A new method of reduction of fractures of the neck of the femur based on anatomical studies of the hip joint
基于髋关节解剖学研究提出的股骨颈骨折新型复位方法

A new method of reduction of fractures of the femoral neck is described, based on anatomical details.
基于解剖学细节，本文描述了一种股骨颈骨折复位的新方法。

In essence the manœuvre consists of external rotation about the long axis of the femoral neck followed by traction in the line of the long axis of the femoral neck, whilst traction is maintained, internal rotation about the long axis of the femoral neck to respiral the fibres of the capsule and the associated ligaments which then support the fragments in the reduced position and in addition render the reduction stable by causing maximal congruity between the femoral head and acetabulum, thus locking the capital fragment. Once reduced, only slight traction is required to steady the limb during internal fixation of the fracture.
该手法的核心在于：首先沿股骨颈长轴进行外旋，随后在维持牵引的同时沿股骨颈长轴方向施力牵引；接着在持续牵引状态下进行内旋，使关节囊纤维及周围韧带重新形成螺旋状结构。这种螺旋结构既能维持骨折断端在复位后的稳定位置，又能通过实现股骨头与髋臼的最大吻合度来增强复位稳定性，从而锁定股骨头骨折块。完成复位后，在骨折内固定过程中仅需轻微牵引即可保持患肢稳定。

Fracture of the femoral neck has acquired the title ’ the unsolved fracture ’ due to the unacceptably high incidence of non-union of the fracture
由于股骨颈骨折不愈合率居高不下，该损伤被称为"未解骨折"。

Fig. 1.-Anterior view of right hip joint in extension showing the spiral arrangement of the capsule and associated ligaments.
图 1. 右髋关节伸展状态前视图，显示关节囊及其相关韧带的螺旋排列结构。
and of avascular necrosis of the femoral head. The uncertainty of prognosis in such fractures has caused many workers to resort to primary prosthetic replacement of the femoral head. This approach to the problem has not met with universal approval; ’ the best prosthesis is inferior to a soundly united fracture of the neck of the femur’ (Nicoll, 1963). ‘Before we adopt a policy of universal decapitation we must be certain that there is no possibility of improvement in our present methods of treatment’ (Barnes, 1967).
以及股骨头缺血性坏死的风险。此类骨折预后难以预测，导致许多医生选择直接进行股骨头假体置换术。但这一解决方案并未获得普遍认可；"最好的假体也比不上股骨颈骨折的完美愈合"（Nicoll，1963 年）。"在我们采取普遍性股骨头切除方案前，必须确认现有治疗方法已无任何改进可能"（Barnes，1967 年）。

The early treatment of displaced fractures of the femoral neck presents two main problems:
股骨颈移位性骨折的早期治疗面临两大主要问题：

A great deal of ingenuity has been employed to solve the problem of adequate fixation. Commencing with Whitman’s abduction treatment (Whitman, 1925) followed by open reduction
为解决充分固定问题，人们运用了大量巧思。从惠特曼的外展治疗法（Whitman，1925）开始，随后采用切开复位术

Fig. 2.-Posterior view of right hip joint in extension showing the spiral arrangement of the fibres of the capsule and associated ligaments.
图 2.-右髋关节伸展状态后视图，显示关节囊纤维及关联韧带的螺旋排列结构。
and trifin nailing (Smith-Peterson, Cave, and Vangoreden, 1931), closed reduction and trifin nailing (Johannson, 1932), Moore’s multiple pin fixation (Moore, 1934), fixation by means of sliding nails (Pugh, 1955; Brown and Abrami, 1964), compression screw fixation (Charnley, Blockley, and Purser, 1957), low-angled nailing (Garden, 1961), triangle fixation (Smyth, Ellis, Manifold, and Dewey, 1964), and crossed screws (Garden, 1964) to mention but a few.
三翼钉固定术（Smith-Peterson、Cave 和 Vangoreden，1931 年），闭合复位三翼钉内固定（Johannson，1932 年），摩尔多针固定法（Moore，1934 年），滑动钉固定术（Pugh，1955 年；Brown 和 Abrami，1964 年），加压螺钉固定（Charnley、Blockley 和 Purser，1957 年），低角度钉固定（Garden，1961 年），三角固定法（Smyth、Ellis、Manifold 和 Dewey，1964 年）以及交叉螺钉固定（Garden，1964 年）等。

