinical or radiological evidence of any developing complication. The average age of the patients was 34 years, 68 per cent of them being males. High energy trauma was the cause of injury in 80 per cent of cases.There were associated injuries in 20 per cent of patients and 32 per cent of patients had associated diseases. The average interval between injury and operation was 6.6 days. Fracture site comminution was seen in 68 per cent of cases.Good (in 80 per cent of cases)to acceptable reduction was achieved in 96 per cent of cases(as per Garden’s alignment index). Average follow-up now is of 32 months.
Results Early post-operative complications were that the screws were too long in three cases(12 per cent) and superficial wound infection in one case (4 per cent). No deep infection was seen in any of the cases. Union was achieved in all cases by three months, except in one patient (case 20) who had a very small capital fragment in which we were not able to achieve good fixation. There was an early loss of fixation and subsequent revision to THR was done. Thus, we were able to achieve a unidn rate of 96 per cent. Evidence of avascular necrosis was seen in three cases(12 per cent); of these only one case (4 per cent) has segmental collapse so far. In all the three cases, the avascular necrosis was detected between 12 and 18 months after the operation.
Discussion Conventionally closed reduction followed by internal fixation has been done for these fractures in the
young, but the closed reduction technique has many disadvantages. Firstly, intracapsular tamponade cannot be relieved; the intracapsular pressure in femoral neck fractures has been found to exceed arteriolar and venous pressure leading to compromised femoral head circulation“‘-12. This circulation has been found to improve after aspiration of the haematoma’3-15. Also, in the closed reduction and fixation technique, the patient remains on the fracture table with the limb in extension and internal rotation for prolonged periods. This manoeuvre reduces the intracapsular volume, compressing the blood and synovial fluid within the joint by a forceful twist or wringing-out process mediated by the inelastic capsulelz. Furthermore, some authors1h,‘7 have found that in extension and internal rotation of the hip, there is a reduction in the blood supply to the femoral head, as shown by P and oxygen tension studies. Melberg et al.‘* found that patients who had normal circulation of the femoral head pre-operatively, developed decreased circulation post-operatively. He suggested that the prolonged extension and internal rotation position on the fracture table was the probable cause. The repeated forceful manipulation tried in the closed technique may break the remaining retinacular vessels - thus increasing the risk of AVN. Then there is uncertainty of adequacy of reduction as there is no direct look and feel of the fracture. Simon and Wyman” took patients who had satisfactory postoperative AI’ and lateral check films and took more X-rays in various planes of flexion and rotation. They found degrees of malalignment in most. As one deviates from anatomical reduction, the crosssectional area of medullary contact between the two fracture surfaces decreases exponentially, thus providing decreased area for ingrowth of vessels from the distal to the proximal fragment increasing the rates of AVN and non-union dramatically. We believe that open reduction of femoral neck fractures overcomes most disadvantages of closed reduction, while allowing for some advantages. We did open reduction through an anterior capsular
Table II. Incidence of non-union and avascular necrosisin young adults with intracapsular fractures, treated by open reduction as seenfrom various published series No. of patients
Non-union (per cent)
A vascular necrosis (per cent)
0 17 -
10.5 10 18
Author(s)
Year
Swiontkowski et al.” Yamano” Gerber et aLz3 Fehr et al.24
1984 1989 1993 1993
27 19 54 49
1975
17
6
1997
25
4.0
Overall
average
Meyers
et aLzSx
8.5
Our series *Used
posterior
20
approach
with
muscle
pedicle
14.6 0
graft.
12.0
Gautam
et al.: Displaced
femoral
217
neck fractures
AVASCULAR NECROSIS
NON-UNION dosed
m
gf&!g our series
open
Figure 2. A comparisonof average rates of non-union and avascular necrosisthrough open/closedreduction of femoral neck
fractures - as seenfrom various published series.
incision. The anterior capsule is devoid of any major vessel supplying the femoral head2”. Thus, femoral head circulation is not impaired. This also decompressesany intracapsular tamponade. Intracapsular femoral neck fracture is unique in that both proximal and distal fragments are mobile. There is no control over the proximal fragment in closed reduction techniques. In an open reduction, one can put a K-wire in the femoral head and use it to manipulate the femoral head to achieve good reduction (Figure 2). Open reduction allows the surgeon to have a direct look and feel of reduction, without having to depend on an image intensifier, thus saving the surgeon from unnecessary exposure to radiation. Our study from a developing country is unique in that rarely do patients present to us with fresh trauma. Most of the time, they had been referred to us from neighbouring small centres after a delay of a few days. So, out of necessity, we were unable to operate on these patients within the initial few hours. Our average interval between injury and operation was 6.6 days. Yet we were able to achieve excellent results. We feel this was because open reduction allowed us to achieve the best reduction of the fracture with maximum medulla to medulla contact, allowing for optimal conditions for union and revascularization of the femoral head. We feel that the factor of paramount importance for achieving good results in this fracture is a good quality reduction, and open reduction is the only method which ensures this reduction. We were able to achieve good to acceptable reduction in 96 per cent of casesin this study, leading to a union rate of 96 per cent and an AVN rate of only 12 per cent. Thus the bad results of internal fixation are usually the results of bad reduction; open reduction and
fixation can be advocated as the ‘treatment of choice’ in femoral neck fractures in young adults (Tables I and II, Fipw 2).
