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A Treatment for Fracture of the Neck of the Femur

2002; Lippincott Williams & Wilkins; Volume: 399; Linguagem: Inglês

10.1097/00003086-200206000-00002

1528-1132

Guy W. Leadbetter,

Bone fractures and treatments

Guy W. Leadbetter (Fig 1) was born in Bangor, ME. In high school and college, he was an outstanding athlete, was the captain of the football team, and excelled in track and field. He threw the 16-lb shotput well enough to try out for the Olympic team. After graduating from Bowdoin College, he went to Johns Hopkins University Medical School where he received his medical degree in 1920. After doing an internship in Cleveland, Leadbetter returned to the Johns Hopkins Hospital for his orthopaedic training. In 1923, he entered private practice in Washington, DC. He became a Clinical Professor of Orthopaedic Surgery at the George Washington Medical School.Fig 1.: Dr. Guy Whitman Leadbetter (Reprinted with permission from J Bone Joint Surg 28:186, 1946.)During World War II, Leadbetter served as a consultant to the Surgeon General and to the Secretary of War. He also was secretary to the orthopaedic committee of the National Research Council. At the time of his death from coronary heart disease, Leadbetter was a member of the American Orthopaedic Association and was President-Elect of the American Academy of Orthopaedic Surgeons. His death, at the age of 52 years, was a great loss to the orthopaedic community. The classic article describes what became known as Leadbetter’s maneuver, by which a displaced fracture of the neck of the femur could be reduced on the operating table before internal fixation. Leonard F. Peltier, MD, PhD Fractures of the neck of the femur have become a vital issue to the surgeon, the patient, and the relatives of the latter. During the last few years the standard of demand by the laity for better functional results of fractures has been more exacting. It is incumbent upon the physician to select the method which, in his judgment, will cause the least amount of primary shock during manipulation, to utilize the fixation which will adequately maintain reduction, and, finally, to secure a high percentage of anatomical reduction and firm union with good physiological results. Whatever method of reduction and fixation is selected, the writer believes that the so called after-care is the most important in the preservation of life. Because of age, the functions of the individual are at a basic level and, in most cases, trauma and subsequent shock have caused the vitality to drop to a still lower level. It is essential, therefore, that no treatment be instituted which will further depress the vital centers, for pain in most fractured hips subsequent to reduction is negligible. Good elimination and frequent change of position are important factors. Due attention to the two dangerous complications—general toxicosis, having its origin in the intestinal tract, and pulmonary hypostasis—will also aid in preventing the third serious complication,—that of mental bewilderment, delirium, or psychosis. Without hesitation the writer recommends plaster fixation, properly applied, as the best means of carrying out all the above mentioned treatment. Plaster fixation must have two objectives: first, to immobilize the fracture; and, second, to facilitate postoperative care. This plaster should be applied tightly and we have found the following technique to be the best. With the hip reduced and in the proper degree of abduction and internal rotation, a one-layer thickness of glazed cotton is placed about the torso from the nipple line over the affected hip to a point about half-way between the hip and the knee. Then a long strip of felt, one-half an inch thick, is placed about the pelvis, extending from just above the iliac crests to the trochanters, and completely encircling the pelvis. This is all the padding necessary and allows very tight application of plaster. The body portion is first applied as tightly as possible, snug coaptation being the aim. Firm pressure over the injured hip is necessary. Below the hip no padding is applied. Two plaster slabs molded carefully to the contour of the leg, one posteriorly and one anteriorly, are bandaged closely to the skin. No padding is placed beneath the heel, as this is molded well and the plaster coapted tightly. If necessary, one may apply a roll of plaster about the two molded splints to insure a little better fixation. The cast is then trimmed around the perineum and the pelvis in the usual manner. The “U” is cut from the body section of the cast, leaving about a six-inch band across the lower abdomen and over the symphysis. The sides must be well supported to prevent the patient from swinging the torso, thereby diminishing the amount of abduction of the injured leg. This method gives firm and comfortable immobilization and allows the treatment previously described to be instituted without danger of changing the position of the reduced fracture. It permits relatively free movement of the thoracic cage, makes a semireclining position possible, and facilitates transportation from bed to chair. In our series of cases, using this type of application, we have had no decubital ulcers. In one or two instances, in which the individual was fairly vigorous, we have been able to allow walking with the aid of crutches after the fourth week. The procedure for manipulation should be non-shocking and one which accomplishes anatomical reduction of the fractured fragments with the greatest degree of accuracy. Anatomical reposition of the fragments is the only position which insures good union and good function. Up to the present time the Whitman method is the widely accepted one. Dr. Whitman’s article written in 1904 clearly shows the genius of his logic. Abduction and internal rotation quite apparently are the only positions for reducing a traumatic coxa vara. The objections to his manipulation are: It is very often a shocking procedure in the hands of the average practitioner, as well as in some skilled hands, and is done too empirically. It does not consider all the anatomical factors present in the hip joint, such as muscular attachment and muscular tension. The extreme degree of abduction called for, often overreduces the fragments and produces no reduction, with poor continuity. The forced internal rotation called for serves only to relax the Y ligament at the hip joint, and many times results in no reduction and gives no splinting effect whatsoever. There is no definite test or examination other than the roentgen ray, which definitely tells the manipulator that the fracture has been reduced. To the postoperative care and to the plaster-fixation method the writer can well subscribe. Treatment by the various traction methods, or by the so called sand-bag method—which is no method at all—is not to be considered. The manipulation suggested here is simple, anatomically sound, nonshocking, and offers opportunity for 100 per cent reduction. The patient is first anaesthetized, usually with ethylene gas, on the fracture table. The uninjured leg is harnessed to the foot stirrup. The injured leg is then flexed at the hip at ninety