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Ipsilateral fractures of the femoral neck and shaft
Injury, Int. J. Care Injured 31 (2000) 719 – 722 www.elsevier.com/locate/injury
Ipsilateral fractures of the femoral neck and shaft Chung Hwan Chen a, Tai Bin Chen a, Yuh Min Cheng a, Je Ken Chang a, Sen Yen Lin a, Shao Hung Hung b,* b
a Department of Orthopaedic Surgery, Kaohsiung Medical Uni6ersity, Kaohsiung, Taiwan Department of Orthopaedic Surgery, Fooyin Institute of Technology Hospital, No. 5 Chung-San Road, Tungkang Chen 928, Ping-Tung, Taiwan
Accepted 9 May 2000
Abstract Ipsilateral femoral shaft and neck fractures are difficult to treat. From 1989 to 1998, we treated 18 patients with these complex fractures. There were 14 male and 4 female with an average age of 40 years. Most resulted from high-energy trauma. The average follow-up period is 41 months. All but one of the fractures united well. The mean time to union is 5.2 92.3 months in the diaphysis and 4.16 92 months in the neck. No cases of the femoral neck fracture or osteonecrosis of the femoral head were observed during the follow-up period. Fourteen cases were treated with a standard protocol of plates for diaphyseal fractures and lag screws or dynamic hip screws (DHS) fixations for the femoral neck fractures. There were 13 good and 1 fair functional results. Two neglected neck fractures were treated with interlocking nailing for diaphyseal fracture with fair results. We conclude that a plate on the shaft and sliding hip screws or separate screws in the hip is a reliable method for ipsilateral femoral neck and shaft fractures. © 2000 Elsevier Science Ltd. All rights reserved.
1. Introduction Ipsilateral fractures of the femoral neck and shaft are rare. They are encountered in high-energy injuries, especially in road traffic accidents [3,4]. The incidence ranges from 2.5 to 6% of the femoral shaft fractures [2,12,15,16]. Femoral neck fractures are commonly missed initially; the rate varies from 19 to 31% [2,11]. There have been nearly 60 recommended methods of managing these concurrent fractures [14], but no consensus exists regarding the optimal treatment of these complex fractures. This paper reports the results of treating the 14 fractures with a standard protocol of plates for diaphyseal fractures and lag screws or dynamic hip screws (DHS) fixations for the femoral neck fractures.
2. Material and methods We reviewed all cases of associated ipsilateral fractures of the femoral neck and shaft treated at Kaohsi* Corresponding author.
ung Medical College Hospital from August 1989 to Feburary 1998 (Table 1). There were 18 patients, 14 male and 4 female, with an age range of 22–77 years (average 40 years). Sixteen (89%) patients were involved in high-energy injuries; 15 (83%) were injured in traffic accidents, and 1 (6%) was injured due to falling from height. Two patients (11%) were injured by slipping down. Thirteen cases (72%) had an associated injury to other parts, viz. abdomen, chest, head and other limbs. Four of the neck fractures were basal neck fractures. The other femoral neck fractures were classified by the Garden classification as follows: type I and type II in six cases, and type III and type IV in eight cases. Two neck fractures were neglected at first. Femoral diaphyseal fractures with intertrochanteric involvement were not included in this series. The diaphyseal fractures were classified according to Hansen–Winquist classification [8]; eight were of type I, two were of type II and four were of type III. In addition, two were segmental fractures and two were supracondylar fractures. There were seven open diaphyseal fractures. Two were Gustilo–Anderson [7] grade I open fracture, three were grade II open fracture and two were grade IIIA open fracture.
