Noncontiguous fractures of the femoral neck, femoral shaft, and distal femur

Femoral shaft displacement and Winquist classification provide predictive characteristics for combined femoral neck and femoral shaft fractures

OBJECTIVES

The goal of this study is to establish radiographic features and characteristics of patient injury in cases of femoral shaft fractures that predict the presence of ipsilateral femoral neck fractures (IFNFs).

METHODS

Patient data was retrospectively assessed from a single level I trauma center through the electronic health record using (Current Procedural Terminology) CPT codes for both isolated and combined ipsilateral femoral shaft and neck fractures. Demographic information, injury characteristics, and independently reviewed radiographic features were collected and compared against the same information from a group of isolated femoral shaft fractures. Multivariable logistic regression was performed to identify risk factors for concomitant IFNFs and their respective odds ratios. A probability algorithm for assessing ipsilateral femoral neck fractures based on independent multivariate predictors was constructed and used.

RESULTS

A total of 113 patients with either isolated femoral shaft fractures or combined femoral shaft and IFNF (n = 33) met inclusion criteria and were identified for this study. Fracture displacement was most strongly associated with increased risk of combined injury with an aOR of 25.64 (95 %CI = 5.96-110.28) for every 100 % displacement. Motorcycle crash (MCC) was the mechanism associated with the highest risk of combined injury, with an aOR of 9.85 (95 % CI = 1.99-48.74). Combined injury was also correlated with lower Winquist score and presentation with a closed fracture, with aORs of 0.38 (95 %CI = 0.21 - 0.68) and 11.61 (95 %CI = 1.93-69.94), respectively. Presence of at least 3 of the statistically significant variables produced a positive predictive value (PPV) of ≥ 89 % for combined femoral shaft and IFNF.

CONCLUSIONS

Identification of combined femoral shaft and IFNF is of critical importance when caring for orthopedic trauma patients. While diagnosis remains a challenging task, MCC mechanism, >100 % fracture displacement, and lower Winquist classification were found to be associated with combined injuries. The combination of these variables might assist in predicting the probability of combined injury and potentially guide decision making on the appropriateness of obtaining single sequence MRI or implementing prophylactic femoral neck fixation.

LEVEL OF EVIDENCE

Level III.

Surgical options for improving the ipsilateral femoral neck, shaft, and distal femoral fracture: A case report and literature review

INTRODUCTION AND IMPORTANCE

Ipsilateral proximal, shaft, and distal femur fractures are extremely uncommon. It might be challenging and contentious to treat ipsilateral multi-level femur fractures. There are still unanswered questions regarding the order of fracture types that should be repaired first and the type of implant that should be used.

CASE PRESENTATION

A twenty-nine-year-old male patient was assessed at the emergency department after a motorcycle accident. The patient had a clearly deformed left lower extremity and was complaining of pain in the left thigh. Preoperative radiographs revealed ipsilateral multi-level femur fracture on the left thigh involved basicervical fracture of femur (AO/OTA 31-B3) with transverse shaft fracture of femur (AO/OTA 32-A3) and extra articular supracondylar femur fracture (AO/OTA 33-A2).

CLINICAL DISCUSSION

First, we performed proximal femur nail antirotation in order to stabilize the fracture of the femur neck and reduce the incidence of nonunion and avascular necrosis of the femoral head in young adults. The next step to fix the shaft and distal femur fracture was to perform the distal femur locking plate. The EQ5D and Harris Hip Score questionnaires showed improvement after implementing these procedures.

CONCLUSION

Ipsilateral multi-level femur fractures have challenges and controversies in their management. In this situation, proximal femur nail antirotation and distal femur locking plates are viable options due to the condition of the injury and the higher risk of negative effects. After all fractures have been fixed, it is important to closely monitor the hip and knee joints to avoid stiffness or contracture.

Application of bridge-link type combined fixation system in the treatment of trifocal femoral fractures

PURPOSE

Ipsilateral combined fractures of the proximal femur, femoral shaft, and distal femur, though uncommon, present significant treatment challenges for orthopaedic surgeons. This retrospective study aims to investigate the intraoperative and long-term postoperative outcomes of this combination fracture when treated using a bridge-link type combined fixation system (BCFS).

