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Ipsilateral hip and distal femoral fractures
Injury, Int. J. Care Injured 31 (2000) 147±151
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Ipsilateral hip and distal femoral fractures Chuan-Mu Chen a, c, Fang-Yao Chiu a, c,*, Wai-Hee Lo a, c, Tien-Yow Chuang b, c a
Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-pai Road, Taipei 11217, Taiwan, ROC b PM&R, Taipei, Taiwan, ROC c National Yang-Ming University, Taipei, Taiwan, ROC Accepted 28 September 1999
Abstract We tried to ®nd the trauma mechanism and treatment rationale of ipsilateral concomitant hip and distal femoral fractures involving the articular surface. Between 1988 and 1995, 15 cases of ipsilateral hip (con®ned to neck or trochanteric areas of the femur) and distal (con®ned to supra- and intercondylar area of the femur) femoral articular fractures were collected. The hip fractures consisted of 10 trochanteric fractures and ®ve neck fractures, which were managed with reduction and ®xation in 14 (Knowles' pin in eight, DHS in four and standard Gamma nail in two), and primary bipolar hemiarthroplastry in one. The distal femoral articular fractures were open in 11; these were managed with radical debridement, implantation of Septopal chains and immediate internal ®xation, followed by prophylactic autogenous bone grafting 6 weeks later in the recent six cases (®ve Judet plates, four dynamic condylar screws and two condylar plates). The other four closed distal femoral fractures were managed with early reduction and internal ®xation (two Judet plate, one dynamic condylar screw and one condylar plate). The union time was 20.3 (12±48) weeks for proximal fractures and 23.7 (12±36) weeks for distal fractures. Early infection developed in three cases. Nonunion of a femoral neck fracture developed in one case. The other complications were implant failure in one, coxa vara in one, refracture in one, delayed union in one and knee stiness in one. # 2000 Elsevier Science Ltd. All rights reserved.
1. Introduction There have been several reports on ipsilateral femoral shaft fractures at dierent sites [1± 6,15,16,18,20,21,23±25], but none was on ipsilateral hip and distal femur involving of the articular surface (supra/intercondyle). This special injury pattern is rare in incidence and its management presents a challenge. This retrospective study tries to elucidate its clinical presentation and management rationale.
2. Materials and methods From January 1988 to June 1995, 15 consecutive * Corresponding author. Tel.: +886-2-2875-7557; fax: +886-22875-4943.
cases were collected in this study, and the follow-up period was 80.2 (36±127) months. All the cases had (1) hip fracture (including intracapsular neck fracture in ®ve cases, intertrochanteric fracture in nine and subtrochanteric fracture in one), (2) ipsilateral distal femoral articular fracture that couldn't be ®xed with any locking intramedullary devices (supra- and intercondylar fracture in 14 and lateral condylar fracture in one) and (3) no other injury of the ipsilateral lower extremity. All the hip fractures were closed; two of the neck fractures and four of the intertrochanteric fractures were undisplaced with the others being displaced. The distal femoral fractures were open in 11 cases and closed in four. Collins and Temple's classi®cation [9] was used for the open fractures. Eight associated injuries were a craniofacial injury a lung contusion an ipsilateral scapular fracture an ipsilateral proximal humeral fracture an ipsilateral distal radius fracture a contralateral femoral
0020-1383/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 9 9 ) 0 0 2 5 0 - 8
33 75
23 63 49
65 72 36
51 37 59
61 39 53
2 3
4 5 6
7 8 9
10 11 12
13 14 15
M M M
F M F
M M M
M M M
M F
M
L L R
R R R
L L R
L R R
L R
L
MCA MCA automobile accident MCA MCA MCA
MCA MCA MCA
MCA automobile accident MCA MCA MCA
MCA
neck ITF ITF
neck ITF ITF
ITF ITF ITF
ITF neck neck
neck STF
ITF
±
SIC,open IIB SIC,open IIIB SIC,open IIIC
SIC,open IC SIC SIC
SIC,open IIB SIC,open IIIC SIC,open IIIB
femur tibia scapula
± ± ±
± tibia humerus
lateral condyle head, face SIC,open IC ± SIC,open IIIC radius
SIC,open IICb ± SIC,open IIIB chest
SIC
DCS DCS Condylar plate
Judet plate Condylar plate Judet plate
Judet plate Judet plate Condylar plate
Judet plate Judet plate
Judet plate
Distal
bipolar hemiarthroplasty DCS pinning DCS pinning DCS
pinning dynamic hip screw gamma nail
dynamic hip screw gamma Nail dynamic hip screw
pinning pinning pinning and MPBG
pinning and MPBG dynamic hip screw (AO)
pinning
Proximal
Associated Treatment Injury
33 29 25
52 46 39
75 70 66
98 90 86
115 108
121
± 12 16
16 16 16
20 24 20
16 20 ±
24 48
16
20 20 20
20 16 16
28 16 36
12 24 32
28 32
36
± ± ±
Knee ROM (8)
± ± ±
0±120 0±130 10±140
0±130 10±140 10±130
0±10 10±130 10±40
0±130 0±120 10±20
infection, 10±20 stiness stiness 0±20 delayed union 0±120 ± implant failure coxa varus ± ± refracture nonunion infection, stiness ± stiness ± ± ± infection, Stiness ± ± ± ± ± ±
±
Distal
Complication
Proximal Distal Proximal
Follow up Union time (mos) (weeks)
a MCA=motorcycle accident; ITF=intertrochanteric fracture; STF=subtrochanteric fracture; SIC=supra- and intercondyle; Pinning=Knowles' pinning; MPBG=muscle pedicle bone graft; DCS=dynamic condylar screw (AO). b Collins/Temple classi®cation13.
