Concomitant ipsilateral fractures of the femoral shaft and trochanteric or intracapsular neck fractures results from a force moving in the direction of femur proximally toward the neck of the femur which can occur in dashboard injury.2
The femoral head, which in such a situation is well contained in the acetabulum, the entire thrust is borne by the femoral shaft and the residual force is responsible for the proximal femoral fracture.
The world literature reveals an incidence of 19-31% of fractures missed during the initial presentation.2,3
None of the documented cases in the world literature have proved the superiority of a particular treatment protocol over the other. The pendulum has shifted from conservative management to operative treatment and the lack of consensus about best modality of fixation has lead to evolution of various techniques and numerous implants over a period of time. Plate fixation of the femoral shaft with lag screws fixation of the femoral neck is widely used in the past.14,15
The advantages of this technique include reliable and familiar methods of fixation for each fracture. The disadvantages include increased blood loss and periosteal stripping of the femoral shaft, extensive surgical dissection, with potential need for bone graft.
Retrograde nailing for the femoral shaft fractures, ipsilateral femoral neck fractures fixation by cancellous screws, and DHS plate, as suggested by Oh et al
can provide easy fixation and favorable results are reported. Theoretically, this seems to be an attractive treatment modality, reducing the incidence of damage of blood supply to the femoral head and fixation of the hip fracture independently. We have had a limited experience with this treatment.
“Miss a nail technique”: Nailing for the comminuted femoral fracture and the cancelleous screw fixation around the nail for the fixation of the hip fracture is also an attractive option. The femoral neck fractures using multiple pins and antegrade nailing of the femoral shaft have also been described.18
Closed reamed antegrade IM nailing with supplemental screw fixation of ipsilateral femoral neck and shaft fractures did not produce uniformly successful results because of the high rates of varus malunion of the femoral neck fracture.8
The simultaneous fixation of femoral neck and shaft fractures by the minimal exposure method using reconstruction nail has many advantages over other methods, less soft tissue dissection, blood loss, better cosmetic appearance, and shorter hospital stay.2
The newer types of the reconstruction nails such as Gamma Nails, the Russel Taylor reconstruction nails, and the long PFN have all been gradually added to the armamentarium of the trauma surgeons.19,20,21
The cephalomedullary femoral reconstruction nails with a trochanteric entry point have recently become more common.19
The reconstruction nails available are theoretically and practically the best option when done by closed means and locked at the either ends. The studies carried out in the anatomic specimens for the suitability of the femoral neck fixation revealed the strength of the reconstruction nail to be 2.5 times superior to the strength of screw fixation of the femoral neck.20
The two sliding screws for stabilization of the femoral neck with distal locking capability aids the strength and stability. But the central placement of the screw is difficult. Introduction of 135° nail dictates that the screws often come to lie in a superior position on the antero-posterior view. The lack of radiolucent jig for proximal screw insertion makes visualization of the screws on the lateral projection difficult. Introduction of nail requires excessive adduction and flexion which can pose difficulty in fatty and obese patients. The risk of avascular necrosis of the femoral head looms largely due to the damage of the blood vessels at the base of the femoral neck as the nail is driven through the pyriform fossa has been reported by Swiontowski et al
Bose et al
reported high complication rate after Russel Taylor reconstruction nails. In their series of 11 patients, there were two delayed union, two cases of shortening of the femur, one had a mal-alignment, and three technical errors during the surgery leading to fracture complications.
The Gamma nail is a versatile implant to deal with this complex fracture pattern, but the results with these implants on the Indian femora have not achieved the success like its western counterparts. There is always a risk of fracture shaft femur,2
by the use of oversized reaming and anterior thigh pain.22
The single screw placement for the stabilization of the trochanter and neck gives rise to the increased incidence of superior migration of the nail and subsequent varus collapse.
The LPFN is available in 130-135° and has a 6° proximal mediolateral angle to facilitate easy insertion from the trochanter. The nail and screw support proximal head/neck fragment. LPFN allows the temporarily mechanically incompetent but biologically viable fragments to heal around the nail.23
IM implant itself acts as a buttress to prevent excessive fracture collapse and shaft medialization.
We feel that the long PFN rigidly stabilizes both the factures adequately leading to osseous healing. It also offers the advantage of a reamed and unreamed implantation technique, high rotational stability of the head-neck fragment, and the possibility of static or dynamic distal locking. Almost all the load is transferred to the nail and negligible portion to the medial femoral cortex. Recently, introduced PFNA-long with ipsilateral basicervical femoral neck and shaft fractures was a good option for the treatment of complex fractures, with the advantages of closed antegrade nailing with minimal exposure, reduced perioperative blood loss, and biological fixation of both fractures with a single implant.
The two major complications are nonunion and osteonecrosis. Osteonecrosis represents perhaps the most devastating complication, especially in a young adult. Wiss8
and co-workers reported a 6% incidence of osteonecrosis at an average followup of 32 months. Swiontkowski et al
reported that 2 of 9 (22%) patients who were followed for a minimum of 3 years developed osteonecrosis. Alho11
found that the incidence of osteonecrosis in ipsilateral femoral neck shaft fractures is less than that in simple femoral neck fracture. In our series, there were 2/36 [6%] cases of osteonecrosis after 2 years. Though numerous authors report a union rate of 100% for both fracture, nonunion of the femoral neck and shaft remains a potential serious complication. Wiss8
and co-workers reported an 18% incidence in his patients. In our serious there was one case of nonunion of the femoral neck and two cases of the femoral shaft which required revision surgery and secondary grafting with good functional outcome.
The entry portal of the PFN through the trochanter limits the surgical injury predominantly to the tendinous hip abductor musculature only24
unlike those nails which need the entry through the pyriformis fossa. The stabilizing and the compression screws of the PFN adequately compress the fracture leaving between them a bone block for further revision of the proximal hip should the need arises. Douša et al
reported good results of ipsilateral fractures of the proximal femur and the femoral shaft treated by the long PFN in 147 cases. They found results do not differ from those reported by other authors. Our results corroborate with those of Pavleka et al
63.9% good, 30.6 % fair, and 5.5% poor.
We conclude that ipsilateral fractures of the proximal femur and femoral shaft if diagnosed early and treated aggressively by LPFN gives a better functional result by a single implant.