Ipsilateral femoral neck and shaft fractures. Retrospective study of 33 cases

Clinical Algorithm for the Management of Ipsilateral Proximal and Shaft Femur Fractures Using Single or Dual Implants

Purpose of the study The current study had two goals: first, it compared the radiological and functional results of the ipsilateral shaft and proximal femur fractures treated by using two different methods, i.e., single implant vs dual implants. The second goal was to devise a clinical algorithm for guiding and managing such fractures. Methods This study was conducted in a level 1 trauma center and included 34 patients with concomitant ipsilateral fractures of the proximal femur and shaft of the femur. The patients were divided into two groups as per our clinical algorithm. Group I, comprising of 16 patients, were treated with a single implant like the proximal femoral nail (PFN) or proximal femoral nail antirotation (PFNA2). Group II of dual implants, comprising of 18 patients, were treated with two types of implants separately for proximal and shaft fracture. Results All patients were followed at monthly intervals up to six months, then at three monthly intervals up to one year, with a minimal follow-up of one year of every patient. On clinical evaluation by Friedman-Wyman criteria, in group I, seven patients had a fair outcome, eight patients had a good outcome, and one patient had a poor outcome, while in group II, eight patients had a fair outcome, nine patients had a good outcome, and one patient had a poor outcome. No patient developed non-union or avascular necrosis of the femoral head in any of the groups. Conclusion For concurrent ipsilateral diaphyseal and proximal femur fractures, both dual and single implants are equally effective alternatives if properly applied as per our clinical algorithm. Implant selection primarily depends on the pattern of injury, and our clinical algorithm can be a suitable guide for guiding the selection of implants.

Biomechanical Comparative Study for Osteosynthesis of Pauwels Type III Femoral Neck Fractures: Conventional Devices versus Novel Fixed Angle Devices

Purpose

Osteosynthesis has been recommended for treatment of Pauwels type III femoral neck fractures in young patients. However, no implant of choice has been reported so far. This study was conducted in order to compare the fixation stability of two conventional fixation methods with three different novel fixed angle devices in this type of fracture.

Materials and Methods

A total of 25 composite femurs (4th Generation Saw bone; Pacific Research Laboratories, USA) corresponding to human bone were used. Pauwels type III fracture type was uniformly reproduced. Specimens were fixed with a cannulated screw, cannulated screw with cable, and Intertan nail, dynamic hip screw, and IKEY nail. Measurement of failure loads and the rotational change of the femoral head fragment was performed for evaluation of fixation stability.

Results

All implants were compared with cannulated screw and dynmaic hip screw. No meaningful improvement was observed for the cannulated screw with cable compared with the cannulated screw and dynamic hip screw. Meaningful improvement in load-to-failure and y-rotation and z-rotation was observed for both the Intertan nail and IKEY nail compared with the cannulated screw. However, compared with the dynamic hip screw, only the IKEY nail showed improvement in the same profile but the Intertan nail did not.

Conclusion

Among novel fixed angle devices, meaningful improvement was observed for the IKEY nail compared with conventional implants. Strengths of this implant include biomechanical stability and simplicity of surgical technique, indicating that it may be another good option for osteosynthesis of Pauwels type III femoral neck fractures.

The Impact of Magnetic Resonance Imaging on the Diagnosis of High-Energy Ipsilateral Femoral Neck and Shaft Fractures

OBJECTIVE

To evaluate the most common femoral shaft fracture morphology associated with an ipsilateral femoral neck fracture in high-energy blunt trauma using magnetic resonance imaging (MRI).

DESIGN

Retrospective review.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

219 consecutive patients sustaining 228 femoral shaft fractures from high-energy blunt trauma.

MAIN OUTCOME MEASUREMENTS

Fracture patterns were analyzed using the OTA/AO classification system. In addition, location of the fracture was measured as the distance from the distal aspect of the lesser trochanter to the center of the femoral shaft fracture.

RESULTS

An OTA/AO 31 type fracture was seen in 16.5% (20/121) of patients presenting with OTA/AO 32-A type fractures, 12% (6/50) of patients with OTA/AO 32-B type fractures, and 26.3% (15/57) of patients with OTA/AO 32-C type fractures. The fractures that occurred in the middle or distal third of the femur shaft constituted 95.1% (39/41).

CONCLUSIONS

In this cohort, patients with middle and distal third OTA/AO 32-C type fractures had the highest association with an ipsilateral OTA/AO 31 type fracture. OTA/AO 32-A2 and 32-A3 type fractures had the highest association with femoral neck fractures seen only on MRI. The data presented suggest continued usage of the rapid sequence pelvic MRI for all patients with high-energy femoral shaft fractures in whom a femoral neck fracture was not seen on an x-ray or a computed tomography scan.

LEVEL OF EVIDENCE

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Spinal fractures and/or spinal cord injuries are associated with orthopedic and internal organ injuries in proximity to the spinal injury

Background

the demographics, mechanisms of injury, and concurrent injuries associated with cervical, thoracic and lumbar spinal fracture and/or spinal cord injury remain poorly characterized.

Methods

Patients aged 18 and older with spinal injury between 2011 and 2015 in the National Trauma Data Bank (NTDB) were identified. Patient demographics, comorbidity burden, mechanism of injury, and associated injuries were analyzed.