64
1
Case Age Sex Side Mechanism Hip Distal No Fracture Femur Fracture
Table 1 Clinical data of the 15 cases of ipsilateral hip and distal femoral articular fracturesa
148 C.-M. Chen et al. / Injury, Int. J. Care Injured 31 (2000) 147±151
C.-M. Chen et al. / Injury, Int. J. Care Injured 31 (2000) 147±151
shaft fracture and a contralateral tibial fracture. All were managed on the same day as the proximal and distal femoral fractures. Twelve were male and three were female of average age 52 (23±75). High velocity motorcycle accidents were the cause in 13 of the 15 cases and automobile accidents in the other two. The clinical data of the 15 cases are shown in Table 1. The authors managed all the cases. In the proximal fractures (Table 1), Knowles' pins were used to ®x four of the ®ve femoral neck fractures, including two undisplaced fractures and two displaced fractures managed with additional open reduction and quadratus femoris muscle pedicle bone grafting because of their young age. The undisplaced fractures were managed percutaneously [7,8]. The other displaced femoral neck fracture was managed with a primary PCA bipolar hemiarthroplasty because of his relatively old age. For the four undisplaced intertrochanteric fractures, Knowles' pins were also used for the ®xation, percutaneously. All the fractures ®xed with Knowles' pins had four pins inserted in a box shape [7,8]. The other ®ve displaced intertrochanteric fractures were managed with open reduction and internal ®xation, with a dynamic hip screw (DHS, AO) in three and Gamma nail in two. The displaced subtrochanteric fracture was managed with open reduction and internal ®xation with DHS. The open distal fractures were initially managed according to Gustilo and Anderson's description [12], immediate internal ®xation was done with Judet plates in ®ve cases, condylar plates in two cases, and dynamic condylar screws (DCS, AO) in four cases. A septopal chain was put in all cases with hemovac drainage and primary wound closure. Five (case 2, 5, 6, 9 and 13 in Table 1) were managed beyond the golden period (8 h) because of late referrals from other local hospitals, and were delayed from 10 to 18 h. In the recent ®ve cases (No. 8, 10, 13, 14 and 15), delayed autogenous bone grafting was done 6 weeks after the initial operation for prevention of delay in union which was suspected in the follow-up X-ray. The closed distal fractures were managed with early open reduction and internal ®xation with Judet plate in two, condylar plate in one and DCS in one, within 7 days of the initial injuries. Autogenous cancellous bone graft was put in all cases except the one with lateral condylar fracture. No Septopal chain was used, but hemovac drainage was put in all cases. Continuous passive motion of the knee and range of motion exercise of the hip and knee were prescribed in all cases from the ®rst postoperative day, and the exercise continued till discharge or stopped, if a wound problem developed. No other supplemental ®xation was used initially for any cases. Non-weight bearing was prescribed after operation and weight bearing started progressively from the 9th postoperative week if no complication devel-
149
oped. Full weight bearing was permitted after the appearance of bridging callus and clinical union of both proximal and distal fractures. The functional results were supervised by senior sta throughout the follow-up period. After discharge, each case was followed once every two weeks in the ®rst month and once every 4 weeks thenceforth. Functional evaluation was done at every visit and once every two months after union of the fracture. Each patient had one special chart with detailed personal data, mechanism and associated condition of the injury, type and classi®cation of the fracture, choice and course of the management, condition and course of the fracture healing, functional recovery, and the total number and average number of operations till the ®nal follow-up. X-ray check-up was done at every follow-up visit, and all the evaluations and records were done by the same sta (C.-M.C. and F.