"Four quadrant parallel peripheral screw fixation for displaced femoral neck fractures in elderly patients.

Sir,

We read the article titled “Four quadrant parallel peripheral screw fixation for displaced femoral neck fractures in elderly patients” by Satish et al.1 with deep interest. We would like to congratulate the authors for this informative paper. We would like to comment on a few points as follows:

We have been using diamond-shaped configuration2 with four screws, where we insert one screw at the apex (Superior-S), one at the bottom of the neck (Inferior-I), and two in the middle portion of the neck, one anteriorly (MA) and the other one posteriorly (MP) [Figure 1b]. We feel this is a superior construct compared to the rectangular configuration, as the distance between the screws is more, giving better rotational control. Also, this technique allows skimming the neck cortex and calcar femorale, giving additional stability [Figure 1].

Figure 1

Schematic representation of screw construct in neck: (a) four quadrant parallel configuration (b) diamond shaped configuration

In the rectangular configuration, putting two screws superiorly and inferiorly will result in the screws being very close to each other [Figure 1a]. Also, it is not possible to skim the calcar with two screws parallel to each other. When this is done, then chances of perforation of neck are higher.

Authors have not mentioned about the patients with posterior or medial comminution, as literature mentions that there is increased risk of re-displacement and avascular necrosis if the posterior cortex is comminuted.2 Fourth screw is shown to be useful in fractures with comminution.3

We would like to know why this study does not include patients of less than 50 years of age.