Results

in total, 520,183 patients with acute spinal injury were identified including 216,522 cervical, 191,218 thoracic, and 220,294 lumbar. The age distributions were trimodal with peaks in incidence at around 2155 and a lesser peak around 85 years of age. The number of comorbidities increased while injury severity decreased with advancing patient age. Motor vehicle accidents (MVAs) were the most common mechanism of injury. Associated bony and internal organ injuries were common and occurred in 63% of cervical spine injury patients, 79% of thoracic spine injury patients, and 71% of lumbar spine injury patients. In all three sub-populations, there was a predominance of injuries in the local area of the primary injury. For cervical, these were rib injuries (28%), thoracic spine injuries (22%), skull fractures (20%), intracranial injuries (26%) and lung injuries (21%). For thoracic, these were rib injuries (47%), lumbar spine injuries (26%), cervical spine injuries (25%), lung injuries (35%) and intracranial injuries (24%). For lumbar, these were rib injuries (38%), thoracic spine injuries (22%), pelvic fractures (20%), lung injuries (26%) and intracranial injuries (19%). Multivariate regression analysis demonstrated that increased injury severity was strongly correlated with increased mortality, with lesser contributions from increased age and comorbidity burden.

Conclusions

the current study revealed spinal fractures and/or cord injuries had high incidences of associated injuries that had a predominance of local distribution. These findings, in combination with the mortality analysis, demonstrate the importance of local targeted evaluations for associated injuries.

Double fractures of the femur: a review of 16 patients

BACKGROUND

Double ipsilateral femoral fractures account for 1-9% of femoral fractures. There is no clear advantage between single or double implant osteosynthesis. We present a series of patients with double ipsilateral femoral fractures, to address the challenges in treatment, namely the implants for osteosynthesis and complications of treatment.

MATERIALS AND METHODS

We retrospectively studied 16 patients (7 men, 9 women; mean age, 51 years) treated from January 2015 to December 2018. Motor vehicle accidents were the leading cause of injury. Types of fractures were pertrochanteric and shaft (6), pertrochanteric and distal (2), double shaft (3), neck and shaft (2), neck and distal (1), shaft and distal (1), and triple fracture including a pertrochanteric, shaft and distal (1). In five patients, two different implants were used (plate and screws, cannulated hip screws, femoral nail), whereas in 11 patients a long femoral nail was used.

RESULTS

Fourteen patients experienced union at a mean of 3 months (2-6 months). Two patients experienced nonunion: both had plate and screws osteosynthesis. One patient died 15 days after admission from polytrauma and another patient experienced central venous catheter thrombosis and pneumonia. Surgical complications (2 patients) included a thigh skin necrosis, and external fixator pin tract infection/infected non-union. Weight-bearing was delayed in all patients; full weight-bearing was allowed in 11 patients at 4 months postoperatively, and in four patients at 5 months.

CONCLUSION

Due to the rarity and the difficulty of standardization of double ipsilateral femoral fractures, there is variable information on the optimal osteosynthesis of the fractures and the outcome of the patients. It seems that closed reduction and long hip nailing is the treatment of choice, with few complications.

Treatment of Ipsilateral Femoral Neck and Shaft Fractures With Cannulated Screws and Antegrade Reconstruction Nail

Ipsilateral femoral neck and shaft fractures are challenging injuries, and there are different fixation options but no consensus on a superior construct. Our preferred method is cannulated screw fixation of the femoral neck and antegrade reconstruction nailing of the shaft. Compressive fixation of the femoral neck fracture with cancellous lag screws followed by reconstruction nail placement provides compressive fixation and fixed angle support of the neck fracture while allowing for more optimal treatment of femoral shaft fractures at or above the isthmus. The purpose of this submission is to describe the surgical decision-making, surgical technique, and all surgically related complications of this technique.

Low-energy atypical femoral shaft and ipsilateral neck fracture: a rare association

This reports a case of a low-energy ipsilateral femoral shaft and neck fracture in a 69-year-old woman with vitamin D deficiency, who was taking long-term steroids and bisphosphonates. This is a fracture more commonly associated with a high-energy trauma. However, with an ageing global population and an increasing prevalence of bone insufficiency, we predict the incidence of this presentation to increase. Long-term bisphosphonate therapy has been associated with bone insufficiency and an increased rate of delayed union, adding to the complexity of management in these patients. There is currently no consensus regarding the choice of optimal implant or fixation technique to treat this challenging fracture pattern. We discuss the considerations that led to our management approach of a non-overlapping dynamic hip screw and femoral shaft plate construct which achieved uneventful bone healing and a good functional outcome within the first year of follow-up.

Analysis of Bony and Internal Organ Injuries Associated With 26,357 Adult Femoral Shaft Fractures and Their Impact on Mortality

The spectrum of injuries associated with femoral shaft fractures and those injuries' association with mortality have not been well delineated previously. Patients in the National Trauma Data Bank who presented with femoral shaft fractures from 2011 to 2012 were analyzed in 3 age groups (18-39, 40-64, and 65+ years). For each group, modified Charlson Comorbidity Index (CCI), mechanism of injury (MOI), injury severity score (ISS), and associated injuries were reported. Multivariate logistic regression was used to identify predictors of mortality. Among the 26,357 patients with femoral shaft fractures, modified CCIs gradually increased with increasing age category and ISS decreased. Motor vehicle accidents were the most common MOI in the younger 2 age groups, whereas falls were the most common MOI in the 65 years and older age group. The top 3 associated bony injuries for the study cohort as a whole were tibia/fibula (20.5%), ribs/sternum (19.1%), and non-shaft femur (18.9%, of which 5.8% of the total cohort were femoral neck) fractures. The top 3 associated internal organ injuries were lung (18.9%), intracranial (13.5%), and liver (6.2%), injuries. A multivariate mortality analysis showed that increasing age, increasing comorbidity burden, and associated injuries all had independent associations with mortality. The injuries most associated with mortality were thoracic organ injuries (adjusted odds ratio [AOR]=3.53), head injuries (AOR=2.93), abdominal organ injuries (AOR=2.78), and pelvic fractures (AOR=1.80). This study used a large, nationwide sample of trauma patients to profile injuries associated with femoral shaft fractures. Associations between injuries and mortality underscore the importance of these findings. [Orthopedics. 2017; 40(3):e506-e512.].

