Noncontiguous fractures of the femoral neck,femoral shaft,and distal femur

BACKGROUND: Multifocal fractures of the femur are uncommon injuries and present unique management challenges. Combined ipsilateral fractures of the femoral shaft and femoral neck or the femoral shaft and distal femur have been described. The combination of noncontiguous ipsilateral femoral neck, femoral shaft, and distal femoral articular injuries, however, has not been described. The purposes of this report are to document the incidence and characteristics of this injury and to present a treatment rationale. METHODS: This was a retrospective study conducted at a Level I trauma center. RESULTS: Over a 5-year period, 1639 adult patients with femur fractures were definitively managed at the authors' institution. Five male and two female patients (average age, 43.3 years) sustained ipsilateral, noncontiguous fractures of the femoral neck, femoral shaft, and distal femoral articular surface (0.43%). All femoral neck fractures were vertically oriented. All distal femoral injuries were unicondylar. A variety of fixation methods were used, dependent on individual fracture characteristics. The femoral neck fractures were prioritized in all cases. Stabilization of the distal femoral articular surface was then performed before diaphyseal fixation in patients with sagittally oriented condylar fractures. Patients were followed for an average of 19.3 months. All fractures healed without the need for secondary procedures. CONCLUSION: This injury constellation is rare. Open reduction and internal fixation of the displaced femoral neck fracture should be the primary focus of orthopedic management, followed by stable reduction and fixation of displaced distal femoral articular injuries. The diaphyseal fracture should be treated with a technique that does not jeopardize either the proximal or the distal fractures. Patients who are critically ill can be managed in a similar sequence over the course of several days, depending on their overall condition.     

Surgical treatment for ipsilateral fractures of the hip and femoral shaft

Concomitant ipsilateral femoral shaft and neck fractures are difficult to treat. There is still no consensus on the optimal treatment of these complex fractures. Forty-seven patients with these complex fractures were treated in Kaohsiung Medical University Hospital between the periods of 1982 and 1998. Our standard treatment protocol is plate fixation for femoral shaft fracture and lag screw or dynamic hip screw (DHS) fixation for hip fracture. Among 42 cases treated with this protocol, 34 were males and 8 were females with an average age of 36 years and average follow-up period of 55 months. We divided hip fractures into two groups: femoral neck fracture as group I and intertrochanteric fracture as group II. There were no non-union and osteonecrosis of the hip in either group. One diaphyseal non-union was observed in group I and four in group II. There were 92 and 76% good functional results in groups I and II, respectively. The result shows that our standard method can yield a reliable outcome in group I, but not in group II.     

Cephalomedullary interlocked nail for ipsilateral hip and femoral shaft fractures

A retrospective study of the management of 23 cases of ipsilateral hip and femoral shaft fractures, between January 1998 and December 2001, is presented. All except two cases were managed by a single implant, i.e. reconstruction nail. There was delayed diagnosis of femoral neck fracture in two cases where the "miss a nail" technique was used for fixation of the femoral neck fracture. All patients managed by reconstruction nail were simultaneously operated on for both fractures and operative treatment was executed as early as the general condition of the patient permitted. Delay in treatment was generally because of the associated injuries (head, chest or abdominal). There were 22 males and 1 female patient with an average age of 34.5 years. Average follow-up was 30.9 months. There was one case of non-union of the femoral neck fracture, one case of avascular necrosis and one femoral neck fracture united in varus. There were four cases of non-union and six cases of delayed union of femoral shaft fractures. Mean time for union of the femoral neck fracture was 15 weeks and for the shaft fracture was 22 weeks. In this series femoral shaft fracture determined the total union period. Complications involving the femoral shaft fracture were more common than those related to femoral neck fractures. Shaft complications were more manageable with or without secondary procedures as compared to femoral neck complications, which usually require more extensive procedures. This stresses the need to realise the significance and seriousness of both components of this complex injury, in evaluation, management and post-operative care. We conclude that, though technically demanding, reconstruction nail is an acceptable alternative for management of concomitant fractures of the femoral neck and shaft with acceptable rates of complications and good results.     

Ipsilateral fractures of the femoral neck and shaft.