-Y.C.) at the same time. Normal union was de®ned as appearance of both bridging callus and partial obliteration of the fracture site within 28 weeks, delayed union as union evidenced in 29±40 weeks and nonunion as no evidence of union after 40 weeks. Malunion was de®ned as varus or valgus deformity over 58 more than the neck±shaft angle or distal femoral axis orientation angle [13] of the contralateral side, anterior or posterior angulation equal to or more than 108, rotational deformity equal to or more than 108 or shortening equal to or more than 5 mm. If the active ROMs of the knee and the hip were evaluated to be within 208 of dierence to the contralateral normal joints, and the patient had full return to the preinjury activity and work without pain or with just little discomfort, the functional result was de®ned to be satisfactory; otherwise to be unsatisfactory. 3. Results The general data of the patients are shown in Table 1. The average hospital stay was 21 (7±63) days. The average time to union of the proximal fractures, excluding the cases with nonunion and primary hemiarthroplasty was 20.3 (12±48) weeks. The average time to union of the distal fractures was 23.7 (16±36) weeks with 20 (12±36) weeks for the closed fractures and 25.1 (16±36) weeks for the open fractures. In the open distal fractures, the average time to union of the ®rst four cases was 29 (24±32) weeks, and that of the recent six cases was 22 (16±36) weeks. The latter received delayed bone grafting 6 weeks after the initial management. One proximal fracture (No. 6) developed nonunion in the 36th postoperative week and a total hip replacement was done. In case 3, breakage of the dynamic hip screw (DHS) with displacement of the fracture was noted in the 26th postoperative week, and change of
150
C.-M. Chen et al. / Injury, Int. J. Care Injured 31 (2000) 147±151
the implant with another DHS and bone grafting were done. Union was achieved in the 48th week after the ®rst operation. The failure of implant to premature weight bearing and slow union of the fracture. Malunion with coxa vara was noted in one case (No. 4) in which the initial reduction was good, but varus change due to sliding of the proximal fragment was found in the 16th postoperative week. The ®nal neck±shaft angle was 1158, compared with 1258 on the normal side. For all the cases, the ROM of the hip with ®nally united proximal fractures was within 108 of the contralateral normal hip. The overall incidence of complication of the proximal fractures was 20%, higher than the reports on unifocal proximal femoral fractures [7,8,10,14,22]. Three cases of distal fractures developed infections, which were managed with repeated debridement, application of a suction±irrigation system for 2±4 weeks, and late autogenous bone grafting. Finally, all united by the 32±36th postoperative week, but stiness of the knees developed due to long-term immobilisation for treatment of the infection. Two infections occurred in open fractures and were managed 12 and 18 h after the initial injury (beyond 8 h of golden period), and the other one was in a closed fracture. That is, two of the ®ve open distal fractures managed beyond the golden period became infected (40%), while none of the six open distal fractures managed immediately after the injury became infected, and one of the four closed fractures became infected (25%). Stiness developed in another two cases without a problem in union; both were open fractures with relatively longer union time compared with cases without complications (cases 2 and 7). Delayed union developed in case 3. One refracture developed in case 5, 2 years after union and 2 months after removal of the implant (Judet plate). The overall incidence of complication in the distal fractures was 46.7% with an incidence of 25% for the closed fractures and 54.5% for the open ones. A higher incidence of complication and longer mean union time were noted in the distal fractures, compared with unifocal distal femoral fractures [11,17,19]. The functional result was unsatisfactory in cases 1, 2, 6, 7 and 9 (1/3), and satisfactory in the other 10 (2/ 3). All the healed hip fractures showed acceptable range of motion (within 208 of dierence to the contralateral normal hips). The range of motion of the knees were shown in Table 1. There was no pain around the fractures in case 8, 10, 11, 13, 14 and 15, mild and occasional pain in case 1, 2, 4, 5, 7 and 12, and bad pain in case 3, 6 and 9. All cases had leg length discrepancy and the discrepancy was less than 2 cm in all cases. The average number of operations were 1.1 (1±2) for the proximal fractures, 2.5 (1±7) for the open distal fractures and two (1±5) for the closed distal fractures.