Special topic: Ipsilateral femoral neck and shaft fractures--does evidence give us the answer?

Ipsilateral fractures of the femoral neck and shaft are rare, high-energy injuries that typically occur in young polytrauma patients. The associated fracture of the neck is often vertical in nature and is more frequently non-displaced than in isolated femoral neck fractures. Historically the diagnosis of an associated femoral neck fracture was delayed or missed in approximately one third of cases. Studies have shown that detection can be significantly improved with the implementation of a protocolized approach to hip imaging in all patients with femoral shaft fractures. Prompt recognition of an associated femoral neck fracture allows for timely stabilization and may decrease the risks of non-union and avascular necrosis. In contrast, failure to recognize a non-displaced or minimally displaced associated neck fracture prior to fixation of the shaft can lead to displacement, a decrease in neck fixation options, a technically challenging secondary procedure and increased risk of long-term sequelae. A vast array of treatment strategies have been described for this combined injury. Published options range from spica casting to open reduction and internal fixation of both fractures and include almost all conceivable combinations in between. While timely surgical stabilization is now universally recommended for both shaft and neck, no consensus exists as to the most appropriate method of fixation for either fracture. Most authors recommend prompt, but not emergent, surgery with priority given to anatomic reduction and stabilization of the neck fracture by either closed or open methods. Fixation of the shaft fracture follows as patient condition allows. The rare nature of this injury makes it very challenging to study and most published series' are retrospective with very small sample sizes. In short, no scientificallycompelling study is available to definitively support any one implant choice or method of stabilzation over another for the treatment of associated fractures of the femoral neck and shaft.

Ipsilateral proximal femur and shaft fractures treated with hip screws and a reamed retrograde intramedullary nail

BACKGROUND

Although not common, proximal femoral fractures associated with ipsilateral shaft fractures present a difficult management problem. A variety of surgical options have been employed with varying results.

QUESTIONS/PURPOSES

We investigated the use of hip screws and a reamed retrograde intramedullary (IM) nail for the treatment of this combined fracture pattern in terms of postoperative alignment (malunion), nonunion, and complications.

METHODS

Between May 2002 and October 2011, a total of 95 proximal femoral fractures with associated shaft fractures were treated at three participating Level 1 trauma centers; all were treated with hip screw fixation (cannulated screws or sliding hip screws) and retrograde reamed IM nails. The medical records of these patients were reviewed retrospectively for alignment, malunion, nonunion, and complications. Followup was available on 92 of 95 (97%) of the patients treated with hip screws and a retrograde nail. Forty were treated with a sliding hip screw, and 52 were treated with cannulated screws.

RESULTS

There were five proximal malunions in this series (5%). The union rate was 98% (90 of 92) for the femoral neck fractures and 91.3% (84 of 92) for the femoral shaft fractures after the initial surgery. There were two nonunions of comminuted femoral neck fractures after cannulated screw fixation. There was no difference in femoral neck union or alignment when comparing cannulated screws to a sliding hip screw. Four open comminuted femoral shaft fractures went on to nonunion and required secondary surgery to obtain union, and one patient developed symptomatic avascular necrosis.

CONCLUSIONS

The treatment of ipsilateral proximal femoral neck and shaft fractures with hip screw fixation and a reamed retrograde nail demonstrated a high likelihood of union for the femoral neck fractures and a low risk of malunion. Comminution and initial displacement of the proximal femoral fracture may still lead to a small incidence of malunion or nonunion, and open comminuted femoral shaft fractures still may progress to nonunion despite appropriate surgical management.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

A cascade of preventable complications following a missed femoral neck fracture after antegrade femoral nailing

Background

Occult femoral neck fractures associated with femoral shaft fractures are frequently missed and may lead to adverse outcomes.

Case presentation

A 46-year old female presented to our institution with increasing groin pain one month after antegrade intramedullary nailing of a femoral shaft fracture at an outside hospital. Radiographic evaluation revealed a displaced ipsilateral femoral neck fracture, adjacent to the piriformis starting point of the nail. A revision fixation of the femoral shaft and neck fracture was performed. The patient sustained a series of complications requiring multiple revision surgeries, including a total hip arthroplasty. Despite the cascade of complications, the patient had an uneventful long-term recovery, without additional complications noted at one-year follow-up.

Conclusion

This case report illustrates the necessity of increased awareness with a high level of suspicion for the presence of associated femoral shaft and neck fractures in any patient undergoing antegrade femoral nailing. Arguably, the cascade of complications presented in this paper could have been prevented with early recognition and initial stabilization of the occult femoral neck fracture. Standardized diagnostic protocols include “on table” pelvic radiographs to rule out associated femoral neck fractures. The diagnosis must be enforced in case of equivocal radiographic findings, either by computed tomography scan or magnetic resonance imaging.

Long proximal femoral nail in ipsilateral fractures proximal femur and shaft of femur

BACKGROUND

Ipsilateral fractures of the proximal femur and femoral shaft are extremely uncommon injuries which occur in young adults who sustain a high energy trauma. A variety of management modalities have been tried to treat this complex fracture pattern ranging from conservative approach to recently introduced reconstruction nails. All these approaches have their own difficulties. We studied the outcome of long proximal femoral nail (LPFN) in the management of concomitant ipsilateral fracture of the proximal femur and femoral shaft.

