A Missed Ipsilateral Femoral Neck Fracture in A

Special Case Report Series JOT CASE REPORTS

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Belgian Orthopaedic Trauma Association Canadian Orthopaedic Trauma Society Foundation for Orthopedic Trauma International Society for Fracture Repair The Japanese Society for Fracture Repair Missed Ipsilateral Femoral Neck Fracture in a Young Patient With a Femoral Shaft Fracture Anthony V. Florschutz, MD, PhD,* Derek J. Donegan, MD,† George Haidukewych, MD,* Mark Munro, MD,‡ and Frank A. Liporace, MD§

Summary: Ipsilateral femoral neck-shaft fractures are uncommon INTRODUCTION but significant injuries that can present a diagnostic difficulty with Femoral neck fractures are associated with up to 9% of ipsilateral respect to recognition of femoral neck component. Although there femoral shaft fractures. Between 20% and 50% of these fractures are are improved diagnostic methodologies, identification of a faction reported to be missed on initial presentation, and although there are of these fractures will be delayed or missed even when the most improved diagnostic methodologies, identification of a faction of sensitive protocols are used. As such, it is essential for treating these fractures will be delayed or missed even when the most surgeons to be attentive to the potential associated femoral neck sensitive protocols are used.1 Although this associated pattern of fracture when managing femoral shaft fractures and consider its fractures is not regularly encountered, it is common enough that possibility even in the postoperative period. This case report orthopaedic surgeons should consider the possibility of its presence describes the case of a young male who was initially managed for when evaluating femoral shaft fractures especially if the injury re- an isolated femoral shaft fracture after a high-energy injury and was sulted from a high-energy mechanism in a young patient.2 Missing postoperatively diagnosed and treated for an ipsilateral femoral a femoral neck fracture has a high potential to lead to significant neck fracture. negative consequences requiring further surgical intervention such as more severe fracture displacement, healing complications, avas- cular necrosis, loss of function, and pain.3,4 This case report discusses Key Words: femur shaft fracture, femoral neck fracture, ipsilateral the case of a missed femoral neck fracture in a young patient who was femoral neck initially treated for a femoral shaft fracture. Accepted for publication September 16, 2015. From the *Orlando Regional Medical Center, Orlando, FL; and †Univer- CASE PRESENTATION sity of Pennsylvania, Philadelphia, PA; and ‡Orlando Regional Medical Center, Orlando, FL; and §NYU-HJD, New York, NY. Patient Presentation G. Haidukewych receives royalties from DePuy and Biomet, Inc, does A 19-year-old white male was brought to the emergency consulting work for DePuy and Biomet, Inc, and owns stock in Institute department by ambulance in the evening after he lost control of his for Better Bone Health and Orthopediatrics. F. A. Liporace has received truck and hit a house while texting and driving. He was hemody- royalties for lower extremity intramedullary nails from Biomet, Inc, namically stable and alert on arrival and denied loss of consciousness Warsaw, IN. The remaining authors report no conflict of interest. during the accident. His primary complaint was deep right thigh pain. Reprints: Derek J. Donegan, MD, Department of Orthopaedic Surgery, The patient’s previous medical and surgical histories were remark- Penn Musculoskeletal Center, 3737 Market St, 7th Floor, Philadelphia, able for appendicitis and appendectomy, respectively. His social habits PA 19014 (e-mail: [email protected]). included regular tobacco, marijuana, and social alcohol use. The re- No other authors have direct or indirect benefits to report in the prepa- maining history was negative for any pertinent positive findings. ration or completion of this article. The views and opinions expressed in this case report are those of the Clinical Findings and Diagnostic Assessment authors and do not necessarily reflect the views of the editors of Journal On physical examination, the patient had an obvious right thigh of Orthopaedic Trauma or Biomet. deformity and tenderness in the same area. His hip and knee motion Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. was restricted secondary to pain. There were no open wounds or

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FIGURE 1. AP pelvis film and also AP and lateral views of the femur demonstrating a transverse femoral shaft fracture in the mid-diaphyseal region. neurologic deficits on examination. Vascular evaluation revealed was no evidence of a concomitant ipsilateral neck fracture. No other a palpable dorsalis pedis and posterior tibial pulse. injuries were identified during workup. Radiographic evaluation included an anteroposterior (AP) pelvis film and also AP and lateral views of the femur, which demonstrated Therapeutic Intervention a transverse femoral shaft fracture in the mid-diaphyseal region Initial management of the femoral shaft fracture involved (Fig. 1). The femoral neck was evaluated on the same films, and there stabilizing the right lower extremity in Buck traction and

FIGURE 2. Intraoperative ﬂuoroscopic evaluation of the femoral neck after IMN placement failing to demonstrate a femoral neck fracture. e2 www.jorthotrauma.com Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Copyright Ó 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Missed Ipsilateral Femoral Neck Fracture