0020-1383/00/$ - see front matter © 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 0 ) 0 0 0 9 6 - 6
36 45 34 55 43 34 24 26 27 22 37 25 31 44 33 52 75 77
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1 1 1 1 1 2 1 1 1 1 1 1 1 2 1 1 2 2
Sexa
5 2 2 4 4 3 1 5 3 2 1 3 3 5 2 5 3 3
Neck fractureb
Yes Yes Yes Yes No Yes Yes Yes Yes Yes No No Yes Yes Yes Yes No No
Associated injury Segmental W3 W1 W3 Segmental W3 W1 W1 W2 W1 W1 W3 W1 W1 W2 Supracondylar W1 Supracondylar
Shaft fracturec
Motorcycle Motorcycle Motorcycle Motorcycle Motorcycle Motorcycle Motorcycle Falling Motorcycle Motorcycle Motorcycle Motorcycle Motorcycle Motorcycle Motorcycle Motor-car Slipping-down Slipping-down
Mechanism
O3a C C O2 O1 C C C C O1 O2 O2 C C C O3a C C
Interlocking nail Plate Plate DHS Interlocking nail Plate Plate Plate Plate Plate Plate Plate Plate Plate Plate Buttress plate Plate DHS
Opend Implant for shaft fracture Screws Screws DHS DHS Screws Screws Screws Screws Screws DHS Screws DHS Screws Screws Screws DHS Bipolar Bipolar
Implant for neck fracture
b
Sex: 1, male; 2, female. Neck fracture (type of neck fracture): 1, Garden type I; 2, Garden type II; 3, Garden type III; 4, Garden type IV; 5, basal neck fracture. c Shaft fracture (type of shaft fracture): W1, Winquist type I; W2, Winquist type II; W3, Winquist type III. d Open (type of open fracture): O1, Gustilo grade I; O2, Gustilo grade II; O3a, Gustilo grade IIIA; C, close fracture.
a
Age
Patient
Table 1 Patient data
17 36 14 27 17 61 16 43 49 105 101 9 48 20 65 20 50 32
Follow-up months
Fair Good Good Good Fair Good Good Good Good Good Good Good Good Good Good Fair Good Good
Functional result
720 C.H. Chen et al. / Injury, Int. J. Care Injured 31 (2000) 719–722
C.H. Chen et al. / Injury, Int. J. Care Injured 31 (2000) 719–722
All patients were resuscitated in the Accident and Emergency Dept. The treatment of the fractures was carried out once the patients were well stabilised. Temporary skeletal traction via a tibial Steinmann pin was performed for patients in whom immediate operation was not possible. After vital sign stabilisation, open reduction and internal fixation was performed. We treated these complex fractures with a standard protocol: plate fixations for diaphyseal fractures and lag screws or DHS fixations for the neck fractures. Two cases of neglected femoral neck fractures were treated with an interlocking nail for diaphyseal fractures.
3. Result The period of follow-up ranged from 9 to 105 months with an average of 41 months. Eleven patients were followed up over 24 months, including nine patients treated with our standard protocol (Table 1). All patients except one united well. The mean time to union was 5.2 9 2.3 months in the diaphysis and 4.16 9 2 months in the neck. Neither non-union of the femoral neck fracture nor osteonecrosis of the femoral head was found during the follow-up period. One (case 5), who had a segmental fracture treated with an interlocking nail, had diaphyseal non-union. Bone graft was performed later and the fracture united well. There was no infection or implant failure. The functional results of the patients were assessed with the system used by Friedman and Wyman [5]. A good result required no limitation of activities of daily living (ADL), no pain, and less than 20% loss of hip or knee motion. A fair result entailed mild limitation of ADL, mild to moderate pain, 20 – 50% loss of motion. A poor result was associated with moderate limitation of ADL, severe pain, more than 50% loss of motion. Thirteen of the 14 patients treated with plates for diaphyseal fractures had good results. The other (case 16) had a fair outcome (Table 1). He also sustained an ipsilateral tibial fracture (open grade IIIB) which was treated with an external fixator. The range of motion of his knee only reached 90°, so he had a mild limitation of ADL. Both patients treated with interlocking nails had fair results. One (case 1) had an associated ipsilateral tibial fracture (open grade II) with an infected non-union. The other (case 5) had a mild limitaion of ADL after a period femoral diaphyseal non-union.