PATIENTS AND METHODS

Four individuals received treatment at a level 1 trauma centre between January 2013 and December 2017 for combined fractures of the proximal femur, femoral shaft, and distal femur. The medical records of these patients were retrospectively examined. In addition to minimally invasive percutaneous plate osteosynthesis (MIO), all patients underwent BCFS.

RESULTS

The median follow-up period for each patient was 28.5 months. The median duration of the surgical procedure was 176.0 min, with intraoperative haemorrhage measured at 470.0 ml. Among the cases, three patients showed firm union of the femoral shaft fractures. However, one patient experienced nonunion 12 months after the procedure, while another patient suffered from refracture of the femoral shaft and postoperative avascular necrosis of the femoral head. At the time of the last follow-up, the Friedman-Wyman functional scores were excellent in one case, good in two cases, and fair in one case.

CONCLUSIONS

Trifocal femoral fractures lack a widely approved therapeutic strategy. Nonetheless, BCFS may present itself as a viable alternative for treating this type of fracture, offering positive clinical outcomes.

Surgical management of bifocal femoral fractures: a systematic review and pooled analysis of treatment with a single implant versus double implants

INTRODUCTION

Fractures of the proximal femur accompanied by a fracture of the femoral shaft are relatively rare, with a reported prevalence between 1 and 12%. Multiple surgical options are available, consisting of treatment with a single implant or with double implants. Controversy exists about the optimal management. A systematic review and pooled analysis were performed to assess the most reliable treatment for bifocal femoral fractures of the femur.

MATERIALS AND METHODS

A literature search was conducted on July 15, 2022. Selected studies were screened on title and abstract by two researchers independently, and full texts were read by both authors. Emphasis was put on adverse events such as postoperative infection, healing complications, malalignment, and functional outcome using either a single implant or double implants.

RESULTS

For the proximal femoral fractures, no significant difference could be confirmed for avascular necrosis of the femoral neck (5.1% for single implant and 3.8% for double implants), nonunion (6.4% for single implant and 7.8% for double implants), or varus malalignment (6.6% for single implant and 10.9% for double implants). This study also suggests that the number of implants is irrelevant for complications of the femoral shaft regarding the rates of postoperative infection and healing complications. Pooled rates of bone healing complications were 1.6-2.7-fold higher when patients were treated with a single implant, but statistical significance could not be confirmed. For hardware failure, revision surgery, leg length discrepancy, and functional outcome, no difference between the two groups was found either.

CONCLUSIONS

The pooled proportions of all postoperative complications had overlapping confidence intervals; thus, no inference about a statistically significant difference on the number of implants used for treating ipsilateral fractures of the femur can be made. Both treatment groups showed a similar functional outcome at the last moment of follow-up, with more than 75% of the patients reporting a good outcome.

The surgical outcomes of fixing ipsilateral femoral neck and shaft fractures: single versus double implants fixation

BACKGROUND

Combined ipsilateral femoral neck and shaft fractures are rare and present a challenging management dilemma. This study aims to assess the outcome of concomitant fixation of the ipsilateral femoral neck and shaft fracture using single versus dual surgical implants.

METHODS

A single-center retrospective analysis of patients who underwent fixation of ipsilateral femoral neck and shaft fractures was performed over a 13-year period. Different techniques were employed to fix the complex injury. Both the reduction and the union time were assessed radiographically.

RESULTS

A total of 36 patients with ipsilateral femoral neck and shaft fractures were retrospectively identified and included in the study. Twenty-four patients (66.6%) were managed with a single cephalomedullary nail, while the remaining cases were treated with two devices. All cases were operated on within an average of 3.7 ± 7.1 days. Eight patients (22.2%) developed postoperative complications. The average follow-up period was 7.3 ± 6.8 months. Although there was no statistically significant difference between the two groups, the femoral neck fractures showed shorter union time in patients treated with one implant compared to patients treated with two implants (3.0 ± 2.3 months vs. 4.2 ± 2.6 months). Another observation was that higher percentages of implant removal/failure and malunion/nonunion were seen in patients who had one implant compared to the two implants group (12.5% vs. 8.3%).

