JOT

JOURNALOF ORTHOPAEDIC

TRAUMA

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OFFICIAL JOURNAL OF

Orthopaedic Trauma Association

Belgian Orthopaedic Trauma Association

Canadian Orthopaedic Trauma Society

Foundation for Orthopedic Trauma

International Society for Fracture Repair

The Japanese Society for Fracture Repair

Special Case Report Series

CASE REPORTS

Missed Ipsilateral Femoral Neck Fracture in a Young PatientWith 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 uncommonbut significant injuries that can present a diagnostic difficulty withrespect to recognition of femoral neck component. Although thereare improved diagnostic methodologies, identification of a factionof these fractures will be delayed or missed even when the mostsensitive protocols are used. As such, it is essential for treatingsurgeons to be attentive to the potential associated femoral neckfracture when managing femoral shaft fractures and consider itspossibility even in the postoperative period. This case reportdescribes the case of a young male who was initially managed foran isolated femoral shaft fracture after a high-energy injury and waspostoperatively diagnosed and treated for an ipsilateral femoralneck fracture.

Key Words: femur shaft fracture, femoral neck fracture, ipsilateralfemoral neck

INTRODUCTIONFemoral neck fractures are associated with up to 9% of ipsilateral

femoral shaft fractures. Between 20% and 50% of these fractures arereported to be missed on initial presentation, and although there areimproved diagnostic methodologies, identification of a faction ofthese fractures will be delayed or missed even when the mostsensitive protocols are used.1 Although this associated pattern offractures is not regularly encountered, it is common enough thatorthopaedic surgeons should consider the possibility of its presencewhen evaluating femoral shaft fractures especially if the injury re-sulted from a high-energy mechanism in a young patient.2 Missinga femoral neck fracture has a high potential to lead to significantnegative consequences requiring further surgical intervention suchas more severe fracture displacement, healing complications, avas-cular necrosis, loss of function, andpain.3,4 This case report discussesthe case of amissed femoral neck fracture in a young patientwhowasinitially treated for a femoral shaft fracture.

CASE PRESENTATION

Patient PresentationA 19-year-old white male was brought to the emergency

department by ambulance in the evening after he lost control of histruck and hit a house while texting and driving. He was hemody-namically stable and alert on arrival and denied loss of consciousnessduring the accident. His primary complaintwas deep right thigh pain.

The patient’s previous medical and surgical histories were remark-able for appendicitis and appendectomy, respectively.His social habitsincluded regular tobacco, marijuana, and social alcohol use. The re-maining history was negative for any pertinent positive findings.

Clinical Findings and Diagnostic AssessmentOn physical examination, the patient had an obvious right thigh

deformity and tenderness in the same area. His hip and kneemotionwas restricted secondary to pain. There were no open wounds or

Accepted for publication September 16, 2015.

From the *Orlando Regional Medical Center, Orlando, FL; and †Univer-sity of Pennsylvania, Philadelphia, PA; and ‡Orlando Regional MedicalCenter, Orlando, FL; and §NYU-HJD, New York, NY.

G. Haidukewych receives royalties from DePuy and Biomet, Inc, doesconsulting work for DePuy and Biomet, Inc, and owns stock in Institutefor Better Bone Health and Orthopediatrics. F. A. Liporace has receivedroyalties for lower extremity intramedullary nails from Biomet, Inc,Warsaw, IN. The remaining authors report no conflict of interest.

Reprints: Derek J. Donegan, MD, Department of Orthopaedic Surgery,Penn Musculoskeletal Center, 3737 Market St, 7th Floor, Philadelphia,PA 19014 (e-mail: derek.donegan@gmail.com).

No other authors have direct or indirect benefits to report in the prepa-ration or completion of this article.

The views and opinions expressed in this case report are those of theauthors and do not necessarily reflect the views of the editors of Journalof Orthopaedic Trauma or Biomet.

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neurologic deficits on examination. Vascular evaluation revealeda palpable dorsalis pedis and posterior tibial pulse.

Radiographic evaluation included an anteroposterior (AP) pelvisfilm and also AP and lateral views of the femur, which demonstrateda transverse femoral shaft fracture in the mid-diaphyseal region(Fig. 1). The femoral neckwas evaluated on the samefilms, and there

was no evidence of a concomitant ipsilateral neck fracture. No otherinjuries were identified during workup.

Therapeutic InterventionInitial management of the femoral shaft fracture involved

stabilizing the right lower extremity in Buck traction and

FIGURE 1. AP pelvis film and also AP andlateral views of the femur demonstratinga transverse femoral shaft fracture in themid-diaphyseal region.

FIGURE 2. Intraoperative fluoroscopic evalua-tion of the femoral neck after IMN placementfailing to demonstrate a femoral neck fracture.

Florschutz et al

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pharmacologic pain management. The patient’s injury wasdescribed in detail to him, and also the necessary surgical manage-ment of his injury with operative reduction and intramedullarynailing (IMN). After this discussion and obtaining surgical consent,the patient was scheduled to undergo retrograde IMN of his femurin the morning.

