Fracture of the Femoral Shaft with Ipsilateral Fracture

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. 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 • 1 st : femur shaft fractures 2 nd : femur neck fractures

Method <Fixation method> Femur shaft Plate & screw (12 cases) Total 21 cases IM nailing (9 cases) Femur neck 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 <The time of the diagnosis>

Results <Location of femoral shaft fractures> Mid-third No. (cases) 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 <Time to Op> • Average : Trauma 7 days ( range : 17 hrs ~ 28 days) • Temporary skeletal traction : impossible to operate immediately • After vital sign stabilization → operation

Results <Combined fracture> Tibia Pelvis Forearm Rib Humerus Patella No. (cases) 7 5 5 4 4 3

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

Case 1 • M/44 • 2006. 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 1 Y

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 1 Y

Case 3 • • M/34 2005. 02. 15 Driver TA • Op. : Trauma 3 days • Neck : neglected pre & intraop. →∴ Neck fixation : Trauma 2 wks shaft : mid-third Fx.

Pre Op

Pre Op

Imm Op

POD 2 wks (detected Neck Fx. )

Imm Op (neck)

POD 1 Y

Discussion • Young and male dominated Alho A (Acta Orthop Scand. 1996) • The incidence ranges from 1% to 6% of the femoral shaft fractures Wolinski PR (Clin Orthop, 1995) Zettas JP (Clin Orthop. 1981)

Discussion • Femoral neck fractures are commonly missed initially; the rate varies from 19% to 31% Bennett FS (Clin Orthop Relat Res. 1993) Swiontkowski MF (Orthop Clin North Am. 1987) • The reported incidence of AVN in ipsilateral femoral neck and shaft fratures (3%) Alho A (Acta Orthop Scand. 1996)

Discussion • <Iatrogenic fracture during nailing> 3 / 300 (1%) - Forceful use of an awl in the wrong direction - Multiple entry points in trochanteric region Khan FA (Injury. 1995) • 4 / 315 (1. 3%) - Insertion jig impinge on valgus femoral neck during final impaction Simonian PT (J Bone Joint Surg. 1994)

Discussion <in Our study> • Mean age: 38 years • Incidence : 21 / 1113 (1. 9%) • Missed neck Fx. : 6 / 21 (29%) • AVN : 1 / 21 (4. 7%)

Discussion • <Incidence of AVN> 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 ↓ Goris RJ. (J Trauma. 1982) Suggested immediate reduction & fixation : avoid displacement of the neck fracture and AVN Swiontkowski MF. (J Bone Joint Surg Am. 1984) • Delay of weeks in the fixation does not increase the complication rate Wolinsky PR. (Clin Orthop Rel Res. 1995)

Discussion • The neck fracture were stabilized first : avoid further displacement of the neck fracture and AVN Leung KS (Injury. 1993) Swiontkowski MF (J Bone Joint Surg. 1984) • The shaft fractures were stabilized first → no further displacement of neck fracture Chen CH (Injury. 2000)

Discussion <in Our study> • 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 <In our study> • 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 • <In our study> Abdominopelvic CT or pelvis 3 D 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