4. Discussion Ipsilateral femoral neck and shaft fractures are rare and challenging. Unlike the common solitary femoral neck fracture, these complex fractures are caused by high-energy trauma. Most of these injured patients are
721
young and male dominated, as in the cases of solitary femoral shaft fractures [1]. Our series showed a similar distribution. The treatment of ipsilateral fractures of the femoral neck and diaphysis is difficult, and there are many protocols for the management of these fractures [4,9,12,13,15]. There is no doubt that ipsilateral fractures of the femoral neck and shaft are best treated with surgical stabilisation. It is controversial which fracture takes priority because the optimal treatment of one fracture may interfere with the optimal treatment of the other. Most investigators suggested that the neck should take precedence over the shaft. This is done to avoid further displacement of the neck fracture and avascular necrosis (AVN). In our series, we did not give all the neck fractures precedence over the diaphyseal fractures. The shaft fractures were stabilised first, and the neck fractures subsequently in 10 of the 14 patients were treated with the standard protocol. There was no further displacement of neck fracture during operation. There may be less risk of further displacement of the fracture of the neck during plating of the diaphysis. Two patients with neglected femoral neck fracture were treated with interlocking nail fixation at the beginning. Both had a segmental diaphyseal fracture; one was a Gustilo–Anderson grade IIIA open fracture and the other was grade I. Displacement of the femoral neck fractures was noted after interlocking nail insertion in both. It may be necessary to fix the neck before the shaft’s intramedullary nailing. Despite these cases, there was still no AVN in our series. A delay in diagnosis and treatment may not increase the rate of osteonecrosis. The reported incidence of AVN in ipsilateral femoral neck and shaft fratures (3%) [1] is lower than that in the solitary femoral neck fracture (10%) [6]. This may be due to the following reasons: (1) the force of trauma is dissipated in the shaft fracture; (2) a larger percentage of basal neck fracture and non-displaced neck fracture; and (3) a different pattern of the neck fracture. These findings were compatible with ours. Controversy also exists over the methods of internal fixation of diaphyseal fracture. Most authors suggest similar fixation to that used in solitary femoral shaft fractures. The advantages of closed treatment of fractures with locked nails are well documented [3,9,13,15]. Plating of the shaft was associated with a higher reported incidence of infection and non-union [1]. Unlocked, reamed intramedullary nail fixation was complicated by rotary malalignment and shortening. From published reports after 1980, we cannot find enough evidence that nailing was better than plating [1,15]. In our series, 14 patients received plates and screws, or plates and DHS. All patients treated with plate fixations of the femoral diaphyseal fractures had solid union without infection. No further operation was
722
C.H. Chen et al. / Injury, Int. J. Care Injured 31 (2000) 719–722
needed except for the removal of the implants. Other investigators have also suggested plate fixation for diaphyseal fractures as a good choice in these complex fractures [10,14]. The treatment principles are optimal management to avoid AVN in neck fracture and optimal stability without interfering with proximal fixation in the shaft fracture. It is technically demanding to insert Knowles’ pins to stabilise the femoral neck fracture after inserting IM nail. Inserting Knowles’ pins around, an interlocking nail is more difficult due to less bone stock for pin insertion [15]. As discussed above, prior fixation of neck fracture may be needed before insertion of an intramedullary nail, but increases the difficulty of nail insertion. Fixation with plate and screws or plate and DHS for ipsilateral femoral neck and shaft fracture is technically much easier than the use of an intramedullary nail with screws, or reconstruction nails. It also provides solid union and low complication rate. A plate on the shaft and sliding hip screw or separate screws in the hip is a reliable method that yielded reliable outcome in our series. It may be also a good method for a less experienced surgeon.
References [1] Alho A. Concurrent ipsilateral fracture of the hip and femoral shaft. Acta Orthop Scand 1996;67:19.
.