MATERIALS AND METHODS

We analysed the prospective data of 36 consecutive patients who had sustained a high energy trauma (30 closed fractures and 6 open shaft fractures) who had concomitant ipsilateral fractures of the femoral shaft associated with proximal femur fractures treated with LPFN between December 2005 and December 2011. The mean age was 39 years (range 28-64 years). Twenty nine males and seven females were enrolled for this study.

RESULTS

The patients were followed up at three, six, twelve, and eighteen months. The mean healing time for the neck fractures was 4.8 months and for the shaft fractures was 6.2 months. The greater trochanter was splintered and widened in two cases which eventually consolidated. Two patients had superficial infection, two patients had lateral migration of the screws with coxa vara which was due to severe osteoporosis detected during the followup. We had two cases of nonunion of shaft fracture and one case of nonunion of neck fracture. Two cases of avascular necrosis of femoral head were detected after 2 years of followup. No cases of implant failure were noted. Limb shortening of less than 2 cms was noted in four of our patients. The functional assessment system of Friedman and Wyman was used for evaluating the results. In our series 59.9% (n = 23) were rated as good, 30.6% (n = 11) as fair, and 5.5% (n = 2) as poor.

CONCLUSION

Long PFN is a reliable option for concomitant ipsilateral diaphyseal and proximal femur fractures.

Complete spontaneous improvement of non-displaced femoral neck fracture without any surgery modality

Background:

Fracture of the femoral neck is still a medical dilemma due to high rates of complications and the choice of treatment. Although rigid internal fixation with cannulated screws through open or percutaneous approaches is the traditional treatment for undisplaced fractures (Garden type I and II) to avoid secondary displacement, considerable controversy still exists regarding the rate of this problem, thus it seems that a new trend in conservative management of this types of femoral neck fracture is emerging.

Case Report:

Our case is a 46-year-old woman with Garden type II femoral neck fracture, who refused all surgical options and willingly ignored her problem. Six months later she returned to our center with uneventful recovery of her fracture.

Conclusions:

The previous belief about the absolute poor prognosis of Garden type II with 100% rate of secondary displacement with non-operative management must have been an overestimation or the success histories in the literature about non-operative treatment of these fractures originates from inherited weakness of the Garden classification in differentiating type I from type II. The patient gave the informed consent prior being included into the study.

Resultados do tratamento das fraturas da diáfise do fêmur ipsilaterais às do colo ou transtrocantérica

OBJETIVO: Avaliação radiográfica, funcional e das complicações do tratamento cirúrgico das fraturas diafisárias do fêmur associadas à fratura transtrocantérica ou do colo do mesmo fêmur. MÉTODOS: De 2002 a 2007 foram tratados 17 pacientes. Eram masculinos 88% e a idade média foi de 31 anos e três meses. Dez (59%) apresentavam associação com fratura do colo do fêmur e sete (41%) com a fratura transtrocantérica. Foram avaliados a dor residual e a amplitude de movimento articular do quadril e joelho, a consolidação radiográfica e o tipo de implante utilizado, pela avaliação atual e retrospectivamente pelo prontuário, com um seguimento médio de 48 meses. RESULTADOS: Todas as fraturas transtrocantéricas evoluíram para consolidação sem deformidade residual. Das fraturas do colo, três (30%) apresentaram retardo da consolidação, e duas consolidaram em varo. Dois pacientes apresentaram retardo de consolidação da fratura diafisária. Todas as fraturas associadas trans-diáfise apresentaram resultado funcional excelente ou bom. Das associadas colo-diáfise, sete (70%) apresentaram resultado funcional excelente ou bom, dois regular e um ruim. CONCLUSÃO: As fraturas associadas da diáfise do fêmur com fratura transtrocantérica apresentaram melhor resultado radiográfico e funcional com menos complicações que a associação da fratura diafisária com a fratura do colo do fêmur

Reconstruction interlocking nails for ipsilateral femoral neck and shaft fractures: biomechanical analysis of effect of supplementary cannulated screw on intracapsular femoral neck fracture

BACKGROUND

To stabilize the femoral head in ipsilateral femoral neck and shaft fractures, one cannulated screw was supplemented in front of the reconstruction interlocking nail (recon nail).

METHODS

Twenty-eight left sawbone femurs were divided into two groups. The 14 femurs in each group were osteotomized with subcapital or transcervical fractures. The shafts of all femurs were also osteotomized, and 1cm of the distal segmental cortex was excised. Next, all the fractures were treated with static recon nails to concomitantly stabilize both femoral neck and shaft fractures. Additionally, seven subcapital fractures and seven transcervical fractures were supplemented with one cannulated screw in front of the recon nails. All specimens were tested with a Material Testing System machine to investigate the relative stability during uniaxial cyclic compression.

FINDINGS

The subcapital and transcervical fractures supplemented with one cannulated screw could bear more loads than those without screw supplementation (P<0.01 and P<0.01, respectively at any testing interval). Moreover, in the case of the subcapital fractures, the single supplemented cannulated screw could reduce the displacement at 500 N by 24% (P< 0.001). On the other hand, in the case of the transcervical fractures, one supplemented cannulated screw could reduce the displacement at 500 N by 4% (P=0.003).

INTERPRETATION

From the biomechanical viewpoint, the subcapital fractures in combined fractures are recommended to supplement with one cannulated screw in front of the recon nails to eliminate complications associated with stabilization.

Treatment for ipsilateral fractures of femoral neck and shaft

BACKGROUND

Concomitant ipsilateral femoral shaft and neck fractures present a challenge to the orthopaedic surgeon, and no consensus has yet emerged on the optimal treatment method. We report the results of a retrospective study of 43 patients with these complex fractures who were treated at a single Level 1 trauma centre.

