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Year : 2013  |  Volume : 47  |  Issue : 5  |  Page : 532-533
Four quadrant parallel peripheral screw fixation for displaced femoral neck fractures in elderly patients

1 Department of Orthopaedics, Bokaro General Hospital, Bokaro, Jharkhand, India
2 Department of Orthopaedics, PGIMER and DR. RML Hospital, New Delhi, India

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Date of Web Publication17-Sep-2013

How to cite this article:
Jaiswal A, Tanwar YS, Habib M. Four quadrant parallel peripheral screw fixation for displaced femoral neck fractures in elderly patients. Indian J Orthop 2013;47:532-3

How to cite this URL:
Jaiswal A, Tanwar YS, Habib M. Four quadrant parallel peripheral screw fixation for displaced femoral neck fractures in elderly patients. Indian J Orthop [serial online] 2013 [cited 2020 Jan 29];47:532-3. Available from:

We read the article [1] "four quadrant parallel screw fixation for displaced femoral neck fractures in elderly patients" with great interest. We would first like to congratulate the authors for drawing our attention toward head salvage surgery in fracture neck femur in the era of arthroplasty where most of the studies are focused on replacement arthroplasty, but we have some reservations regarding it.

The authors had inserted first guide wire in the inferior posterior part of femoral neck and tightened the screw on single guide wire only. We would like to know whether this may not had resulted in the rotation of the already vascular compromised femoral head and increase further vascular insult to the femoral head.

Second it is recommended in the literature that fracture neck femur may be associated with posterior comminution so, it is advised to compress anterior screws first and posterior screws last to prevent collapse of the posterior aspect of femoral neck, if comminution is present, [2] but the author has compressed the posterior screw first. This may have reflected as an addition to increased percentage of malunion in this study (70%).

Third, Parker and Blundell [3] in a meta-analysis of 25 randomized controlled trials concluded it was not possible to determine the optimum number or types of screws. Patwa et al. [4] in a bio geometric study on Indian femur concluded that inferior half of femoral neck in Indians is narrower than superior half and implantation of two screws in inferior half of the femoral neck with precision is difficult in Indian patients.

Fourth, study by Zlowodzki et al. [5] had shown that functional outcome is better if screws are used with washers rather than without washers and implantation of four screws may not be possible if washers are used and it is especially, important in osteopenic bone.

Fifth, Subtrochanteric femur fractures after pin or screw fixation of femoral neck fractures have been documented in all age groups. These typically transverse or short oblique fractures are the result of the minimal trauma and have been reported to occur from 1 week to 2 years after femoral neck fracture fixation. Further, two screws at the level of lesser trochanter may predispose the femur in elderly patients to subtrochanteric fractures. Oakey et al. in a study on cadaveric femora concluded that using an inverted triangle configuration (apex-distal) is less likely to result in a subtrochanteric femur fracture when compared to an apex-proximal configuration; thus, two screws distally have more chances of subtrochanteric fractures. [6]

Lastly, authors had operated 180 patients, but the study included the followup of only 64 patients, which are approximately one third of the total operated patients. The remaining patients result is unknown so it is very difficult to comment on the results.

   References Top

1.Satish BR, Ranganadham AV, Karruppasamy R, Tripathy SK. Four quadrant parallel peripheral screw fixation for displaced femoral neck fractures in elderly patients. Indian J Orthop 2013;47:174-81.  Back to cited text no. 1
  Medknow Journal  
2.Kyle RF. Operative technique of fixation of femoral neck fractures in young adults. Tech Orthop 1986;1:33.  Back to cited text no. 2
3.Parker MJ, Blundell C. Choice of implant for internal fixation of femoral neck fractures. Meta-analysis of 25 randomised trials including 4,925 patients. Acta Orthop Scand 1998;69:138-43.  Back to cited text no. 3
4.Patwa JJ, Krishnan A, Pamecha CC. Biogeometry of femoral neck for implant placement. Indian J Orthop 2006;40:224-7.  Back to cited text no. 4
  Medknow Journal  
5.Zlowodzki M, Weening B, Petrisor B, Bhandari M. The value of washers in cannulated screw fixation of femoral neck fractures. J Trauma 2005;59:969-75.  Back to cited text no. 5
6.Oakey JW, Stover MD, Summers HD, Sartori M, Havey RM, Patwardhan AG. Does screw configuration affect subtrochanteric fracture after femoral neck fixation? Clin Orthop Relat Res 2006;443:302-6.  Back to cited text no. 6

Correspondence Address:
Atin Jaiswal
Quarter Number 4172, Sector 4F, Bokaro Steel City, Bokaro 827 004, Jharkhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5413.118217

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Satish Kumar, B.R.J., Ranganadham, A.V., Ramalingam, K., Tripathy, S.K.
Indian Journal of Orthopaedics. 2013; 47(5): 533-534


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