[2] Bennett FS, Zinar DM, Kilgus DJ, et al. Ipsilateral hip and femoral shaft fracture 1993;296:169 [3] Bucholz RW, Rathjen K. Concomitant ipsilateral fracture of the hip and femur treated with interlocking nail. Orthopaedics 1985;8:1402. [4] Casey MJ, Chapman MW. Ipsilateral concomitant fracture of the hip and femoral shaft. J Bone Joint Surg 1979;61A:503. [5] Friedman RJ, Wyman ET. Ipsilateral hip and femoral shaft fractures. Clin Orthop Rel Res 1986;208:188. [6] Gerber C, Strehle J, Ganz R. The treatment of fractures of the femoral neck. Clin Orthop Rel Res 1993;292:77. [7] Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of the long bones. Retrospective and prospective analysis. J Bone Joint Surg 1976;58A:453. [8] Hansen ST, Winquist RA. Closed intramedullary nailing of fracture of the femoral shaft. Part II: technical considerations. In: Instructional Course Lectures, The American Academy of Orthopaedic Surgeons, vol. vol. 27. St. Louis: CV Mosby, 1978. [9] Leung KS, So WS, Lam TP, Leung PC, et al. Treatment of ipsilateral femoral shaft fracture and hip fracture. Injury 1993;24:41. [10] Peljovich AE, Patterson BM. Ipsilateral femoral neck and shaft fractures. J Am Acad Orthop Surg 1998;6:106. [11] Swiontkowski MF. Ipsilateral femoral shaft and hip fractures. Orthop Clin North Am 1987;18:73. [12] Swiontkowski MF, Hansen ST, Kellam J et al. ipsilateral fractures of the femoral neck and shaft. J Bone Joint Surg 1984;66A:260. [13] Wiss DA, Sima W, Brien WW. Ipsilateral fractures of the femoral and neck and shaft. J Trauma 1992;6:159. [14] Wolinsky PR, Johnson KD. ipsilateral femoral neck and shaft fracture. Clin Orthop Rel Res 1995;318:81. [15] Wu CC, Shih CH. Ipsilateral femoral neck and shaft fracture. Acta Orthop Scand 1991;62:346. [16] Zettas JP, Zettas P. Ipsilateral fractures of the femoral neck and shaft. Clin Orthop Rel Res 1981;160:63.
Ipsilateral fractures of the femoral neck and shaft Chung Hwan Chen a, Tai Bin Chen a, Yuh Min Cheng a, Je Ken Chang a, Sen Yen Lin a, Shao Hung Hung b,* b
a Department of Orthopaedic Surgery, Kaohsiung Medical Uni6ersity, Kaohsiung, Taiwan Department of Orthopaedic Surgery, Fooyin Institute of Technology Hospital, No. 5 Chung-San Road, Tungkang Chen 928, Ping-Tung, Taiwan
Accepted 9 May 2000
Abstract Ipsilateral femoral shaft and neck fractures are difficult to treat. From 1989 to 1998, we treated 18 patients with these complex fractures. There were 14 male and 4 female with an average age of 40 years. Most resulted from high-energy trauma. The average follow-up period is 41 months. All but one of the fractures united well. The mean time to union is 5.2 92.3 months in the diaphysis and 4.16 92 months in the neck. No cases of the femoral neck fracture or osteonecrosis of the femoral head were observed during the follow-up period. Fourteen cases were treated with a standard protocol of plates for diaphyseal fractures and lag screws or dynamic hip screws (DHS) fixations for the femoral neck fractures. There were 13 good and 1 fair functional results. Two neglected neck fractures were treated with interlocking nailing for diaphyseal fracture with fair results. We conclude that a plate on the shaft and sliding hip screws or separate screws in the hip is a reliable method for ipsilateral femoral neck and shaft fractures. © 2000 Elsevier Science Ltd. All rights reserved.
1. Introduction Ipsilateral fractures of the femoral neck and shaft are rare. They are encountered in high-energy injuries, especially in road traffic accidents [3,4]. The incidence ranges from 2.5 to 6% of the femoral shaft fractures [2,12,15,16]. Femoral neck fractures are commonly missed initially; the rate varies from 19 to 31% [2,11]. There have been nearly 60 recommended methods of managing these concurrent fractures [14], but no consensus exists regarding the optimal treatment of these complex fractures. This paper reports the results of treating the 14 fractures with a standard protocol of plates for diaphyseal fractures and lag screws or dynamic hip screws (DHS) fixations for the femoral neck fractures.
