ORIGINAL ARTICLE
Is the Cranial and Posterior Screw of the “Inverted Triangle”
Configuration for Femoral Neck Fractures Safe?
Jacob C. Hoffmann, MD,* James Kellam, MD,* Manickam Kumaravel, MD,† Kurt Clark, BA,‡
Milton L. “Chip” Routt, MD,* and Joshua L. Gary, MD*
Objectives: To determine the frequency where a posterior and
cranial screw in a femoral neck that appeared contained on
fluoroscopy violates the cortex.
Methods: Ten specimens including the hemipelvis with the
proximal femur were obtained from unidentified embalmed speci-
mens that were to be cremated after an institutional review board
waiver was granted. Under fluoroscopy, the posterior and cranial
screw of the inverted triangle configuration for the femoral neck was
placed using standard technique with a cannulated 6.5-mm screw.
Anterior–posterior and lateral images of the final screw placement
were blinded to 2 orthopaedic traumatologists and 1 musculoskeletal
radiologist who were asked to determine whether the screw radio-
graphically breached the posterior and cranial cortex. Cadavers were
stripped of soft tissues and inspected for screw perforation. Screws
were grouped as contained, thread extrusion, or core extrusion.
Results: Reviewers classified all 10 screws as radiographically
contained within the femoral neck. Cadavers were inspected and
found to show: 4 of 10 with core extrusion, 3 of 10 with thread
extrusion, and 3 of 10 screws contained within the femoral neck.
Conclusions: Seventy percent of screws that were judged to be
radiographically contained had cortical breach near the area where
the lateral epiphyseal vessels enter the femoral neck. We urge
caution against placement of posterior-cranial implants with fluo-
roscopy alone even if they appear radiographically contained.
Key Words: femoral neck fractures, posterior-cranial femoral neck
cortex, cannulated screw fixation, avascular necrosis, fixation failure
(J Orthop Trauma 2019;33:331–334)
INTRODUCTION
Femoral neck fractures are a common injury encoun-
tered by orthopaedic surgeons. In the United States, it is
Accepted for publication February 13, 2019.
From the *Departments of Orthopedic Surgery, and; †Radiology; and ‡Anat-
omy and Neuroscience, McGovern Medical School at UTHealth Houston,
Houston, TX.
The authors report no conflict of interest.
Presented in part as a poster at the Annual Meeting of the Orthopedic Trauma
Association, Vancouver, BC, October 2017, AAOS New Orleans, LA,
March 2018; American Orthopaedic Association, Boston, MA, June 2018,
and as a podium presentation at the JOA, Kobe, Japan, May 24, 2018.
Reprints: Joshua L. Gary, MD, Department of Orthopaedic Surgery, Mc-
Govern Medical School at UTHealth Houston, 6400 Fannin St. Ste 1700,
Houston, TX 77030 (e-mail: joshgary14@gmail.com).
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BOT.0000000000001461
J Orthop Trauma  Volume 33, Number 7, July 2019
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
estimated that 250,000 patients per year sustain a hip fracture
and is expected to double over the next 30 years.1 They occur
in a bimodal distribution with low-energy mechanisms in older,
osteopenic patients frequently encountered and high-energy
mechanisms in younger patients less commonly seen.2 Elderly
patients with stable femoral neck fractures are frequently man-
aged with in situ screw fixation, and younger patients are
almost always treated with open reduction and internal fixa-
tion.3,4 In either group, when the femoral head is preserved,
avoiding nonunion and avascular necrosis is paramount to pre-
vent secondary surgeries in the future, which are needed in
approximately 20% of patients in both age groups.3,5
In adults, the lateral epiphyseal artery enters the femoral
head from the cranial and posterior femoral neck.6 Traumatic
or iatrogenic injury to these vessels may have devastating
consequences to the hip joint associated with avascular necro-
sis of the femoral head. For younger patients, in whom hip
arthroplasty is not an ideal option, the consequences of avas-
cular necrosis may be life-altering for decades. Placement of
peripheral screws abutting the cortices of the femoral neck in
an inverted triangle configuration has been suggested as a bio-
mechanically advantageous construct.7 The inverted triangle
configuration consists of screws placed peripherally in the
femoral neck in anterior and cranial, central and caudal, and
posterior and cranial positions. An aberrantly placed
posterior-cranial screw has the potential to injure the femoral
head blood supply (Figs. 1 and 2).
