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 injuries Bennett 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 ~ Jan patients Male / Female: 17 / 4 Mean age: 38 years (19 – 66 years)

Method Use Fracture table : for exact reduction 1 st : femur shaft fractures 2 nd : femur neck fractures

Method Femur shaftFemur 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) Driver117 Passenger seat20 Back seat10

Results

Results No. (cases) Mid-third17 Distal-third4 Total21

Results Garden classification No. (cases) Stage I3 cases Stage II6 cases Stage III8 cases Stage IV4 cases

Results Average : Trauma 7days ( range : 17hrs ~ 28days) Temporary skeletal traction : impossible to operate immediately After vital sign stabilization → operation

Results No. (cases) Tibia7 Pelvis5 Forearm5 Rib4 Humerus4 Patella3

Complicaiton AVN: 1 case Trauma # 5D : Op. with plate (shaft) & DHS (neck) → POD # 6mon : THRA

Case 1 M/ Driver TA Trauma 28 days Op. d/t aortic dissection, liver rupture Neck : Garden stage II, shaft : mid-third Fx.

Pre Op

POD 1Y

Case 2 M/ Driver TA Op. : Trauma 2 days Neck : initially neglected → detected intraop. shaft : mid-third Fx.

Pre Op

POD 1Y

Case 3 M/ Driver TA Op. : Trauma 3 days Neck : neglected pre & intraop. → ∴ Neck fixation : Trauma 2wks shaft : mid-third Fx.

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 impaction Simonian PT (J Bone Joint Surg. 1994) Khan FA (Injury. 1995)

Discussion Mean age: 38 years Incidence : 21 / 1113 (1.9%) Missed neck Fx. : 6 / 21 (29%) AVN : 1 / 21 (4.7%)

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)

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

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

Discussion Abdominopelvic CT or pelvis 3D CT checked - 6 cases : detecting a fracture → CT reading : careful attention

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