Segmental neck of femur fractures: A unique case report of an ipsilateral subcapital, greater trochanteric and intertrochanteric fracture and proposed management algorithm

Ipsilateral femoral neck, intertrochanteric and acetabular fractures with posterior dislocation of the hip: A case report and literature review

INTRODUCTION

Traumatic hip dislocation with ipsilateral femoral neck fracture, intertrochanteric fracture and acetabular fracture is a rare and serious injury that occurs mostly in young patients and after high-energy trauma. The treatment of these injuries is a major challenge for orthopedic surgeons; it can have devastating consequences if not treated properly, including avascular necrosis of the femoral head and traumatic osteoarthritis of the hip. In previous case reports only internal fixation of femoral neck fracture was performed without revascularisation and there was a lack of long-term follow-up results. In this report, we fixed the fracture revascularised the patient, and obtained good prognostic results at up to 20 months of follow-up.

CASE PRESENTATION

Here, we report an 18-year-old patient with systemic polytrauma resulting from a car accident. The trauma included ipsilateral posterior hip dislocation, acetabular fracture, femoral intertrochanteric fracture, and femoral neck fracture. In addition, the patient also had an ipsilateral open tibiofibula fracture. We chose the surgical treatment of a proximal femoral locking compression plate (PFLCP), femoral quadratus bone flap graft, and cannulated compression screw to treat the proximal femoral fracture. The patient was followed up for nearly 20 months; the range of motion of his hip was close to normal, and his hip function was good.

DISCUSSION AND CONCLUSIONS

Traumatic hip dislocation with ipsilateral femoral neck fracture, intertrochanteric fracture and acetabular fracture is a rare and serious injury, and surgical intervention is often needed. Because of the high risk of femoral head necrosis in such complex injuries, it is very important to protect/restore the blood supply of the femoral head during surgery. Therefore, in younger patients, we believe that the use of a quadratus femoris bone flap graft and PFLCP is an acceptable treatment for this severe injury. We discuss the management of this rare case and review the current literature to provide the best evidence-based recommendations for this injury pattern. We conclude that for patients with complex ipsilateral proximal femoral and acetabular fractures combined with hip dislocation, the key to surgical treatment, in addition to anatomic reduction and good fixation, is the primary reconstruction of the femoral head blood supply.

Concomitant Ipsilateral Intracapsular and Extracapsular Femoral Neck Fractures in Young Individuals: A Report of 3 Cases

CASES

Concomitant ipsilateral intracapsular and extracapsular fractures of the femoral neck, also termed "segmental fracture neck femur," are rare injuries, especially in physiologically young patients. We present 3 such cases that successfully underwent operative fixation with an extramedullary implant.

CONCLUSION

Good clinical outcomes may be obtained after osteosynthesis with extramedullary fixation devices in concomitant ipsilateral intracapsular and extracapsular fractures of the femoral neck in young patients (<60 years). They should be followed for a long duration to look for avascular necrosis.

What Is the Best Treatment Choice for Concomitant Ipsilateral Femoral Neck and Intertrochanteric Fracture? A Retrospective Comparative Analysis of 115 Consecutive Patients

PURPOSE

Although a concomitant ipsilateral femoral neck and intertrochanteric fracture has been considered to be a rare type of injury, its incidence has been increasing, especially among elderly hip fracture patients. However, there is limited evidence on the optimal treatment option. This study surveys surgical outcomes of different implants in order to assist in selecting the best possible implant for a combined femoral neck and intertrochanteric fracture.

METHODS

The postoperative complications after the treatment of a concomitant ipsilateral femoral neck and intertrochanteric fracture via cephalomedullary nail (CMN), dynamic hip screw (DHS), and hip arthroplasty groups were analyzed by retrospectively reviewing the electronic medical records of 115 consecutive patients.

