Ipsilateral Femoral Shaft Fractures Research Articles

MRI characteristics of radiographically occult femoral neck fractures in trauma patients with ipsilateral femoral shaft fractures.

Ipsilateral femoral neck fractures can be seen alongside femoral shaft fractures in high-velocity trauma patients. These neck fractures are often occult on radiographs and CT, and can have a significant impact on patient outcomes if not treated promptly. Limited protocol pelvic MRI has been used to increase sensitivity for these occult fractures. Detailed characterization of these fractures on MRI is lacking. 427 consecutive trauma patients presenting to our emergency department who had known femoral diaphyseal fractures but no ipsilateral femoral neck fracture on radiographs or CT were included in this study. These patients were scanned using a limited protocol MRI with coronal T1 and coronal STIR sequences. Presence of an ipsilateral femoral neck fracture and imaging characteristics of the fracture were obtained. 31 radiographically occult ipsilateral femoral neck fractures were found, representing 7% of all cases. All neck fractures were incomplete. All fractures originated along the lateral cortex of the femoral neck and extended medially towards the junction of the medial femoral neck and the lesser trochanter. 58% (18/31) were vertical in orientation. 61% (19/31) did not demonstrate any appreciate edema on STIR images. Implementation of limited protocol MRI protocol increases sensitivity for detection of femoral neck fractures in the setting of ipsilateral femoral shaft fractures not seen on radiograph or CT imaging. We describe the characteristic MR imaging features of these fractures.

Management of ipsilateral femoral neck and shaft fracture using reconstruction nail: A case report

Abstract Ipsilateral fractures of femoral shaft and neck of femur fracture are rare but challenging and typically caused by high energy trauma. Review of literature shows various options for implants and surgical techniques for the treatment of Ipsilateral femoral neck shaft fractures but still none of them can be considered as standard, or even preferable. This is a case of 25 year old male who had suffered injury to his left hip and left thigh following an RTA. Radiographs of pelvis and thigh showed fracture of neck of right femur [basicervial] with fracture of shaft of right femur [junction of proximal 2/3rd and distal 1/3rd]. He was managed using reconstruction nail for both fractures 3 days after injury. The patient has attained bony union of both fractures in 8 months and was able to carry out his all routine activities and has attained good functional range of motion at hip and knee joint. We concluded that reconstruction nail is an acceptable implant for the management of ipsilateral neck and shaft of femur fracture with good radiological and clinical outcomes.

Comparison of reconstruction nails versus dual implants in the treatment of ipsilateral femoral neck and shaft fractures in adults: a meta-analysis and systematic review

ObjectiveThere is no consensus on the optimal treatment for ipsilateral femoral neck and shaft fractures. This meta-analysis aims to assess the effectiveness of reconstruction nails and dual implants in treating ipsilateral femoral neck and shaft fractures to provide a basis for decision-making when selecting the optimal approach.MethodsRelevant articles were retrieved from Pubmed, Embase, and Cochrane databases using the keywords "neck of femur", "shaft" and "fracture fixation" from inception until November 17, 2022. The screening process of the studies was conducted independently by two assessors, who assessed each study's eligibility and two assessors assessed the quality. Then compared differences in outcome measures using RevMan 5.3 software.ResultsA total of ten retrospective cohort studies were included. There were no significant differences in union time, union rate, union-related complications (malunion, nonunion, delayed union) of femoral neck and shaft fractures, osteonecrosis of the femoral head, and functional outcomes (Friedman-Wyman scoring system) (P > 0.05).ConclusionOur pooled estimates indicated that reconstruction nails and dual implants for ipsilateral femoral neck and shaft fractures could yield satisfactory surgical results, and that there is no difference between the two treatment methods.Trial registrationThis meta-analysis was registered on the PROSPERO website (registration number: CRD42022379606).

Capsular distension in high-energy femoral shaft fractures is associated with occult femoral neck fracture: a preliminary retrospective comparative study.

