Anteversion and Retroversion of the Neck of Femur

The Reference Axes

1. Femoral neck axis - a line drawn along the long axis of the femoral neck, from the center of the femoral head to the base of the neck.
2. Transcondylar (condylar) axis - a line drawn through the two femoral condyles at the knee.

Anteversion (Coxa Anteverta)

• Adults: approximately 10-15° (some sources quote 12°, others 15-25°)
• Neonates/infants: 30-40° at birth - all femurs are anteverted at birth
• Decreases progressively through childhood, reaching the adult value by the end of the 2nd decade of life

• Called coxa anteverta when the angle is excessively large
• The hip has excessive internal rotation range and limited external rotation
• The patient walks with a "toeing-in" gait (in-toed or pigeon-toed gait)
• In children: persistent femoral neck anteversion is best assessed with the patient prone - excessive internal rotation of the hip is the hallmark finding
• All femurs are anteverted at birth, and spontaneous improvement usually occurs as the femur lengthens and rotates during growth
• If persistent beyond age 10-12 years with functional difficulty, corrective derotational osteotomy may be justified
• Compensatory external tibial torsion may develop, normalizing the foot progression angle but causing the "miserable malalignment syndrome" (knee pain, instability)

Retroversion (Coxa Retroverta)

• Called coxa retroverta
• The patient walks with a "toeing-out" gait (out-toed gait)
• There is excessive external rotation at the hip and limitation of internal rotation
• Associated with conditions like femoroacetabular impingement (cam/pincer type) and slipped capital femoral epiphysis (SCFE) in some contexts

How to Measure

• Imaging: Axial CT of the femoral neck and distal femur can be superimposed to measure the angle between the femoral neck axis and the posterior condylar axis. Normal is 10-20° of anteversion on CT.
• Clinical test: The angle difference between a radiographic true lateral of the knee and hip also represents hip anteversion.

Summary Table

• General Anatomy and Musculoskeletal System, THIEME Atlas - p. 437-438
• Rockwood and Green's Fractures in Adults, 10th ed. 2025 - p. 2642
• Bailey and Love's Short Practice of Surgery, 28th ed. - p. 631

Distal Radius Fracture with Dorsal Tilt - Percutaneous K-Wire Fixation

Background

Indications for Percutaneous K-Wire Fixation

• Metaphyseal instability after closed reduction
• Simpler intraarticular displacement (not severely comminuted)
• Fractures that cannot be maintained in cast alone
• Preferred when ORIF is not required

Step-by-Step Technique (Glickel et al. - Campbell's Operative Orthopaedics)

Step 1 - Anesthesia and Setup

• Brachial block or general anesthesia
• Supine position, arm on radiolucent hand table
• C-arm fluoroscope available

Step 2 - Reduction (Fig. A)

• Place thumb and index fingers in finger traps for longitudinal traction (typically 10 lb / ~4.5 kg)
• This allows disimpaction of the fracture
• Apply dorsal-to-palmar pressure with the thumb over the distal fragment to correct dorsal tilt
• Simultaneously apply ulnar deviation to correct radial displacement
• The wrist is brought into slight palmar flexion and ulnar deviation (cotton-loader position)

Step 3 - Fluoroscopic Assessment

• Evaluate reduction on AP and lateral fluoroscopic views
• If reduction is anatomic or acceptable (see table above) - proceed with pinning
• If reduction is not anatomic or there is severe comminution - consider ORIF

Step 4 - Radial Styloid Wires (Primary Wires)

• Make a 1.5 cm longitudinal incision starting at the radial styloid, proceeding distally (Fig. B)
• Identify and retract branches of the superficial radial nerve (blunt dissection)
• Identify the first extensor compartment (APL and EPB tendons)
• Place two 1.6 mm (0.062-inch) K-wires in succession from the radial styloid:
  • Directed across the fracture site
  • To engage the ulnar cortex of the radius proximal to the fracture
  • Place wires divergent in both AP and lateral planes for better stability
  • Wires may be placed dorsal or volar to the first extensor compartment depending on fracture pattern
  • Aim for subchondral bone distally (better bone density)

Step 5 - Dorsal Wire (Third Wire)

• Place one 1.6 mm K-wire percutaneously, starting at the dorsal rim of the distal radius just distal to Lister's tubercle (Fig. C)
• This wire is placed 90° orthogonally to the radial styloid wires
• Confirm starting point with fluoroscopy
• Drive in a proximal and volar direction across the fracture to engage the volar cortex of the radius proximal to the fracture
• This wire acts as a dorsal buttress against re-displacement