4. Discussion This study report the clinical presentation and management of the ipsilateral proximal and distal femoral fractures. All were caused by high energy trauma. The distal fractures were usually more severe than the proximal ones and were mostly open joint injuries. We thought this was due to the energy of the injury force dissipated mostly directly to the distal femur and less to the proximal femur, or, the force injured the distal femur directly and injured the proximal femur indirectly. Our experience showed that operative treatment was necessary, and that the distal fractures should be managed ®rst and aggressively, especially in open fractures in which early aggressive debridement with septopal chain insertion, anatomical reduction, rigid internal ®xation, early mobilisation of the joint and delayed autogenous bone grafting in the 6th postoperative week could get early union and satisfactory functional results. The closed distal fractures should be managed the same for all the intraarticular fractures: early anatomical reduction, rigid internal ®xation and early mobilisation, so as to get good union and a satisfactory functional result. Proximal fractures are relatively simple, so simple ®xation for the undisplaced ones and good reduction with rigid ®xation for the displaced ones, along with early mobilisation, were the treatment of choice. Since one case (in this series) and other cases (not in this series) with displaced femoral neck fractures developed nonunion in spite of anatomical reduction, rigid internal ®xation and quadratus femoris muscle pedicle bone grafting, we have changed muscle pedicle bone grafting MPBG since 1993 to iliac vascularised bone grafting if open reduction with internal ®xation was chosen as the treatment. For the subtrochanteric fracture, additional bone grafting during the ®rst operation could promote union to prevent late implant failure. No matter what management, the patients' cooperation was an important prognostic factor. Early (within the golden period) aggressive management of the open fractures again was one of the most important prognostic factors in preventing infection. Nevertheless, infection could not be avoided completely, even in closed fracture, as poor soft tissue condition was caused by the severity of trauma. The decreased morbidity and improved functional results that we continuously observed validated our advocacy for more aggressive treatment. Stiness of the knee was another problem associated with infection and delayed union. It seemed to relate to the severity of soft tissue, articular and bony injury, i.e. the poorer the soft tissue, articular and bony conditions, the more likely and severe the stiness. Thus, if we could improve the soft tissue, articular and bony
C.-M. Chen et al. / Injury, Int. J. Care Injured 31 (2000) 147±151
conditions, the result would be more promising. In our experience, the more recent cases had better results. Thus, early aggressive management with radical debridement, anatomical reduction, rigid internal ®xation, delayed bone grafting and early mobilisation should be the treatment of choice for the distal femoral fractures. Unlike the ipsilateral proximal femur and femoral shaft fractures [1±6,15,16,18,20,21,23±25], the associated injuries were less in incidence and severity in this series, due to less force being needed for the distal femoral fractures than for the shaft fractures. The higher incidence of open fractures in this series might relate to less soft tissue being around the knee. The two kinds of injury are dierent in their presentation, management and prognosis. In conclusion, in the management of ipsilateral proximal and distal femoral fractures, early aggressive management is mandatory. The prognosis depends on the fracture personality, the associated injury and the management. References [1] Alho A, Ekeland A, Grogaard B. A locked hip screw-intramedullary nail (cephalomedullary nail) for the treatment of fractures of the proximal part of the femur combined with fractures of the femoral shaft. J Trauma 1996;40:10±8. [2] Alho A. Concurrent ipsilateral fractures of the hip and femoral shaft: a meta-analysis of 659 cases. Acta Orthop Scand 1996;67:19±24. [3] Ashby ME, Anderson JC. Treatment of fractures of the hip and ipsilateral femur with Zickel device: a report of three cases. Clin Orthop 1977;62:156±62. [4] Bennet FS, Zinar DM, Kilgus DJ. Ipsilateral hip and femoral shaft fractures. Clin Orthop 1993;296:168±74. [5] Casey MJ, Chapman MW. Ipsilateral concomitant fractures of the hip and femoral shaft. J Bone Joint Surg Am 1979;61:503±8. [6] Chaturvedi S, Sahu SC. Ipsilateral concomitant fractures of the femoral neck and shaft. Injury 1993;24:243±6. [7] Chiu FY, Lo WH, Chen TH. Surgical treatment for undisplaced
[8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25]