CONCLUSION

Early surgical fixation of both fractures is associated with good outcome results. No difference in outcome was observed between both groups.

Medium-term clinical results in patients with floating hip injuries

BACKGROUND

The objective of this study was to evaluate the effectiveness of our strategy for managing floating hip injuries.

METHODS

From January 2014 and December 2019, all patients with a floating hip underwent surgical treatment in our hospital were included in the retrospective study, with a minimum follow-up of 1 year. All patients were managed according to a standardised strategy. Data on epidemiology, radiography, clinical outcomes and complications were collected and analysed.

RESULTS

Twenty-eight patients were enrolled, with an average age of 45 years. The mean follow-up was 36.9 months. According to the Liebergall classification, Type A floating hip injuries predominated (n = 15, 53.6%). Head and chest injuries were the most common associated injuries. When multiple operative settings were required, we prioritized the fixation of the femur fracture at the first operation. The mean time from injury to definitive femoral surgery was 6.1 days, with most (75%) femoral fractures treated with intramedullary fixation. More than half (54%) of acetabular fractures were treated with a single surgical approach. Pelvic ring fixation included isolated anterior fixation, isolated posterior fixation, combined anterior and posterior fixation, of which isolated anterior fixation was the most common. Postoperative radiographs suggested that the anatomic reduction rates of acetabulum and pelvic ring fractures were 54% and 70%, respectively. According to grading system of Merle d'Aubigne and Postel, 62% of patients achieved satisfactory hip function. Complications included delayed incision healing (7.1%), deep vein thrombosis (10.7%), heterotopic ossification (10.7%), femoral head avascular necrosis (7.1%), post-traumatic osteoarthritis (14.3%), fracture malunion (n = 2, 7.1%) and nonunion (n = 2, 7.1%). In the patients with complications described above, only two patients underwent resurgery.

CONCLUSIONS

Although there is no difference in clinical outcomes and complications among different types of floating hip injuries, special attention should be paid to anatomical reduction of the acetabular surface and restoration of the pelvic ring. In addition, the severity of such compound injuries often exceeds that of an isolated injury and often requires specialised multidisciplinary management. Because of no standard guidelines for treatment of such injuries, our experience in the management of such a complex case is to fully assess the complexity of the injury and formulate an appropriate surgical plan based on the principles of damage control orthopaedics.

Minimally invasive dual plating of a complex femoral fracture; a case report

Complex femur fractures are defined as combined fractures of shaft and proximal or the distal femur. It usually occurs in young adults due to high energy trauma. Treatment of this type of fracture is challenging. Herein, we present the management of multi-level complex femoral fracture in 38 years old using minimally invasive overlapping dual plating with bridge proximal femoral locking plate from above and distal femoral locking plate from below. Favourable clinical and radiologic outcomes were observed. The result demonstrates dual plating of complex femoral fracture using MIPO could be considered as a suitable treatment option for complex femoral fracture.

Outcomes of Ipsilateral Femoral Neck and Shaft Fractures Treated With Proximal Femoral Nail Antirotation 2

Ipsilateral femoral neck and shaft fractures are relatively rare fractures, which most commonly occur in young adults following high-energy trauma. In most cases of such fractures, neck fracture is undisplaced and often of basicervical type. Many treatment methods have been described, but there is still no generalized consensus on the same. Cephalomedullary nails are one of the preferred modalities of treatment. A cephalomedullary nail-like proximal femoral nail antirotation 2 (PFNA 2) of recent design is being widely used currently. In this study, we present 13 cases of ipsilateral femoral neck and shaft fractures treated with PFNA 2 implants. The advantages of the PFNA 2 system include reduced blood loss, reduced operative time, and fewer fluoroscopy shots. PFNA 2 is a biomechanically better implant than many cephalomedullary implants. It provides satisfactory results in ipsilateral femoral neck and shaft fractures, especially where neck fracture is of a basicervical type. Some aspects have to be taken care of when employing PFNA 2, such as anatomical reduction, and length, angulation, and rotation of both neck and shaft.

