Chinese Journal of Traumatology 18 (2015) 304e306
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Case report
Simultaneous bilateral fractures of the femoral neck caused by high energy: A case report and literature review You-Shui Gao, Zhen-Hong Zhu, Chang-Qing Zhang* Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, China
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 October 2014 Received in revised form 9 April 2015 Accepted 15 April 2015 Available online 14 November 2015
Simultaneous bilateral fractures of the femoral neck are rare injuries, which are reportedly induced by low-speed energy with predisposing factors including systemic diseases, medications and eclamptic seizures. Those caused by high energy are even rarer. High energy-induced bilateral fractures of the femoral neck conceive of high incidence of mortality and present great challenges in the early management. We report one case of a 52-year-old man with simultaneous bilateral fractures of the femoral neck which resulted from a motor pedestrian accident. One-stage closed reduction and internal fixation was done following the emergent resuscitation and neurosurgical management for concomitant brain injuries. The fractures united. There was no pain in the hips, and they had a normal range of motion. The treatment protocol, mechanism of the injury and possible postoperative complications were discussed to expand a comprehensive understanding about these infrequent types of fractures. © 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Femoral neck fractures Clinical protocol Postoperative complications
1. Introduction
2. Case report
Simultaneous bilateral fractures of the femoral neck (SBFFN) are infrequent. The majority of these injuries are induced by a lowspeed energy with predisposing conditions, including coeliac disease,1 chronic renal failure (CRF),2e4 malnutrition,5e7 metabolic diseases,8,9 osteoporosis,10e12 cystic fibrosis,13 eclamptic seizures,14,15 steroid and alendronate medications.16,17 Electric shock injury is also a rare causative factor for SBFFN.18 An accident, assuming the term to indicate violent injury to normal structures, is of rarity as a cause of these combined lesions.19 High energy SBFFN are so rarely seen that orthopedic surgeons seem to be lacking enough experience to deal with these extreme challenges. Even in low energy-induced SBFFN, the mortality is high even though appropriate and timely management is adopted. Therefore, we report one case of SBFFN caused by a severe traffic accident. Meanwhile, the treatment protocol, mechanism of the injuries and possible postoperative complications would be discussed based on current case and literature review.
A 52-year-old man was subjected to a severe traffic accident and brought to a local trauma center by a first-aid team. There was no abnormality about his previous health conditions. On primary physical examination, the patient was in a coma with unstable hematodynamics. Both lower limbs were of abnormality to external rotation and proximal displacement. According to the Glasgow Coma Score system, he had a score of 10. Emergent resuscitation was employed to regain a stable circulation. Further computed tomography (CT) to the head revealed cranial fractures and a moderate subarachnoid hemorrhage. Radiological examination to the pelvis indicated simultaneous bilateral fractures of the femoral neck (Fig. 1), both of which were graded as type IV according to Garden classification. A comprehensive treatment protocol was made by an experienced team composed of neurosurgical and orthopedic surgeons when the patient regained stable vital signs. The pelvis and bilateral lower limbs were protected by brace and elastic straps, then he was transmitted to the neurosurgical department to receive an emergent operation. Fortunately, the operation was successful and the patient came to consciousness one week later. Repeated X-ray images on the pelvis showed that the configuration of bilateral fractures of the femoral head was similar to previous conditions, and the patient complained of moderate pain
* Corresponding author. Tel.: þ86 18917233480. E-mail address:
[email protected] (C.-Q. Zhang). Peer review under responsibility of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University.
http://dx.doi.org/10.1016/j.cjtee.2015.11.003 1008-1275/© 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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months postoperatively, and a gradual conversion to full-weight bearing was achieved at the end of six months. He conformed to regular follow-up with an interval of three months for four times, then semiannually for four times. In the last follow-up, plain radiograph (Fig. 2B) and CT scanning (Fig. 2C) showed the fracture healing was satisfactory. The patient was able to walk in normal gait without any supportive devices, and he obtained a clerk position in a company. According to Harris hip scoring system, the left hip got 92 points while the right got 95. The patient and surgeons were satisfied with the results. 3. Discussion
Fig. 1. Anteroposterior view of the pelvis showing bilateral femoral necks fractured and displaced.
