PREOPERATIVE DIAGNOSIS: Basilar neck fracture, left hip.
POSTOPERATIVE DIAGNOSIS: Basilar neck fracture, left hip.
OPERATIVE PROCEDURE: Closed reduction and compression screw fixation of left femoral neck fracture along with anterior capsulotomy, left hip.
INDICATIONS: Patient is 14 years old and injured his left hip on a rope swing over the river up at …. today. He has a basilar neck fracture with minimal displacement, primarily rotational displacement. His growth plates are beginning to close. He has secondary sex characteristics. After discussing options with his parents and presenting potential complications, I have elected to proceed with stabilization of this fracture using a compression screw, possible other screw fixation if necessary, and also a limited anterior capsulotomy to evacuate hematoma from the joint.
DESCRIPTION OF PROCEDURE: The patient was given 1 g of Ancef. He was given a general anesthetic by Dr. ….. He was moved onto the fracture table and placed up against the padded perineal post. The right leg was flexed up out of the way from the position of the fluoroscope. The left lower extremity was placed under traction, and then internally rotated and slightly adducted using fluoroscope to demonstrate anatomic reduction of the fracture. This basically involved internal rotation as the angular line of the fracture was already anatomic. I then had the lateral hip area prepared with a Betadine gel paint and was draped out with a large sticky hip drape.
I made a lateral longitudinal approach to the hip beginning at the level of the greater trochanter and also extended the incision a little proximally and anteriorly above the trochanter. Dissection was carried down through the subcutaneous tissues, cauterizing bleeding vessels as encountered. I dissected bluntly with my finger up onto the anterior hip capsule initially up between the gluteus medius and the tensor fascia lata muscles. I considered evacuating the hematoma from the capsule at that time but elected instead to stabilize the hip before doing so. I continued dissection down through the fascia lata below the trochanter and then carefully divided the vastus lateralis muscle near its posterior insertion and elevated it up off the lateral cortex just enough to place a plate on the cortex. The shortest plate we had was a 4-hole 135-degree plate.
I placed a Synthes guidepin up the femoral neck in a 135-degree angle just slightly inferior of the center line on the AP view and in the center line on the lateral view. This was placed just slightly beyond the epiphysis. I then measured, over-drilled to 95 mm, and then tapped the hole. I placed a 95 mm screw up the hole with a nice snug fit obtained. I then placed a 4-hole 135-degree plate in place, impacted it up against the cortex, and fixed it with 4 bicortical screws of appropriate length. Good stability was obtained, and it was not necessary to use any extra screw fixation.
Through this incision, I placed my finger directly up along the femoral neck, and using a 15 blade carefully split the anterosuperior capsule just enough to evacuate the hematoma from the area. The more proximal aspect of the incision was not used for that. I then copiously irrigated the wound. I laid the vastus lateralis muscle in place and closed the fascia lata with #0 Maxon suture. Subcutaneous tissues were then closed with 2-0 Polysorb, and the skin was closed with staples. Sterile compressive dressing was applied. The patient tolerated the procedure well. There were no complications. Blood loss was approximately 400 mL. He was taken to recovery in stable condition postoperatively.