2. Material and methods We reviewed all cases of associated ipsilateral fractures of the femoral neck and shaft treated at Kaohsi* Corresponding author.
ung Medical College Hospital from August 1989 to Feburary 1998 (Table 1). There were 18 patients, 14 male and 4 female, with an age range of 22–77 years (average 40 years). Sixteen (89%) patients were involved in high-energy injuries; 15 (83%) were injured in traffic accidents, and 1 (6%) was injured due to falling from height. Two patients (11%) were injured by slipping down. Thirteen cases (72%) had an associated injury to other parts, viz. abdomen, chest, head and other limbs. Four of the neck fractures were basal neck fractures. The other femoral neck fractures were classified by the Garden classification as follows: type I and type II in six cases, and type III and type IV in eight cases. Two neck fractures were neglected at first. Femoral diaphyseal fractures with intertrochanteric involvement were not included in this series. The diaphyseal fractures were classified according to Hansen–Winquist classification [8]; eight were of type I, two were of type II and four were of type III. In addition, two were segmental fractures and two were supracondylar fractures. There were seven open diaphyseal fractures. Two were Gustilo–Anderson [7] grade I open fracture, three were grade II open fracture and two were grade IIIA open fracture.
0020-1383/00/$ - see front matter © 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 0 ) 0 0 0 9 6 - 6
36 45 34 55 43 34 24 26 27 22 37 25 31 44 33 52 75 77
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1 1 1 1 1 2 1 1 1 1 1 1 1 2 1 1 2 2
Sexa
5 2 2 4 4 3 1 5 3 2 1 3 3 5 2 5 3 3
Neck fractureb
Yes Yes Yes Yes No Yes Yes Yes Yes Yes No No Yes Yes Yes Yes No No
Associated injury Segmental W3 W1 W3 Segmental W3 W1 W1 W2 W1 W1 W3 W1 W1 W2 Supracondylar W1 Supracondylar
Shaft fracturec
Motorcycle Motorcycle Motorcycle Motorcycle Motorcycle Motorcycle Motorcycle Falling Motorcycle Motorcycle Motorcycle Motorcycle Motorcycle Motorcycle Motorcycle Motor-car Slipping-down Slipping-down
Mechanism
O3a C C O2 O1 C C C C O1 O2 O2 C C C O3a C C
Interlocking nail Plate Plate DHS Interlocking nail Plate Plate Plate Plate Plate Plate Plate Plate Plate Plate Buttress plate Plate DHS
Opend Implant for shaft fracture Screws Screws DHS DHS Screws Screws Screws Screws Screws DHS Screws DHS Screws Screws Screws DHS Bipolar Bipolar
Implant for neck fracture
b
Sex: 1, male; 2, female. Neck fracture (type of neck fracture): 1, Garden type I; 2, Garden type II; 3, Garden type III; 4, Garden type IV; 5, basal neck fracture. c Shaft fracture (type of shaft fracture): W1, Winquist type I; W2, Winquist type II; W3, Winquist type III. d Open (type of open fracture): O1, Gustilo grade I; O2, Gustilo grade II; O3a, Gustilo grade IIIA; C, close fracture.
a
Age
Patient
Table 1 Patient data
17 36 14 27 17 61 16 43 49 105 101 9 48 20 65 20 50 32
Follow-up months
Fair Good Good Good Fair Good Good Good Good Good Good Good Good Good Good Fair Good Good
Functional result
720 C.H. Chen et al. / Injury, Int. J. Care Injured 31 (2000) 719–722
C.H. Chen et al. / Injury, Int. J. Care Injured 31 (2000) 719–722
All patients were resuscitated in the Accident and Emergency Dept. The treatment of the fractures was carried out once the patients were well stabilised. Temporary skeletal traction via a tibial Steinmann pin was performed for patients in whom immediate operation was not possible. After vital sign stabilisation, open reduction and internal fixation was performed. We treated these complex fractures with a standard protocol: plate fixations for diaphyseal fractures and lag screws or DHS fixations for the neck fractures. Two cases of neglected femoral neck fractures were treated with an interlocking nail for diaphyseal fractures.