degrees, with the lower leg at ninety degrees to the thigh. Direct manual traction in the axis of the flexed thigh is then made, together with slight adduction of the femoral shaft. In this position the thigh is internally rotated approximately forty-five degrees. The leg is slowly circumducted into abduction, the internally rotated position being maintained. The amount of abduction varies with the individual and can be measured accurately, representing the difference in degrees of the angle made by the fractured neck with the shaft and the angle between the neck and the shaft on the normal side, as evidenced by the roentgenogram. The test which in our experience has indicated that the fracture has been completely reduced is as follows. After the leg has been brought down in the measured degree of abduction and internal rotation, the heel of the injured leg is allowed to rest on the outstretched palm. If the reduction is complete, the leg will not evert itself. Should there be no interlocking of the fragments, however, the leg will slowly rotate externally. This has been found to be an invariable test. In all instances where the test evidenced internal rotation, the reduction was anatomically complete. In cases where the internal rotation had to be forced, the reduction was never complete, as proven by stereoscopic roentgenograms, the only criterion for a good reduction. The observation is made that as the leg is circumducted into a position of abduction and internal rotation without tension, the position of the leg tends to assume the proper degree of abduction and internal rotation. If abducted too far, one will feel the definite tension of the adductors which can be neutralized by allowing the leg to assume a smaller angle of abduction. If internal rotation is too great, the leg, under the heel-palm test, will rotate outward until the proper degree of internal rotation is reached. One can approximate the desired degree of such abduction and rotation by a study of premanipulative roentgenograms, for, at the time of the actual manipulation, the finer degrees will be adjusted automatically by muscle tension of the hip. The consideration of the embryology and anatomy of the hip joint lays the foundation of the manipulation described. In the embryo, the hip joint is in the quadrupedal position,—namely, it is flexed and only after several weeks of extra-uterine life does the flexed position tend to assume that which is necessary for bipedal ambulation. This change of position accounts for the rotation in the neck of the femur, also for that of the fibers constituting the capsular ligament. It. is a physical fact that when the hip is brought back to the quadrupedal position, all structures about the hip joint are relaxed, since the base of the neck of the femur is the insertion point of the hip joint muscles; this forms the center of rotation which relaxes these structures in manipulation. One cannot depend upon an extreme grade of abduction or upon the tenseness of the Y ligament, as suggested by Dr. Whitman, since it is not true that these ligamentous fibers are taut in internal rotation. One must depend upon an accurate interlocking of the fragments. The type of fracture must also be considered, for in fractures of the neck of the femur one sees not only transverse fractures, but also spiral, oblique, and comminuted fractures. It is, therefore, just as difficult to maintain the position in a spiral, or comminuted, fracture of the neck of the femur as in any other bone. The fixation must be equally complete. The transverse type of fracture, as a rule, gives little difficulty in maintenance of position. In general the oblique, or spiral, fracture must be abducted slightly more than the transverse type after reduction. An extreme grade of accuracy in completing the apposition of the fragments is the factor on which rests the possibility of union, for, with the absence of periosteum, the presence of synovial fluid, and the activity of the cancellous structure of the neck as the only real source of bone formation, it can readily be seen that, if this cancellous tissue is encroached upon or blocked by an inaccurate reduction, by improper fixation, or by the use of internal metal fixatives, proper bony healing can never take place. Circulation is important only in so far as it is allowed to course through its normal channels which supply nourishment to both ends of the fractured fragments. In reconstruction operations for non-union, the author has been much impressed with the very rapid and strong bridging over of the fractured surface of the head and of the neck in cases in which imperfect apposition had been made. This shows in itself that healing properties are present in the necks of most femora, and that all that is demanded is proper, careful reduction with thorough fixation for a period of not more than ten to twelve weeks. In this paper is presented a study of thirty-six cases, all treated by the method just described. The five cases of intertrochanteric fracture obtained bony union. The thirty-one cases of intracapsular fracture reported here have been checked and rechecked and represent accurate findings. These patients have been interviewed or heard from through their personal physicians. Of these thirty-one cases, a total of twenty-two, or 70.9 per cent., obtained bony union and nine, or 29 percent., presented fibrous union and are considered in this series as non-union cases. Of the non-union group two, or 6.4 per cent., showed absorption within a period of approximately six weeks. The remaining seven, or 22.5 per cent., obtained fair function. Of the cases showing fracture of the anatomical neck, in which union was obtained, ten, or 32.2 per cent., were patients over sixty years of age, and four, or 12.8 per cent., were over seventy years of age. The remainder were in the decades between forty and sixty years. All of these cases united well. The deaths numbered four, or 12.8 per cent. The first was due to embolism at the tenth week and the second was due to diabetic coma at the twelfth week. Both of these cases belonged in that group in which absorption occurred. The third died of cellulitis of the neck at the twentieth week, and the fourth of acute nephritis at the fourteenth week. With the exception of the first and last named cases, fracture of the neck of the femur was not implicated in the cause of mortality. This paper, then, presents a method of manipulation which is anatomically and physiologically logical. It is easy to accomplish and, by applying the test which the author believes to be infallible, assures one of good anatomical reduction, thereby greatly enhancing the chances of bony union by preserving the normal relations of the only source of callus in the neck of the femur,—namely, the cancellous structure. As soon as we free ourselves from the didactic and empirical teachings which have been in vogue for the last twenty-five years and apply ourselves to the anatomical and physiological problems presented in fractures of the neck of the femur, and arrive at agreement on better methods of complete fixation of these fractures, then, and only then, will the percentage of good end results increase.