1. Fracture of theFemoral ShaftwithIpsilateralFracture of theFemoral neck 박희곤ㆍ김명호ㆍ유문집ㆍ유현열ㆍ이대희 Dept. of Orthopaedic Surgery, Dankook University Hospital

2. Introduction • Ipsilateral fractures of the femoral neck and shaft are rare • In high-energy injuries, especially in road traffic accidents • The incidence ranges : 1% to 6% of the femoral shaft fractures • Jain P (Injury, 2004) • Wolinski PR (Clin Orthop, 1995)

3. Introduction • Bennett FS (Clin Orthop Relat Res. 1993) • Swiontkowski MF (Orthop Clin North Am. 1987) • Femoral neck fractures are commonly missed 19% to 31% - Multiple injuries - the main focus : other life-threatening injuries

4. Purpose To analyze the clinical data in cases of fracture of the femoral shaft with ipsilateral fracture of the femoral neck

5. Material • Sep. 1995 ~ Jan. 2008 • 21 patients • Male / Female: 17 / 4 • Mean age: 38 years (19 – 66 years)

6. Method <operation method> • Use Fracturetable : for exact reduction • 1st : femur shaft fractures 2nd: femur neck fractures

7. Method <Fixation method> Femur shaft Femur neck DHS (8 cases) Plate & screw (12 cases) Cann. screws (4 cases) Total 21 cases Cann. screws (9 cases) IM nailing (9cases)

8. Results • 21 cases of 1113 cases (1.9%) • All cases were traffic accidents

9. Results <The time of the diagnosis>

10. Results <Location of femoral shaft fractures>

11. Results <Type of fracture of neck of the femur>

12. Results <Time to Op> • Average : Trauma 7days ( range : 17hrs ~ 28days) • Temporary skeletal traction : impossible to operate immediately • After vital sign stabilization → operation

13. Results <Combined fracture>

14. Complicaiton • AVN: 1 case Trauma # 5D : Op. with plate (shaft) & DHS (neck) → POD # 6mon : THRA

15. Case 1 • M/44 • 2006.06.09 Driver TA • Trauma 28 days Op. d/t aortic dissection, liver rupture • Neck : Garden stage II, shaft : mid-third Fx.

16. Pre Op

17. Pre Op

18. Pre Op

19. POD 1Y

20. Case 2 M/27 2007.12.14 Driver TA Op. : Trauma 2 days Neck : initially neglected → detected intraop. shaft : mid-third Fx.

21. Pre Op

22. Pre Op

23. POD 1Y

24. Case 3 M/34 2005.02.15 Driver TA Op. : Trauma 3 days Neck : neglected pre & intraop. →∴ Neck fixation : Trauma 2wks shaft : mid-third Fx.

25. Pre Op

26. Pre Op

27. Imm Op

28. POD 2wks (detected Neck Fx.)

29. Imm Op (neck)

30. POD 1Y

31. Discussion • Young and male dominated • The incidence ranges from 1% to 6% of the femoral shaft fractures • Alho A (Acta Orthop Scand. 1996) • Wolinski PR (Clin Orthop, 1995) • Zettas JP (Clin Orthop. 1981)

32. Discussion Femoral neck fractures are commonly missed initially; the rate varies from 19% to 31% The reported incidence of AVN in ipsilateral femoral neck and shaft fratures(3%) • Bennett FS (Clin Orthop Relat Res. 1993) • Swiontkowski MF (Orthop Clin North Am. 1987) • Alho A (Acta Orthop Scand. 1996)

33. Discussion 3 / 300 (1%) - Forceful use of an awl in the wrong direction - Multiple entry points in trochanteric region 4 / 315 (1.3%) - Insertion jig impinge on valgus femoral neck during final impaction <Iatrogenic fracture during nailing> • Khan FA (Injury. 1995) • Simonian PT (J Bone Joint Surg. 1994)

34. Discussion Mean age: 38 years Incidence : 21 / 1113 (1.9%) Missed neck Fx. : 6 / 21 (29%) AVN : 1 / 21 (4.7%) <in Our study>

35. Discussion Lower than the solitary femoral neck fracture(10%) Because 1. The force is dissipated in the shaft fracture 2. Base of neck fracture and non-displaced neck fracture <Incidence of AVN> • Gerber C. (Clin Orthop Rel Res. 1993)

36. Discussion Early fixation & ambulation : morbidity ↓ Suggested immediate reduction & fixation : avoid displacement of the neck fracture and AVN Delay of weeks in the fixation does notincrease the complication rate • Goris RJ. (J Trauma. 1982) • Swiontkowski MF. (J Bone Joint Surg Am. 1984) • Wolinsky PR. (Clin Orthop Rel Res. 1995)

37. Discussion The neck fracture were stabilized first : avoid further displacement of the neck fracture and AVN The shaft fractures were stabilized first → no further displacement of neck fracture • Leung KS (Injury. 1993) • Swiontkowski MF (J Bone Joint Surg. 1984) • Chen CH (Injury. 2000)

38. Discussion <in Our study> • In our cases, the shaft fractures were stabilized first, and the neck fractures treated later • Use Fx. table : for exact reduction → no further displacement of neck fracture

39. Discussion Cancellous lag screws or DHS (neck) compression plate (shaft) : 15 cases VS Intramedullary nailing : 12 cases → Both achieved satisfactory functional outcome • Singh R. (J Orthop Traumatol. 2008)

40. Discussion Both hip AP X-ray checked: 18/21 cases - 3 of 18 (16.7%): missed diagnosis No evaluation of hip (femur neck) : 3 cases → Pre or intra Op C-arm manipulation <In our study>

41. Discussion Abdominopelvic CT or pelvis 3D CT checked - 6 cases : detecting a fracture → CT reading : careful attention <In our study>

42. Conclusion • Can be missed during the initial diagnosis in high-energy injuries • Demands careful attention - Adding AP x-rays of the hip joint - Hip CT - Bone scan - Pre Op C-arm manipulation - Follow up x-rays

43. Thank you for your attention