Ipsilateral Femoral Neck and Shaft Fractures with a Floating Knee Injury: a Case Report Matthew T

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Ipsilateral Femoral Neck and Shaft Fractures with a Floating Knee Injury: A Case Report Matthew T. Philippi, BS*; Scott M. Sandilands, DO†; Paul J. Goodwyn, MD†; Samer Kakish, MD†

*School of Medicine, The University of Utah, Salt Lake City, Utah †Department of Orthopaedics & Rehabilitation, The University of New Mexico Health Sciences Center, Albuquerque, New Mexico

Corresponding Author Scott Sandilands, DO. Department of Orthopaedics & Rehabilitation, MSC10 5600, 1 University of New Mexico, Albuquerque, NM 87131 ([email protected]).

Funding The authors received no financial support for the research, authorship, and publication of this article.

Conflict of Interest The authors report no conflicts of interest.

Informed Consent The patient was informed that the data concerning his case would be submitted for publication, and he provided verbal consent.

ABSTRACT of the knee (IIc). Floating knee injuries are associated Isolated ipsilateral fractures of the femoral neck with open injuries with soft-tissue damage, occurring in and shaft are rare injuries. Similarly, a floating knee 54% to 62% of patients. Amputation is performed 1% to (ie, ipsilateral fractures of the femur and tibia) is 3% of patients.1,9-11 uncommon. We describe a 34-year-old man with In isolation, both ipsilateral femoral neck and shaft ipsilateral fractures of the femoral neck and shaft with fractures and floating knee injuries present various an ipsilateral floating knee after a motorcycle collision. treatment considerations that surgeons must take into He was treated with operative fixation, and was walking account; yet, reports of patients presenting with both without assistive devices at his most recent follow-up injuries are rare. We describe a patient who underwent appointment in February 2019. We believe this to be surgical fixation for treating ipsilateral femoral neck and a unique combination of injuries not yet described in shaft fractures as well as a floating knee injury. studies. CASE REPORT Keywords: Ipsilateral Neck Shaft, Floating Knee, A 34-year-old man was transported directly to the Femoral Neck, Femoral Shaft, Tibial Shaft emergency department after a motorcycle collision. On admission, he was given cefazolin and gentamycin and INTRODUCTION Advanced Trauma Life Support protocol was initiated. Ipsilateral femoral neck and shaft fractures are typically At that time, the patient had a Glasgow Coma Scale of associated with high-energy polytrauma.1,2 The 15. Subsequent imaging revealed a displaced fracture ipsilateral femoral neck and shaft fracture combination about the right vertical basicervical femoral neck was originally described by Delaney and Street.3 (Figure 1), a right femoral shaft fracture (Figure 2), Femoral neck fractures accompany femoral shaft and a right tibial shaft fracture (Figure 3). The patient fractures 6% of the time4 and are most commonly sustained a comminuted right patella fracture, right tibial vertically-oriented basicervical, whereas femoral shaft shaft and fibula fractures, left distal radius fracture, left fractures are most commonly transverse and butterfly patella fracture, and a grade IIIA open left tibial plateau fractures.2,5,6 To decrease the frequency of misdiagnosis, fracture. A thoracostomy tube was placed to treat his various protocols such as pre- and postoperative right-sided hemopneumothorax and intraventricular and computed tomography scans and intraoperative stress subarachnoid hemorrhages. examinations have been recommended.7 Although these About 12 hours after presentation, the patient was injuries are typically treated surgically, no consensus cleared by the neurosurgical team and taken back exists on the order of fixation techniques or most to the operating room by the orthopaedic trauma effective fixation strategy. team. The patient was placed in supine position on Ipsilateral tibia fractures, also called floating a radiolucent table. First, the open left tibial plateau knee injuries, are similarly difficult to treat. They fracture was irrigated and debrided. The wound was were originally classified by Blake and McBryde8 in then closed, and a knee spanning external fixator was 1975 as Type I (extraarticular) or Type II (articular). placed. The right femoral neck fracture was treated Subsequently, Fraser et al9 added subclassifications to with open reduction using a lateral approach to the Type II fractures to indicate tibial plateau injury (IIa), proximal femur. A capsulotomy was performed along distal femur (IIb), or articular involvement of both sides the anterior neck, and the fracture was then reduced

140 CASE REPORTS • UNMORJ VOL. 8 • 2019 Figure 2. (Left) anteroposterior view and (right) lateral view of the right femur showing a displaced, shortened, transverse shaft fracture. Figure 1. Anteroposterior view of initial radiograph of the right hip showing a displaced vertical femoral neck fracture.