PATIENTS AND METHODS

The study participants consisted of 28 males and 15 females with a mean age of 43 years. The mean follow-up period was 48 months. Four different treatment methods were used: (1) antegrade reamed intramedullary nailing of the shaft with cancellous screw fixation of the neck, (2) dynamic hip screw (DHS) fixation of the neck and low-contact dynamic compression plate (LCDCP) fixation of the shaft, (3) cancellous screw fixation of the neck and LCDCP fixation of the shaft, and (4) reconstruction nailing of both shaft and neck.

RESULTS

No statistically significant differences in amount of blood loss, duration of surgery, total complication rate, nor clinical results were found among the four treatment methods. For femoral neck fracture, however, the complication rate of cannulated screw with antegrade intramedullary nailing fixation was 11 times that of DHS with LCDCP fixation.

CONCLUSIONS

Antegrade nail with screw fixation is not a recommended treatment method in patients with ipsilateral femoral shaft and neck fractures.

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.

A retrospective review of high-energy femoral neck-shaft fractures

OBJECTIVES

To determine the incidence of femoral neck fractures with high-energy shaft fractures and to determine whether there was a correlation of neck fractures with antegrade or retrograde intramedullary nailing. We also evaluated the timing of diagnosis and the treatment options and outcomes.

DESIGN AND SETTING

A retrospective review of patients with femoral shaft fractures treated at 8 level 1 trauma centers from 2001 to 2005. Two thousand eight hundred ninety-seven fractures were identified, and 89 patients had 91 femoral neck-shaft combinations (3.2%).

PATIENTS

Average age: 36 years (15-72 years) and average Injury Severity Score: 18 (9-66). Seventy-eight patients had associated injuries; 67 of 91 femoral neck fractures were discovered before nailing.

RESULTS

There were 24 missed femoral neck fractures, 11 discovered intraoperatively and 13 postoperatively. Of these 24 patients, 15 had retrograde fixation and 9 had antegrade femoral shaft fixation. There was a high rate of open femur fractures (34%) and an increased incidence of associated injuries (88%) with neck-shaft combinations. In 12 of 67 patients with a preoperative computed tomography scan, the scan did not demonstrate a femoral neck fracture.

CONCLUSIONS

This study found a similar rate of neck-shaft combinations (3.2%), a higher rate of open fractures, and increased incidence of associated injuries compared with the literature. Most importantly, our data indicate that even with a negative preoperative computed tomography scan, a femoral neck fracture can be present. A trend also indicated more missed femoral neck fractures with retrograde nailing, which may be attributed to less fluoroscopic imaging of the hip with this technique. Patients with femoral shaft fractures should have good quality radiographs after femoral nailing to minimize the risk of missed femoral neck fractures.

Cephalomedullary nails in the management of ipsilateral neck and shaft fractures of the femur--one or two femoral neck screws?

This was a prospective study of 43 consecutive cases of combined ipsilateral femoral neck and shaft fractures treated with cephalomedullary nails. Sequential clinicoradiological evaluation of all high-energy femoral shaft fractures to detect associated ipsilateral neck fracture improved diagnosis. All but 1 of 35 cases included in the study achieved union of both fractures and excellent or good functional outcome. Mean Harris Hip Score at the last follow-up was 92+/-4 in single-neck screw configurations, and 94+/-3 for two-neck screw cephalomedullary nails which had better tip-apex distance. Mean sliding of the neck screw was 5+/-2mm with single-neck and 3+/-2mm with two-neck screw constructs. In six cases shortening was <1cm; 22 had delayed union of the shaft fracture, but only four of these needed additional surgery. Early aggressive fixation of both fractures using a cephalomedullary nail with the least possible surgical trauma is the key to success in these polytrauma cases.

Ipsilateral femoral neck and shaft fractures: a retrospective analysis of two treatment methods

Background

No consensus exists regarding the optimal treatment of ipsilateral femoral neck and shaft fractures. The three major issues related to these fractures are the optimal timing of surgery, which fracture to stabilize first, and the optimal implant to use. In an effort to find answers to these three key issues, we report our experience of managing 27 patients with ipsilateral femoral neck and shaft fractures by using two different treatment methods, i.e., reconstruction-type intramedullary nailing and various plate combinations.

Materials and methods

We divided patients into two groups. Group I included 15 patients (13 males and 2 females) who were operated with cancellous lag screws or dynamic hip screws (DHS) for fractured neck and compression plate fixation for fractured shaft of the femur. Group II included 12 patients (11 males and 1 female) who were operated with reconstruction-type intramedullary nailing.

Results

Mean age was 33.2 and 37.9 years in group I and II, respectively. Mean delay in surgery was 5.9 and 5.4 days in group I and II, respectively. Average union time for femoral neck fracture in groups I and II were 15.2 and 17.1 weeks, respectively; and for shaft fracture these times were 20.3 and 22.8 weeks, respectively. There were 13 (86.6%) good, 1 (6.7%) fair and 1 (6.7%) poor functional results in group I. There were 10 (83.3%) good, 1 (8.3%) fair and 1 (8.3%) poor functional results in group II.

Conclusions

Both of the treatment methods used in the present study achieved satisfactory functional outcome in these complex fractures. Fixation with plate for shaft and screws or DHS for hip is easy from a technical point of view. Choice of the treatment method should be dictated primarily by the type of femoral neck fracture and the surgeon’s familiarity with the treatment method chosen. The femoral neck fracture should preferably be stabilized first, and a delay of 5–6 days does not affect the ultimate functional outcome.

