Injuries associated with a fractured shaft of the femur

Trauma patients with tibia/fibula fractures are associated with an increased risk of torso, severe head, and severe spine injuries compared to patients with femur fractures

BACKGROUND

Although previous studies have demonstrated an association between lower extremity fractures and concomitant torso (thorax and abdomen) injuries in trauma patients, they do not compare different types of fractures. Therefore, we investigated the risk of associated torso injuries between femur and tibia/fibula fractures, hypothesizing that trauma patients with femur fractures are at higher risk of torso injuries compared to patients with tibia/fibula fractures.

METHODS

The Trauma Quality Improvement Program database (2010-2016) was queried for patients presenting with either femur or tibia/fibula fractures. Patients with ground-level falls and penetrating injuries were excluded. Univariable and multivariable logistic regression analyses were performed.

RESULTS

From 162,354 patients, 104,075 (64.1%) patients had femur fractures and 58,279 (35.9%) had tibia/fibula fractures. Compared to those with femur fractures, patients with tibia/fibula fractures had a higher incidence of torso injuries (32.2% vs. 17.7%, p<0.001). The tibia/fibula fracture group was also associated with an increased risk of torso (OR 2.22, CI 2.17-2.27, p<0.001), severe (abbreviated injury scale grade > 3) head (OR 2.38, CI 2.30-2.46, p<0.001), and severe spine injuries (OR 2.33, CI 2.07-2.62, p<0.001) compared to the femur fracture group. Additionally, patients with tibia/fibula fractures had a higher rate of deep vein thrombosis (2.5% vs. 1.8%, p<0.001) than patients with femur fractures.

CONCLUSIONS

Contrary to previous studies, we demonstrate patients with tibia/fibula fractures have a higher associated risk of torso, severe head and severe spine injuries than patients with femur fractures. Therefore, trauma surgeons should manage tibia/fibula fracture patients with similar clinical vigilance as femur fracture patients.

Dilemma for Fracture Fixation of Paediatric Ipsilateral Neck with Shaft Femur Fracture

BACKGROUND

Ipsilateral femoral neck with shaft fracture (IFNSF) in the paediatric population is a rare injury. This high-impact trauma is often associated with other orthopaedic and systemic injuries. Prognosis is usually guarded as both these osseous injuries are serious and exist together. We report two such patients of IFNSF.

METHODS

Two children with IFNSF were admitted at our hospital in 2018. The first patient had an associated head injury, while in the second patient, the shaft femur fracture was open. We report on the treatment and results in these two patients. Both the patients were serially assessed and followed 2 years after the injury.

RESULTS

Union was achieved in neck and shaft femur fractures in both the patients by 3 months. Complications like avascular necrosis (AVN) of the femoral head, coxa vara, non-union or malunion of fractures, limb length discrepancy, knee and hip stiffness were not seen in either of the patients.

CONCLUSION

IFNSF is a rare injury pattern seen in children, usually associated with concomitant orthopedic and other systemic injuries. Early operative stabilization is the preferred modality of treatment. For an undisplaced neck fracture, a provisional temporary fixation of a relatively less displaced neck fracture, definitively stabilizing the shaft fracture, and thereby returning to fix neck fracture is advocated. For displaced neck fractures, a direct open reduction is advocated. Anatomical fixation with separate implants and a relatively longer immobilization can provide the best-expected results. Long-term follow-up is needed to foresee any complications.

LEVEL OF EVIDENCE

V (case series). Therapeutic.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-020-00315-z.

Low-Energy Traumatic Obturator Hip Dislocation with Ipsilateral Femoral Shaft Fracture in a Patient with Omolateral Knee Arthroplasty

Ipsilateral obturator hip dislocation and femoral shaft fracture are rare. We report such a case in an older woman after a low-energy injury. She had a knee prostheses in the same limb. The patient was treated by open manipulative reduction of the luxation without opening joint and open reduction and internal fixation of the femur with angular stability plate and screws. We could not find a similar case in the literature. An early diagnosis of the dislocation is crucial in order to obtain good results. Great awareness and radiologic examination are fundamental to achieve precocious diagnosis of both these rare combined injuries, as treatment in these cases is considered an emergency. The first step was an attempt to reduce the dislocation by closed means but it failed. Then we performed a short approach at the trochanteric region and used Lambotte forceps to manoeuvre the proximal femur without opening the joint achieving reduction. Thereafter the femoral shaft fracture underwent open reduction and internal fixation with an angular stable plate. After a 2-year follow-up the outcome was very good.