3. Result The period of follow-up ranged from 9 to 105 months with an average of 41 months. Eleven patients were followed up over 24 months, including nine patients treated with our standard protocol (Table 1). All patients except one united well. The mean time to union was 5.2 9 2.3 months in the diaphysis and 4.16 9 2 months in the neck. Neither non-union of the femoral neck fracture nor osteonecrosis of the femoral head was found during the follow-up period. One (case 5), who had a segmental fracture treated with an interlocking nail, had diaphyseal non-union. Bone graft was performed later and the fracture united well. There was no infection or implant failure. The functional results of the patients were assessed with the system used by Friedman and Wyman [5]. A good result required no limitation of activities of daily living (ADL), no pain, and less than 20% loss of hip or knee motion. A fair result entailed mild limitation of ADL, mild to moderate pain, 20 – 50% loss of motion. A poor result was associated with moderate limitation of ADL, severe pain, more than 50% loss of motion. Thirteen of the 14 patients treated with plates for diaphyseal fractures had good results. The other (case 16) had a fair outcome (Table 1). He also sustained an ipsilateral tibial fracture (open grade IIIB) which was treated with an external fixator. The range of motion of his knee only reached 90°, so he had a mild limitation of ADL. Both patients treated with interlocking nails had fair results. One (case 1) had an associated ipsilateral tibial fracture (open grade II) with an infected non-union. The other (case 5) had a mild limitaion of ADL after a period femoral diaphyseal non-union.
4. Discussion Ipsilateral femoral neck and shaft fractures are rare and challenging. Unlike the common solitary femoral neck fracture, these complex fractures are caused by high-energy trauma. Most of these injured patients are
721
young and male dominated, as in the cases of solitary femoral shaft fractures [1]. Our series showed a similar distribution. The treatment of ipsilateral fractures of the femoral neck and diaphysis is difficult, and there are many protocols for the management of these fractures [4,9,12,13,15]. There is no doubt that ipsilateral fractures of the femoral neck and shaft are best treated with surgical stabilisation. It is controversial which fracture takes priority because the optimal treatment of one fracture may interfere with the optimal treatment of the other. Most investigators suggested that the neck should take precedence over the shaft. This is done to avoid further displacement of the neck fracture and avascular necrosis (AVN). In our series, we did not give all the neck fractures precedence over the diaphyseal fractures. The shaft fractures were stabilised first, and the neck fractures subsequently in 10 of the 14 patients were treated with the standard protocol. There was no further displacement of neck fracture during operation. There may be less risk of further displacement of the fracture of the neck during plating of the diaphysis. Two patients with neglected femoral neck fracture were treated with interlocking nail fixation at the beginning. Both had a segmental diaphyseal fracture; one was a Gustilo–Anderson grade IIIA open fracture and the other was grade I. Displacement of the femoral neck fractures was noted after interlocking nail insertion in both. It may be necessary to fix the neck before the shaft’s intramedullary nailing. Despite these cases, there was still no AVN in our series. A delay in diagnosis and treatment may not increase the rate of osteonecrosis. The reported incidence of AVN in ipsilateral femoral neck and shaft fratures (3%) [1] is lower than that in the solitary femoral neck fracture (10%) [6]. This may be due to the following reasons: (1) the force of trauma is dissipated in the shaft fracture; (2) a larger percentage of basal neck fracture and non-displaced neck fracture; and (3) a different pattern of the neck fracture. These findings were compatible with