The main concentration of research has been directed towards new methods of fixation. Yet without an accurate reduction, good fixation is
研究的主要焦点一直集中在新的固定方法上。然而若缺乏精确的复位，再好的固定技术也

Fig. 3.-Anterior view of right hip joint in a position of flexion combined with slight abduction showing the arrangement of the fibres of the capsule and associated ligaments.
图 3.-右髋关节屈曲合并轻度外展位的前视图，显示关节囊纤维及相关韧带的排列方式。

Fig. 5.-A diagrammatic representation of a fracture of a right femoral neck with displacement.
图 5.-右侧股骨颈骨折伴移位的示意图。
difficult and may even be impossible to achieve: ‘No device will hold a badly reduced fracture’ (Nicoll, 1963). Many eminent workers in this field have stressed the need for an accurate reduction. Trueta (1957) said 'It must not be forgotten that one of the main causes of failure in the treatment of fractures of the femoral neck is a technical fault such as inadequate reduction whereby a gap is left between the raw surfaces of the fragments, or inadequate fixation by poor placing of the nail '. Smith (1959) reporting on a series of 56 cases of fracture of the neck of the femur treated by open operation, stated that he
实现这一目标十分困难，甚至可能无法达成："任何器械都无法固定复位不良的骨折"（尼科尔，1963 年）。该领域许多杰出工作者都强调精确复位的必要性。特鲁埃塔（1957 年）指出："必须牢记，股骨颈骨折治疗失败的主要原因之一在于技术缺陷，如复位不充分导致骨折断面间存在间隙，或内固定不当造成钢钉位置不佳"。史密斯（1959 年）在报告 56 例开放性手术治疗股骨颈骨折病例时指出，他

Fig. 4.-Posterior view of right hip joint in a position of flexion combined with slight abduction showing the arrangement of the fibres of the capsule and associated ligaments.
图 4：右髋关节屈曲合并轻度外展位的后视图，显示关节囊纤维及相关韧带的排列结构。
found at operation that rotary or valgus malposition of the capital fragment impaired its blood supply to the point of interruption, and suggested that this may account for the many instances of delayed union, non-union, avascular necrosis and even the late complication of degenerative arthritis. Garden (1961) recorded an ischaemic necrosis of the capital fragment in every case in his series in which the extreme valgus position was accepted. He stated that a poor reduction was almost synonymous with non-union. Brown and Abrami (1964) showed that the main factors which influenced their results were age, sex, degree of displacement and accuracy of reduction. Charnley (1965) said ’ It is imperative to reduce the fracture accurately’. But perhaps one of the most thorough and prolonged investigations of this difficult fracture is that of Garden (1971). Following a close analysis of 500 cases of subcapital fractures of the neck of the femur, he concluded that ’ the quality of reduction has clearly emerged as the
研究发现，在手术操作中，股骨头骨折块的旋转或外翻错位会严重损害其血液供应直至中断，并指出这可能是导致许多延迟愈合、不愈合、缺血性坏死甚至晚期退行性关节炎并发症的原因。Garden（1961 年）在其病例系列中发现，所有接受极端外翻位置固定的患者均出现股骨头缺血性坏死。他明确指出复位不良几乎等同于不愈合。Brown 和 Abrami（1964 年）证实影响疗效的主要因素包括年龄、性别、移位程度及复位精确度。Charnley（1965 年）强调"必须实现骨折的精确复位"。而针对这一复杂骨折最为全面且长期的研究或许当属 Garden（1971 年）的工作——通过对 500 例股骨颈头下型骨折病例的深入分析，他最终得出结论："复位质量已明确成为......"
factor most commonly affecting both the early and late results of the treatment. Accurate apposition of the fragments is already known to be conducive to union; but it also seems that the fate of the femoral head is determined by the degree of reduction’. Speaking of anatomical reduction, he stated that ’ this position is achieved largely by chance, for no consistently dependable method of reduction has yet been described’. He achieved anatomical reduction in 57 cases, none of which developed segmental collapse later. In his series he showed that as the accuracy
影响治疗效果早期和晚期结果的最常见因素。众所周知，骨折断端的精确对位有利于愈合；但股骨头的命运似乎也取决于复位程度"。在谈到解剖复位时，他指出"这种位置很大程度上是偶然实现的，因为目前尚未描述出始终可靠的复位方法"。他在 57 例实现解剖复位的病例中，后期均未发生节段性塌陷。其研究系列表明，随着复位

