|MISSION HOSPITAL SECTION
|Year : 2016 | Volume
| Issue : 3 | Page : 214-217
Challenges in managing ipsilateral femoral neck and shaft fracture at Mission Hospital
Department of Orthopedics, Christian Hospital Mungeli, Mungeli, Chhattisgarh, India
|Date of Web Publication||9-Jun-2016|
Department of Orthopedics, Christian Hospital Mungeli, Lormi Road, Mungeli - 495 334, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Rarity of ipsilateral femoral neck and shaft fracture qualifies it as a difficult fracture to diagnose as well as treat. No ideal treatment option has been defined, and no ideal implant has been assigned for the management of such fractures. Fixation of ipsilateral fractures of femoral neck and shaft are technically demanding. They are also associated with complications such as osteonecrosis of femoral head, delayed union, varus malunion, and nonunion. Treating such complicated fractures in a level V trauma center such as rural mission hospital with limited resources multiplies the difficulty of managing such fracture. This case report highlights the outcome and challenges in treating a patient with ipsilateral femoral neck and shaft fracture in a mission hospital in rural central India.
Keywords: Femoral neck and shaft, fracture, ipsilateral
|How to cite this article:|
James D. Challenges in managing ipsilateral femoral neck and shaft fracture at Mission Hospital. CHRISMED J Health Res 2016;3:214-7
|How to cite this URL:|
James D. Challenges in managing ipsilateral femoral neck and shaft fracture at Mission Hospital. CHRISMED J Health Res [serial online] 2016 [cited 2019 May 19];3:214-7. Available from: http://www.cjhr.org/text.asp?2016/3/3/214/183744
| Introduction|| |
Ipsilateral femoral neck and shaft fracture are an uncommon injury associated with high-velocity trauma.  Up to 9% of all femoral shaft fractures can be associated with ipsilateral femoral neck fractures.  As nearly a third of ipsilateral neck fractures are missed on the initial radiographs, internal rotation view, and computed tomography scan are necessary. ,, Treatment of such fracture is technically challenging and associated with high incidence of complications. ,,, Managing such injury in rural mission hospital scenario becomes more difficult due to reasons not seen at the level I to III trauma centers, where such injury is generally managed. To the best of my knowledge, this is the first report of treatment of such fracture pattern from a level V trauma center. This report aims to forewarn the orthopedic surgeon of the challenges one has to overcome in managing such complicated injury in a level V trauma center.
| Case report|| |
A 30-year-old male patient presented with pain, swelling, and deformity over left thigh, both wrists and minor head, and chest injuries following motor vehicle accident. Fracture of midshaft left femur was associated with displaced basicervical Garden IV fracture neck of left femur and comminuted bilateral distal radius fractures [Figure 1]. Preoperative consultation was done with extramural faculty. Femur neck and shaft fractures were stabilized using "miss a nail technique [Figure 2]." Patient underwent closed reamed interlocked antegrade femur nailing under spinal anesthesia. A 9.0 mm femur nail was used to ensure enough space for femoral neck screws [Figure 3] and [Figure 4]. Fracture neck of femur was reduced and fixed with two 6.5 mm cancellous screws, placed anterior to the femur nail. Femur neck fracture was fixed within 12 h of the injury. He underwent a second stage K-wire fixation for left distal radius and ligamentotaxis for right distal radius fractures 48 h later. Bilateral upper limb injury ruled out assisted weight bearing. Left femur shaft fracture united in 16 weeks. Fracture neck of left femur united in 20 weeks [Figure 5] and [Figure 6]. Patient was followed up for 2½ years. Patient regained full range of movement of left hip and both wrists [Figure 7] and [Figure 8]. There was no clinical or radiological evidence of osteonecrosis of femoral head. Fracture neck of femur malunited in varus with 5 mm shortening of the left lower limb.
|Figure 3: Lateral postoperative radiograph (two femoral neck screws applied posterior to the femoral nail)|
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|Figure 7: Two and half years follow-up (weight bearing on operated limb)|
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| Discussion|| |
A small subset of femoral shaft fractures is associated with ipsilateral femoral neck fractures. Such fracture patterns are considered difficult to diagnose and treat. ,, Fixation of femoral neck fracture is the priority; however, open reduction or initial stabilization of the femoral shaft fracture is essential for reduction of a displaced femoral neck fracture. ,,,, No implant of choice or ideal method of fixation has yet been defined. ,, Several modalities such as reconstruction nail, long proximal femoral nail, antegrade femur nail with supplementary cancellous screws, retrograde femur nail with multiple femoral neck screws or dynamic hip screw plate fixation, and plate fixation of the femoral shaft with separate femoral neck screws are published options for treating such fractures. ,,,,,,, Rarity of such fracture pattern and limited availability of published scientific evidence for the treatment of such fractures pose a challenge to the treating surgeon. ,
Femoral neck fractures when associated with ipsilateral femoral shaft fractures are commonly undisplaced or minimally displaced, vertically oriented, and basilar. ,, Our patient had a Garden IV (Pauwels class 3) basicervical neck of femur fracture. Implant choice was changed from recon nail to antegrade femur nail as instrumentation for recon nail was unavailable. Limited implant option is a common issue at our center, located 60 km away from a Tier III city, with limited connectivity.
The ideal "inverted triangle" configuration for femoral neck screws cannot be achieved in "miss a nail technique."  As the procedure understandably took nearly 5 h, spinal anesthesia had to be supplemented by ketamine which offered no muscle relaxation, making femoral neck fracture reduction very difficult. Femoral neck was reduced and fixed with K-wires. Two 6.5 mm cancellous screws were inserted to hold the femoral neck fracture. It can be difficult to insert large diameter cancellous screws around a femur nail.  No space was available to insert a posterior screw. Slightly convergent configuration of the femoral screw was accepted as there was limited space available between proximal interlocking bolt and slightly wider portion of the femoral nail. Some manufacturers produce "miss a nail" jig, but we did not have access to such a jig.
Common complications described with ipsilateral femoral neck and shaft fractures are osteonecrosis of femoral head, delayed union or nonunion of both or either femoral neck fracture or femoral shaft fracture, and varus malunion of femoral neck fracture. ,,, Time to the union for femoral shaft and neck was comparable to other published data. , There was no clinical or radiological evidence of osteonecrosis at 2½ years follow-up. Patient has an excellent functional outcome. The femoral neck fracture united in varus. Closed reamed antegrade femoral nailing with additional screw fixation of the ipsilateral femoral neck tend to have high rates of varus malunion of the femoral neck. ,
Such high-velocity injuries are generally associated with multisystem injury, requiring intensive care and multidisciplinary approach. , We treated the patient for lung contusion and minor head injury. Level V trauma center has limited critical care facility. Lack of qualified surgical assistants and trained personnel is a common difficulty one faces in rural hospitals.  The first assistant in this surgery was our dentist.
| Conclusion|| |
Limited access to implants, unavailability of implants and instruments, limited critical care facility, and lack of trained personnel are common problems in level V trauma center such as rural mission hospital in India. However, with good preoperative planning and networking such challenging case can have a good outcome in level V trauma center. Displaced femoral neck fracture, lack of adequate muscle relaxation for reduction of femoral neck fracture, and "miss a nail technique" contributed to varus malunion of the femoral neck fracture.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]