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femoral neck fracture in a 20- to 59-year age group. Orthop 1995;3:489±95. Chiu FY, Lo WH. Undisplaced femoral neck fracture in the elderly. Arch Orthop Trauma Surg 1996;115:90±6. Collins DN, Temple SD. Open joint injuries-classi®cation and treatment. Clin Orthop 1989;243:48±53. Esser MP, Kassab JY, Jones DHA. Trochanteric fractures of the femur. J Bone Joint Surg Br 1986;68:557±60. Foster TE, Healy WL. Operative management of distal femoral fractures. Orthop Rev 1991;20:962. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and 25 open fractures of long bones. J Bone Joint Surg Am 1976;58:453±8. Hsu RWW, Himeno S, Coventry MB. Normal axis alignment of the lower extremity and load-bearing distribution at the knee. Clin Orthop 1990;255:215±9. Jacobs RR, McClain O, Armstrong HJ. Internal ®xation of intertrochanteric hip fractures: a clinical and biomechanical study. Clin Orthop 1980;146:62±72. Kimbrough EE. Concomitant unilateral hip and femoral shaft fracture: a too frequent unrecognized syndrome. Report of ®ve cases. J Bone Joint Surg Am 1961;43:443±8. Leung KS, So WS, Lam TP. Treatment of ipsilateral femoral shaft fractures and hip fractures. Injury 1993;24:41±5. Radford PJ, Howell CJ. The AO dynamic condylar screw for fractures of the femur. Injury 1992;23:89±92. Riemer BL, Butter®eld SL, Ray RL. Clandestine femoral neck fractures with ipsilateral diaphyseal fractures. J Orthop Trauma 1994;8:443±7. Sanders R, Swiontkowski M, Rosen H. Double plating of comminuted, unstable fractures of the distal part of the femur. J Bone Joint Surg Am 1991;73:341±5. Swiontkowski MF, Hansen ST, Kellam J. Ipsilateral fractures of the femoral neck and shaft: a treatment protocol. J Bone Joint Surg Am 1984;66:260±6. Swiontkowski MF. Ipsilateral femoral shaft and hip fractures. Orthop Clin North Am 1987;18:17±23. Villar RN, Thomas G. Subtrochanteric fractures: Zickel nail or nail plate? J Bone Joint Surg Br 1986;68:255±9. Wiss DA, Sima W, Brien WW. Ipsilateral fractures of the femoral neck and shaft. J Orthop Trauma 1992;6:159±64. Wolfgang GL. Combined trochanteric and ipsilateral shaft fractures of the femur treated with the Zickel device: a case report. Clin Orthop 1976;117:241±7. Zettas JP, Zettas PZ. Ipsilateral fractures of the femoral neck and shaft. Clin Orthop 1981;160:63±9.
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Ipsilateral hip and distal femoral fractures Chuan-Mu Chen a, c, Fang-Yao Chiu a, c,*, Wai-Hee Lo a, c, Tien-Yow Chuang b, c a
Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-pai Road, Taipei 11217, Taiwan, ROC b PM&R, Taipei, Taiwan, ROC c National Yang-Ming University, Taipei, Taiwan, ROC Accepted 28 September 1999
Abstract We tried to ®nd the trauma mechanism and treatment rationale of ipsilateral concomitant hip and distal femoral fractures involving the articular surface. Between 1988 and 1995, 15 cases of ipsilateral hip (con®ned to neck or trochanteric areas of the femur) and distal (con®ned to supra- and intercondylar area of the femur) femoral articular fractures were collected. The hip fractures consisted of 10 trochanteric fractures and ®ve neck fractures, which were managed with reduction and ®xation in 14 (Knowles' pin in eight, DHS in four and standard Gamma nail in two), and primary bipolar hemiarthroplastry in one. The distal femoral articular fractures were open in 11; these were managed with radical debridement, implantation of Septopal chains and immediate internal ®xation, followed by prophylactic autogenous bone grafting 6 weeks later in the recent six cases (®ve Judet plates, four dynamic condylar screws and two condylar plates). The other four closed distal femoral fractures were managed with early reduction and internal ®xation (two Judet plate, one dynamic condylar screw and one condylar plate). The union time was 20.3 (12±48) weeks for proximal fractures and 23.7 (12±36) weeks for distal fractures. Early infection developed in three cases. Nonunion of a femoral neck fracture developed in one case. The other complications were implant failure in one, coxa vara in one, refracture in one, delayed union in one and knee stiness in one. # 2000 Elsevier Science Ltd. All rights reserved.
1. Introduction There have been several reports on ipsilateral femoral shaft fractures at dierent sites [1± 6,15,16,18,20,21,23±25], but none was on ipsilateral hip and distal femur involving of the articular surface (supra/intercondyle). This special injury pattern is rare in incidence and its management presents a challenge. This retrospective study tries to elucidate its clinical presentation and management rationale.
2. Materials and methods From January 1988 to June 1995, 15 consecutive * Corresponding author. Tel.: +886-2-2875-7557; fax: +886-22875-4943.
