Osteonecrosis of the Femoral Head After Retrograde Intramedullary Nailing of a Femoral Shaft Fracture in an Adolescent

Abstract

O steonecrosis of the capital femoral epiphysis following antegrade intramedullary nailing of femoral shaft fractures has been generally described as occurring in adolescent and pediatric patients1-10. However, a limited number of cases have been reported in adults11,12. The condition appears to represent an iatrogenic injury resulting from the proximity of the medial femoral circumflex artery to the piriformis fossa, which is the typical starting point for intramedullary nailing13. To our knowledge, there have been no previously published reports of osteonecrosis of the femoral head following retrograde intramedullary nailing of a femoral shaft fracture. Retrograde insertion techniques are applicable to adults and older adolescents, after closure of the distal femoral physis. We present the case of an adolescent male with osteonecrosis of the femoral head following retrograde femoral intramedullary nailing, and we review the osteonecrosis risk factors that may be present in patients who sustain polytrauma. Our patient and his legal guardian were informed that data concerning the case would be submitted for publication. Fig. 1-A Initial anteroposterior radiograph showing an open comminuted fracture of the right femoral shaft. There is no apparent associated fracture of the femoral neck. A seventeen-year-old boy was involved as an unrestrained, front-seat passenger in a high-energy, head-on motor-vehicle collision. Paramedics found the boy trapped under the dashboard and required more than thirty minutes to extricate him. On arrival at our institution, the patient was tachypneic (respiratory rate, 33 breaths/min), tachycardic (heart rate, 105 beats/min), and hypotensive (blood pressure, 76 mm Hg) but was alert and oriented and had a Glasgow Coma Scale score of 15. Radiographs revealed multiple long-bone fractures, including a type-I open comminuted fracture of the right femoral shaft (Fig. 1-A), according to the system of Gustilo and Anderson14, and closed diaphyseal fractures …