Dynamic hip screw and compression plate fixation of ipsilateral femoral neck and shaft fractures

PURPOSE

To evaluate surgical outcomes of ipsilateral femoral neck and shaft fractures.

METHODS

Between April 1997 and September 2004, 29 men and 8 women (mean age, 37 years) underwent fixation of femoral neck and shaft fractures using a dynamic compression plate plus a dynamic hip screw or screws. There were 30 femoral neck and 7 pertrochanteric fractures. Functional results were assessed according to the Friedman and Wyman classification.

RESULTS

The mean follow-up period was 49 months. Of the femoral neck fractures, 34 united in a mean of 4 months; 33 of them healed anatomically and one with a 6-degree varus angulation. No osteonecrosis of the femoral head was noted. Of the femoral shaft fractures, 32 united in a mean of 6 months, 5 were non-unions (2 persisted even after revision surgery). Seven patients developed infections (5 superficial and 2 deep), which resolved with debridement and antibiotic treatment. Functional results were good in 29 patients, fair in 5, and poor in 3.

CONCLUSION

The use of dynamic hip screws and compression plates for ipsilateral femoral neck and shaft fractures is reliable in achieving bone union with few complications.

Diagnosis of femoral neck fractures in patients with a femoral shaft fracture. Improvement with a standard protocol

BACKGROUND

An ipsilateral fracture of the femoral neck is seen in association with 1% to 9% of femoral shaft fractures, and 20% to 50% of these injuries are missed initially. Recognition of an associated femoral neck fracture prior to stabilization of the femoral shaft fracture is imperative to avoid or minimize complications of displacement and osteonecrosis.

METHODS

A protocol to look for a femoral neck fracture in all patients with a femoral shaft fracture was instituted at a single level-I trauma center. This protocol consisted of a dedicated anteroposterior internal rotation plain radiograph, a fine (2-mm) cut computed tomographic scan through the femoral neck, and an intraoperative fluoroscopic lateral radiograph prior to fixation as well as postoperative anteroposterior and lateral radiographs of the hip in the operating room prior to awakening the patient. A chi-square analysis comparing pre-protocol and post-protocol fracture prevalences was used to assess the relative risk of missing an associated femoral neck fracture.

RESULTS

Two hundred and sixty-eight consecutive patients with a femoral shaft fracture formed the basis of the study group. Of 254 who were followed for at least two months, sixteen were identified as having an associated ipsilateral femoral neck fracture with use of the protocol. Thirteen associated femoral neck fractures were identified before the patient entered the operating room for definitive fixation, and twelve of them were identified with the fine-cut computed tomographic scan. One fracture was identified intraoperatively. There was one iatrogenic fracture and one delayed diagnosis of a femoral neck fracture. With this protocol, we reduced the delay in diagnosis by 91% as compared with our experience in the year prior to the initiation of the protocol.

CONCLUSIONS

In the presence of a femoral shaft fracture, evaluation of the femoral neck with fine-cut computed tomography and dedicated internal rotation hip radiographs significantly improves the ability to diagnose an associated femoral neck fracture.

Retrograde nailing with subsequent screw fixation for ipsilateral femoral shaft and neck fractures

INTRODUCTION

Although ipsilateral femoral shaft and neck fractures are difficult to treat, there is still no consensus on the optimal treatment of this complex injury. We report the results of treating the 17 fractures with a standard protocol of retrograde nailing for diaphyseal fractures and subsequent screw fixation for the femoral neck fractures.

MATERIALS AND METHODS

Seventeen injuries (16 patients) sustained femoral shaft fractures, which were treated with retrograde intramedullary nails and subsequent screw fixation. Femoral neck fracture was noted before the operation in all patients except one. A femoral shaft fracture was always addressed first with unreamed retrograde nailing. Then, the femoral neck fracture was treated by cannulated screws or dynamic hip screw according to the level of fracture.

RESULTS

The average time for union of femoral shaft fractures was 27.3 (14-60) weeks. Nonunion occurred in five patients, who required bone grafts or changes of fixation. The average time for union of femoral neck fractures was 11 (8-12) weeks. All united, except for one case of nonunion with avascuar necrosis, which was a Garden stage IV fracture. Functional results using Friedman-Wyman criteria were good in 16 cases, and fair in one. The only fair result was nonunion of the femoral neck, which had the joint arthroplasty.

CONCLUSION

Retrograde nailing of femoral shaft fractures can provide an easy fixation and a favorable result for ipsilateral femoral neck fractures.

Ipsilateral hip and femoral shaft fractures treated with intramedullary nails

This study retrospectively analysed 34 patients with ipsilateral hip and femoral shaft fractures treated over a period of 10 years between January 1995 and January 2005. They had an average age of 35 years. Twenty-six (76.47%) of these cases suffered high-velocity trauma (RTA); six others had fallen from a height (17.65%), and two had suffered only minimal trauma (5.88%). Twenty were extracapsular (58.82%) and 14 were intracapsular. They were evaluated with an average follow-up of 28 months, both clinically and radiologically; 26 patients (76.47%) had a good result (Friedman and Wyman score). When the intracapsular fracture was detected postperatively, there was one delayed union and one non-union. When the fracture is diagnosed preoperatively, we recommend reconstruction nail fixation. If the hip fracture is diagnosed intra- or postoperatively following nailing of the shaft, we propose the miss-a-nail technique as an option.