Step 6 - Additional Wires as Needed (Fig. D)

• Dorsal comminution: A second dorsal pin into the dorsal rim, or used as an intrafocal pin (Kapandji technique variant)
• Radial comminution with radial translation: Additional buttress pin from the radial aspect into the proximal ulnar cortex
• Crossed-pin configuration: Pins placed from the distal ulnar radial cortex to engage the intact radial cortex - useful for added stability

Step 7 - Wire Finishing

• Check reduction and wire position fluoroscopically on AP and lateral views
• Bend and cut the wires, leaving them superficial to the skin (for easy removal)
• Apply a well-padded splint

Postoperative Care

Key Anatomical Notes

• Superficial radial nerve - must be identified and protected during radial styloid wire insertion (most common nerve injury)
• Lister's tubercle - key landmark for the dorsal wire entry point
• First extensor compartment - reference for radial styloid wire placement
• Wires placed in subchondral bone (distally) grip better due to higher bone density

Complications

• Tendon tethering, injury, or rupture (EPL most vulnerable with dorsal wire)
• Pin migration
• Superficial radial nerve injury
• Pin site infection
• Loss of reduction

Criss-Cross (Crossed) K-Wire Fixation

What is it?

• Angular displacement (varus/valgus)
• Rotational forces
• Translational forces

Criss-Cross K-Wire in Supracondylar Humerus Fracture (Classic Use)

Two Configurations Available:

Key point from Campbell's: Although crossed medial and lateral pins are more stable than two lateral pins in vitro, two or three lateral pins appear to be equal to crossed pins in vivo. Most centers now use lateral-only pinning for most fractures, reserving a medial pin for very unstable fractures.

Step-by-Step Crossed K-Wire Technique (Supracondylar Fracture)

• Patient supine, elbow on inverted image intensifier
• Countertraction on humerus; apply traction to forearm with elbow in extension
• Correct varus/valgus and rotational malalignment
• Gently flex elbow to 120° while applying anterior pressure on the olecranon to correct posterior displacement of the distal fragment
• Confirm reduction on AP and lateral fluoroscopy

• From the lateral epicondyle, drive a 1.6 mm K-wire percutaneously
• Aim the wire to cross the fracture site and engage the medial cortex of the proximal fragment
• Confirm bicortical purchase under fluoroscopy

• Make a 1-cm incision over the medial epicondyle
• Spread soft tissues so the epicondyle is visible
• Use a retractor to protect the ulnar nerve (the nerve lies just posterior to the medial epicondyle)
• A small soft-tissue drill sleeve can also be used
• Drive the wire from the medial epicondyle, crossing the fracture site, to engage the lateral cortex of the proximal fragment
• The two wires now cross each other at the fracture site (criss-cross pattern)

• Extend the elbow as far as possible without bending the pins
• Stress test under fluoroscopy (rotate and stress the elbow) to check if a third pin is needed
• Compare carrying angle with the normal contralateral elbow

• Cut and bend pins outside the skin
• Apply a well-padded posterior splint with elbow at 60° flexion (to allow for swelling)

• At 1 week: convert to long arm cast at 90° elbow flexion
• At 3-4 weeks: cast and pins removed
• Begin gentle range-of-motion exercises

Criss-Cross K-Wire in Distal Radius Fracture

• Radial comminution with pre-reduction radial translation
• Need for additional stability

• Pins placed from the distal ulnar radial cortex, passed to engage the intact cortex radially
• These cross the pins already placed from the radial styloid side
• This buttresses against re-displacement in the radial direction

Why Criss-Cross is Biomechanically Superior

1. Each wire blocks displacement in the opposite direction - the lateral wire blocks medial displacement, the medial wire blocks lateral displacement
2. The two wires together resist rotation - a single wire cannot prevent rotation along its own axis, but two crossed wires interlock to prevent it
3. The crossing point near the fracture site acts as a pivot lock

Key Risk: Ulnar Nerve Injury

• Make a small skin incision (do not go blind percutaneously on the medial side)
• Spread soft tissues and directly visualize the medial epicondyle
• Use a retractor to protect the nerve
• Avoid pinning with the elbow in maximal flexion (nerve is most taut and at risk)