Trifocal Femoral Fracture Treated With an Intramedullary Nail Accompanied With Compression Bolts and Lag Screws: Case Presentation and Literature Review

Ipsilateral combined fractures of the proximal femur, femoral shaft, and distal femur occur rarely with few published cases in the literature. These injures are classified as type 4 combined femoral fractures according to the classification of Lambiris et al. We present a rare case of a combined injury including an ipsilateral intertrochanteric fracture, a mid-shaft transverse femoral fracture, and a Y-shaped intra-articular fracture of distal femur in a 36-year-old man following a traffic accident. There was also an un-displaced extra-articular fracture of the ipsilateral patella. This combined injury has been reported only once, while our treatment strategy has never been reported in the literature. We used a single long Gamma-nail to treat all three fractures, while we locked the nail distally with compression bolts. The intra-articular part of the distal femoral fracture was managed with two cannulated percutaneous 6.5 mm lag screws. This modification of the nail allowed us to lock the nail and also to compress the metaphyseal part of the distal femoral fracture and secure this fracture to the nail. Our patient had an uneventful recovery, while the union was observed to all fractures four months postoperatively. As these combined femoral injuries are rare, there is no consensus of the management of such fractures. Many authors suggest an individualized approach to these rare cases based on the configuration of all fractures, especially the proximal and the distal one. By this case presentation we cite an alternative treatment of type 4 combined femoral fractures. Trauma surgeons may benefit from this Gamma-nail modification for such complicated injuries.

Treatment comparison of femoral shaft with femoral neck fracture: a meta-analysis

Background

To compare the efficacy and complications between reconstruction nail and hollow screw+plate in patients with femoral shaft and femoral neck fracture.

Methods

The full text of studies on clinical efficacy involving reconstruction nail and hollow screw+plate was retrieved from multiple databases. Review Manager 5.0 was adopted for meta-analysis, sensitivity analysis, and bias analysis. The meta-analysis was conducted with respect to the operation time, blood loss, healing time of the femoral shaft, healing time of the femoral neck, and complications. Finally, 10 studies met the eligibility criteria, including 991 patients.

Results

The meta-analysis suggested better characteristics for the reconstruction nail compared with the hollow screw+plate regarding operation time (OR = − 82.41, 95% CI [− 91.72, − 73.10], P < 0.00001; P for heterogeneity < 0.00001, I² = 98%), blood loss (OR = − 388.01, 95% CI [− 422.95, − 353.06], P < 0.00001; P for heterogeneity < 0.00001, I² = 99%), healing time of femoral shaft (MD = − 3.89, 95% CI [− 4.74, − 3.05], P < 0.00001; P for heterogeneity < 0.00001, I² = 99%), healing time of femoral neck (MD = − 4.04, 95% CI [− 4.33, − 3.75], P < 0.00001; P for heterogeneity = 0.008, I² = 60%), and complications (OR = 0.47, 95% CI [0.31, 0.73], P = 0.0006; P for heterogeneity = 1.00, I² = 0%).

Conclusion

This meta-analysis shows that a reconstruction nail is a more efficient and safer treatment than a hollow screw+plate for patients with femoral shaft and femoral neck fracture.

The Hoffa fracture: Coronal fracture of the femoral condyle a review of literature

This article aims to provide a systematic review of the limited literature and clinical knowledgebase available on the Hoffa fractures. It is inclusive of the normal anatomy, pathology, diagnosis, treatment options comprising of non-operative and operative protocols, and postoperative findings.

"Kissing Nail Technique" for the exchange of intramedullary implants in adjacent peri-implant fractures

One third of the people aged 65 years and over fall every year, and 1–5% of these falls result in a fracture. For these people, history of fracture and surgery become a risk factor for recurrent falls. In osteoporotic patients, repeated fractures often require several osteosynthetic procedures within a short time frame. Despite the lack of biomechanical studies, clinical experience suggests that additional fractures adjacent to implants occur because of the difference in stiffness between the metallic implant and the osteoporotic bone. This requires customized fixation techniques to ensure stability.