The purpose of this study was to determine the
frequency that a posterior and cranial screw in a femoral
neck that appeared contained on fluoroscopy violates the
cortex. We hypothesize that a screw appearing contained on
fluoroscopy in the posterior and cranial aspect of the femoral
neck does not violate the cortex near the entry of the femoral
head blood supply.
MATERIALS AND METHODS
Ten cadaveric specimens consisting of the hemipelvis
with the proximal femur and surrounding soft tissues were
obtained from unidentified embalmed specimens. An institu-
tional review board waiver was obtained as the specimens
were donated to the university for scientific purposes. Under
fluoroscopic guidance, only the posterior and cranial 6.5-mm
cannulated screw of the inverted triangle configuration was
placed over a threaded guide pin. Two experienced ortho-
paedic traumatologists placed terminally threaded guide pins
using sequential anterior–posterior (AP) and lateral
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Hoffmann et al J Orthop Trauma  Volume 33, Number 7, July 2019

FIGURE 1. A and B, Postoperative AP and lateral radiographs of a 21-year-old man after open reduction internal fixation of
a femoral neck fracture with appearance of contained posterior and superior screws. C Axial CT cut obtained for nonorthopaedic
issue in the postoperative period with appearance of cortical breach of posterior and cranial screw.

fluoroscopic views until they deemed satisfactory position
had been achieved, and that screws would be contained
within the femoral neck. The final AP and lateral images of
the screw placement were saved for every specimen. Each set
of AP and lateral fluoroscopic images were randomized and
blinded to 2 attending orthopaedic traumatologists (Re-
viewers A and B) and 1 musculoskeletal radiologist. Re-
viewers were asked to determine whether the screw appeared
to have radiographically breached the posterior and cranial
femoral cortex using both the AP and lateral image for each

FIGURE 2. A, A 33-year-old man sustained a displaced femoral neck fracture after a motor vehicle collision. B and C, The patient
underwent open reduction and internal fixation through a Smith–Peterson approach. D–F, Cannulated screw fixation was used. Post-
operative CT demonstrated posterior-cranial screw breach. Editor’s Note: A color image accompanies the online version of this article.

332 | www.jorthotrauma.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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J Orthop Trauma  Volume 33, Number 7, July 2019
screw. The reviewers simply classified the screws as either
safely contained or if the screw breached the cortex.
The screws were retained in the specimens after
placement. After images had been classified, the proximal
femur specimens were stripped of soft tissues. The posterior
aspect of the femoral neck was inspected for screw perfora-
tion. Screws were grouped into 3 categories: (1) contained if
no perforation was seen, (2) thread extrusion if only screw
threads were visualized, and (3) core extrusion if screw
threads and the screw core were visualized. Screws were
retrieved, and the specimens were cremated according to
institutional policy after conduction of study.
RESULTS
All 10 screws were classified as radiographically con-
tained within the femoral neck on both the AP and lateral
fluoroscopic views by 2 orthopaedic traumatologists and 1
musculoskeletal radiologist after blinded review. There was no
suspicion for cortical breach. The 10 specimens were inspected
after soft-tissue stripping and found to show 4 of 10 with core
extrusion (Fig. 3), 3 of 10 with thread extrusion (Fig. 4), and 3
of 10 screws contained within the femoral neck.
DISCUSSION
This study was designed to determine whether a fluoro-
scopically contained posterior and cranial screw was safe and
did not violate the cortex of the femoral neck. We demon-
strated that a cranial and posterior screw that appeared
radiographically contained with the femoral neck on ante-
roposterior and lateral views frequently violated the cortex in
the area where the lateral epiphyseal vessels enter the femoral
head. Avascular necrosis of the femoral head after femoral
neck fractures may be multifactorial.8,9 A potential mecha-
nism is the initial displacement causing compression or
stretching of the terminal branches of the medial femoral
circumflex artery (MFCA), or the lateral epiphyseal vessels,
to the femoral head. In addition, iatrogenic injury to the
FIGURE 3. AP and lateral fluoroscopic images showing contained screw. Stripped cadaveric specimen with posterior-cranial screw
breach with core extrusion. Editor’s Note: A color image accompanies the online version of this article.