References 1 Kuslich S. D. and Gustilo R. B. Fractures of the femoral neck in young adults. J. Bone Joint Stq. 1976; 58A: 724. 2 Massie W. K. Fractures of the hip. I. Bme loid Szrrg. 1964; 46A: 658. 3 Protzman R. R. and Burkhalter W. E. Femoral neck fractures in young adults. J. Bone Joiwf Surg. 1976; 58A: 689. 4 Zetterberg C. H., Instam L. and Andersson G. B. J.
Femoral neck fractures in young adults. Actn Scund.
Orfhop.
1982; 53: 427.
5 Zolczer L., Kazar G., Manninger J. and Nagy E. Fractures of the femoral neck in adolescence.Injury 1972; 4: 41. 6 Askin S. R. and Bryan R. S. Femoral neck fractures in young adults. Clin. Orthop. 1976; 114: 259.
7 Kofoed H. Femoral neck fractures in young adults. lnjuty 1982;14: 146. 8 Tooke S. M. T. and Favero K. J. Femoral neck fractures in skeletally mature patients, fifty years old or less. J. Bone Joint Surg. 1985; 67A: 1255. 9 Nagi 0. N., Gautam V. K. and Marya S. K. S. Treatment
of femoral neck fractures with a cancellousscrew and fibular graft. I. Bone Joint Surg. 1986; 68B(3): 387. 10 Crawford E. J. I’., Emery R. J. H., Hausell D. M., Phelan M. and Andrews B. G. Capsular distension capsular pressure in subcapital fractures of J. Bone Joint Surg. 1988; 708: 195. 11 Soto-Hall R. Alterations in the intra-articular trans-cervical fractures of the hip. J. Bo,le 1963; 45A: 662.
and intrathe femur. pressure in Joint Surg.
218
Injury:
International
12 Soto-Hall R., Johnson L. H. and Johnson R. A. Variations in the intra-articular pressure of the hip joint in injury and disease. J. Bone Joint Surg. 1964; GA: 509. 13 Bauer G., Weber D. A., Ceder L., Dart L., Egund N., Hansson L. I. and Stromqvist B. Dynamics of technitium-99m methylene diphosphonate imaging of the femoral head after hip fractures. Clin. Orthop. 1981; 15: 85. 14 Stromqvist B. Femoral head vitality after intracapsular hip fracture - 490 cases studied by intravital tetracycline labelling and Tc-MDP radionuclide imaging. Acta Orthop. Stand. 1983; 54(suppl.): 200. 15 Wingstrand H., Stomqvist B., Egund N., Gustafson T., Nilsson L. T. and Thorngren K. G. Haemarthrosis in undisplaced cervical fractures. Acta Orthop. Stand. 1986; 57: 305. 16 Boyd H. B., Zilversmit D. B. and Calandruccio R. A. The use of radioactive phosphorus P to determine the viability of the head of the femur. 1. Bone Joint Surg. 1955; 37A: 260. C. F. An instrument for the measurement 17 Woodhouse of oxygen tension in bone. A preliminary report. J. Bone Joint Surg. 1961; 43A: 119. 18 Melberg I’. E., Korner L. and Lansinger 0. Hip joint pressure after femoral neck fractures. Acta Orthop. Stand. 1986; 57: 501. 19 Simon W. and Wyman T. E. Femoral neck fractures - a study of adequacy of reduction. C/in. Orthop. 1970; 70: 152.
Journal
of the Care of the Injured
Vol. 29, No. 3,1998
20 Trueta J. and Harrison M. H. M. The normal vascular anatomy of the human femoral head in adult man. J. Bone Joirzt Surg. 1953; 358(3): 442. 21 Swiontkowski M. F., Winquist R. A. and Hansen S. T. Fractures of the femoral neck in patients between the ages of twelve and forty nine years. J. Bone Joint Surg. 1984; 66A(6): 837. 22 Yamano Y. Prong plate fixation for displaced intracapsular fractures of the femoral neck. J. Booze Joint Surg. 1989; 71B: 598. 23 Gerber C., Stehle J. and Ganz R. The treatment of fractures of the femoral neck. Clin. Orthop. 1993; 292: 77. 24 Fehr H. R., Steiner W. and Moesberger B. Osteosynthesis in dislocated femoral neck fractures (Garden III and IV) - long term results and treatment concept. Helu. Chir. Acta 1993; 59(4): 539. 25 Meyers M. M., Moore T. M. and Harvey J. I’. Displaced fractures of the femoral neck treated with muscle pedicle graft: with emphasis on the treatment of these fractures in young adults. J. Bone Joint Sztrg. 1975; 57A: 718.
Paper
accepted
20 October
1997.
Requests for reprints should be addressed to: Dr V. K. Gautam, Department of Orthopaedics, Maulana Azad Medical College, New Delhi, India. Fax: +Oll-3235574.