To determine the association between hip capsular distension, the computed tomography (CT) capsular sign, and lipohemarthrosis as they relate to occult femoral neck fracture (FNF) in the setting of ipsilateral femoral shaft fracture (FSF). Retrospective comparative study. Level 1 trauma center. Two hundred and forty-two patients with high-energy FSF and no evidence of FNF on preoperative radiographs and pelvis CT. All patients were stabilized with non-reconstruction style nails. Pelvis CT scans were examined for hip capsular distension irrespective of the other side, differing side-to-side measurements of capsular distension (i.e., the CT capsular sign), and lipohemarthrosis. FNF was observed for on postoperative radiographs. Relative risk (RR), number needed to treat (NNT), sensitivity (SN), and specificity (SP) were determined. Fifty-eight patients (24.0%) had capsular distension. Forty-two patients (17.4%) had differing capsular measurements (i.e., the CT capsular sign), and 16 (6.6%) had symmetrical distension from bilateral hip effusions. Eight patients (3.3%) had lipohemarthrosis. Four FNFs (1.7%) were identified. Three patients had capsular distension, 2 had CT capsular signs, and 1 had lipohemarthrosis. The last patient had no CT abnormalities. Only capsular distension (RR = 10, CI = 1.001-90, P = 0.049; SN = 75%, SP = 77%; NNT = 22) and lipohemarthrosis (RR = 23, CI = 1.6-335, P = 0.022; SN = 50%, SP = 96%; NNT = 8) were associated with occult FNF. Capsular distension is associated with FNF irrespective of the contralateral hip. Preemptive stabilization using a reconstruction nail could be considered in the setting of capsular distension or lipohemarthrosis to prevent displacement of an occult FNF. Diagnostic Level III.

Surgical fixation of ipsilateral femoral neck and shaft fractures: a matter of debate?

Segmental femoral fractures represent a rare but complex clinical challenge. They mostly result from high-energy mechanisms, dictate a careful initial assessment and are managed with various techniques. These often include an initial phase of damage control orthopaedics while the initial manoeuvres of patient and soft tissue resuscitation are employed. Definitive fixation consists of either single-implant (reconstruction femoral nails) or dual-implant constructs. There is no consensus in favour of one of these two strategies. At present, there is no high-quality comparative evidence between the various methods of treatment. The development of advanced design nailing and plating systems has offered fixation constructs with improved characteristics. A comprehensive review of the existing evidence with a step-by-step description of these different definitive fixation strategies based on three case examples was conducted. Furthermore, the rationale for using single vs dual-implant strategy in its case is presented with supportive references. The prevention of complications relies mainly on the strict adherence to basic principles of fracture fixation with an emphasis on careful preoperative planning, the quality of the reduction, and the application of soft tissue-friendly surgical methods.

Surgical treatment for ipsilateral femoral neck and shaft fracture

To retrospectively analyze efficacy of single structure internal fixation and double structure internal fixation in the treatment of ipsilateral femoral shaft and neck fracture, and analyze their indications. From June 2015 to December 2020, 21 patients with ipsilateral femoral shaft and femoral neck fracture were treated, including 14 males and 7 females, aged 23 to 69 years old with an average of(38.1±12.9) years old. According to different femoral shaft fracture sites, some patients were fixed with cephalomedullary implant for both femoral neck and the femoral shaft(single structure, InterTan or PFNA Ⅱ), some patients were fixed with cannulated screws for the femoral neck and a retrograde locking nail for the femoral shaft (dual structure), and postoperative function and complications were recorded during follow-up. In 10 cases of single-structure fixation, the femoral necks were all basicervical fractures, and the femoral shaft fractures were located in the proximal isthmus;11 cases were double-structure fixation, 9 cases in 11 were basal type of femoral neck, 2 cases in 11 were neck type, and the femoral shaft fractures were located in the isthmus and the distal isthmus. All patients were followed up for 12 to 27 months. No femoral head necrosis, deformity, delay or nonunion occurred in the patients with single-structure fixation, and no delayed union or nonunion occurred in femoral shaft fractures;At the final follow-up, Harris score of patients with single-structure fixation was 91.8±4.1, with 8 cases were excellent and 2 cases were good. The fractures of patients with dual-structure fixation achieved good union without femoral head necrosis, except 1 case of femoral shaft fracture had delayed union;At the final follow-up, Harris score of patients with dual-structure fixation was 92.4±5.9, 7 cases were excellent, 3 cases were good, and 1 case was fair. Good reduction and fixation is the key to the treatment of such fractures. Both the single-structure fixation and the dual-structure fixation are good methods, and it should be selected according to the locations of femoral shaft and femoral neck fractures. Single-structure fixation is a good choice for femoral shaft fractures located at the proximal isthmus and basal femoral neck fractures. For isthmus and distal femoral shaft fractures combined with ipsilateral femoral neck fractures, dual-structure fixation is recommended.