Cephalomedullary interlocked nail for ipsilateral hip and femoral shaft fractures

A retrospective study of the management of 23 cases of ipsilateral hip and femoral shaft fractures, between January 1998 and December 2001, is presented. All except two cases were managed by a single implant, i.e. reconstruction nail. There was delayed diagnosis of femoral neck fracture in two cases where the "miss a nail" technique was used for fixation of the femoral neck fracture. All patients managed by reconstruction nail were simultaneously operated on for both fractures and operative treatment was executed as early as the general condition of the patient permitted. Delay in treatment was generally because of the associated injuries (head, chest or abdominal). There were 22 males and 1 female patient with an average age of 34.5 years. Average follow-up was 30.9 months. There was one case of non-union of the femoral neck fracture, one case of avascular necrosis and one femoral neck fracture united in varus. There were four cases of non-union and six cases of delayed union of femoral shaft fractures. Mean time for union of the femoral neck fracture was 15 weeks and for the shaft fracture was 22 weeks. In this series femoral shaft fracture determined the total union period. Complications involving the femoral shaft fracture were more common than those related to femoral neck fractures. Shaft complications were more manageable with or without secondary procedures as compared to femoral neck complications, which usually require more extensive procedures. This stresses the need to realise the significance and seriousness of both components of this complex injury, in evaluation, management and post-operative care. We conclude that, though technically demanding, reconstruction nail is an acceptable alternative for management of concomitant fractures of the femoral neck and shaft with acceptable rates of complications and good results.

Surgical treatment for ipsilateral fractures of the hip and femoral shaft

Concomitant ipsilateral femoral shaft and neck fractures are difficult to treat. There is still no consensus on the optimal treatment of these complex fractures. Forty-seven patients with these complex fractures were treated in Kaohsiung Medical University Hospital between the periods of 1982 and 1998. Our standard treatment protocol is plate fixation for femoral shaft fracture and lag screw or dynamic hip screw (DHS) fixation for hip fracture. Among 42 cases treated with this protocol, 34 were males and 8 were females with an average age of 36 years and average follow-up period of 55 months. We divided hip fractures into two groups: femoral neck fracture as group I and intertrochanteric fracture as group II. There were no non-union and osteonecrosis of the hip in either group. One diaphyseal non-union was observed in group I and four in group II. There were 92 and 76% good functional results in groups I and II, respectively. The result shows that our standard method can yield a reliable outcome in group I, but not in group II.

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

BACKGROUND

Multifocal fractures of the femur are uncommon injuries and present unique management challenges. Combined ipsilateral fractures of the femoral shaft and femoral neck or the femoral shaft and distal femur have been described. The combination of noncontiguous ipsilateral femoral neck, femoral shaft, and distal femoral articular injuries, however, has not been described. The purposes of this report are to document the incidence and characteristics of this injury and to present a treatment rationale.

METHODS

This was a retrospective study conducted at a Level I trauma center.

RESULTS

Over a 5-year period, 1639 adult patients with femur fractures were definitively managed at the authors' institution. Five male and two female patients (average age, 43.3 years) sustained ipsilateral, noncontiguous fractures of the femoral neck, femoral shaft, and distal femoral articular surface (0.43%). All femoral neck fractures were vertically oriented. All distal femoral injuries were unicondylar. A variety of fixation methods were used, dependent on individual fracture characteristics. The femoral neck fractures were prioritized in all cases. Stabilization of the distal femoral articular surface was then performed before diaphyseal fixation in patients with sagittally oriented condylar fractures. Patients were followed for an average of 19.3 months. All fractures healed without the need for secondary procedures.

CONCLUSION

This injury constellation is rare. Open reduction and internal fixation of the displaced femoral neck fracture should be the primary focus of orthopedic management, followed by stable reduction and fixation of displaced distal femoral articular injuries. The diaphyseal fracture should be treated with a technique that does not jeopardize either the proximal or the distal fractures. Patients who are critically ill can be managed in a similar sequence over the course of several days, depending on their overall condition.

A new classification and treatment protocol for combined fractures of the femoral shaft with the proximal or distal femur with closed locked intramedullary nailing: clinical experience of 63 fractures

The medical records and radiographs of 63 patients, who were admitted between 1989-1997, with a combined femur fracture, were reviewed. Associated injuries were present in 38 (60%) patients. The combined fractures were classified into four major types depending on their anatomical position: type I, femoral shaft fracture combined with hip neck fracture; type II, femoral shaft fracture combined with a trochanteric fracture; type III, femoral shaft fracture combined with a distal femur fracture; and type IV, femoral shaft fracture combined with a proximal or distal femur fracture. The fractures were treated with locked intramedullary nailing and additional free cancellous 6.5-mm screws as needed. Fifty-six fractures healed without further operations. Of the remaining 6 fractures, 2 were material failures, 1 malunion with 3-cm shortening and external rotation of the femoral diaphysis, 2 early infections of the surgical wound, and 1 pseudarthrosis of the femoral shaft. All fractures were healed between 16 and 32 weeks (average: 20 weeks).

Use of reconstruction nails to manage ipsilateral displaced femoral neck-shaft fractures: assessment of a new approach

PURPOSE

Owing to unpredictable femoral neck reduction, reconstruction nails are not suitable for fixation of group 3 ipsilateral femoral neck-shaft fractures. We developed a new one-step fixation technique to overcome this problem. This study aims to assess this new technique at the Orthopaedic Department, Chi-Mei Foundation Medical Center, Tainan.

METHODS

Of 31 consecutive patients with femoral fractures treated by reconstruction nails, five patients had group 3 ipsilateral femoral neck-shaft fractures, 4 of whom were treated by a new surgical technique. Two 5.0-mm drills were firstly inserted to tether the trochanter fragment, and distal locking screws were secondly applied to immobilise the shaft fracture. The neck-shaft angle was then restored in a closed fashion and proximal cephalomedullary screws were attached. Patients were followed up by post-operative radiography.