cases were collected in this study, and the follow-up period was 80.2 (36±127) months. All the cases had (1) hip fracture (including intracapsular neck fracture in ®ve cases, intertrochanteric fracture in nine and subtrochanteric fracture in one), (2) ipsilateral distal femoral articular fracture that couldn't be ®xed with any locking intramedullary devices (supra- and intercondylar fracture in 14 and lateral condylar fracture in one) and (3) no other injury of the ipsilateral lower extremity. All the hip fractures were closed; two of the neck fractures and four of the intertrochanteric fractures were undisplaced with the others being displaced. The distal femoral fractures were open in 11 cases and closed in four. Collins and Temple's classi®cation [9] was used for the open fractures. Eight associated injuries were a craniofacial injury a lung contusion an ipsilateral scapular fracture an ipsilateral proximal humeral fracture an ipsilateral distal radius fracture a contralateral femoral
0020-1383/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 9 9 ) 0 0 2 5 0 - 8
33 75
23 63 49
65 72 36
51 37 59
61 39 53
2 3
4 5 6
7 8 9
10 11 12
13 14 15
M M M
F M F
M M M
M M M
M F
M
L L R
R R R
L L R
L R R
L R
L
MCA MCA automobile accident MCA MCA MCA
MCA MCA MCA
MCA automobile accident MCA MCA MCA
MCA
neck ITF ITF
neck ITF ITF
ITF ITF ITF
ITF neck neck
neck STF
ITF
±
SIC,open IIB SIC,open IIIB SIC,open IIIC
SIC,open IC SIC SIC
SIC,open IIB SIC,open IIIC SIC,open IIIB
femur tibia scapula
± ± ±
± tibia humerus
lateral condyle head, face SIC,open IC ± SIC,open IIIC radius
SIC,open IICb ± SIC,open IIIB chest
SIC
DCS DCS Condylar plate
Judet plate Condylar plate Judet plate
Judet plate Judet plate Condylar plate
Judet plate Judet plate
Judet plate
Distal
bipolar hemiarthroplasty DCS pinning DCS pinning DCS
pinning dynamic hip screw gamma nail
dynamic hip screw gamma Nail dynamic hip screw
pinning pinning pinning and MPBG
pinning and MPBG dynamic hip screw (AO)
pinning
Proximal
Associated Treatment Injury
33 29 25
52 46 39
75 70 66
98 90 86
115 108
121
± 12 16
16 16 16
20 24 20
16 20 ±
24 48
16
20 20 20
20 16 16
28 16 36
12 24 32
28 32
36
± ± ±
Knee ROM (8)
± ± ±
0±120 0±130 10±140
0±130 10±140 10±130
0±10 10±130 10±40
0±130 0±120 10±20
infection, 10±20 stiness stiness 0±20 delayed union 0±120 ± implant failure coxa varus ± ± refracture nonunion infection, stiness ± stiness ± ± ± infection, Stiness ± ± ± ± ± ±
±
Distal
Complication
Proximal Distal Proximal
Follow up Union time (mos) (weeks)
a MCA=motorcycle accident; ITF=intertrochanteric fracture; STF=subtrochanteric fracture; SIC=supra- and intercondyle; Pinning=Knowles' pinning; MPBG=muscle pedicle bone graft; DCS=dynamic condylar screw (AO). b Collins/Temple classi®cation13.
64
1
Case Age Sex Side Mechanism Hip Distal No Fracture Femur Fracture
Table 1 Clinical data of the 15 cases of ipsilateral hip and distal femoral articular fracturesa
148 C.-M. Chen et al. / Injury, Int. J. Care Injured 31 (2000) 147±151
C.-M. Chen et al. / Injury, Int. J. Care Injured 31 (2000) 147±151
shaft fracture and a contralateral tibial fracture. All were managed on the same day as the proximal and distal femoral fractures. Twelve were male and three were female of average age 52 (23±75). High velocity motorcycle accidents were the cause in 13 of the 15 cases and automobile accidents in the other two. The clinical data of the 15 cases are shown in Table 1. The authors managed all the cases. In the proximal fractures (Table 1), Knowles' pins were used to ®x four of the ®ve femoral neck fractures, including two undisplaced fractures and two displaced fractures managed with additional open reduction and quadratus femoris muscle pedicle bone grafting because of their young age. The undisplaced fractures were managed percutaneously [7,8]. The other displaced femoral neck fracture was managed with a primary PCA bipolar hemiarthroplasty because of his relatively old age. For the four undisplaced intertrochanteric fractures, Knowles' pins were also used for the ®xation, percutaneously. All the fractures ®xed with Knowles' pins had four pins inserted in a box shape [7,8]. The other ®ve displaced intertrochanteric fractures were managed with open reduction and internal ®xation, with a dynamic hip screw (DHS, AO) in three and Gamma nail in two. The displaced subtrochanteric fracture was managed with open reduction and internal ®xation with DHS. The open distal fractures were initially managed according to Gustilo and Anderson's description [12], immediate internal ®xation was done with Judet plates in ®ve cases, condylar plates in two cases, and dynamic condylar screws (DCS, AO) in four cases. A septopal chain was put in all cases with hemovac drainage and primary wound closure. Five (case 2, 5, 6, 9 and 13 in Table 1) were managed beyond the golden period (8 h) because of late referrals from other local hospitals, and were delayed from 10 to 18 h. In the recent ®ve cases (No. 8, 10, 13, 14 and 15), delayed autogenous bone grafting was done 6 weeks after the initial operation for prevention of delay in union which was suspected in the follow-up X-ray. The closed distal fractures were managed with early open reduction and internal ®xation with Judet plate in two, condylar plate in one and DCS in one, within 7 days of the initial injuries. Autogenous cancellous bone graft was put in all cases except the one with lateral condylar fracture. No Septopal chain was used, but hemovac drainage was put in all cases. Continuous passive motion of the knee and range of motion exercise of the hip and knee were prescribed in all cases from the ®rst postoperative day, and the exercise continued till discharge or stopped, if a wound problem developed. No other supplemental ®xation was used initially for any cases. Non-weight bearing was prescribed after operation and weight bearing started progressively from the 9th postoperative week if no complication devel-