Ipsilateral Femoral Neck and Shaft Fracture; A Case Series of 5 Patients

Femoral shaft fractures are very common following trauma in adults and sometimes the patient may have an ipsilateral neck of femur fractures too. Unfortunately, the neck of femur fractures may be missed. The challenge lies in detecting and properly managing the neck of femur fracture in the presence of a femoral shaft fracture. We share our experience in treating 5 patients with ipsilateral neck and shaft of femur fractures and discuss the learning points in regards to diagnosis and treatment of this condition.International Journal of Human and Health Sciences Vol. 07 No. 02 April’23 Page: 188-194

Conversion hip arthroplasty for failed internal fixation of ipsilateral femoral neck and shaft fractures: a case report

BackgroundIpsilateral femoral neck and hip fractures are uncommon high energy injuries. In the literature no single method of treatment has emerged as superior to the others. A recent publication has documented the successful application of the rendezvous technique using dual-implants for treating these injuries. However in some cases, this technique may fail and revision surgery is required.Case presentationA 67-year old man sustained ipsilateral fractures of his femur and femoral neck in a road traffic accident. His injuries were treated by a dual construct consisting of a retrograde femoral nail and dynamic hip screw. Three months after surgery the hip screw cut out of the femoral head necessitating revision to a total hip arthroplasty. Surgery was carried out using a single stage two part procedure on a standard operating table without having to reposition or redrape the patient. There were no postoperative complications and at 1 year from surgery the patient is satisfied with the result and has returned to work.ConclusionConversion hip arthroplasty in the presence of dual implants is a technically challenging and unpredictable procedure, with an increased risk of complications. Our surgical approach provides a framework for orthopedic surgeons to safely perform this complex procedure.

Protocolised MRI as an adjunct to CT in the diagnosis of femoral neck fracture in high energy ipsilateral femoral shaft fractures – A break-even analysis

BackgroundIn high-energy femoral shaft fractures (FSFs), ipsilateral femoral neck fractures (FNFs) can be missed by conventional trauma computed topography (CT) imaging, resulting in increased treatment costs and patient complications. Preliminary evidence suggests that a rapid, limited-sequence pelvis and hip magnetic resonance imaging (MRI) protocol can identify these occult fractures and be feasibly implemented in the trauma setting. This study aims to establish the economic break-even point for implementing such an MRI protocol in all high-energy FSFs. MethodsWe used an adapted break-even economic tool to determine whether the costs of a targeted MRI protocol can be offset by cost-savings achieved through prevention of missed fractures (thus avoiding prolonged admission and re-operation). Sensitivity analyses were performed to demonstrate reliability of the economic modelling across a range of assumptions. ResultsAssuming a baseline of FNFs missed on CT of 12%, an MRI cost of £129 and cost of treating each missed FNF of £2457.5, the equation yielded a break-even rate of 7% and absolute risk reduction (ARR) of 5%, indicating that for every 100 FSFs, MRI would need to diagnose 5 of the 12 missed FNF to be economically viable (number needed to treat (NNT)=20). Economic viability was maintained even at double the cost of MRI, while increasing the cost of treating each complication served to reduce the ARR further, increasing cost-savings. ConclusionA rapid, limited-sequence MRI protocol to exclude occult ipsilateral FNFs in all high-energy FSFs appears to be economically justified measure. Further research exploring the feasibility of such a protocol, as well as the role of intra-operative fluoroscopy in this context, is required.

SP5.2.3 Protocolised MRI as an Adjunct to CT in the Diagnosis of Femoral Neck Fracture in High Energy Ipsilateral Femoral Shaft Fractures – a Breakeven Analysis