Use of femoral shaft fracture classification for predicting the risk of associated injuries

OBJECTIVES

To investigate the hypothesis that specific fracture patterns in patients with femoral shaft fractures can predict the likelihood of associated injuries.

DESIGN

Retrospective cohort study.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Consecutive patients treated because of a traumatic diaphyseal femoral fracture.

MAIN OUTCOME MEASUREMENT

We studied the association between the Orthopaedic Trauma Association (OTA) fracture classification (derived from initial radiographs) and concomitant injuries of the head, spine, chest, abdomen, and pelvis with a severity of two or more points according to the Abbreviated Injury Scale by logistic regression analysis.

RESULTS

One hundred forty-three of 203 patients (80 men, 63 women; mean age 54 ± 26 years) met the inclusion criteria. All patients had unilateral diaphyseal fractures, 64 OTA 32.A (45%), 46 OTA 32.B (32%), and 33 OTA 32.C (23%). In addition, 134 associated injuries were identified in 52 patients. Increasing fracture severity, as expressed by the OTA classification (ie, A, B, C), was significantly associated with a higher likelihood of thoracic (odds ratio [OR], 5.89; 95% confidence interval [CI], 2.59-13.40), pelvic (OR, 4.55; 95% CI, 2.01-10.28), upper (OR, 2.38; 95% CI, 1.27-4.48), and lower extremity injuries (OR, 3.12; 95% CI, 1.78-5.46). Fracture severity explained between 70% and 86% of the probability of having accompanying injuries.

CONCLUSION

Radiographic grading of the severity of a femoral shaft fracture may signal the presence of accompanying injuries and should contribute to the clinical decision-making process in severe trauma.

Severity of injuries associated with femoral fractures as a result of motor vehicle collisions

INTRODUCTION

Femoral fractures are often the result of high-velocity injuries, and the early identification of associated injuries is important. The purpose of this study was to review the associated injuries present in a current UK series of patients who sustain femoral fractures as a result of motor vehicle accidents.

MATERIALS AND METHODS

All cases of femoral fractures were extracted from the UK co-operative crash injury study (CCIS) database, from 1998 to 2002. Associated injuries, skeletal and non-skeletal, were identified by body region and severity (according to the abbreviated injury scale and injury severity scale).

RESULTS

A total of 5,841 crashes were investigated in that time period, and there were 365 car occupants who sustained a femoral fracture. The 16-35 age group accounted for nearly half of all cases. A total of 313 patients (85.2%) had at least one other concomitant significant injury, of which 84 (23.0%) had skeletal injury only, 45 (12.3%) had non-skeletal injury only, and 184 (50.4%) had both. The opposite lower limb was the most common skeletal injury, and thoracic injuries were the most common visceral injuries. Thoracic injuries also accounted for the most serious injuries (AIS 4-6). The overall mortality was 40.5% in our series.

CONCLUSION

Concomitant injuries are to be expected in the majority of cases of femoral fractures sustained as a result of MVCs. There should be a low threshold for involving a general surgical team in the management of these cases.

Childhood femur fractures, associated injuries, and sociodemographic risk factors: a population-based study

OBJECTIVE

The objectives of this study were to determine the incidence of femur fractures in Colorado children, to assess underlying causes, to determine the prevalence and predictors of associated injuries, and to identify potentially modifiable risk factors.

METHODS

The study population included all Colorado residents who were aged 0 to 17 years at the time of injury between January 1, 1998, and December 31, 2001. Cases of femur fracture were ascertained using the population-based Colorado Trauma Registry and International Classification of Diseases, Ninth Revision, Clinical Modification codes 820.0 to 821.39. Associated injuries with an Abbreviated Injury Scale of 2 or higher were classified into 5 categories. Poisson regression, small area analysis, and multivariate logistic regression were used to identify predictors of femur fractures and associated injuries, respectively.