149
oped. Full weight bearing was permitted after the appearance of bridging callus and clinical union of both proximal and distal fractures. The functional results were supervised by senior sta throughout the follow-up period. After discharge, each case was followed once every two weeks in the ®rst month and once every 4 weeks thenceforth. Functional evaluation was done at every visit and once every two months after union of the fracture. Each patient had one special chart with detailed personal data, mechanism and associated condition of the injury, type and classi®cation of the fracture, choice and course of the management, condition and course of the fracture healing, functional recovery, and the total number and average number of operations till the ®nal follow-up. X-ray check-up was done at every follow-up visit, and all the evaluations and records were done by the same sta (C.-M.C. and F.-Y.C.) at the same time. Normal union was de®ned as appearance of both bridging callus and partial obliteration of the fracture site within 28 weeks, delayed union as union evidenced in 29±40 weeks and nonunion as no evidence of union after 40 weeks. Malunion was de®ned as varus or valgus deformity over 58 more than the neck±shaft angle or distal femoral axis orientation angle [13] of the contralateral side, anterior or posterior angulation equal to or more than 108, rotational deformity equal to or more than 108 or shortening equal to or more than 5 mm. If the active ROMs of the knee and the hip were evaluated to be within 208 of dierence to the contralateral normal joints, and the patient had full return to the preinjury activity and work without pain or with just little discomfort, the functional result was de®ned to be satisfactory; otherwise to be unsatisfactory. 3. Results The general data of the patients are shown in Table 1. The average hospital stay was 21 (7±63) days. The average time to union of the proximal fractures, excluding the cases with nonunion and primary hemiarthroplasty was 20.3 (12±48) weeks. The average time to union of the distal fractures was 23.7 (16±36) weeks with 20 (12±36) weeks for the closed fractures and 25.1 (16±36) weeks for the open fractures. In the open distal fractures, the average time to union of the ®rst four cases was 29 (24±32) weeks, and that of the recent six cases was 22 (16±36) weeks. The latter received delayed bone grafting 6 weeks after the initial management. One proximal fracture (No. 6) developed nonunion in the 36th postoperative week and a total hip replacement was done. In case 3, breakage of the dynamic hip screw (DHS) with displacement of the fracture was noted in the 26th postoperative week, and change of
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the implant with another DHS and bone grafting were done. Union was achieved in the 48th week after the ®rst operation. The failure of implant to premature weight bearing and slow union of the fracture. Malunion with coxa vara was noted in one case (No. 4) in which the initial reduction was good, but varus change due to sliding of the proximal fragment was found in the 16th postoperative week. The ®nal neck±shaft angle was 1158, compared with 1258 on the normal side. For all the cases, the ROM of the hip with ®nally united proximal fractures was within 108 of the contralateral normal hip. The overall incidence of complication of the proximal fractures was 20%, higher than the reports on unifocal proximal femoral fractures [7,8,10,14,22]. Three cases of distal fractures developed infections, which were managed with repeated debridement, application of a suction±irrigation system for 2±4 weeks, and late autogenous bone grafting. Finally, all united by the 32±36th postoperative week, but stiness of the knees developed due to long-term immobilisation for treatment of the infection. Two infections occurred in open fractures and were managed 12 and 18 h after the initial injury (beyond 8 h of golden period), and the other one was in a closed fracture. That is, two of the ®ve open distal fractures managed beyond the golden period became infected (40%), while none of the six open distal fractures managed immediately after the injury became infected, and one of the four closed fractures became infected (25%). Stiness developed in another two cases without a problem in union; both were open fractures with relatively longer union time compared with cases without complications (cases 2 and 7). Delayed union developed in case 3. One refracture developed in case 5, 2 years after union and 2 months after removal of the implant (Judet plate). The overall incidence of complication in the distal fractures was 46.7% with an incidence of 25% for the closed fractures and 54.5% for the open ones. A higher incidence of complication and longer mean union time were noted in the distal fractures, compared with unifocal distal femoral fractures [11,17,19]. The functional result was unsatisfactory in cases 1, 2, 6, 7 and 9 (1/3), and satisfactory in the other 10 (2/ 3). All the healed hip fractures showed acceptable range of motion (within 208 of dierence to the contralateral normal hips). The range of motion of the knees were shown in Table 1. There was no pain around the fractures in case 8, 10, 11, 13, 14 and 15, mild and occasional pain in case 1, 2, 4, 5, 7 and 12, and bad pain in case 3, 6 and 9. All cases had leg length discrepancy and the discrepancy was less than 2 cm in all cases. The average number of operations were 1.1 (1±2) for the proximal fractures, 2.5 (1±7) for the open distal fractures and two (1±5) for the closed distal fractures.