Thirty-three patients with ipsilateral intracapsular femoral neck and shaft fractures were treated with antegrade reamed intramedullary (IM) nails and cancellous screw fixation of the femoral neck. The shaft fractures were fixed prior to definitive neck stabilization. A "reversed" nail construct was used in 13 patients, a conventional interlocked nail was used in 6, and a reconstruction nail was used in the remaining 14. Thirty-one (94%) of the femoral shaft fractures healed primarily. In two patients, the shaft fracture failed to unite and was bone grafted and plated, respectively; the fractures subsequently healed. However, only 27 (82%) of the femoral neck fractures healed after initial fixation. In six patients (18%), a symptomatic varus nonunion developed, requiring a valgus osteotomy. Five of the six femoral neck non-unions and all of the osteotomy sites united; however, two of these patients later developed osteonecrosis of their femoral heads. Closed reamed antegrade IM nailing with supplemental screw fixation of ipsilateral femoral neck and shaft fractures did not produce uniformly successful results because of high rates of varus nonunion of the femoral neck fracture.     

Retrograde nailing with subsequent screw fixation for ipsilateral femoral shaft and neck fractures

Introduction Although ipsilateral femoral shaft and neck fractures are difficult to treat, there is still no consensus on the optimal treatment of this complex injury. We report the results of treating the 17 fractures with a standard protocol of retrograde nailing for diaphyseal fractures and subsequent screw fixation for the femoral neck fractures. Materials and methods Seventeen injuries (16 patients) sustained femoral shaft fractures, which were treated with retrograde intramedullary nails and subsequent screw fixation. Femoral neck fracture was noted before the operation in all patients except one. A femoral shaft fracture was always addressed first with unreamed retrograde nailing. Then, the femoral neck fracture was treated by cannulated screws or dynamic hip screw according to the level of fracture. Results The average time for union of femoral shaft fractures was 27.3 (14–60) weeks. Nonunion occurred in five patients, who required bone grafts or changes of fixation. The average time for union of femoral neck fractures was 11 (8–12) weeks. All united, except for one case of nonunion with avascuar necrosis, which was a Garden stage IV fracture. Functional results using Friedman–Wyman criteria were good in 16 cases, and fair in one. The only fair result was nonunion of the femoral neck, which had the joint arthroplasty. Conclusion Retrograde nailing of femoral shaft fractures can provide an easy fixation and a favorable result for ipsilateral femoral neck fractures.This study was conducted at Kyungpook National University Hospital, Daegu, South Korea. The authors have and will not receive any financial benefit in association with the present paper.     

Clinical study on internal fixation of femoral neck fractures.

A clinical study on the results of internal fixation of femoral neck fractures treated by multiple Knowles pinning was undertaken and correlated with the results of an experimental study. Experimentally, failures were produced by downwards migration of the Knowles pins. This phenomenon accounts for the settling of the femoral head on the neck and the frequency of non-union or malunion in patients with subcapital fractures. The type of fracture, type of reduction and age correlate with failure rate. This has to be explained by biomechanical considerations based upon the mode of failure of the internal fixation. A Garden stage III and IV, a varus or anatomical reduction of the fracture and an old age predispose to failure of the internal fixation and consequent non-union.     

Reconstruction nailing for ipsilateral femoral neck and shaft fractures

The surgical management of ipsilateral fractures of the femoral neck and shaft presents a difficult and challenging problem for the orthopaedic surgeon. The purpose of the present study was to report the mid-term results and complications in a series of patients who sustained ipsilateral femoral neck and shaft fractures and treated in our trauma department with a single reconstruction nail for both fractures. Eleven patients were included in the study with an average age of 46.4 years. The mean follow-up was 47 months (range, 15–75 months). There were no cases of a missed diagnosis at initial presentation. The mean time to union was 4.5 months for the neck fracture and 8.2 months for the shaft. There were no cases of avascular necrosis of the femoral head or non-union of the neck fracture. The mean Harris Hip Score was (85 ± 4.3). Complications included two cases of shaft fracture non-union and one case of peroneal nerve palsy. Heterotopic ossification at the tip of the greater trochanter was evident in two cases without causing any functional deficit. The current study suggests that reconstruction nailing produces satisfactory clinical and functional results in the mid-term. The complications involved only the femoral shaft fracture and were successfully treated with a single operative procedure.     

Treatment of distal tibial fractures: plate versus nail

A study of 24 patients who sustained an extra-articular fracture of the distal third of the tibial shaft was performed to determine the effect of the type of treatment, open reduction and internal fixation (ORIF) or closed reduction and intramedullary (IM) nailing, on the occurrence of malalignment. All patients were treated in our clinic between 1993 and 2001 for a fracture in the distal third of the tibia. Twelve patients treated with ORIF were matched to 12 patients treated with IM nailing, with regard to gender, age decade, and the AO classification of the fracture. The group treated with IM nailing was assessed after a mean 6.0 years versus ORIF after a mean of 4.5 years. Two patients treated with ORIF versus six patients treated with IM nailing had a malalignment of the tibia. Furthermore, we found no difference with regard to time to union, non-union, hardware failure or deep infections between ORIF and IM nailing. Our results suggest that control of alignment is difficult with IM nailing of distal tibial fractures. For optimal alignment we advise considering the use of ORIF for closed and type I open extra-articular fractures in the distal third of the tibia.     