Abstract Background In high-energy femoral shaft fractures, ipsilateral femoral neck fractures can be missed by conventional trauma computed-topography (CT) imaging, resulting in increased treatment costs and patient complications. Evidence suggests that a rapid, limited-sequence pelvis and hip magnetic resonance imaging (MRI) protocol can identify these occult fractures and be feasibly implemented in the trauma setting. This study aims to analyse the economic viability of implementing a such an MRI protocol for all high-energy femoral shaft fractures. Methods We used an adapted break-even economic tool to determine whether the costs of an MRI protocol can be offset by cost-savings achieved through prevention of missed fractures (thus avoiding prolonged inpatient admission, re-operation and implant costs). Sensitivity analyses were performed to demonstrate the reliability of the economic modelling across a range of assumptions. Results Assuming a baseline of hip fractures missed on CT of 12%, an MRI cost of £129 and cost of treating each missed hip fracture of £2633.5, the equation yielded a breakeven rate of 7% and absolute risk reduction (ARR) of 5%, indicating that for every 100 femoral shaft fractures, MRI would need to diagnose 5 of the 12 missed hip fractures to be economically viable (NNT=20). Economic viability was maintained even at double the cost of MRI, while increasing the cost of treating each complication served to reduce the ARR further, increasing cost effectiveness. Conclusion A rapid, limited-sequence MRI protocol to exclude occult ipsilateral hip fractures in all femoral shaft fractures would be an economically justified measure.

The surgical outcomes of fixing ipsilateral femoral neck and shaft fractures: single versus double implants fixation

BackgroundCombined ipsilateral femoral neck and shaft fractures are rare and present a challenging management dilemma. This study aims to assess the outcome of concomitant fixation of the ipsilateral femoral neck and shaft fracture using single versus dual surgical implants.MethodsA single-center retrospective analysis of patients who underwent fixation of ipsilateral femoral neck and shaft fractures was performed over a 13-year period. Different techniques were employed to fix the complex injury. Both the reduction and the union time were assessed radiographically.ResultsA total of 36 patients with ipsilateral femoral neck and shaft fractures were retrospectively identified and included in the study. Twenty-four patients (66.6%) were managed with a single cephalomedullary nail, while the remaining cases were treated with two devices. All cases were operated on within an average of 3.7 ± 7.1 days. Eight patients (22.2%) developed postoperative complications. The average follow-up period was 7.3 ± 6.8 months. Although there was no statistically significant difference between the two groups, the femoral neck fractures showed shorter union time in patients treated with one implant compared to patients treated with two implants (3.0 ± 2.3 months vs. 4.2 ± 2.6 months). Another observation was that higher percentages of implant removal/failure and malunion/nonunion were seen in patients who had one implant compared to the two implants group (12.5% vs. 8.3%).ConclusionEarly surgical fixation of both fractures is associated with good outcome results. No difference in outcome was observed between both groups.

The Impact of Magnetic Resonance Imaging on the Diagnosis of High-Energy Ipsilateral Femoral Neck and Shaft Fractures

To evaluate the most common femoral shaft fracture morphology associated with an ipsilateral femoral neck fracture in high-energy blunt trauma using magnetic resonance imaging (MRI). Retrospective review. Level 1 trauma center. 219 consecutive patients sustaining 228 femoral shaft fractures from high-energy blunt trauma. Fracture patterns were analyzed using the OTA/AO classification system. In addition, location of the fracture was measured as the distance from the distal aspect of the lesser trochanter to the center of the femoral shaft fracture. An OTA/AO 31 type fracture was seen in 16.5% (20/121) of patients presenting with OTA/AO 32-A type fractures, 12% (6/50) of patients with OTA/AO 32-B type fractures, and 26.3% (15/57) of patients with OTA/AO 32-C type fractures. The fractures that occurred in the middle or distal third of the femur shaft constituted 95.1% (39/41). In this cohort, patients with middle and distal third OTA/AO 32-C type fractures had the highest association with an ipsilateral OTA/AO 31 type fracture. OTA/AO 32-A2 and 32-A3 type fractures had the highest association with femoral neck fractures seen only on MRI. The data presented suggest continued usage of the rapid sequence pelvic MRI for all patients with high-energy femoral shaft fractures in whom a femoral neck fracture was not seen on an x-ray or a computed tomography scan. Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical outcomes and affecting factors of ipsilateral femoral neck and shaft fractures - Multination, multicenter analysis

