LONGITUDINAL FRACTURE OF THE HEAD OF THE FEMUR ASSOCIATED WITH DISLOCATION OF THE FEMUR

S. L. HAAS, M.D.

ConsuItant Orthopedist, Marine Hospital

SAN FRANCISCO, CALIFORNIA

T HE head of the femur is protected from direct injury because of its deep seated position in the acetabuIum.

When the force of impact is in direct Iine with the neck of the femur, it may be crushed by the impact or protruded into the acetabuIum. Any force at right angIes to the neck wiI1 produce a sub-capita1 or other type of fracture of the neck of the femur. When a disIocation of the head of the femur occurs the femora1 head is rarely injured because of its firm covering of articuIar cartiIage. The acetabuIar margins are frequentIy torn off or there may be a smaI1 chipping fracture of the head. A IongitudinaI fracture invoIving a third or more of the head is reIativeIy rare. LittIe information is given in the standard text- books on fractures and few cases are re- ported in the Iiterature. Watson-Jones gives a short paragraph in his textbook on fractures. From persona1 communications of J. M. Murray, J. Warren White and Austin Moore, who have had one or more cases, we are incIined to beIieve that if a compIete survey were made, a considerabIe number of IongitudinaI fractures couId be gathered together and some vaIuabIe data obtained about this clinical entity.

The mechanism of the production of a IongitudinaI fracture is specuIative and may depend on a number of factors. UsuaIIy it is associated with other injuries and due to a considerabIe force, as a faI1 from a height or automobiIe coIIision. Just why the head shouId spIit IongitudinaIIy may depend on a number of factors. The reIative size of the head and its relation to the acetabuIum may be important; as when the head is Iarge and not deep seated in the acetabuIum so that a considerabIe portion protrudes IateraIIy from the ace-

tabuIum. The reIative density of the head and acetabulum, the angle of the neck with the shaft and the amount of antiversion may be influencing factors. The position of the extremity at the time of the injury, whether in adduction or abduction, in- terna or externa1 rotation may be a contributing factor.

The diagnosis of a fracture in associa- tion with the disIocation can onIy be made from the roentgenogram, as the physical findings do not differ from those of a simpIe disIocation.

The prognosis for a norma functioning hip, after a longitudinal fracture with dis- location, is not very good and shouId be guarded. Even if the dislocation is reduced accurate apposition of the haIf head with the fragment in the acetabuIum is dificuIt. If good apposition is obtained, union may not resuIt; and even shouId it take pIace, Iate aseptic necrosis with dissoIution of the head may occur. Furthermore, Ioss of strength, Iimitation of motion and a pain- fu1 hip are possibiIities.

The treatment of a Iongitudinal fracture of the head of the femur with disIocation is difficult because of the possibiIity of the previously mentioned compIications. It may be treated by a cIosed or open operation.

Primary cIosed reduction should first be tried utiIizing the standard procedures of simpIe dislocation at the hip joint. PreIiminary skin or skeIeta1 traction may be heIpfu1. If a successfu1 reduction with apposition of the fragments is secured, immobiIization by a pIaster spica is insti- tuted untif union is obtained, which may be considerabIy deIayed because of cir- cuIatory disturbances. Because of the lack of reported cases no data can be given reIative to the Iate resuIts, but the possi-

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ties of aseptic necrosis must aIways be of the remaining part of the head and

Isidered. neck into the acetabuIum. The dec aision

f the attempt at closed reduction is not as to which type of procedure to adopt may

FIG. I. LongitudinaI fracture of the head of the femur with distocation; free

fragment in acetahuIum. (In this instance, negative of picture has been

reversed.)

successfu1, one must resort to open opera- tion. Either the anterior or posterior ap- proach may be utiIized. If the posterior approach is made, one can determine more accurateIy the condition of the posterior rim of the acetabuIum. There are four main aIternative methods of treating the dis- Iocation: (I) Reduction of the portion of the head into the acetabuIum and ap- proximating it to the remaining portion in the acetabuIum; (2) reduction of the head after first removing the piece in the acetabuIum ; (3) removing the part of the head from the neck and after remova of the piece from the acetabuIum, per- forming a reconstruction operation, either according to the Whitman, Colonna or AIbee type of operation; (4) arthrodesis

depend on a number of factors. The age of the patient, sex, type of work to be performed, economica factors, whether one wishes onIy one operation, and if onIy one, the type that wiI1 be definitely free from the possibiIity of a painIess extremity. Keeping in mind the previously mentioned possibiIities of failure of union, of Iate aseptic necrosis, possibility of a painful movable hip and recurring deformity, an arthodesis offers the best chance to obtain a satisfactory result with only one opera- tion. If mobihty is important or desired, reposition with or without approximation of the two fragments or a reconstruction operation should be performed, reserving arthrodesis for a Iater procedure.