Fig. 6.-A diagrammatic representation of the lateral view of a fracture of right femoral neck with the hip joint in flexion, combined with slight abduction.
图 6.-右股骨颈骨折在髋关节屈曲合并轻度外展时的侧视图示意图
of reduction decreased, the incidence of segmental collapse increased until it reached 100 per cent.
精确度的降低，节段性塌陷发生率逐渐升高直至达到 100%。

Despite the continuing emphasis on the necessity for an anatomical reduction of the fracture, little change has taken place in the methods of reduction since the days of Whitman (1925), and Leadbetter (1933); the last mentioned method is probably still the most widely used. Forceful manipulation may cause comminution of the fragments and may also jeopardize the blood supply.
尽管持续强调骨折解剖复位的必要性，但自 Whitman（1925 年）和 Leadbetter（1933 年）时代以来，复位方法几乎没有变化；后者提出的方法可能仍是目前应用最广泛的。强力手法复位可能导致骨折块粉碎，并危及血液供应。

The method of reduction about to be discussed was suggested by an observation of Walmsey (1928) and its further elaboration by MacConaill (1946) who coined the term ‘close packed’ position of joints. Walmsey stated that the femoral head fitted the acetabular socket more and more closely as the position of full extension was approached, and eventually the two surfaces fitted exactly. MacConaill (1953), speaking to the British Orthopaedic Association, defined the
即将讨论的复位方法源自 Walmsey（1928 年）的观察发现，后经 MacConaill（1946 年）进一步发展完善，他创造了关节"紧密嵌合"位置这一术语。Walmsey 指出，随着髋关节逐渐接近完全伸直位，股骨头与髋臼窝的匹配度会越来越高，最终达到完全契合状态。MacConaill（1953 年）在英国骨科协会演讲中将这种
’ close packed’ position of a joint as one in which the surfaces are completely congruent, the ligaments taut, and the bones inseparable by traction. A brief study of the anatomy of the hip joint will show why this occurs. Figs. 1 and 2 which are line drawings of an osteoligamentous preparation of the hip joint, show from anterior and posterior views respectively the arrangement of the capsular fibres and the associated ligaments of the hip joint; as they course downwards from the innominate bone to the femur they spiral around the neck of the femur when the joint is in
关节的"紧密嵌合"位置是指关节面完全吻合、韧带紧绷、骨骼无法通过牵引分离的状态。简要研究髋关节解剖结构即可明白其成因。图 1 和图 2 是髋关节骨韧带标本的线条图，分别从前后视角展示了髋关节囊纤维及相关韧带的排列方式：当关节处于该位置时，这些结构从无名骨向下延伸至股骨的过程中，会沿股骨颈呈螺旋状缠绕。

Fig. 7.-A diagrammatic representation of the effect of traction in the line of the long axis of the femoral neck on the fracture whilst the hip is in a position of flexion, combined with slight abduction.
图 7.-示意图显示髋关节处于屈曲伴轻度外展位时，沿股骨颈长轴方向牵引对骨折端的作用效果。

Fig. 8.-A diagrammatic representation showing the fracture in the reduced position with the hip joint in a position of extension, combined with some medial rotation.
图 8.-示意图展示髋关节处于伸展伴内旋位时骨折复位后的状态。