BackgroundThis study aimed to evaluate the clinical outcomes of ipsilateral femoral neck and shaft fractures and identify the risk factors associated with missed diagnosis of femoral neck fractures and clinical outcomes of this fracture. MethodsThe ipsilateral femoral neck and shaft fractures from seven centers were retrospectively reviewed. Data on injury mechanism, fracture pattern, and fracture classification; surgical factors including fixation method; and timing of detection of femoral neck fracture were analyzed. The clinical outcomes, complications, and the incidence of avascular necrosis of the femoral head (AVNFH) were reviewed. Risk factors for missed femoral neck fracture and complications were analyzed. ResultsIn total, 74 patients with an average age of 43.6 years were included. Of the femoral shaft fractures, 56.8% were type A, 21.6% were type B, and 21.6% were type C. Sixteen patients had an open fracture of the femoral shaft. Femoral neck fracture was initially missed in 27% patients and the timing of delayed diagnosis was at an average of 11.1 days after injury. For detecting femoral neck fractures, minimal displacement of the femoral neck fracture was a risk factor, whereas computed tomography (CT) was a protective factor. The incidence of AVNFH was 6.8% at an average of 36.8 months after injury. The AVNFH group had more displaced femoral neck fractures at the time of surgery, but there was no difference in the timing of diagnosis compared to non-AVNFH group. The femoral shaft showed considerable healing problems, with an average union time of 29.7 weeks and a 20.2% nonunion rate. ConclusionIpsilateral femoral neck and shaft fractures had a high rate of missed diagnosis, especially in minimally displaced fractures; however, CT was a protective factor. AVNFH occurred in 6.8% and was related to femoral neck fracture displacement, but not delayed diagnosis. The femur nonunion rate was high, which warrants attention.

A Methodical Approach to Treatment Following Failed Internal Fixation of Ipsilateral Femoral Neck and Shaft Fractures

A Methodical Approach to Treatment Following Failed Internal Fixation of Ipsilateral Femoral Neck and Shaft Fractures

Surgical Window and Treatment Strategy for Patient with Multiple Fractures Escaping Inflammatory Response: A Case Report

Today’s Orthopedic surgeons must be adept at the evaluation and management of complicated Multiple Injured Patients (MIP). Despite dynamic strategies, advance modern medical care, the mortality rate of 50-70% has been reported due to high-velocity accidental cases with femoral shaft fractures associated with pelvic fractures and injuries to other organs. We hereby present an interesting case of MIP with the unstable pelvic acetabulum, ipsilateral femoral shaft fracture, floating elbow, and distal radius fracture. It is essential to follow an optimal protocol for such complex fractures. Therefore, we stated the appropriate surgical window and treatment intervention to fix all the major fractures by overcoming the hyperinflammatory state.

Outcomes of Ipsilateral Femoral Neck and Shaft Fractures Treated With Proximal Femoral Nail Antirotation 2.

Ipsilateral femoral neck and shaft fractures are relatively rare fractures, which most commonly occur in young adults following high-energy trauma. In most cases of such fractures, neck fracture is undisplaced and often of basicervical type. Many treatment methods have been described, but there is still no generalized consensus on the same. Cephalomedullary nails are one of the preferred modalities of treatment. A cephalomedullary nail-like proximal femoral nail antirotation 2 (PFNA 2) of recent design is being widely used currently. In this study, we present 13 cases of ipsilateral femoral neck and shaft fractures treated with PFNA 2 implants. The advantages of the PFNA 2 system include reduced blood loss, reduced operative time, and fewer fluoroscopy shots. PFNA 2 is a biomechanically better implant than many cephalomedullary implants. It provides satisfactory results in ipsilateral femoral neck and shaft fractures, especially where neck fracture is of a basicervical type. Some aspects have to be taken care of when employing PFNA 2, such as anatomical reduction, and length, angulation, and rotation of both neck and shaft.

Hip dislocation with ipsilateral femoral shaft fracture (closed treatment of both injuries in a single setting): Case report and literature review

Hip dislocation with concomitant femur shaft fracture is a rare and complex injury that results from high velocity trauma. There is lack of literature regarding pattern and management guidelines of these complex injuries. Here we report such rare case of posterior dislocation of hip associated with an ipsilateral fracture shaft of femur in a 21 year old male patient. Both the injuries were treated with closed reduction in a single anesthesia. The femoral head was first reduced with help of temporary external fixator and then closed antegrade femoral interlocking nailing was done for femoral shaft fracture. This resulted with a good functional outcome (Harris hip score-95) at one year follow up.

Ipsilateral femoral neck and shaft fractures. When do we need further image screening of the hip?