股骨重建钉治疗股骨干合并同侧髋部骨折适应证探讨

目的探讨股骨重建钉治疗股骨干合并同侧髋部骨折的手术适应证。方法根据入选标准和排除标准,回顾2001年1月至2011年1月收治的股骨干合并同侧髋部骨折病例15例,其中男14例,女1例;年龄21~64岁,平均35.5岁。通过比较术前、术后即刻、术后1、3、6和12个月的临床和影像学随访结果,评估骨折愈合情况和并发症,分析股骨重建钉治疗股骨干合并同侧髋部骨折的最佳适应证。结果全部病例获得随访,随访时间14~48个月,平均27.8个月。13例股骨干骨折一期获得骨性愈合,愈合时间(6.2±4.1)个月,14例股骨颈骨折一期获得骨性愈合,愈合时间(5.4±2.9)个月。合并症:1例股骨远端骨折由于狭部限制,重建钉过细,局部旋转不稳定,并发肥大性骨不连;1例股骨中段骨折延迟愈合;2例股骨干旋转畸形愈合;1例股骨颈头下型骨折不愈合。末次随访时进行Friedman-Wyman评定,优12例,良2例,差1例,优良率93.3%。结论股骨重建钉适用于绝大部分股骨干骨折合并髋部骨折,尤其是股骨颈基底部骨折合并股骨干近端或狭部骨折。但对于股骨颈头下型、难复位的股骨颈骨折合并股骨干远端骨折,股骨重建钉并非最佳的治疗方案。     

Delayed recognition of an ipsilateral femoral neck and shaft fracture leading to preventable subsequent complications: a case report

Background

Ipsilateral 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 presentation

A 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.

Conclusion

This 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.

     

Is there a place for external fixation in humeral shaft fractures?

There is a good indication for unilateral axial dynamic external fixation in fractures of the humeral shaft when the fracture appears in the distal third or in cases of bilateral fractures. A non-union or a posttraumatic paralysis of the radial nerve may be indications for external fixation as well as fractures associated with multiple injuries. Further indications include osteitis, infected non-union and comminuted fracture. There is maximum protection of the soft tissue with this method of treatment. External fixation combines the advantages of conservative and operative treatment by influencing callus formation by dynamizing, distraction or compression. Minimizing soft tissue damage facilitates the decision for early exploration of the radial nerve in cases of palsy. A safer positioning technique of the distal screws of the fixator is described.     

Intracapsular hip fractures in end-stage renal failure

Patients with end-stage renal failure (ESRF) have metabolic bone disease. This increases the risk of femoral neck fracture and increases the risk of complications associated with fracture fixation such as non-union and avascular necrosis (AVN). We report the results of treatment in a consecutive series of 15 intracapsular fractures of the hip occurring in 13 patients with ESRF over a 5-year period. Six intracapsular hip fractures (of which five were undisplaced) were treated by internal fixation. Five out of these six (mean=83.3%) required conversion to total hip arthroplasty because of non-union or AVN. In all six of these patients, internal fixation was considered adequate post operatively. Of the remaining nine intracapsular hip fractures treated by hemiarthroplasty, only one required conversion to total hip arthroplasty because of stem subsidence (mean=11%). The difference in the revision rate for the two groups i.e. primary fixation versus primary hemiarthroplasty was statistically significant (p-value=0.01). The six patients with undisplaced intracapsular fractures treated by internal fixation required a total of 14 major operations, at an average rate (including initial fracture fixation and revision surgery) of 2.3 per patient. The 9 displaced fractures treated by hemiarthroplasty required just 10 operations in total, at an average rate of 1.1 per patient. (The difference was significant; p-value=0.006.) The 1-year mortality in the whole group (13 patients with 15 fractures) was 44.4%. We suggest that patients with ESRF with an intracapsular fracture of the neck of femur should be treated by replacement arthroplasty irrespective of femoral head displacement because of the high risk of revision surgery associated with internal fixation.     

