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ORIGINAL ARTICLE Table of Contents   
Year : 2002  |  Volume : 36  |  Issue : 2  |  Page : 11
Ipsilateral hip and femoral shaft fractures


Department of Orthopaedics, SMS Medical College, Jaipur, India

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   Abstract 

Sixty cases of ipsilateral fracture of femoral neck and shaft were treated. The most preferred methods were placement of multiple screws around a previously placed intramedullary nail or a distal broad dynamic compression plate. Final functional outcome was evaluated in 52 cases (limbs) using criteria of pain, ability to work, shortening, range of movements at hip and knee, ability to squat/ sit cross legged and infection. We noticed a better prognosis after operative fixation for fracture neck in such combination injuries in comparison to isolated neck fractures. Follow up revealed no case of nonunion or avascular necrosis of fracture neck femur. Shaft fractures were the high-energy fractures in these cases and took longer time to heal. We conclude that ipsilateral hip and shaft fracture be diagnosed early and treated operatively simultaneously for better functional outcome.

Keywords: Ipsilateral -hip-femoral-shaft-fractures.

How to cite this article:
Agarwal A, Gupta S P. Ipsilateral hip and femoral shaft fractures. Indian J Orthop 2002;36:11

How to cite this URL:
Agarwal A, Gupta S P. Ipsilateral hip and femoral shaft fractures. Indian J Orthop [serial online] 2002 [cited 2019 Feb 17];36:11. Available from: http://www.ijoonline.com/text.asp?2002/36/2/11/48643

   Introduction Top


Midshaft femoral fracture in a high energy trauma victim should prompt the orthopaedist to search carefully for an ipsilateral fracture of the hip. The rate of occurrence is about 6% of all femoral shaft fractures but it is believed that incidence is increasing steadily. These fracture patterns pose diagnostic difficulties and complex treatment decisions. This paper highlights a simple approach to early detection.


   Materials & Methods Top


We reviewed 60 cases of ipsilateral fractures of the hip (including both intracapsular and extracapsular types) and femoral shaft between the periods of May 1997 to October 2000 (prospective and retrospective follow up cases). Three cases were lost in follow up, 3 are still continuing treatment and 2 patients expired. These 8 cases were not included in final functional evaluation. One patient with fracture dislocation hip and fracture shaft femur underwent Girdlestone operation, hence not included in observation of avascular necrosis. Results were assessed in 52 cases (38 intracapsular and 14 extracapsular fractures).

In every case of fracture shaft femur special emphasis was given to get an X-ray pelvis in the emergency department itself. The preoperative planning and implant choice was made taking into consideration the age, socioeconomic conditions and facilities available. Our operative choice was fixation of neck fracture by multiple screw placement around a previously inserted intramedullary K-nail.

The criteria used to evaluate the results included pain, ability to work, shortening, range of movements at hip and knee, ability to squat/ sit cross-legged and infection. To upgrade our results assessment, in each case we inquired whether patient returned to his/ her original work.


   Observations Top


This fracture combination was most common among young males (86%) with road traffic accidents being predominant cause of injury [Table 1]. Forty one cases had intracapsular fracture of neck and nineteen were trochanteric fractures. The ratio of neck to trochanter fractures in our series was 2.1: 1. Twenty five fractures of femoral neck were Garden's type II, ten type III and five type IV. One fracture was Garden's type I. Among nineteen trochanteric fractures five were two part undisplaced, three two part displaced and eleven were comminuted fractures. The hip fracture was initially overlooked in ten cases including one trochanter fracture. Femoral shaft fractures pattern is shown in [Table 2]. The commonest associated injury was fracture leg bones in eleven cases followed by knee injuries in nine cases. Treatment methods are reviewed in [Table 3].

Forty one cases (78%) of hip fractures united within 6 months [Table 4]. Nearly 92% cases of shaft fractures (48 cases) had radiological union by 12 months [Table 4]. The main complication was limb length discrepancy seen in cases [Table 5]. Infection was seen in 7.6 % cases. Gross restriction of movements occurred at hip in two cases and knee in nine cases. The range of knee movements was between 0° - 90° in 38 % cases (20 out of 52). Nearly 76% cases returned to their original work post injury.


   Discussion Top


Fractures of the hip and femur are difficult to diagnose and treat. Reviewing the literature on the subject offers one with ample treatment choices for management of this fracture combination. We have used cancellous screw with intramedullary nailing in 19 out of 60 cases [Figure 1],[Figure 2]. Although concern has been raised about difficulty in inserting screws around an intramedullary nail, we suggest this method as preferred method of treatment except in distal third shaft fractures because of wider canal [Figure 3]a,b. It is a cheap, load sharing device which can be inserted without much dissection when inserted by close method with added benefits of lower infection rate and less quadriceps scarring. Both hip and shaft could be approached through the same surgical incision. The surgical operative time and exposure under image intensifier were significantly decreased by this method. Implant removal was also comparatively easy. Another method of fixation is retrograde nailing.It is said that this avoided potential iatrogenic devascularization of the femoral head while driving an intramedullary nail adjacent to an unstabile femoral neck fracture. Retrograde nailing, however, requires use of a relatively small diameter rod. This method of fixation is also dependent on initial recognition of femoral neck fractures, which is frequently not the case. Furthermore, it is not applicable to distal diaphyseal fractures because of risk of fracture into entry portal. The same disadvantages are encountered when multiple flexible retrograde nails are used. Inadequate stability may lead to complications and may necessitate postoperative traction or casting. Such potential delay in patient mobilization should be avoided in setting of multiple trauma. Others have simply recommended against open retrograde nailing to avoid increasing the varus deformity of the femoral neck or displacing an undisplaced fracture. We share the view with Bennet et al ,that ante grade nailing is preferable to retrograde nailing when femoral neck has not been stabilised because of valgus force it imparts. The new generation of femoral reconstruction nails offers a possible solution for ipsilateral hip and femur fractures with relatively few disadvantages when proximally and distally interlocked. The main practical disadvantage lies in the difficulty of rotationally aligning the nail and proximal interlocking holes within the femoral shaft in such a way that the proximal screw will engage the femoral head after the hip fracture is reduced. Passing screws around the proximal end of the conventional nail avoids this potential problem. Other factors disfavoring use of reconstruction nails are its high cost, greater exposure time under image intensifier television and long time of operations. We have limited experience with use of such nails.

It is suggested that the shaft fracture be treated first for the following reasons­

i. Once the continuity of the shaft has been restored, the reduction of the neck becomes easier.

ii. The initial placement of the screw hampers the nail insertion.

In this series 26 cases out of 41 neck cases were Garden's type I and II, suggesting the absence of rotatory stress and minimal soft tissue disruption. This finding and comminution at fracture shaft site support the view that this injury results from force moving in the direction of femur to the neck of the femur i.e. 'Dashboard injury' when the hip is flexed and abducted as seated on a motorcycle.Once the head is well inside the acetabulum, the entire thrust falls on the shaft of femur with residual force leading to fracture neck. We feel that it is the direction of force and the position of the patient which determine this pattern of injury. Probably for the same reasons, intracapsular fractures were more common than the extracapsular variety (2.1:1). We had only 15% cases with associated fractures of patella/knee injury though the incidence has been to the extent of 25% in published English literature.

Top
Correspondence Address:
A Agarwal
60/99 Mansarovar, Jaipur - 302020.
India
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Source of Support: None, Conflict of Interest: None


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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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    Abstract
    Introduction
    Materials & Methods
    Observations
    Discussion
    Article Figures
    Article Tables
 

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