ours. Controversy also exists over the methods of internal fixation of diaphyseal fracture. Most authors suggest similar fixation to that used in solitary femoral shaft fractures. The advantages of closed treatment of fractures with locked nails are well documented [3,9,13,15]. Plating of the shaft was associated with a higher reported incidence of infection and non-union [1]. Unlocked, reamed intramedullary nail fixation was complicated by rotary malalignment and shortening. From published reports after 1980, we cannot find enough evidence that nailing was better than plating [1,15]. In our series, 14 patients received plates and screws, or plates and DHS. All patients treated with plate fixations of the femoral diaphyseal fractures had solid union without infection. No further operation was
722
C.H. Chen et al. / Injury, Int. J. Care Injured 31 (2000) 719–722
needed except for the removal of the implants. Other investigators have also suggested plate fixation for diaphyseal fractures as a good choice in these complex fractures [10,14]. The treatment principles are optimal management to avoid AVN in neck fracture and optimal stability without interfering with proximal fixation in the shaft fracture. It is technically demanding to insert Knowles’ pins to stabilise the femoral neck fracture after inserting IM nail. Inserting Knowles’ pins around, an interlocking nail is more difficult due to less bone stock for pin insertion [15]. As discussed above, prior fixation of neck fracture may be needed before insertion of an intramedullary nail, but increases the difficulty of nail insertion. Fixation with plate and screws or plate and DHS for ipsilateral femoral neck and shaft fracture is technically much easier than the use of an intramedullary nail with screws, or reconstruction nails. It also provides solid union and low complication rate. A plate on the shaft and sliding hip screw or separate screws in the hip is a reliable method that yielded reliable outcome in our series. It may be also a good method for a less experienced surgeon.
References [1] Alho A. Concurrent ipsilateral fracture of the hip and femoral shaft. Acta Orthop Scand 1996;67:19.
.
[2] Bennett FS, Zinar DM, Kilgus DJ, et al. Ipsilateral hip and femoral shaft fracture 1993;296:169 [3] Bucholz RW, Rathjen K. Concomitant ipsilateral fracture of the hip and femur treated with interlocking nail. Orthopaedics 1985;8:1402. [4] Casey MJ, Chapman MW. Ipsilateral concomitant fracture of the hip and femoral shaft. J Bone Joint Surg 1979;61A:503. [5] Friedman RJ, Wyman ET. Ipsilateral hip and femoral shaft fractures. Clin Orthop Rel Res 1986;208:188. [6] Gerber C, Strehle J, Ganz R. The treatment of fractures of the femoral neck. Clin Orthop Rel Res 1993;292:77. [7] Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of the long bones. Retrospective and prospective analysis. J Bone Joint Surg 1976;58A:453. [8] Hansen ST, Winquist RA. Closed intramedullary nailing of fracture of the femoral shaft. Part II: technical considerations. In: Instructional Course Lectures, The American Academy of Orthopaedic Surgeons, vol. vol. 27. St. Louis: CV Mosby, 1978. [9] Leung KS, So WS, Lam TP, Leung PC, et al. Treatment of ipsilateral femoral shaft fracture and hip fracture. Injury 1993;24:41. [10] Peljovich AE, Patterson BM. Ipsilateral femoral neck and shaft fractures. J Am Acad Orthop Surg 1998;6:106. [11] Swiontkowski MF. Ipsilateral femoral shaft and hip fractures. Orthop Clin North Am 1987;18:73. [12] Swiontkowski MF, Hansen ST, Kellam J et al. ipsilateral fractures of the femoral neck and shaft. J Bone Joint Surg 1984;66A:260. [13] Wiss DA, Sima W, Brien WW. Ipsilateral fractures of the femoral and neck and shaft. J Trauma 1992;6:159. [14] Wolinsky PR, Johnson KD. ipsilateral femoral neck and shaft fracture. Clin Orthop Rel Res 1995;318:81. [15] Wu CC, Shih CH. Ipsilateral femoral neck and shaft fracture. Acta Orthop Scand 1991;62:346. [16] Zettas JP, Zettas P. Ipsilateral fractures of the femoral neck and shaft. Clin Orthop Rel Res 1981;160:63.