Session VI - Geriatric Trauma

Impacted Garden I Fractures of The Femoral Neck (31-Bl): Operative vs. Nonoperative Treatment

Robin E. Peter, MD, Bernard Bedat, MD, Jacques Rossier, MD, Pierre Hoffmeyer, MD

University Hospital, Geneva, Switzerland

Purpose: The type of treatment for valgus impacted fractures of the femoral neck (Garden type I), has differed at our institution depending on patient's age and activity level. Younger patients were always fixed internally, whereas elderly and sedentary patients were often offered functional reeducation without ORIF. The result of these options is evaluated.

Material and Methods: This retrospective study is based on the review of our clinical and radiological files. Between January 1988 and December 1994, 1,296 fractures of the femoral neck were treated at our institution. Out of 1,194 usable files, 191 Garden I fractures (16%) were isolated (79% female). The mean age of these patients was 80.9 years (27 to 95 years).

Results: The primary treatment was nonoperative in 124 of 191 patients (65%). In 54 patients, the primary treatment was internal fixation; with cancellous screws in 46 and DHS in 8. Their mean age was 64.7 years (27 to 93 years). In 13 patients an endoprosthesis was chosen (mean age 79 years).

Out of the 124 patients treated nonoperatively, 52 (41.9%) sustained a secondary dislocation of the fracture, treated with hemiarthroplasty in 48, cancellous screws once, DHS once, Girdlestone arthroplasty once and therapeutic abstention once.

In the nonoperative group, patients were reeducated to partial weightbearing beginning at day 5. The fracture dislocation rate increased according to age, progressively from 0% in the fifth decade to 50% in the eighth decade. Disimpaction occurred after a mean delay of 19.6 days (2 to 89 days). Fifty percent occurred within 14 days and 90% within 40 days. The disimpaction rate increased according to the number of associated pathologies, particularly senility.

The study of diverse radiological criteria revealed a relationship between secondary dislocation and the amount of valgus displacement as well as head retroversion.

The mean hospitalization stay was 23.4 days after nonoperative treatment without disimpaction, 40 days after disimpaction, 20 days after primary ORIF and 38 days after primary endoprosthesis.

After nonoperative treatment without disimpaction, 4 avascular necrosis (5.6%) and one non-union (1.4%) occurred. After primary ORIF these complications were respectively 2 (4.3%) and 1 (2.2%).

During the hospitalization period, 4 patients died, all 4 after secondary dislocation.

Conclusions: A higher rate of Garden type I fracture disimpaction was observed after nonoperative treatment in older patients or patients in poor general condition. This result argues in favor of internal fixation in this group of patients as well. Most of the secondary disimpactions occurred early, but some also occurred 3 months after the initial trauma.