HUCKSTEP INTRAMEDULLARY NAILING FOR NON-UNION OF HUMERAL SHAFT FRACTURES

Background : Various techniques of internal fixation for non-union of humeral shaft fractures have been attempted, leading to union rates of between 50 and 90% with persisting non-union causing pain and disability. Some of these techniques have led to shoulder and elbow dysfunction. Methods : Eight patients treated with Huckstep nail fixation for humeral shaft non-union were reviewed and the rate of union was determined. Elbow and shoulder function were assessed as well as the presence of pain or disability. Results : Union was achieved in seven of the eight patients (87.5%). Four patients had occasional mild pain after union. All patients achieved good arm function. Average shoulder abduction was 157° and flexion 151° excluding one patient with antecedent advanced osteoarthrosis of the gleno-humeral joint. No patient experienced any permanent neurological deficit. Conclusions : Huckstep nail fixation achieved union rates comparable to or higher than the other techniques of internal fixation for non-union of humeral shaft fractures. Unlike the various methods of closed nailing, Huckstep nail fixation is not associated with shoulder and elbow dysfunction. It should be considered as a therapeutic option in humeral shaft fracture and non-union, especially where the fracture site needs to be opened.     

Non-union of fractures of the distal end of the humerus

The records of twenty patients who had been treated for a non-union of the distal end of the humerus at the Massachusetts General Hospital from 1968 to 1984 were reviewed. Thirteen of the fractures were extra-articular and seven were intra-articular. Seven fractures had been open and nine had been associated with multiple trauma. Eight had been initially treated by open reduction and internal fixation; five, by closed reduction and immobilization; four, by skeletal traction; two, by external fixation; and one, by débridement and immobilization. The average time from the original fracture to the treatment of the non-union was twenty months (range, three to 120 months). All but one patient had pain and instability, and fifteen (75 per cent) had limited motion of the elbow. Radiographically, eleven were considered to have a reactive non-union and nine, a non-reactive non-union. Seventeen (94 per cent) of the eighteen non-unions ultimately united. Two patients underwent excision of the distal end of the humerus and replacement with an allograft. At follow-up (average, 3.6 years), function in one patient was rated as excellent; in six, as good; in seven, as fair; and in six, as poor. The patients who had an extra-articular supracondylar non-union had the best over-all results, while those who had a non-union that was associated with an intra-articular component or severe soft-tissue trauma did less well. It should be emphasized, however, that most of the patients in this study continued to have a major long-term disability, despite the fact that union was successful.     

Treatment of ipsilateral femoral neck and shaft fractures

Objective：To investigate the clinical characteristics, treatment options and causes of misdiagnosis of ipsilateral femoral neck and shaft fractures.
Methods： Among 20 patients with ipsilateral femoral neck and shaft fractures, 19 were treated operatively and 1 was treated conservatively. Sixteen cases of femoral shaft fractures were treated by open reduction and internal fixation with compressive plate, and 2 cases were treated with interlocking intramedullary nailing. Eighteen femoral neck fractures were treated with cannulated screws. Another patient was treated with proximal femoral nail to fix both the neck and shaft. Delayed diagnosis for femoral neck frac-tures occurred in 2 cases preoperatively. Results： A total of 19 patients were followed up. The follow up period ranged from 5 to 48 months with an average of 15 months. All the fractures were healed.
Conclusion： For case of femoral shaft fracture caused by high energy injury, an AP pelvic film should be routinely taken. Once the femoral neck fracture is recognized, operative reduction and fixation should be performed in time. Femoral neck and shaft fractures should be fixed separately.     

To fix or not to fix? The role of fibular fixation in distal shaft fractures of the leg

Background

The role of stabilisation of the fibula in distal two-bone fractures of the leg is controversial. Some studies indicate the need for fibular stabilisation in 43 AO fractures, but few studies consider the role of the fibula in 42 AO fractures. The aim of the current paper is to explain the role of stabilisation of the fibula in 42 AO fractures, correlating the rates of healing and non-union between patients with and without fibula fixation.

Materials and methods

A total of 60 patients with 42 AO (distal) shaft fracture of the tibia with associated fracture of the fibula were selected. Patients were divided into two groups according to whether or not the fibula was fixed: Group I (n = 26) comprised patients who had their fibula fixed while Group II (n = 34) comprised patients who did not. The fibular fracture was classified according to the AO and related to the level of the tibial fracture. Other parameters examined were the union rate of the two groups correlated to the fracture pattern and position of the fibular fracture; the demographic data, such as age and gender; the presence of an open fracture, and the type of tibial fixation device used (nail or plate).

Results

None of the parameters considered (open injury, AO classification, device used and level of the fibular fracture relative to the tibial) were shown to have an influence on the development of a non-union.