The technique was first performed in an 81-year old female patient presenting with a dislocated proximal femoral fracture at the tip of a previously implanted distal femoral nail (DFN), and non-union of the old fracture. For this technique, the DFN was advanced until it passed the proximal fracture, thereby reducing both fractures, while a lateral femoral nail (LFN), extra-long and 3 mm thicker than the DFN, was introduced and advanced distally. The LFN was implanted in a “kissing nail technique,” meaning the tips of the two nails were touching each other, and all fracture fragments were held in functional reduction. The DFN was slowly pulled backwards and fragment stability was maintained, while both nails passed the distal non-union.

The Kissing Nail Technique allows simple, safe and fast reduction of all instable fragments, precise and easy positioning of the proximal entry point by the retrograde guide wire, a minimally invasive procedure, and stable fixation of a periprosthetic fracture.

We found this new customized procedure accommodating to the unique anatomical features of a single patient, that can be applied as a strategy especially for osteoporotic patients with periprosthetic fractures.

Vertical femoral neck fractures in young adults: a closed fixation strategy using a transverse cancellous lag screw

Vertical femoral neck fractures (Pauwels type III classification) in young adults generally occur as a consequence of high-energy trauma and are frequently seen in association with multiple injuries. Considering the controversies regarding the optimal fixation for this fracture, our aim was to evaluate the clinical outcome of a closed fixation strategy for vertical femoral neck fractures in young adults using two parallel and one transverse cancellous lag screws. This was a single-surgeon, prospective study including 20 young adults with average age of 38.75 years (range 18-59 years) with a high-energy Pauwels III femoral neck fracture. Closed reduction and internal fixation with three cancellous lag screws were performed. The first screw was inserted crosswise to avoid further shear forces. Second and third parallel screws were placed above the lesser trochanter and centrally on the greater trochanter, respectively. Clinical outcomes were assessed by comparing postoperative and final follow-up radiographs 24 months post-injury. Eleven patients had an isolated vertical femoral neck fracture. Of these, five had further femoral neck comminution. Nine patients had an associated ipsilateral femoral shaft fracture. All fractures were displaced at the time of the first radiological evaluation. Closed reduction quality was considered excellent or good in 15 patients. After 24 months, bone union was achieved in 16 cases. Osteonecrosis of the femoral head developed in association with two fractures, and a nonunion developed in association with two fractures. We conclude that vertical high-energy femoral neck fractures can be treated successfully with internal fixation with two parallel cancellous lag screws positioned above the lesser trochanter and a third screw inserted centrally on the greater trochanter at an angle perpendicular to the fracture line.

Noncontiguous and open fractures of the lower extremity: Epidemiology, complications, and unplanned procedures

INTRODUCTION

Isolated fractures of the lower extremity are relatively common injuries while multifocal injuries resulting from high-energy trauma are less frequently encountered. Our objectives are to characterise patients who sustained multiple noncontiguous fractures and open fractures of the lower extremity, report the incidence of major complications, and identify factors that may contribute to complications and unplanned re-operations.

PATIENTS AND METHODS

A retrospective review of patients was performed at a Level 1 trauma centre from 2000 to 2013. Patients who sustained two or more noncontiguous operative fractures in an ipsilateral lower extremity, with at least one open fracture were included. Noncontiguous was defined as fractures in the same lower limb that were not in continuity on preoperative radiographs or intra-operatively. Demographic, injury characteristics, and hospitalisation data were collected. Primary outcomes included non-union, deep infection, and the need for unplanned surgeries.

