Displaced ORIF



< 60 with good bone stock and preserved joint space




Union rates increased with anatomical reduction



- closed reduction

- open reduction / if closed reduction fails



- no varus

- < 15o valgus

- < 10o AP plane


Assessment of reduction


1.  Femoral neck shaft angle


2.  Garden alignment index

- angle of compression trabeculae to femoral shaft on AP should be 160o

- angle of compression trabeculae to femoral shaft on lateral should be 180o


3.  Lowell's alignment theory

- head neck junction should make a smooth S / reverse S on all views


4.  Restoration of Shentons line


Closed Reduction


Set up


Traction table / radiolucent table


Leadbetter Maneuver



- flexion / adduction / traction / IR 

- circumduction / abduction

- reduction Check in extension

- "Foot in Palm Test"

- if sufficiently reduced will sit without ER




Cannulated screws / DHS + derotation screw


Aminian JOT 2007

- biomechanical study of strength of fixation of vertical fractures

- locking plate > dynamic condylar screw > dynamic hip screw / 3 cannulated screws





- decrease intracapsular pressure

- in animal models increases blood flow



- open capsulotomy via Smith Peterson

- percutaneous needle drainage of hematoma


Open Reduction


Vumedi surgical technique


Set up


Radiolucent table

- floppy lateral with sandbag under affected hip


Technique Watson Jones approach


Lateral incision

- curvilinear between anterior aspect greater trochanter and ASIS


Flexing hip 20-30o helps exposure


Superficial dissection

- identify interval between gluteus medius and tensor fascia lata (TFL)

- divide fascia lata

- identify fat pad inferiorly, muscle gluteus medius superiorly

- develop this interval to anterior femoral neck

- lateral femoral circumflex artery in this interval

- place retractors over inferior femoral neck and superior femoral neck


Deep dissection

- remove fat pad

- release reflected head of rectus femoris off anterior capsule


L or T Capsulotomy

- superior border femoral neck and intertrochanteric line

- tag and reflect capsule

- place retractors inside the capsulotomy to expose the femoral neck

- avoid dissecting superior aspect of femoral neck where major artery of MCFA runs

- can place superior retractor on ilium


Steinman pin in femoral head

- allows manipulation and reduction


Second steinman pin in femur

- correct external rotation force


- obtain anatomical reduction under direct vision


Can place the implant through the same incision

- split ITB and vastus lateralis

- fixation of reduction


Check reduction on image intensifier

- ensure no varus on AP

- obtain lateral by adducting and IR hip / ensure good reduction on lateral


Ensure 2 guide wires centrally in femoral head

- 2 hole DHS + derotation screw (strongest)

- 3 or 4 cannulated screws


Open subcapital ORIF


Technique Smith Petersen



- may be better in larger patients



- separate incision for implants




3 - 4 cm lateral to ASIS


Superficial approach

- between TFL and sartorius

- divide fasica over TFL

- reflect muscle of TFL laterally

- identify and control branches of lateral circumflex artery



- superior femoral neck and intertrochanteric line


Smith Petersen Approach 1Smith Petersen Approach 2Smith Petersen Approach ORIF




Unstable fracture

- augment with a plate on inferior neck


Displaced Subcapital Inferior PlateDisplaced ORIF Lateral






Rogmark et al JBJS Am 2002

- multicenter RCT patients > 70 years with displaced fracture

- ORIF 43% failure

- hemiarthroplasty 6% failure




Jain et al JBJS Am 2002

- retrospective review of displaced fractures in 29 patients < 60

- significant reduction in AVN if fixed within 12 hours






Subcapital NOF AVN




Undisplaced <10%

Displaced  20-33% 


Risk factors



Injury velocity

Delay in Reduction

Non-anatomical Reduction




Whole head or small wedge 

- most common anterosuperiorlateral



- existing med and lateral epiphyseal blood vessels

- metaphyseal BV crossing fracture

- reduced by mal-reduction / non union


Only 30% with AVN will need re operation


Management Options


Older patient

- arthroplasty


Younger patient

- forage / vascularized fibula graft / non vascularised bone graft

- osteotomy








Risk Factors


Intial displacement

Non anatomical reduction


No compression across fracture

Vascularity - can unite if avascular


Failed Subcapital ORIFSubcapital ORIF Lateral


Subcapital Nonunion 1Subcapital Nonunion 2




Older patient

- arthroplasty


Young patient

- valgus osteotomy


Subcapital NOF Non UnionSubcapital NOF Nonunion CTTHR post Subcapital Nonunion


Valgus osteotomy



- patient must have at least 15o adduction



- aim to reduce the angle of the neck fracture to between 20 - 30o from horizontal

- this places it perpendicular to the forces acting across the hip

- measure angle of fracture from horizontal (usually 40 - 50o up to 70o)

- difference is angle of correction (20 - 30o)



- insert guide wire in centre of head / for screw

- place K wire superiorly in same plane as this wire at level of LT

- second K wire below at angle of required osteotomy

- resect bone piece

- apply appropriately angle device

- ensure straight line down femur in AP and lateral if need subsequent THR