Fracture of the Femoral Shaft with Ipsilateral Fracture of the Femoral neck

Fracture of the Femoral Shaft with Ipsilateral Fracture of the Femoral

neck

박희곤ㆍ김명호ㆍ유문집ㆍ유현열ㆍ이대희

Dept. of Orthopaedic Surgery,

Dankook University Hospital

Introduction

• Ipsilateral fractures of the femoral neck and shaft are rare

• In high-energy injuries, especially in road traffic accidents

• The incidence ranges : 1% to 6% of the femoral shaft fractures

Jain P (Injury, 2004)

Wolinski PR (Clin Orthop, 1995)

Introduction

• Femoral neck fractures are commonly missed 19% to 31%

- Multiple injuries - the main focus : other life-threatening

injuriesBennett FS (Clin Orthop Relat Res. 1993)

Swiontkowski MF (Orthop Clin North Am. 1987)

Purpose

To analyze the clinical data in cases of fracture of the femoral shaft with ipsilateral fracture of the femoral neck

Material

• Sep. 1995 ~ Jan. 2008

• 21 patients

• Male / Female: 17 / 4

• Mean age: 38 years (19 – 66 years)

Method <operation method>

• Use Fracture table : for exact reduction

• 1st : femur shaft fractures

2nd : femur neck fractures

Method <Fixation method>

Femur shaft Femur neck

Plate & screw(12 cases)

IM nailing (9cases)

Total 21 cases

DHS(8 cases)

Cann. screws(4 cases)

Cann. screws(9 cases)

Results

• 21 cases of 1113 cases (1.9%)

• All cases were traffic accidents

Car (14) Motorcycle (7)

Driver 11 7

Passenger seat 2 0

Back seat 1 0

Results

1(5%)5(24%)

15(71%) Pre op.

Intra op.

Post op.

<The time of the diagnosis>

Results <Location of femoral shaft fractures>

No.(cases)

Mid-third 17

Distal-third 4

Total 21

Results<Type of fracture of neck of the femur>

Garden classification

No.(cases)

Stage I 3 cases

Stage II 6 cases

Stage III 8 cases

Stage IV 4 cases

Results

• Average : Trauma 7days ( range : 17hrs ~ 28days)

• Temporary skeletal traction : impossible to operate immediately

• After vital sign stabilization → operation

<Time to Op>

Results<Combined fracture>

No. (cases)

Tibia 7

Pelvis 5

Forearm 5

Rib 4

Humerus 4

Patella 3

Complicaiton

• AVN: 1 case Trauma # 5D : Op. with plate (shaft) & DHS

(neck) → POD # 6mon : THRA

Case 1

• M/44

• 2006.06.09 Driver TA

• Trauma 28 days Op. d/t aortic dissection, liver

rupture

• Neck : Garden stage II, shaft : mid-third Fx.

Pre Op

Pre Op

Pre Op

POD 1Y

Case 2

• M/27

• 2007.12.14 Driver TA

• Op. : Trauma 2 days

• Neck : initially neglected → detected intraop. shaft : mid-third Fx.

Pre Op

Pre Op

POD 1Y

Case 3

• M/34

• 2005.02.15 Driver TA

• Op. : Trauma 3 days

• Neck : neglected pre & intraop. →∴ Neck fixation : Trauma 2wks shaft : mid-third Fx.

Pre Op

Pre Op

Imm Op

POD 2wks (detected Neck Fx.)

Imm Op (neck)

POD 1Y

Discussion

• Young and male dominated

• The incidence ranges from 1% to 6% of the femoral shaft fractures Wolinski PR (Clin Orthop, 1995)

Alho A (Acta Orthop Scand. 1996)

Zettas JP (Clin Orthop. 1981)

Discussion

• Femoral neck fractures are commonly missed initially; the rate varies from 19% to 31%

• The reported incidence of AVN in ipsilateral femoral neck and shaft fratures (3%)

Bennett FS (Clin Orthop Relat Res. 1993)

Swiontkowski MF (Orthop Clin North Am. 1987)

Alho A (Acta Orthop Scand. 1996)

Discussion

• 3 / 300 (1%) - Forceful use of an awl in the wrong direction - Multiple entry points in trochanteric region

• 4 / 315 (1.3%) - Insertion jig impinge on valgus femoral neck

during final impactionSimonian PT (J Bone Joint Surg. 1994)

Khan FA (Injury. 1995)

<Iatrogenic fracture during nailing>

Discussion

• Mean age: 38 years

• Incidence : 21 / 1113 (1.9%)

• Missed neck Fx. : 6 / 21 (29%)

• AVN : 1 / 21 (4.7%)

<in Our study>

Discussion

• Lower than the solitary femoral neck fracture(10%)

Because 1. The force is dissipated in the shaft fracture 2. Base of neck fracture and non-displaced

neck fracture Gerber C. (Clin Orthop Rel Res. 1993)

<Incidence of AVN>

Discussion • Early fixation & ambulation : morbidity ↓

• Suggested immediate reduction & fixation

: avoid displacement of the neck fracture and AVN

• Delay of weeks in the fixation does not increase the complication rate

Goris RJ. (J Trauma. 1982)

Swiontkowski MF. (J Bone Joint Surg Am. 1984)

Wolinsky PR. (Clin Orthop Rel Res. 1995)

Discussion

• The neck fracture were stabilized first : avoid further displacement of the neck fracture and AVN

• The shaft fractures were stabilized first → no further displacement of neck fracture

Leung KS (Injury. 1993)

Chen CH (Injury. 2000)

Swiontkowski MF (J Bone Joint Surg. 1984)

Discussion

• In our cases, the shaft fractures were stabilized first, and the neck fractures treated later

• Use Fx. table : for exact reduction

→ no further displacement of neck fracture

<in Our study>

Discussion

• Cancellous lag screws or DHS (neck) compression plate (shaft) : 15 cases

VS• Intramedullary nailing : 12 cases

→ Both achieved satisfactory functional outcome Singh R. (J Orthop Traumatol. 2008)

Discussion

• Both hip AP X-ray checked: 18/21 cases

- 3 of 18 (16.7%): missed diagnosis

• No evaluation of hip (femur neck) : 3 cases

→ Pre or intra Op C-arm manipulation

<In our study>

Discussion

• Abdominopelvic CT or pelvis 3D CT checked

- 6 cases : detecting a fracture

→ CT reading : careful attention

<In our study>

Conclusion• Can be missed during the initial diagnosis in high-energy injuries

• Demands careful attention - Adding AP x-rays of the hip joint - Hip CT - Bone scan - Pre Op C-arm manipulation - Follow up x-rays

Thank you for your attention