ObjectiveThe objective of the present study was to identify patterns of femoral diaphyseal fractures which are associated with fractures of the ipsilateral femoral neck according to the AO classification. We propose an algorithm of investigation based on plain radiographs, recognizing cases that need additional screening with computed tomography. Patients and MethodsThis observational retrospective study included patients with combined diaphyseal and femoral neck fractures. These patients were retrieved from a total of 1398 patients with the diagnoses of diaphyseal fractures of the femur, who were admitted to our hospital for surgical treatment between January 2009 and October 2019. All included cases had both fractures analyzed for their geometry and were classified according to the AO Classification, seeking to find a correlation between the types of fractures. ResultsSixteen diaphyseal fractures associated with ipsilateral neck fractures were detected during the period. The distribution of the diaphyseal fractures according to the AO Classification was as follows: 5 of type A3 (31,2%) 6 type B2 (37.5%), 1 type B3 (6,2%), 2 type C2 (12,5%) and 2 type C3 (12,5%). One A2 femoral fracture occurred during the surgical procedure. No type A1 fractures were detected. ConclusionThe patterns of high-energy diaphyseal fractures (A3, B and C) have a higher prevalence of associated ipsilateral neck fractures. Our study suggests that routine additional methods of image investigation of femoral neck fractures may be unnecessary for diaphyseal fractures type A1 and A2.

Dual-construct fixation is recommended in ipsilateral femoral neck fractures with infra-isthmus shaft fracture: A STROBE compliant study.

The aim of this study was to evaluate the risk factors related to osteosynthesis failure in patients with concomitant ipsilateral femoral neck and shaft fractures, including old age; smoking habit; comminuted fragments; infra-isthmus fracture; angular malreduction; unsatisfactory reduction (fracture gap >5 mm); and treatment with single construct.Patients over the age of 20 with concomitant ipsilateral femoral neck and shaft fractures diagnosed at a level one medical center between 2003 and 2019 were included. Treatment modalities included single construct with/without an antirotational screw for the neck and dual constructs. Radiographic outcomes were assessed from anteroposterior and lateral hip radiographs at follow-up. Fisher exact test was used to analyze categorical variables. The presence of avascular necrosis of the femoral head, delayed union, atrophic or hypertrophic nonunion of the femoral shaft fracture, and loss of reduction were identified as factors related to treatment failure.A total of 22 patients were included in this study. The average age was 58.5 years, and the majority was male (68.2%). The minimum radiographic follow-up duration was 12 months, and the median follow-up time was 12 (interquartile range 12–24) months.Femoral neck osteosynthesis failed in 3 patients, whereas femoral shaft osteosynthesis failed in 12 patients. Fisher exact test demonstrated the failure of femoral shaft osteosynthesis was significantly more frequent in the single-construct cohort in 16 infra-isthmus femoral fracture cases (P = .034).In ipsilateral femoral neck and infra-isthmus shaft fractures, it is better to treat the neck and shaft fractures with separate implants (dual constructs).In a dual-construct cohort, separate plate fixation of the femoral shaft achieved a better result in terms of bone union than retrograde nailing of the shaft (bone union rate: 4/8 vs 0/2).

An Occult Ipsilateral Femoral Neck Fracture Associated With Mid-Shaft Femur Fracture

Occult ipsilateral femoral neck fractures associated with femoral shaft fractures are frequently missed. They may lead to adverse outcomes, such as fracture displacement and delayed treatment followed by poor outcomes, including delayed union, malunion, nonunion, and osteonecrosis, which may lead to early arthroplasty. These adverse effects can be prevented by the awareness of this combined injury pattern, the adequate preoperative and intraoperative imaging of the femoral neck, and proper treatment. A 27-year-old man was admitted with a displaced fracture of the right femur. Fluoroscopic evaluation was performed after the intramedullary nailing of the shaft fracture. The evaluation revealed an ipsilateral displaced femoral neck fracture, which was fixed with two cannulated screw inserted anterior to the nail. Between 2% and 9% of all femoral shaft fractures are associated with ipsilateral femoral shaft fractures. This case report necessitates the increase of awareness for the presence of associated femoral shaft and neck fractures in patients undergoing antegrade femoral nailing. Also, we recommend appropriate preoperative, intraoperative, and postoperative imaging.