RESULTS

All 5 cases of group 3 ipsilateral femoral neck-shaft fracture obtained radiographic union without significant surgical sequelae. Three of the patients had implants removed. No patients presented with osteonecrosis at the 3-year follow-up.

CONCLUSION

The new approach to manage ipsilateral femoral neck-shaft fractures by using reconstruction nails obtains relatively good clinical results.

Complicated femoral shaft fractures

The treatment of femoral shaft fractures has become safe and reproducible since the advent of popularization of intramedullary nailing, however, many femoral shaft fractures are complicated by associated fractures, extensive comminution, extensive contamination, and arterial injury compartmental syndrome. Other conditions associated with the use of femoral nailing include femora nonunions, broken hardware, acute fractures with prior implants, and infections. The management of these complex femoral shaft fractures demands special techniques for successful outcome.

Ipsilateral fractures of the femoral neck and shaft

Ipsilateral femoral shaft and neck fractures are difficult to treat. From 1989 to 1998, we treated 18 patients with these complex fractures. There were 14 male and 4 female with an average age of 40 years. Most resulted from high-energy trauma. The average follow-up period is 41 months. All but one of the fractures united well. The mean time to union is 5.2+/-2.3 months in the diaphysis and 4.16+/-2 months in the neck. No cases of the femoral neck fracture or osteonecrosis of the femoral head were observed during the follow-up period. Fourteen cases were treated with a standard protocol of plates for diaphyseal fractures and lag screws or dynamic hip screws (DHS) fixations for the femoral neck fractures. There were 13 good and 1 fair functional results. Two neglected neck fractures were treated with interlocking nailing for diaphyseal fracture with fair results. We conclude that a plate on the shaft and sliding hip screws or separate screws in the hip is a reliable method for ipsilateral femoral neck and shaft fractures.

Ipsilateral femoral neck and shaft fractures

Ipsilateral femoral neck and shaft fractures are uncommon injuries that present a surgical challenge. Patients are relatively young, are usually victims of high-energy trauma, and have frequently sustained multisystem injuries. A comminuted midshaft femoral fracture secondary to axial loading should alert the treating physician to the possibility of an associated femoral neck fracture. This is important in light of the frequency of unrecognized ipsilateral femoral neck fractures. Several treatment options are described in the literature, but no clear consensus exists regarding the optimal treatment of these complex fractures. The authors contend that, given the potentially devastating complications of the femoral neck fracture in young patients (e.g., avascular necrosis, nonunion, and malunion), the neck fracture should be treated first and the shaft fracture second. The authors present an algorithm for the diagnosis and management of this injury based on a review of the literature, an understanding of the biology and severity of this injury, and the technical aspects of surgical treatment.

Femoral neck and ipsilateral neck and shaft fractures in the young adult

Femoral neck and ipsilateral neck and shaft fractures in the young adult represent a significant source of morbidity and mortality. This article reviews the anatomy, pathophysiology, radiographic evaluation, timing of surgery, and complications in an attempt to increase recognition of these injuries and provide better patient care.

Concurrent ipsilateral fractures of the hip and femoral shaft: a meta-analysis of 659 cases

659 cases of concurrent, ipsilateral fractures in the hip and femoral shaft reported in 59 studies were analyzed. The causes were a road traffic accident in 78% and other types of high-energy traumas in 13% of the patients. This injury combination was rare in children. The median age was 34 years. 78% of the patients were men. One-third had multiple injuries, one-half had injuries of the ipsilateral knee and one-half had other lower limb injuries. The femoral neck fractures were most often basilar and the reported rate of avascular necrosis was 3%. The trochanteric fractures were intertrochanteric transverse, and seldom comminuted. The important factors in reducing morbidity were an early diagnosis of all injuries and efficient treatment of the shaft fractures. Locked intramedullary nails yielded results which were superior to combinations of plates or unlocked nails and separate hip screws. Reconstruction nails (cephalomedullary nails) gave results equal to those of customary locked nails and separate hip screws. The rate of healing of the hip fracture was over 99%, the treatment of the shaft fracture being of main importance for the outcome.

A locked hip screw-intramedullary nail (cephalomedullary nail) for the treatment of fractures of the proximal part of the femur combined with fractures of the femoral shaft

Twenty-seven patients with complex femoral fractures (combined shaft and proximal femoral fractures) were treated with a modified Grosse-Kempf slotted locking nail (cephalomedullary nail), wherein two screws were inserted in the hip. Four types of complex, multifocal femoral fractures were represented in the series. Eleven of the femoral shaft fractures were secondary to a previous, internally fixed, not yet united hip fracture (type I). Ten comminuted peritrochanteric fractures occurred in normal bone (type II). Three similar fractures were pathologic because of metastasis. Two patients had an ipsilateral fracture of the femoral shaft and the trochanteric area (type III), and one of the shaft and the femoral neck (type IV). Locking was made static in 24 cases. Additional cerclage wiring was used in three type II fractures. Five complications were as follows: one cutting out of a screw in the femoral head, two fractures of the nail, one deep venous thrombosis, and one wound hematoma. Reoperations were two salvage operations using a new nail and one evacuation of hematoma. One patient with multiple injuries and four elderly patients died within 2 months. Eighteen patients with fractures in normal bone were followed for a median of 20 (6 to 37) months. All fractures united. Two nails were removed. The end result was excellent in ten patients, good in seven, and fair in one (2-cm shortening and 20-degree external rotation). We conclude that a locked intramedullary construct with locking screws in femoral neck and distal femur controls a complex fracture situation well.