RESULTS

257 patients sustained a total of 876 lower extremity fractures with an average of 1.7 open and 2.7 operative fractures in the qualifying limb. Ninety-nine patients (38.5%) sustained bilateral lower extremity injuries. Following their initial stay, 22.6% of patients had planned procedures (definitive fixation, skin, or planned bone grafting). Nearly half (45.9%) required one or more unplanned re-operation. Complications included deep infections (19.5%), non-unions (19.5%), and mal-unions (2.7%). 17.5% of the patients had at least one procedure for removal of painful implants. A deep infection was predictive of having a non-union (odds ratio, OR 7.5). The presence of a Gustilo-type IIIB/IIIC (OR 24.6/16.0) fracture was predictive of having a deep infection. After excluding painful implant removal, a type IIIB fracture was associated with an unplanned procedure (OR 13.8).

CONCLUSIONS

Patients with multiple non-contiguous lower extremity injuries associated with open fractures can expect complications including non-unions, deep infections, and painful implants. Nearly half of the patients will need further operative treatment.

Operative Treatment of Isolated Bicondylar Hoffa Fracture With a Modified Swashbuckler Approach

Introduction:

An isolated coronal fracture of either or both femoral condyles is a rare entity and is usually associated with high-energy injury trauma. Such fractures should be meticulously fixed for a good functional outcome as they involve the articular surface of a weight bearing joint. A modified swashbuckler approach provides adequate exposure for appropriate reduction and fixation of such fractures.

Case Presentation:

A 32-year-old male sustained a bicondylar Hoffa fracture of the right femur which was treated by open reduction and internal fixation using a modified swashbuckler approach. At two years of follow-up, the patient had excellent radiological and functional outcome.

Conclusions:

In our study, we treated this rare fracture successfully using a modified swashbuckler approach and found it to be a good approach for such fractures as compared to the conventional approach.

Ipsilateral Acetabular and Femoral Neck and Shaft Fractures

Floating hip injuries and ipsilateral femoral neck and shaft fractures are rare. Additionally, the simultaneous occurrence of these injuries is extremely rare, and only one case report of the simultaneous occurrence of these injuries has been published. Here, we report the case of a patient with ipsilateral acetabular and femoral neck and shaft fractures following a suicide attempt. The patient experienced nonunion of the femoral neck and shaft after the initial operation and therefore underwent reconstruction using a femoral head prosthesis with a long stem and interlocking screws. Our procedure may be used in primary and/or secondary reconstruction for ipsilateral acetabular and femoral neck and shaft fractures.

Identification of Differentially Expressed Gene after Femoral Fracture via Microarray Profiling

We aimed to investigate differentially expressed genes (DEGs) in different stages after femoral fracture based on rat models, providing the basis for the treatment of sport-related fractures. Gene expression data GSE3298 was downloaded from Gene Expression Omnibus (GEO), including 16 chips. All femoral fracture samples were classified into earlier fracture stage and later fracture stage. Total 87 DEGs simultaneously occurred in two stages, of which 4 genes showed opposite expression tendency. Out of the 4 genes, Rest and Cst8 were hub nodes in protein-protein interaction (PPI) network. The GO (Gene Ontology) function enrichment analysis verified that nutrition supply related genes were enriched in the earlier stage and neuron growth related genes were enriched in the later stage. Calcium signaling pathway was the most significant pathway in earlier stage; in later stage, DEGs were enriched into 2 neurodevelopment-related pathways. Analysis of Pearson's correlation coefficient showed that a total of 3,300 genes were significantly associated with fracture time, none of which was overlapped with identified DEGs. This study suggested that Rest and Cst8 might act as potential indicators for fracture healing. Calcium signaling pathway and neurodevelopment-related pathways might be deeply involved in bone healing after femoral fracture.

Outcomes after trifocal femoral fractures

Trifocal femur fractures are those of the femoral neck, diaphysis, and distal femur. These high-energy injuries predominantly occur in young people with the potential for long-term complications and disability. We present the cases of two men who were treated with proximal dynamic hip screws and distal periarticular locking plates to effectively manage trifocal femur fractures. Our cases have shown union at 2 years with good functional outcomes without the need for reintervention. We provide evidence for a successful surgical treatment option for these rare and complex injuries.

