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Fracture of the Femoral Shaft with Ipsilateral Fracture of the Femoral neck

Fracture of the Femoral Shaft with Ipsilateral Fracture of the Femoral neck. 박희곤 ㆍ김명호ㆍ유문집ㆍ유현열ㆍ이대희 Dept. of Orthopaedic Surgery, Dankook University Hospital. Introduction. Ipsilateral fractures of the femoral neck and shaft are rare

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Fracture of the Femoral Shaft with Ipsilateral Fracture of the Femoral neck

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  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

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