RESULTS

The patient demographics and perioperative details showed no significant discrepancies amongst different surgical groups, except for the operative time; a CMN had the shortest mean operative time (standard deviation) of 85.6 min (31.1), followed by 94.7 min (22.3) during a DHS, and 107.3 min (37.2) during an HR (p = 0.021). Of the 84 osteosynthesis patients, 77 (91.7%) achieved a fracture union. Only one (3.2%) of the 31 HR cases had a dislocation. The sub-analysis of the different osteosynthesis methods showed a higher incidence of excessive sliding and the nonunion of the fracture fragment in the DHS group than that in the CMN group (p = 0.004 and p = 0.022, respectively). The different surgical methods did not significantly vary in other outcome variables, such as the re-operation rate, mortality, and hip function.

CONCLUSIONS

For the surgical treatment of combined femoral neck and trochanteric fractures, osteosynthesis did not differ significantly from an HR in terms of the overall postoperative complications, reoperation and mortality rate, and hip function, however, the risk of nonunion and more mechanical complications should be considered when choosing a DHS. Our suggestion for the treatment of a femoral neck and ipsilateral trochanteric fracture is that a surgeon should choose wisely between an HR and a CMN depending on the patient's age, the displacement of the femoral neck, and one's expertise.

[Patterns and research progress on the concomitant ipsilateral fractures of intracapsular femoral neck and extracapsular trochanter]

OBJECTIVE

To summarize the patterns and research progress of the concomitant ipsilateral fractures of intracapsular femoral neck and extracapsular trochanter, and to provide a common language among orthopedic surgeons for scientific exchange.

METHODS

According to related literature and authors own experiences concerning the anatomic border between femoral neck and trochanter region, the intertrochanteric line (or intertrochanteric belt) and its capsularligament attachment footprint, fracture patterns, and treatment strategies were reviewed and analyzed.

RESULTS

With the rapid growing of geriatric hip fractures, an increased incidence was noted in recent years regarding the proximal femoral comminuted fractures that involving ipsilateral intracapsular neck and extracapsular trochanter regions simultaneously. But the concept of femoral neck combined with trochanter fractures was ambiguous. Based on the anatomic type of femoral neck fracture, the location of fracture center, and the ability to achieve direct inferior calcar or anteromedial cortex-to-cortex apposition and buttress, we classified these complex fractures into 3 sub-types: ① Segmental femoral neck fractures (two separate fracture centers at subcapital and trochanteric region respectively); ② Femoral neck fracture (trans-cervical) with extension to the supero-lateral trochanteric region (fracture center in femoral neck); ③ Trochanteric fracture with extension to the medio-inferior femoral neck region (fracture center in trochanter, comminuted basicervical fracture, or variant type of comminuted trochanter fracture). For treatment strategy, surgeons should consider the unique characteristics of femoral neck and trochanter, usually with combined fixation techniques, or arthroplasty supplemented with fixation.

CONCLUSION

Currently there is no consensus on diagnosis and terminology regarding the concomitant ipsilateral fractures of femoral neck and trochanter. Further studies are needed.

Management of two-level proximal femoral fractures

We present the case of an 82-year-old female, who experienced a ground-level fall on the trochanter of the right femur. X-rays showed a proximal femoral fracture (PFF) with an unclear and unusual fracture pattern. Three-dimensional CT images were obtained and showed a displaced femoral neck fracture and ipsilateral fracture of the greater trochanter. Our patient underwent unipolar hemiarthroplasty and fixation of the greater trochanter with a hook plate and cable grip. At 11 months, functional outcomes, patient satisfaction and quality of life were excellent. Primary osteoporosis was diagnosed and treatment with bisphosphonates was initiated.Two-level PFFs are rare and complex. Due to ageing and a subsequent increase in osteoporosis, numbers of PFFs with complex fracture patterns might increase in the future. Adequate treatment and early prevention of osteoporosis are key to reduce this risk and lower the overall burden. Surgical treatment should be patient-tailored and focus on minimising the risk of complications and reinterventions.

Segmental Fractures of the Neck of Femur: Fix or Replace?

