Abstract
BackgroundIpsilateral femoral shaft and neck fractures are rare injuries, affecting mostly young patients who sustained high-energy traumas. In 19–50% of cases, the femoral fracture is misdiagnosed or overlooked at the initial presentation, with reportedly increased risk of complications such as non-union and avascular necrosis. We present a case of an ipsilateral femoral neck and shaft fracture, which was missed at initial presentation despite radiographic and computed tomography (CT) scan evaluation.Case presentationA 56-year old female was admitted to our institution following a high-energy trauma (fall from 6 m). Initial radiographic and CT scan evaluation revealed a displaced femoral shaft fracture but no other femoral fractures were detected. Closed reduction and external fixation of the femoral shaft fracture was performed in the emergency setting. Follow-up radiologic evaluations revealed an ipsilateral laterally displaced femoral neck fracture. Despite cephalomedullary nail fixation of both fractures performed on the third day from the initial injury, the patient developed a non-union of the femoral neck fracture, which led to cut-out of the lag screw with associated varus failure of the femoral neck fracture requiring surgical revision and implant of a bipolar hemiarthroplasty at one year follow up. The postoperative course was uneventful and the patient had a full long-term recovery.ConclusionThis case report exemplifies the need to maintain the highest level of suspiciousness for the concomitant presence of an ipsilateral femoral neck fracture when treating polytraumatized patients who sustained a femoral shaft fracture as a consequence of a high-energy trauma. Furthermore, the pre-operative standardized radiological evaluation (plain x-ray and CT scan) might not always help in ruling out these fractures. It is therefore necessary to adopt additional standardized radiographic protocols not only in the pre-operative but also in the intra-operative and immediate post-operative settings.
Highlights
Ipsilateral femoral shaft and neck fractures are rare injuries, affecting mostly young patients who sustained high-energy traumas
We report our experience with a patient affected by femoral shaft and neck fractures and we discuss the proposed diagnostic algorithms, the treatment approaches, and the complications presented in the literature
Combining different preoperative, intraoperative and postoperative clinical and radiological measures should help reduce the incidence of a missed femoral neck fracture
Summary
In polytraumatized patients with injuries caused by high-energy trauma one must expect and rule out combined injuries of the femur at different levels. The use of specific standardized protocols for the correct diagnosis and treatment of such fractures in order to decrease the incidence of devastating complications should be implemented. It is important to understand that, especially in polytraumatized, non-collaborating patient who present with femoral shaft fracture, the highest level of suspiciousness must be maintained for the concomitant presence of an ipsilateral femoral neck fracture. The combination of specific radiographic preoperative, intraoperative and postoperative views of the femoral neck should be integrated in the ATLS algorithm of the polytraumatized patient [26] to help reduce the incidence of a missed femoral neck fracture. Abbreviations 2D CT: Two dimensional computerized tomography; AIS: Abbreviated injury score; AP: Antero-posterior; ATLS: Advanced trauma life support; CT: Computed tomography; FAST: Focused assessment for sonography in trauma; GCS: Glasgow coma scale; ISS: Injury severity score
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