RESULTS

During the study period, 1139 Colorado children (795 boys, 344 girls) sustained femur fractures, resulting in the incidence of 26.0 per 100000 person-years. Rates were higher in boys than in girls in all age groups (overall risk ratio: 2.19; 95% confidence interval: 1.92-2.47) but did not differ by race/ethnicity. Femur fractures that were caused by nonaccidental trauma showed more distal and combined shaft + distal pattern; their incidence did not differ by gender or race but was higher in census tracts with more single mothers and less crowded households. Associated injuries were present in 28.6% of the cases, more often in older children. Fatalities occurred only among children with associated injuries. Children who were involved in nonaccidental trauma, motor vehicle crashes, or auto-pedestrian accidents were 16 to 20 times more likely to have associated injuries than those with femur fractures as a result of a fall. In small-area analysis, the incidence of femur fractures in infants and toddlers was higher in census tracts characterized by higher proportion of Hispanics, single mothers, and more crowded households. Among children 4 to 12 years of age, the incidence was higher in census tracts with fewer single-family houses and more crowded households. Finally, the incidence of femur fractures among teenagers was higher in rural tracts and those with a higher proportion of Hispanics.

CONCLUSIONS

Femur fractures and associated injuries remain a major cause of morbidity in children. Predictors of femur fractures change with age; however, the risk is generally higher among children who live in the areas with lower socioeconomic indicators.

Talar fractures associated with ipsilateral femoral shaft fractures: report of three cases

Talar fractures associated with ipsilateral femoral shaft fractures have been occasionally reported, but an unexpectedly high potential for simultaneous occurrence of the fractures in head-on collisions has not been well documented. We treated three patients with ipsilateral femoral shaft and talar fractures in a 2-year period starting in 2000. The patients were male, aged 25, 34 and 40 years, polytraumatized with other injuries. In all cases, the fractures occurred in the right lower extremities of drivers involved in head-on collisions. The talar fractures were not detected at the initial diagnosis. We considered that the feet had been dorsiflexed and exposed to an axial load from the front when the drivers pushed the brake pedals. This condition was considered to cause both fractures. Careful examination should be carried out to rule out talar fractures in swollen feet associated with femoral shaft fractures in head-on collisions.

Knee injuries in traumatic hip dislocation

Of 187 patients treated at the author's institutions for fracture and/or dislocation of the hip during a 10-year period (1985-1994), 46 patients (25%) with a knee injury on the same side as the hip injury were evaluated 6 months to 11 years after the initial accident (mean, 3.65 years). Thirty-nine patients (85%) had symptoms or clinical signs in the knee. Ligamentous injuries overlooked in the initial examination were found in seven patients. Knee injuries often accompany hip fracture and/or dislocation, and can be produced by direct or indirect trauma. A delayed diagnosis of such injuries may lead to their treatment in the sequela phase, which complicates the final outcome. Therefore, an exhaustive physical examination is recommended for patients with traumatic hip dislocation to detect potential injuries to the ipsilateral knee. Early diagnosis and treatment of such injuries greatly improve final outcome.

Specific features associated with femoral shaft fractures caused by low-energy trauma

OBJECTIVE

To scrutinize the fracture patterns of femoral shaft fractures caused by low-energy injury mechanism and to delineate the problems associated with the treatment of these fractures.

MATERIALS AND METHODS

Of a total of 192 consecutive skeletally mature patients with 201 acute fresh femoral shaft fractures admitted during a 10-year period (1985-1994), 50 patients had a fracture caused by low-energy trauma. The fractures were classified in terms of their configuration, site, degree of comminution, and soft-tissue injury. The previous fractures, chronic illnesses, and continuous medications of the patients as well as the injury mechanisms and concomitant injuries were registered. All general and local complications and their consequences were recorded. Forty patients could be followed until the bony union of the fracture was achieved, the mean follow-up time being 14 months.

RESULTS

The incidence of these injuries was 2.5 per 100,000 person-years. There were 32 women and 18 men. The mean age of the patients was 65 years (range, 17-92 years). Thirteen patients were younger than 60 years of age. Thirty-two (64%) had at least one local or general factor weakening the mechanical strength of the bone that predisposed them to a fracture. Thirty-two patients sustained a fracture of the left femur (p < 0.05). All fractures were closed. None of the patients had significant concomitant injuries. In 33 cases, the site of the fracture was in the middle third of the femur. The fracture configuration was spiral in 29, transverse in 10, oblique-transverse in 7, and oblique in 4 cases. Postoperative complications, including delayed union, nonunion, and malunion, occurred with 29 patients. Eighteen reoperations among 12 patients were performed because of these complications.

CONCLUSIONS

Femoral shaft fractures caused by low-energy violence occur mainly in patients suffering from a chronic disease or a condition causing osteopenia of the femur. The most common fracture pattern was a spiral one in the middle third of the femoral shaft. Despite the low-energy violence, the treatment of these fractures is not devoid of complications. The treatment of these seemingly simple fractures requires careful planning and meticulous operative technique.