IPSILATERAL FEMORAL NECK AND SHAFT FRACTURE
A 20-year-old man is brought to the emergency department following a high-speed road traffic accident in which he was the seat belt–restrained driver of a car. He is treated along ATLS guide- lines and is found to have an isolated left lower limb injury as shown in this radiograph.
Describe the appearance in this radiograph.
This is an AP radiograph of the left hip and femur. It shows fractures of the ipsilat- eral neck and shaft of femur, both of which are displaced.
How would you manage and investigate this patient following the initial resuscitation?
This represents a high-energy injury and this patient would be received and treated in the emergency department along ATLS principles.
I would ensure that the patient is given adequate analgesia. I would perform a full circumferential examination of the limb paying attention to the state of the soft tissues. I would make an assessment of the neurovascular status. I would be careful to look for associated injuries to the knee, ankle and foot. It may be difficult to assess for ligamen- tous injuries of the knee at this time, but I would remain suspicious. I would ensure that I had good AP and lateral imaging to include the joint above and the joint below. Assuming this is a closed injury without neurovascular deficit, I would then apply skin traction to the lower leg if the soft tissues would permit this using a 5 kg weight. I would advise operative treatment for this patient and I would prepare the patient for this, including routine blood tests and group and save blood samples and
an electrocardiogram, chest radiograph and other perioperative tests as indicated.
What would be your operative plan for this patient? Describe the sequence of surgery.
This is a high-energy injury. The potential for serious complications is greatest with the femoral neck fracture in this patient and I would address this first. In a con- sented and appropriately anaesthetised patient, I would position the patient on a fracture table and under traction I would perform a closed anatomic reduction of the femoral neck fracture under image intensification. If required, I would perform an open reduction to achieve this using a Smith–Petersen surgical approach. Once reduced, I would stabilise the femoral neck fracture with three cannulated cancel- lous large-fragment 6.5 mm screws. For high-grade Pauwels hip fractures with ver- tically orientated fracture lines, I would choose to use a dynamic hip screw rather than cannulated screws in order to obtain greater stability.
Having achieved rigid fixation of the femoral neck, my preference would be to release the traction, place the patient on a radiolucent table and achieve stable femo- ral shaft fixation using retrograde intramedullary nailing. This would allow me to avoid potentially interfering with and possibly compromising the proximal fixation to or the residual blood supply of the hip.
What are the potential complications of this injury?
This is a high-energy injury and the patient could be susceptible to early compli- cations of respiratory compromise, bleeding, compartment syndrome, fat embolus or neurovascular injury. Later, there is the potential for soft tissue complications, wound infection and pulmonary embolus. Specific to this injury there are also the risks of non-union, avascular necrosis of the hip, limb length discrepancy, altered gait and persistent hip or lower limb pain.