404 American Joornal of Surgery Haas-Fracture of Femur SEPTEMBER. 194 j

The report of the history and procedure ous injuries xi& from the one under discussion

on one patient with longitudinal fracture \verc taken care of by appropriate methods in of the head of the femur with dislocation the convalescent period. There was a shorten-

FIG. 2. After excision of the fragment from the acetabuIum and reduction of the remainder of the head.

wiII serve as an exampIe and bring forth some of the probIems that one may en- counter. It may aIso heIp to form some concIusion as to the best type of procedure to institute in the treatment of this Iesion.

CASE REPORT

R. M., age forty-three, a roof worker, fell from a second story roof Ianding onto the pavement on ApriI I 6, 1943. In addition to a IongitudinaI fracture with disIocation of the head of the right femur, he sustained numerous other injuries which wil1 be mentioned as they had some influence on determining the type of treatment. There was a very severeIy com- minuted fracture of the upper end of the Ieft tibia and IibuIa with dispIacement of the fibuIa and part of the tibia, fracture and disIocation of the metatarsals of the right foot, fracture and dislocation of the scaphoid of the Ieft foot, and disIocation of the Ieft humerus.

The patient was in fairIy good condition when first seen. It suffices to say that the vari-

ing of the right extremity. The Ieg was in exter- nal rotation. AI1 movements were painfu1. The head of the femur was felt posteriorIy. The roentgenogram showed the head of the femur spht in haIf and disIocated. (Fig. I.) The remaining portion was in the acetabuIum. There was no fracture seen about the rim of the acetabumm. An attempt to reduce the fracture disIocation of the right femur was unsuccessful. SkeIetaI traction was applied and after several days another attempt was made to reduce the hip but it was unsuccessfu1. Open operation through a posterior approach was then performed. Because of the numerous other severe injuries and the necessity of not performing too many operations it was thought best to remove the portion of the head from the acetabulum and pIace the remainder of the disIocated head of the femur in the acetabulum. This portion of head was diffrcuIt to maintain at the time of the operation and did not sink in like an entire head usuahy does when re- duced. This may have been due to the Iack of the cohesive force exerted by an entirely

NEW SERIES VOL. LXIX, No. 3 Haas-Fracture of Femur American Journal of Surgery 405

rounded head with the smooth surface of the left knee joint. If his trochanter had been acetabuIum. (Fig. 2.) Later check showed a transferred down or a bone Iever operation redislocation of reduced half head of the femur. been performed, he wouId have had greater

A second operation was performed and in stability of the right hip.

FIG. 3. Present condition after removal of remainder of the head and pIacing the neck of the femur in the acetabulum.

attempting to place the head portion in the acetabuIum it broke off. Then a decision was necessary as to whether to attempt an ar- throdesing or a reconstruction operation. It was thought that an arthrodesis of the hip would be preferable as it wouId give him a stabIe hip and save him from the chance of another operation. It was aIso thought at the time that he wouId have a flail knee on the opposite side. There was a faiIure of bony union after this operation which in view of subsequent events appears to be fortunate. (Fig. 3.) He obtained a stable knee on the opposite side with Iimited motion in the knee joint on the side of the dislocation. The patient is at present abIe to walk with a cane. He had about 40

degrees of painIess fIexion in the right hip with about IO degrees abduction and practicaIIy no rotation. He has onIy 80 degrees of motion in the right knee joint and 30 degrees in the

CONCLUSIOK

In genera1 in IongitudinaI fracture with dislocation, closed reduction shouId be attempted. If reduction is not successfut or good apposition of the fragments is obtained, open operation is necessary. RemovaI of the loose ‘piece of the head fragment from the acetabujum and then reducing the haIf head may be tried. It may be preferabIe to remove the half head attached to the neck and perform a re- construction operation according to the method of Whitman, Colonna or AIbee.

Arthrodesis shouId be reserved for later painfu1 hips. If only one operation is advisabIe an arthrodesis may be the pro- cedure of choice if knee joints and opposite hip are not impaired.