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

OBJECTIVE: The 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 METHODS: This 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. RESULTS: Sixteen 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. CONCLUSION: The 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.

Interlocking nailing of femoral shaft fractures with an extremely narrow medullary canal is associated with iatrogenic fractures.

INTRODUCTION: Controversy exists regarding the use of reamed interlocking nailing in femoral shafts with extremely narrow medullary canals (diameter ≤ 9 mm). The aims of this study were to (1) investigate the association of age and sex on femoral canal diameter in patients with a simple femoral shaft fracture and (2) compare the outcomes and complications of interlocking nailing between wide and extremely narrow intramedullary canals. PATIENTS AND METHODS: For the purposes of this retrospective cohort study, consecutive patients with simple femoral shaft fractures were recruited between January 2009 and December 2016. The patient demographic data were analyzed. Then, fractures treated with interlocking nailing were divided into the wide group (canal diameter > 9 mm) and narrow group. The primary outcome was union rate, and the secondary outcomes were complications such as thermal necrosis, fat embolism syndrome, iatrogenic fracture, and implant failure. RESULTS: This study included 340 femoral shaft fractures. The average canal diameter was 9.97 ±â€¯1.79 mm, with significantly wider canals in men than in women. Overall, 289 of the patients had undergone interlocking nail fixation, and a similar union rate and complications were noted between the wide canal and narrow canal groups, with the exception of the incidence of iatrogenic fracture. CONCLUSIONS: Femoral shaft fractures associated with extremely narrow medullary canals are more common in women than in men. There was a similar union rate found when using interlocking nailing in a femoral shaft fracture in cases with extremely narrow and wider canals. Iatrogenic fracture is the only significant risk when using interlocking nailing in femoral shafts with extremely narrow canals.

Fractura de cuello femoral en trauma de alta energía: ¿podemos confiar en la tomografía computarizada multicorte? caso clínico / High energy femoral neck fracture: can we trust the computerized tomography scan? case report

Las fracturas asociadas de diáfisis y cuello femoral son lesiones infrecuentes. A pesar de ser una asociación conocida, es pasada por alto entre un 19-31% de las veces. A continuación presentamos un caso de una fractura de diáfisis femoral en la cual la tomografía computarizada inicial no evidenció ningún rasgo a nivel del cuello femoral; sin embargo, este rasgo se hizo presente en las imágenes de control. Existen diversos exámenes para reconocer las fracturas de cuello femoral asociadas a diáfisis femoral, como la radiografía y la tomografía computarizada. Sin embargo, a pesar de estas imágenes, pueden no ser diagnosticadas. Con este caso reafirmamos la necesidad del uso de imágenes preoperatorias e intraoperatorias en pacientes con fracturas de diáfisis femoral de alta energía y que la tomografía computarizada multicorte de ingreso puede no evidenciar fracturas mínimamente desplazadas del cuello femoral.

Simultaneous fractures of the neck and shaft of the femur are uncommon injuries. Despite it being a known combination, it is overlooked in between 19 and 31% of cases. This case report describes a femoral shaft fracture in which the initial computed tomography did not show the femoral neck fracture, although it was present in the follow-up images. There are different imaging techniques to recognise femoral neck fractures associated with femoral shaft fractures, such as radiography and computed tomography. However, despite these images, they cannot be diagnosed. This case re-affirms the need for using imaging techniques before and during the operation in patients presenting with high energy femoral shaft fractures, in order to look for an associated femoral neck fracture. Although the use of fine-cut computed tomography scan may improve the diagnostic accuracy of this test, some femoral neck fractures will still go under-diagnosed.

Subtrochanteric and Distal Femur Fractures in a Patient with Femoral Shaft Fracture Malunion and Knee Disarticulation: A Rare and Challenging Case Report.

This study aims to describe a rare and challenging case of a patient who presented ipsilateral subtrochanteric and distal femur fractures due to low-energy trauma. The peculiarity of this case is the presence of femoral shaft fracture malunion and knee disarticulation in the same limb resulting from an accident suffered 30 years ago. The patient underwent femoral diaphyseal osteotomy and fixation of the subtrochanteric and distal femur fractures with a long cephalomedullary nail and distal femur locking plate, respectively. Despite the magnitude of the surgical procedure, all fractures healed, preserving the femoral length with the absence of infection and clinical complications. There was an improvement of the preinjury function attributed to the osteotomy of the femoral diaphyseal, which alleviated the anterior thigh discomfort.

Assessment of bone microarchitecture in postmenopausal women on long-term bisphosphonate therapy with atypical fractures of the femur.

Reports of atypical femoral fractures (AFFs) in patients receiving long- term bisphosphonate therapy have raised concerns regarding the genesis of this rare event. Using high-resolution peripheral quantitative computed tomography (HR-pQCT), we conducted a study to evaluate bone microarchitecture in patients who had suffered an AFF during long-term bisphosphonate treatment. The aim of our study was to evaluate if bone microarchitecture assessment could help explain the pathophysiology of these fractures. We compared bone volumetric density and microarchitectural parameters measured by HR-pQCT in the radius and tibia in 20 patients with AFFs with 35 postmenopausal women who had also received long-term bisphosphonate treatment but had not experienced AFFs, and with 54 treatment-naive postmenopausal women. Control groups were similar in age, body mass index (BMI), and bone mineral density (BMD). Mean age of the 20 patients with AFFs was 71 years, mean lumbar spine T-score was -2.2, and mean femoral neck T-score was -2. Mean time on bisphosphonate treatment was 10.9 years (range, 5-20 years). None of the patients had other conditions associated with AFFs such as rheumatoid arthritis, diabetes or glucocorticoid use. There were no statistically significant differences in any of the parameters measured by HR-pQCT between postmenopausal women with or without treatment history and with or without history of atypical fractures. We could not find any distinctive microarchitecture features in the peripheral skeleton of women who had suffered an atypical fracture of the femur while receiving bisphosphonate treatment. This suggests that risk of developing an atypical fracture is not related to bone microarchitecture deterioration. Our results indicate that there may be other individual factors predisposing to atypical fractures in patients treated with bisphosphonates, and that those are independent of bone microarchitecture. In the future, identification of those factors could help prevent and understand the complex physiopathology of these rare events.