Conclusion

This study showed a higher non-union rate when the fracture of the tibia and fibula were at the same level, the tibia was fixed with a bridging plate and the fibula left untouched. For this reason, we recommend fibular fixation in all 42 distal fractures when both fractures lie on the same plane and the tibial fracture is relatively stabilised.     

Non-union of fractures of the mid-shaft of the clavicle. Treatment with a modified Hagie intramedullary pin and autogenous bone-grafting

We reviewed a series of fifty patients who had a non-union of a fracture of the clavicle. Twenty-one patients (42 per cent) who had a symptomatic non-union of the middle of the shaft of the clavicle were treated with open reduction, internal fixation with a modified Hagie intramedullary pin, and autogenous bone-grafting, and those patients form the basis for the report. The average duration of follow-up was thirty-five months (range, five months to eleven years). Healing occurred in twenty (95 per cent) of the twenty-one patients. Intramedullary fixation has several advantages compared with other treatments, such as fixation with a plate and screws. It can be performed through a cosmetically acceptable incision in the Langer line; less dissection of the soft tissues is needed; and, after healing, the pin can be removed through a small incision under local anesthesia.     

Ipsilateral femoral shaft and neck fractures: are cephalomedullary nails appropriate?

A retrospective review was conducted to examine rates of malreduction and nonunion in ipsilateral femoral neck and shaft fractures using different fixation strategies. Twenty-two consecutive patients with 23 fractures were identified. Participants were treated with various fixation strategies for ipsilateral femoral neck and shaft fractures. Cephalomedullary devices were used in 13 cases, while cannulated screws and a retrograde femoral nail were used in nine cases. One patient was treated with cannulated screws and external fixation of the femoral shaft. Radiographic assessment of the quality of reduction and union of both fractures was evaluated. Clinical and radiographic follow-up was available in 20 fractures (87%) with a mean of 12 months (range 3-50). Two femoral neck nonunions occurred; both had fair reductions of the fractures obtained by closed maneuvers, and two-device fixation was used in each. One femoral shaft nonunion occurred in a fracture treated with a cephalomedullary nail. All three united after revision surgery. No cases of osteonecrosis or conversion to hip arthroplasty were noted. A combination of retrograde femoral nailing and screw fixation of the femoral neck or placement of a cephalomedullary nail can provide excellent reduction and rate of union in the treatment of this injury pattern. Excellent reduction of the femoral neck fracture is key to preventing femoral neck nonunion.     

Factors affecting the fracture healing in treatment of tibial shaft fractures with circular external fixator

This study aims to analyse the contribution of various risk factors for the delay of tibial shaft fractures treated by circular external fixator and predicting the high risk fractures for delayed union. 32 extraarticular tibial shaft fractures of 31 adult patients treated with circular external fixator were included. The patients were analysed according to age, energy of trauma, having an open fracture or not, AO classification, obliquity, use of supplementary fixation techniques in surgery, distance of fracture line to neighbouring rings, having a pin-track infection or not, reduction score, and smoking. There were eight delayed unions and two non-unions in our study. Consolidation time was significantly shorter (p = 0.01) between the supplementary fixation group and the others. There was a significant difference in fracture healing time between pin-track-infected patients and the patients who did not have pin-track infection (p = 0.037). In conclusion, our results indicate that non-union infection and not using supplementary fixation techniques are the major factors that delay the healing time. Supplementary fixation enhances the reduction rate and a low reduction score is related with the occurrence of a pin-track infection.     

Ipsilateral fractures of femoral neck and shaft

Thirteen cases of ipsilateral intracapsular femoral neck and shaft fractures were seen. All cases occurred in young adults, with the mechanism of injury in all instances being high-energy trauma. The diagnosis of the femoral neck fracture was missed initially in four cases. The patients were divided into four groups according to treatment protocol: group 1 (two cases), both fractures treated nonoperatively; group 2 (four cases), femoral neck fracture treated nonoperatively, open reduction and internal fixation of femoral shaft fracture; group 3 (three cases), McMurray's osteotomy for femoral neck fracture and internal fixation for the femoral shaft fracture; and group 4 (four cases), open reduction and internal fixation of both fractures. The follow-up period ranged from 6 months to 10.1 years. There was a nonunion of one femoral neck fracture, while all shaft fractures united. The best results were seen in group 4 cases. It is also recommended that routine high-quality X-ray films of the hip should be done in all cases of femoral shaft fracture to decrease the high incidence of missed femoral neck fractures in ipsilateral injuries of the femur.