Abstract
BackgroundOccult femoral neck fractures associated with femoral shaft fractures are frequently missed and may lead to adverse outcomes.Case presentationA 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.ConclusionThis 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.
Highlights
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
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
Summary
This case report highlights multiple unfortunate events and preventable complications in a young patient treated for bilateral femur fractures after a motor vehicle accident. The sentinel complication consists of a missed femoral neck fracture during the initial work-up or at the time of antegrade femoral fixation This case illustrates the importance of an adequate pre-operative radiographic workup, including internally rotated anteroposterior and lateral plain radiographs of the hip for visualization of the femoral neck, both prior to and after completion of antegrade femoral nailing. The present case report serves as a reminder to orthopaedic trauma surgeons, and to the generation of surgeons in training, to carefully analyze all pre-/intra-/and post-operative radiographs for associated injury, and to have a low threshold for further the preoperative evaluation of suspected concomitant femoral neck and shaft fractures with adjunctive diagnostic strategies including thin-cut CT scans and magnetic resonance imaging (MRI) when radiographic findings are equivocal. Author details 1Department of Orthopaedics, Naval Medical Center, San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, USA. 2Department of Orthopaedics, Denver Health Medical Center, University of Colorado, School of Medicine, 777 Bannock Street, Denver, CO 80204, USA
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