Combined intracapsular and extracapsular fractures of the proximal femur—segmental fractures of neck of femur (SFNOF)—are rare and complex injuries. Literature regarding SFNOF is very limited; only one small retrospective study and 19 unique case reports have been described. We report the case of a 42-year-old man who suffered a compound subcapital femur fracture type Garden IV and an ipsilateral multifragmentary greater trochanter fracture from severe crush trauma. Neither the precise fracture constellation nor our management strategy, primary cemented total hip arthroplasty combined with tension band cerclage and triple K-wire trochanteric fixation, has been described in contemporary literature. We conclude that SFNOF needs clear categorization and derivative treatment principles. Prosthesis longevity, risk of nonunion, and avascular necrosis should be considered.

The Missing Piece: A Subtrochanteric Hip Fracture Presenting with Abdominal Pain: A Case Report

CASE

A 33-year-old man presented with acute abdominal and left hip pain after being struck by a motor vehicle. Radiographs revealed a comminuted left subtrochanteric femoral fracture. Computed tomography demonstrated a large pelvic hematoma and a radiopaque mass in the abdomen. Laparoscopy revealed the mass to be a large bone fragment lying within the greater omentum. The bone fragment, which seemed to be a femoral fracture fragment, was removed, and the fracture was repaired with a short cephalomedullary nail.

CONCLUSION

Rarely, subtrochanteric fracture fragments can penetrate the pelvis or abdomen because of high-energy trauma. Recognizing this possibility is important to assure a correct diagnosis and subsequent treatment.

Quality assurance in segmental neck of femur fractures

Purpose The purpose of this paper is to report a rare case of segmental neck of femur fracture (SNoFF) and highlight its quality assurance and governance implications with respect to national guidelines, care pathways and best practice tariff. Design/methodology/approach Case report of an SNoFF in a 67-year-old woman treated at a district general hospital (DGH) was used in this study. Findings SNoFF required additional implants that delayed the surgery by five days. The authors were unable to adhere to the British Orthopaedic Association standards for trauma and Scottish Inter-Collegiate Guidelines Network recommendations which indicate that all neck of femur fractures (NoFFs) be fixed within 48 h. Though the patient was discharged without any untoward event and had an uneventful recovery, this case led us to introspect and learn how best to avoid such an incident from repeating again. Research limitations/implications This case led to an overhaul of NoFF and trauma services. The local logistics was restructured to procure "Trochanteric grip plates" within 24 h to provide mandated quality of care in an effort towards improving patient experience/outcomes. Originality/value SNoFF are rare injuries and its diagnosis is either delayed or missed in at least 20 per cent of the cases on initial evaluation. The non-availability of additional implants readily on the shelf coupled with lack of a trauma bed at the tertiary centre resulted in an unacceptable delay from admission to definitive surgery. The authors recommend that all DGHs have a mechanism/emergency procurement procedure system in place to obtain the required instrumentation kits rapidly through a sharing scheme with regional hospitals or through implant vendor to avoid unacceptable delays to surgery.

Combined Intracapsular And Extracapsular Neck Of Femur Fractures Case Series, Literature Review And Management Recommendations

Concomitant ipsilateral intracapsular and extracapsular fractures of the femoral neck are rare injuries with only 14 cases described in the literature as single case reports. We present three cases that were successfully and uniquely treated by uncemented hip arthroplasties. Two patients underwent complex primary uncemented total hip replacements, and one patient underwent an uncemented bipolar fluted stem hemiarthroplasty. The level of bearing constraint varied between implants. After describing our cases we review the literature and make recommendations on the management of these injuries. We believe that these are significant injuries and best functional results can be achieved with an early diagnosis and patient-specific approach that can include a total hip replacement in appropriate cases.

Literature review and case report: Current concepts for concomitant intra and extracapsular fractures of neck of femur in elderly patients

Though the incidence of concomitant ipsilateral intracapsular and extracapsular fracture neck of femur is still a rare presentation in day to day fracture hip admissions. Cases of simultaneous ipsilateral intra- and extra-capsular neck of femur fractures are forestalled with problems relating to diagnosing this injury as well as debate regarding optimal methods of fixation versus arthroplasty. We did a literature review to assess frequency of such fracture incidence, highlight methods of treatment applied, current practice for management as well as case report presentation.