around the inguinal regions and restricted motion to all directions of bilateral hip joints. Considering his age, repetitive trauma of operations and the fracture pattern, a closed reduction and internal fixation was designed to stabilize the unstable intracapsular fractures. The patient was placed in a supine position on the traction table and put under general anesthesia. Conventional techniques were followed to finish the operation by a single team via closed reduction and internal fixation. Three 6.5 mm canulated screws were drilled in parallel to fix the unstable fractures through lateral approaches. Immediate postoperative image showed the reduction and internal fixation were satisfactory (Fig. 2A). The patient was discharged thereafter, and selfdependent exercise was encouraged keeping bilateral lower limbs loading-free. Partial weight bearing was initiated three
With a brief review of the literature concerning simultaneous bilateral fractures of the femoral head, the majority of these injuries are induced by low-speed energy, among which, eclamptic seizures and associated systemic diseases are common predisposing factors. The largest number of simultaneous bilateral hip injuries comprised of fractures of the femoral neck and central dislocations of the hip joints occurring during convulsion, but their treatment protocols and prognosis varied greatly.18 Although SBFFN are still considered to be one of the most severe complications in eclamptic seizure and electroconvulsive therapy, it has become relatively infrequent nowadays. Other systemic diseases, including CRF, malnutrition, parathyroid diseases and osteoporosis, are all closely related to the metabolic disorders of calcium; furthermore, medications interfering with bone metabolism may contribute to rare SBFFN. Therefore, abnormal bone quality could be regarded as a high-risk factor for SBFFN. Far different from above-mentioned conditions, high-energy bilateral fractures of the femoral neck are rarer for most of these injuries, and concomitant polytrauma may cooperate to lead to instant death.
Fig. 2. (A) Postoperative immediate anteroposterior view of the pelvis showing the bilateral fractures of the femoral head to be repositioned and stabilized by paralleled screws. (B) The fractures united uneventfully three years postoperatively. (C) Coronal CT scanning showing a satisfactory fracture healing.
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The mechanism of SBFFN is complex and might differ from each other. Upadhyay et al20 reported two cases of SBFFN in children and inferred possible mechanism to the unique injuries. They found that the fracture on one side occurred when the child fell astride an object such as a bicycle or running, and during this process the limb was forced into abduction, extension and external rotation and a further continuation of these forces caused the neck to break. The opposite side was fractured due to the adduction forces acting on the femoral head following the direct impact on the ground. However in our case caused by traffic accident, we infer that one side of the hip was smashed directly by a car from lateral, flexion muscles and capsule-ligamentous structures prevented the head from being dislocated anteriorly. Thus, the femoral neck was broken due to biomechanical weakness. The patient was bumped to a considerable height, and following impaction of the contralateral lower limb on the ground made an impingement force causing the fracture of the femoral neck. Due to complexity of primary trauma and possibility of concomitant injuries, it is a great challenge for orthopedic surgeons to manage SBFFN. Generally, early reduction and internal fixation is beneficial for functional exercise and preventing late sequela. However, as mentioned above, life-threatening concomitant injuries probably postpone an immediate operation. We should notice the mortality incidence is always very high in high energy and even in low energy SBFFN. Carpintero and associates11 reported two cases of SBFFN in elderly patients, and both resulted in death as a result of worsened general conditions pre- and postoperatively. For the rarity of simultaneous factures of both femoral necks, there is a lack of powerful references and experience to guide treatment protocol. Checking basic conditions is a prerequisite before treatment and early operation should be cautiously selected for patients with an unstable hematodynamics and lifethreatening concomitant injuries. Secondary stress, induced by the operation, should be as minor as possible. Therefore, closed reduction and percutaneous internal fixation becomes the best choice for people who have suffered SBFFN. Saied and Jalili reported21 SBFFN in a child whose femoral necks were fixed with non-threaded Kirschner wires, and satisfactory results were achieved in 2-year follow-up. Naturally, for low energy SBFFN in the old, one-stage primary hip arthroplasty at both sides could be employed; or conservatively, in two separate operations. Similar to principles in the management of unilateral fractures of the femoral neck, great efforts should be made to reasonably preserve the femoral head in young patients. Considering the severity of primary high energy injuries, it might be speculated that both early and late incidences of complications would be higher for SBFFN in comparison to a unilateral fracture. Although osteonecrosis of the femoral head and osteoarthritis secondary to femoral neck fractures in young patients are trouble to deal with,22,23 an early detection could help to make a logical decision, but not on the subject of whether to use arthroplasty directly. It is much wiser to prevent fractures in patients with systemic diseases, or patients using medications interfering with bone metabolism.24 For high-energy injuries induced by traffic accidents, high falling, earthquake and/or explosions, we always feel quite helpless.