Ipsilateral fractures of the femoral neck, shaft and distal end: long-term outcome of five cases

Out of 52 cases of ipsilateral femoral fractures treated at a level I trauma centre between June 1994 and March 2008, the diaphyseal fracture was accompanied by a intracapsular neck fracture in only 20 cases. In the rest of the cases, the diaphyseal fracture was combined with either an extracapsular or pertrochanteric fracture. Five of these patients also had fractures of the distal femur. In three of those patients we began treatment with osteosynthesis of the femoral neck and shaft, using a reconstruction nail, then stabilized the distal fracture with a 95° blade plate or with lag screws. In the other two cases, initial treatment dealt with the distal femoral fracture, stabilizing it with a 95° blade plate, which was also used for stabilization of the diaphyseal fracture. In these patients, the proximal fracture was treated using dynamic hip screws (DHS). All fractures healed, two after initial treatment, while the other three needed one reoperation. The follow-up period was 2-13 years after the injury. The order in which fractures are treated is best left to the discretion of the physician and the circumstances. In our experience, two implants are sufficient for osteosynthesis, one for stabilizing one end of the femur together with the shaft, and the other is used for treating the other end of the femur.

Accuracy of reduction of ipsilateral femoral neck and shaft fractures--an analysis of various internal fixation strategies

OBJECTIVES

Controversy surrounds the selection of the proper internal fixation device for treatment of ipsilateral fractures of the femoral neck and shaft. The purpose of this study was to review a large consecutive series of patients to learn more about the efficacy of various internal fixation strategies in maintaining an excellent reduction of both fractures.

DESIGN

Retrospective multicenter.

SETTING

Two level 1 trauma centers.

PATIENTS/PARTICIPANTS

Between 1989 and 2006, 40 consecutive patients underwent internal fixation of an ipsilateral femoral neck and shaft fracture at 2 level 1 trauma centers. Thirty-seven of 40 patients (95%) with a mean age of 38 years (range, 18-73 years) had sufficient radiographs to assess accuracy of fracture reduction.

INTERVENTION

Patients with displaced femoral neck fractures were typically treated with 2 separate devices and underwent formal open reduction of the femoral neck. Patients with nondisplaced neck fractures were treated with closed reduction and fixation with either 1 or 2 devices based on surgeon preference. The femoral neck fractures were displaced in 21 patients and nondisplaced in 16 patients. Nine fractures were addressed with a single implant and 28 with 2 separate devices.

MAIN OUTCOME MEASUREMENTS

Radiographs were reviewed to evaluate the quality of reduction of both fractures. Clinical follow-up of 12 months or greater was available on 16 patients with a mean of 34.4 months (range, 12-112 months).

RESULTS

Thirty-six of 37 patients (97%) obtained or maintained excellent femoral neck reductions. The only poor neck reduction occurred in the case of a displaced femoral neck-shaft fracture treated with a single cephalomedullary implant. Thirty-five excellent (95%) and 2 poor shaft reductions were obtained. Both shaft malreductions occurred in comminuted shaft fracture patterns in which a single cephalomedullary device was used for both fractures. Performing internal fixation of both fractures with a single cephalomedullary device led to a significantly higher rate of fracture malreduction of one of the fractures (3 of 9) as compared with a 2-device strategy (0 of 28) (P = 0.01).

CONCLUSIONS

Open reduction and internal fixation of a displaced femoral neck fracture followed by retrograde nailing of the femoral shaft allowed accurate reduction and uneventful union of both fractures in most patients. The use of a cephalomedullary device to address both fractures simultaneously led to a significantly higher rate of malreduction of one of the fractures.

Resuscitation of patients after traumatic brain injury

Traumatic brain injury (TBI) is the commonest worldwide cause of death and disability in people under 45 years of age. Following an injury of this nature, physiological derangements, both systemic and within the brain, rapidly progress and have a deleterious effect on outcome. There is a lack of brain specific treatments that significantly improve outcome and management must therefore be best care of appropriate physiology, along the familiar ABC lines. There are international guidelines that describe targets to be achieved. Methods to do this plus the rationale for doing so are discussed in this article.