Figure 3. (Left) anteroposterior view and (right) lateral view of the right tibia and fibula showing comminuted fracture. with use of a Cobb and Schanz pin in the lateral nail was placed normally. After fixation, fluoroscopic femur. Reduction was verified by digital palpation and views were obtained to verify reduction and hardware fluoroscopy findings, which was held provisionally with placement (Figures 6 through 8). At the conclusion of multiple K-wires. Next, a sliding screw was placed at a the procedure, no instability or laxity was noted after 130° angle into a four-hole side plate, with use of 4-mm examining the full ligamentous knee. antirotation screws placed proximal to the side plate. After being admitted to the hospital, the patient In a transpatellar manner, a retrograde intramedullary subsequently returned to the operating room on days 5 nail was placed in the femur. The distal two holes and 7 for definitive treatment of his other injuries. These of the dynamic hip screw with a plate were placed included operative fixation of the left tibial plateau, around the femoral nail. Reduction was confirmed with operative fixation of the left distal radius, and partial findings of fluoroscopic images (Figures 4 and 5). To patellectomies of both patellas. The patient was posi- treat the tibia fracture, a suprapatellar intramedullary tioned to avoid weight bearing on the right and left

CASE REPORTS • UNMORJ VOL. 8 • 2019 141 Figure 4. (Left) intraoperative anteroposterior view and (right) lateral Figure 5. Intraoperative fluoroscopic fluoroscopic image of the right hip confirming reduction femoral neck image of the right femoral shaft fracture with appropriate placement of hip screw with side plate and confirming adequate reduction and antirotation screw. intramedullary placement of nail.

Figure 6. (Left) intraoperative anteroposterior view and (right) lateral fluoroscopic image of right knee confirming appropriate placement of femoral and tibial nails.

Figure 7. (Left) intraoperative anteroposterior view and (right) lateral fluoroscopic image of right tibia confirming adequate reduction and intramedullary placement of nail.

142 CASE REPORTS • UNMORJ VOL. 8 • 2019 Figure 8. (Left) intraoperative anteroposterior view and (right) lateral fluoroscopic image of right ankle displaying appropriate placement of intramedullary nail and distal locking screws.

Figure 9. Radiographs at 5 months postoperatively. A) (Left) anteroposterior view and (right) lateral right hip. B) (Left) anteroposterior view and (right) lateral femur. C) (Left) anteroposterior view and (right) lateral tibia and fibula.

CASE REPORTS • UNMORJ VOL. 8 • 2019 143 lower extremities, with the knees maintained in Regarding treatment of floating knee injuries, extension for the partial patellectomies. Additionally, he fixation strategies should be tailored to each individual was positioned to avoid weight bearing on the left patient’s fracture pattern because no standard method upper extremity, with weight bearing allowed through exists. Type I floating knee injuries have been treated the elbow. using intramedullary nails in both femur and tibia At 10 days postoperatively, the patient was given fractures, with promising results.1,4 It is recommended enoxaparin to treat venous thrombosis prophylaxis and that the femur undergo fixation before the tibia. This was discharged to a skilled nursing facility. At 8 weeks is because of a concern that further soft-tissue injury postoperatively, knee range of motion was initiated and might happen in the unstable femur fracture when the patient was advised to bear weight as tolerated on reducing and stabilizing the tibia fracture. Additionally, the right lower and left upper extremities. At 12 weeks stabilization of the femur allows for a more stable postoperatively, the patient could bear weight on the position to approach the tibia fracture and allows left lower extremity as tolerated. access to the starting point.4,22 At the most recent follow-up 5 months Femoral neck and shaft fractures as well as floating postoperatively, he could walk without assistive knee injuries result from high-energy trauma, and they devices. The range of motion of both knees was 0° often include various associated injuries that affect to 90°. The patient continued to undergo physical treatment outcomes. In the current case, we described therapy to increase the range of motion and strength treatment of a unique injury pattern that has not yet of his knees. At this time, radiographs showed healing been reported. Ultimately, because no standard method of the femoral neck and shaft fractures as well as the exists, surgical management should be tailored to tibia fracture. Additionally, no loss of reduction was patients’ injury patterns and surgeons’ preference and observed in the femoral neck fracture (Figures 9A experience.

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