The patient was brought to the operating suite the followingmorning, and radiographs were again reviewed to assess thefemoral shaft fracture and closely inspect the femoral neck forany evidence of injury (Fig. 1). Surgery proceeded with inductionof anesthesia and sterile preparation and draping of the extremity ona Jackson table. Before incision, the femoral neck was examinedunder intraoperative fluoroscopy to rule out an ipsilateral femoralneck fracture. This assessment was negative and surgery proceededwith successful reduction of the femoral shaft fracture and place-ment of a retrograde IMN. Before closing the operative sites, thefemoral neckwas examined againwithfluoroscopy, and no femoralneck fracture was identified (Fig. 2). The operative sites were thenclosed, sterile dressings applied, and the patient was awakenedfrom anesthesia without issue and taken to the postanesthesia careunit. Postoperative AP and lateral radiographs of the femur wereobtained in the postanesthesia care unit per standard protocol andrevealed an ipsilateral basicervical femoral neck fracture (Fig. 3).The surgery and postoperative findings were discussed with thepatient and also the indicated further surgical intervention. Hewas posted for femoral neck fixation using a sliding hip screw(SHS) implant the next day. At the time of surgery, the patient

was positioned on a fracture table, and after sterile preparationand draping, a lateral approach was used to gain access to theproximal femur. Intraoperative fluoroscopic images obtainedbefore fixation clearly showed a basicervical fracture of the femoralneck (Fig. 4). The fracture was then closed, reduced, and internallystabilized using a SHS implant. Interestingly, the tip of the retro-grade IMN was positioned in very close proximity to the trajectoryof the cephalic screw on the SHS implant, which required slightlyreaming through the tip of the IMN (Figs. 5, 6).

Postoperatively, a standard course of postoperative antibioticsand venous thromboembolism prophylaxis was instituted. Thepatient was allowed to weight bear as tolerated on the right lowerextremity and discharged from the hospital on postoperative day 2.At his most recent follow-up period of 2 months out from surgery,he has no complaints and subjectively states he feels he is doingwell. Follow-up radiographs show maintained fracture reductionand stable fixation (Fig. 7).

DISCUSSIONIpsilateral femoral neck-shaft fractures are uncommon but

significant injury patterns that potentially lead to serious compli-cations if missed. The femoral neck fracture in these cases is oftensubtle with minimal displacement and difficult to visualize onstandard plain radiographs of the pelvis and hip.2 Improvements foreffective diagnosis of these associated injuries using fine-cut com-puted tomography (CT) and dedicated internal rotation radiographshave been advocated to significantly reduce delays in diagnosis.

FIGURE 4. Intraoperative fluoroscopic imagesobtained before fixation demonstrating a basicer-vical fracture of the femoral neck.

FIGURE 3. Postoperative AP and lateralradiographs of the femur obtained in thepostanesthesia care unit per standard pro-tocol revealing an ipsilateral basicervicalfemoral neck fracture.

Missed Ipsilateral Femoral Neck Fracture

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Tornetta et al1 described their experience with these diagnosticmethods in 16 cases of ipsilateral femoral neck-shaft fracturesand reported 1 missed femoral neck fracture diagnosed intraoper-atively and 1 that was diagnosed postoperatively after fixation ofthe femoral shaft. As such, even with these recognized diagnosticimprovements, there remain some ipsilateral femoral neck-shaftfractures that will still be missed on initial evaluation.5 Further-more, it is also important to consider ipsilateral injury to the distalfemur as there is evidence in the literature describing this evenmorecomplex although rare pattern of injury.6

In this case, therewas a recognized deficiency of sufficient qualityimaging preoperatively during the workup phase. A standardintraoperative evaluation of the femoral neck using fluoroscopywas used as a diagnostic adjunct during the initial procedure (Fig. 2)but failed to reveal the presence of the femoral neck fracture. Incomparison, the intraoperative fluoroscopic images obtained duringthe second operation (Fig. 4) clearly demonstrated the fracture and

highlight how subtle these fractures may be. Ideally, preoperativeimages should at minimum include AP pelvis and also AP, lateral,and internal rotation hip views with no equipment obstructing theclear visualization. CTmay also be used in cases with suggestive butno definite findings on preoperative plain films.

CONCLUSIONSPatients presenting with femoral shaft fractures, especially if

the injury resulted from a high-energy mechanism, should alwaysbe evaluated for an associated femoral neck fracture. Appropriatepreoperative, intraoperative, and postoperative imaging of thefemoral neck can be effectively used to rule out or identifya fracture of the femoral neck. Furthermore, consideration ofadvanced imaging modalities such as fine-cut CT may improvediagnostic efficiency and reduce the rate of missed femoral neckfractures.

FIGURE 6. Final intraoperative fluoroscopic im-ages demonstrating completed placement of SHS.

FIGURE 7. Radiographs of 2-monthfollow-up show maintained fracturereduction and stable fixation.

FIGURE 5. Intraoperative fluoroscopicimages demonstrating placement of the SHS.

Florschutz et al

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REFERENCES1. Tornetta P III, Kain MS, Creevy WR. Diagnosis of femoral neck fracturesin patients with a femoral shaft fracture. Improvement with a standardprotocol. J Bone Joint Surg Am. 2007;89:39–43.

2. Wojcik K, Nowak R, Chmielewski L, et al. Concomitant ipsilateral fem-oral neck and shaft fractures–analysis of cases. Ortop Traumatol Rehabil.2009;11:271–279.

3. Watson JT, Moed BR. Ipsilateral femoral neck and shaft fractures: com-plications and their treatment. Clin Orthop Relat Res. 2002;399:78–86.

4. McDonald LS, Tepolt F, Leonardelli D, et al. A cascade of preventablecomplications following a missed femoral neck fracture after antegradefemoral nailing. Patient Saf Surg. 2013;7:16.

5. Heiney JP, Leeson MC, Vrabec GA. Delayed diagnosis of an ipsilateralfemoral neck fracture with an associated femoral shaft fracture in

light of a negative computed tomography scan. J Trauma. 2009;67:E129–E131.

6. Barei DP, Schildhauer TA, Nork SE. Noncontiguous fractures of the fem-oral neck, femoral shaft, and distal femur. J Trauma. 2003;55:80–86.

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Missed Ipsilateral Femoral Neck Fracture

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