4. Discussion This study report the clinical presentation and management of the ipsilateral proximal and distal femoral fractures. All were caused by high energy trauma. The distal fractures were usually more severe than the proximal ones and were mostly open joint injuries. We thought this was due to the energy of the injury force dissipated mostly directly to the distal femur and less to the proximal femur, or, the force injured the distal femur directly and injured the proximal femur indirectly. Our experience showed that operative treatment was necessary, and that the distal fractures should be managed ®rst and aggressively, especially in open fractures in which early aggressive debridement with septopal chain insertion, anatomical reduction, rigid internal ®xation, early mobilisation of the joint and delayed autogenous bone grafting in the 6th postoperative week could get early union and satisfactory functional results. The closed distal fractures should be managed the same for all the intraarticular fractures: early anatomical reduction, rigid internal ®xation and early mobilisation, so as to get good union and a satisfactory functional result. Proximal fractures are relatively simple, so simple ®xation for the undisplaced ones and good reduction with rigid ®xation for the displaced ones, along with early mobilisation, were the treatment of choice. Since one case (in this series) and other cases (not in this series) with displaced femoral neck fractures developed nonunion in spite of anatomical reduction, rigid internal ®xation and quadratus femoris muscle pedicle bone grafting, we have changed muscle pedicle bone grafting MPBG since 1993 to iliac vascularised bone grafting if open reduction with internal ®xation was chosen as the treatment. For the subtrochanteric fracture, additional bone grafting during the ®rst operation could promote union to prevent late implant failure. No matter what management, the patients' cooperation was an important prognostic factor. Early (within the golden period) aggressive management of the open fractures again was one of the most important prognostic factors in preventing infection. Nevertheless, infection could not be avoided completely, even in closed fracture, as poor soft tissue condition was caused by the severity of trauma. The decreased morbidity and improved functional results that we continuously observed validated our advocacy for more aggressive treatment. Stiness of the knee was another problem associated with infection and delayed union. It seemed to relate to the severity of soft tissue, articular and bony injury, i.e. the poorer the soft tissue, articular and bony conditions, the more likely and severe the stiness. Thus, if we could improve the soft tissue, articular and bony
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conditions, the result would be more promising. In our experience, the more recent cases had better results. Thus, early aggressive management with radical debridement, anatomical reduction, rigid internal ®xation, delayed bone grafting and early mobilisation should be the treatment of choice for the distal femoral fractures. Unlike the ipsilateral proximal femur and femoral shaft fractures [1±6,15,16,18,20,21,23±25], the associated injuries were less in incidence and severity in this series, due to less force being needed for the distal femoral fractures than for the shaft fractures. The higher incidence of open fractures in this series might relate to less soft tissue being around the knee. The two kinds of injury are dierent in their presentation, management and prognosis. In conclusion, in the management of ipsilateral proximal and distal femoral fractures, early aggressive management is mandatory. The prognosis depends on the fracture personality, the associated injury and the management. References [1] Alho A, Ekeland A, Grogaard B. A locked hip screw-intramedullary nail (cephalomedullary nail) for the treatment of fractures of the proximal part of the femur combined with fractures of the femoral shaft. J Trauma 1996;40:10±8. [2] Alho A. Concurrent ipsilateral fractures of the hip and femoral shaft: a meta-analysis of 659 cases. Acta Orthop Scand 1996;67:19±24. [3] Ashby ME, Anderson JC. Treatment of fractures of the hip and ipsilateral femur with Zickel device: a report of three cases. Clin Orthop 1977;62:156±62. [4] Bennet FS, Zinar DM, Kilgus DJ. Ipsilateral hip and femoral shaft fractures. Clin Orthop 1993;296:168±74. [5] Casey MJ, Chapman MW. Ipsilateral concomitant fractures of the hip and femoral shaft. J Bone Joint Surg Am 1979;61:503±8. [6] Chaturvedi S, Sahu SC. Ipsilateral concomitant fractures of the femoral neck and shaft. Injury 1993;24:243±6. [7] Chiu FY, Lo WH, Chen TH. Surgical treatment for undisplaced
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