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Cranial and Posterior Screw
vessels may occur during placement of implants into the
proximal femur.
Gautier et al6 used latex cast die to delineate the course
of the MFCA in 24 cadaveric specimens and showed that the
dominant blood supply to the femoral head originated from
the superior retinacular branches in 20 specimens. These ret-
inacular branches from the MFCA course beneath the syno-
vial sheath along the posterior-cranial aspect of the femoral
neck before perforating into the cortex 2–4 mm lateral to the
bone-cartilage junction. Vascular foramina occur more fre-
quently on the posterior-cranial aspect of the femoral head
and neck junction with few anteriorly.10,11 Potential destruc-
tion of these vessels or vascular foramina could occur due to
destruction by a extruded wires, drill, or implants in this
anatomical location. An extruded and retained implant could
also theoretically interfere with revascularization and cause
avascular necrosis of the femoral head.
Screws that appear close to the cortex on AP and lateral
fluoroscopy or plain radiographs may perforate the cortex
because of the anatomy of the femoral neck. Zhang et al12
created 3-dimensional reconstructions of proximal femurs
based on computed tomography (CT) data obtained from 24
adults and calculated the risk zones for perforation of cortex
when placing 6.5-mm screws. Risk for perforation was
greater in the anterior-caudal (10.7%) and posterior-cranial
(6.7%) quadrants of the femoral neck. These authors suggest
that although they may appear contained on AP and lateral
radiographs, the anterior-caudal and posterior-cranial quad-
rants were at highest risk of perforation.
Maintaining integrity of the posterior-cranial femoral
neck cortex is an important factor in preventing fracture
fixation failure and avascular necrosis. If there is violation of
the posterior cortex, there is significantly lower resistance to
axial loads regardless of anatomical reduction.13 A core screw
breach, where there are no threads into the posterior-cranial
cortex, could theoretically cause further comminution placing
the construct at higher risk of failure.
There are several limitations to this study. The cadav-
eric specimens available to us were hemipelvis, which
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Hoffmann et al
FIGURE 4. AP and lateral fluoroscopic images showing contained screw. Stripped cadaveric specimen with posterior-cranial screw
breach with thread extrusion. Editor’s Note: A color image accompanies the online version of this article.
prevented us from standardized positioning of the specimens
before screw placement; this also precluded views of the
contralateral hip for comparison. The embalmed hemipelvis
also precluded dissection of injection of cast die into the
microvasculature including the lateral epiphyseal vessels from
the medial femoral circumflex system. Our technique using
self-drilling, self-tapping screws placed over terminally
threaded guide pins also limits tactile feedback that could
be used to identify extrusion intraoperatively. The use of drill-
tipped guide pins, a cannulated drill bit over the guide pin, or
“probing” the drill tunnel, as performed with pedicle screw
placement in the spine, would likely improve tactile feedback
to alert the surgeon of cortical extrusion. We used 6.5-mm
diameter cannulated screws. Although these screws usually
have the same core diameter as 7.3-mm or 8.0-mm screws,
the risk of thread extrusion would be higher in these screws
with larger thread diameters. A total of 6.5-mm screws pres-
ent a “best case” scenario to prevent cortical violation.
Critical assessment of safety of screw placement on
fluoroscopic imaging is subjective, and our surgeons only
used AP and lateral images to position guide pins before
screw placement. It is possible that continuous imaging
frequently used to ensure that the ends of screws do not
extrude from the femoral head may have also demonstrated
posterior cortical breach but was not performed in our
specimens. We mitigated and pooled our risk assessment by
asking 2 experienced orthopaedic traumatologists and 1
experienced musculoskeletal radiologist to reply in a binomial
response: contained or not. Because the lateral epiphyseal
arteries of our embalmed cadavers could not be dissected or
marked by cast die, we cannot say with absolute certainty the
screw perforation violated these arteries.
In conclusion, 70% of 6.5-mm screws placed in
a posterior and cranial position in the femoral neck that were
judged to be radiographically contained had cortical breach
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J Orthop Trauma  Volume 33, Number 7, July 2019
and were “in-out-in” near the area where the lateral epiphy-
seal vessels enter the femoral neck. We urge caution against
placement of posterior and cranial implants in the femoral
neck with fluoroscopy alone as the appearance of radio-
graphic containment on anteroposterior and lateral views is
deceiving.
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