FIGURE 3. Postoperative AP and lateral radiographs of the femur obtained in the postanesthesia care unit per standard protocol revealing an ipsilateral basicervical femoral neck fracture. pharmacologic pain management. The patient’s injury was was positioned on a fracture table, and after sterile preparation described in detail to him, and also the necessary surgical manage- and draping, a lateral approach was used to gain access to the ment of his injury with operative reduction and intramedullary proximal femur. Intraoperative fluoroscopic images obtained nailing (IMN). After this discussion and obtaining surgical consent, before fixation clearly showed a basicervical fracture of the femoral the patient was scheduled to undergo retrograde IMN of his femur neck (Fig. 4). The fracture was then closed, reduced, and internally in the morning. stabilized using a SHS implant. Interestingly, the tip of the retro- The patient was brought to the operating suite the following grade IMN was positioned in very close proximity to the trajectory morning, and radiographs were again reviewed to assess the of the cephalic screw on the SHS implant, which required slightly femoral shaft fracture and closely inspect the femoral neck for reaming through the tip of the IMN (Figs. 5, 6). any evidence of injury (Fig. 1). Surgery proceeded with induction Postoperatively, a standard course of postoperative antibiotics of anesthesia and sterile preparation and draping of the extremity on and venous thromboembolism prophylaxis was instituted. The a Jackson table. Before incision, the femoral neck was examined patient was allowed to weight bear as tolerated on the right lower under intraoperative fluoroscopy to rule out an ipsilateral femoral extremity and discharged from the hospital on postoperative day 2. neck fracture. This assessment was negative and surgery proceeded At his most recent follow-up period of 2 months out from surgery, with successful reduction of the femoral shaft fracture and place- he has no complaints and subjectively states he feels he is doing ment of a retrograde IMN. Before closing the operative sites, the well. Follow-up radiographs show maintained fracture reduction femoral neck was examined again with fluoroscopy, and no femoral and stable fixation (Fig. 7). neck fracture was identified (Fig. 2). The operative sites were then closed, sterile dressings applied, and the patient was awakened DISCUSSION from anesthesia without issue and taken to the postanesthesia care Ipsilateral femoral neck-shaft fractures are uncommon but unit. Postoperative AP and lateral radiographs of the femur were significant injury patterns that potentially lead to serious compli- obtained in the postanesthesia care unit per standard protocol and cations if missed. The femoral neck fracture in these cases is often revealed an ipsilateral basicervical femoral neck fracture (Fig. 3). subtle with minimal displacement and difficult to visualize on The surgery and postoperative findings were discussed with the standard plain radiographs of the pelvis and hip.2 Improvements for patient and also the indicated further surgical intervention. He effective diagnosis of these associated injuries using fine-cut com- was posted for femoral neck fixation using a sliding hip screw puted tomography (CT) and dedicated internal rotation radiographs (SHS) implant the next day. At the time of surgery, the patient have been advocated to significantly reduce delays in diagnosis.

FIGURE 4. Intraoperative ﬂuoroscopic images obtained before ﬁxation demonstrating a basicervical fracture of the femoral neck.

FIGURE 5. Intraoperative ﬂuoroscopic images demonstrating placement of the SHS.

FIGURE 6. Final intraoperative ﬂuoroscopic images demonstrating completed placement of SHS.

Tornetta et al1 described their experience with these diagnostic highlight how subtle these fractures may be. Ideally, preoperative methods in 16 cases of ipsilateral femoral neck-shaft fractures images should at minimum include AP pelvis and also AP, lateral, and reported 1 missed femoral neck fracture diagnosed intraoper- and internal rotation hip views with no equipment obstructing the atively and 1 that was diagnosed postoperatively after fixation of clear visualization. CT may also be used in cases with suggestive but the femoral shaft. As such, even with these recognized diagnostic no definite findings on preoperative plain films. improvements, there remain some ipsilateral femoral neck-shaft fractures that will still be missed on initial evaluation.5 Further- more, it is also important to consider ipsilateral injury to the distal CONCLUSIONS femur as there is evidence in the literature describing this even more Patients presenting with femoral shaft fractures, especially if complex although rare pattern of injury.6 the injury resulted from a high-energy mechanism, should always In this case, there was a recognized deficiency of sufficient quality be evaluated for an associated femoral neck fracture. Appropriate imaging preoperatively during the workup phase. A standard preoperative, intraoperative, and postoperative imaging of the intraoperative evaluation of the femoral neck using fluoroscopy femoral neck can be effectively used to rule out or identify was used as a diagnostic adjunct during the initial procedure (Fig. 2) a fracture of the femoral neck. Furthermore, consideration of but failed to reveal the presence of the femoral neck fracture. In advanced imaging modalities such as fine-cut CT may improve comparison, the intraoperative fluoroscopic images obtained during diagnostic efficiency and reduce the rate of missed femoral neck the second operation (Fig. 4) clearly demonstrated the fracture and fractures.

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