In summary, simultaneous bilateral fractures of the femoral neck are infrequent and severe and need logical treatment protocol. Even with all our modern advances the mortality may be never low. High energy SBFFN should be cautiously indicated for emergency orthopedic operation and delayed, less invasive, management of closed reduction and internal fixation should be the first choice. Regular follow-up for early detection of complications and effective prevention in patients at risk is of great significance. References 1. Rubinstein A, Liron M, Bodner G, et al. Bilateral femoral neck fractures as a result of coeliac disease. Postgrad Med J. 1982;58:61e62. 2. Karapinar H, Ozdemir M, Akyol S, et al. Spontaneous bilateral femoral neck fractures in a adult with chronic renal failure. Acta Orthop belg. 2003;69:82e85. 3. Madhok R, Rand JA. Ten-year follow-up study of missed, simultaneous, bilateral femoral-neck fractures treated by bipolar arthroplasties in a patient with chronic renal failure. Clin Orthop Relat Res. 1993;291:185e187. 4. Gerster JC, Charhon SA, Jaeger P, et al. Bilateral fractures of femoral neck in patients with moderate renal failure receiving fluoride for spinal osteoporosis. BMJ. 1983;287:723e725. 5. Nagao S, Ito K, Nakamura I. Spontaneous bilateral femoral neck fractures associated with a low serum level of vitamin D in a young adult. J Arthroplasty. 2009;24:e1e4. 6. Chadha M, Balain B, Maini L, et al. Spontaneous bilateral displaced femoral neck fractures in nutritional osteomalacia: a case report. Acta Orthop Scand. 2001;72: 94e96. 7. Aviner S, Dabby D, London D, et al. Renal cell carcinoma in a child presented as bilateral femur neck fractures caused by severe vitamin D deficiency. J Pediatr Hematol Oncol. 2007;29:848e850. 8. Negishi H, Kobayashi M, Nishida R, et al. Primary hyperparathyroidism and simultaneous bilateral fracture of the femoral neck during pregnancy. J Trauma. 2002;52:367e369. 9. Chen CE, Kao CL, Wang CJ. Bilateral pathological femoral neck fractures secondary to ectopic parathyroid adenoma. Arch Orthop Trauma Surg. 1998;118:164e166. 10. Aynaci O, Kerimoglu S, Ozturk C, et al. Bilateral non-traumatic acetabular and femoral neck fractures due to pregnancy-associated osteoporosis. Arch Orthop Trauma Surg. 2008;128:313e316. 11. Carpintero P, Abad JA, Urbano D, et al. Simultaneous bilateral fracture of femoral neck in elderly patients: report on two cases. Eur J Orthop Surg Traumatol. 2006;16:172e174. 12. Kumar S, Petros JG, Sheehan LJ, et al. Simultaneous bilateral femoral-neck fractures in an elderly woman. Am J Emerg Med. 1997;15:619e620. 13. Lim AY, Isopescu S, Thickett KM, et al. Bilateral fractured neck of the femur in an adult patient with cystic fibrosis. Eur J Intern Med. 2003;14:196e198. 14. Kause J, Parr MJ. Bilateral subcapital neck of femur fractures after eclamptic seizures. Br J Anaesth. 2004;92:590e592. 15. Grimaldi M, Vouaillat H, Tonetti J, et al. Simultaneous bilateral femoral neck fractures secondary to epileptic seizures: treatment by bilateral total hip arthroplasty. Orthop Traumatol Surg Res. 2009;95:555e557. 16. Haddad FS, Mohanna PN, Goddard NJ. Bilateral femoral neck stress fractures following steroid treatment. Injury. 1997;28:671e673. 17. Capeci CM, Tejwani NC. Bilateral low-energy simultaneous or sequential femoral fractures in patients on long-term alendronate therapy. J Bone Jt Surg Am. 2009;91:2556e2561. 18. Sohal HS, Goyal D. Simultaneous bilateral femoral neck fractures after electric shock injury: a case report. Chin J Traumatol. 2013;16:126e128. 19. Powell HD. Simultaneous bilateral fractures of the neck of the femur. J Bone Jt Surg Br. 1960;42:236e252. 20. Upadhyay A, Maini L, Batra S, et al. Simultaneous bilateral fractures of femoral neck in children e mechanism of injury. Injury. 2004;35:1073e1075. 21. Saied A, Jalili A. Bilateral simultaneous femoral neck fractures in a child. Eur J Orthop Surg Traumatol. 2009;19:349e351. 22. Giannoudis PV, Kontakis G, Christoforakis Z, et al. Management, complications and clinical results of femoral head fractures. Injury. 2009;40:1245e1251. 23. Fujita S, Morihara T, Arai Y, et al. Absence of osteonecrosis of the femoral head following bilateral femoral neck fracture with a high degree of displacement. J Orthop Sci. 2006;11:628e631. 24. Woolf AD, Åkesson K. Preventing fractures in elderly people. BMJ. 2003;327: 89e95.
