Ipsilateral fractures of the femoral neck and shaft are challenging injuries that represent 1-9% of high-energy femoral shaft fractures. Early fixation is important to decrease morbidity and mortality and allow early mobilization, while prioritizing fracture reduction and considering future reconstructive options. There is no consensus on the optimal fixation method, but options include cannulated screws, sliding hip screw, cephalomedullary nail, or reconstruction nail alone. Regardless, the goal is anatomic reduction and stable fixation of both fractures.

1. Combination Injury :
Hip Fractures with Fractures of the
Shaft of Femur
Prepared by Dr MADAN MOHAN
Consultant in Orthopaedics,
KIMS Trivandrum
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2. econd level
Ipsilateral fractures of the femoral
neck and femoral shaft are a
particularly challenging injury
pattern with an overall incidence of
1-9% of all high-energy femoral shaft
fractures.
Dr Madan's Slide

3. econd level
• Early fixation decreases morbidity and mortality and
allows for early patient mobilization and
rehabilitation.
• Prioritization of fracture reduction and fixation must
be performed within the framework of the patient’s
general condition.
• The complexity and success of potential late
reconstructive procedures must be considered in
surgical planning
Dr Madan's Slide

4. econd level
• Questions remain about the optimal fixation construct
to treat this challenging injury pattern.
• Treatment options for fixation of the femoral neck
fracture include cannulated screws, sliding hip screw,
and cephalomedullary nail fixation.
• Intramedullary nail fixation has long been the gold
standard for treatment of femoral shaft fractures.
• In light of this information, some authors have
promoted use of an isolated reconstruction type
medullary nail as the sole method of fixation for both
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5. econd level
• No studies to date have conclusively demonstrated the superiority of any
internal fixation strategy.
• Only limited evidence from case series suggests that
separate femoral neck and shaft implants may result in
fewer reoperations compared with stabilization with a
single cephalomedullary device.
• Regardless of implant choice, surgical treatment must aim to achieve
anatomic reduction and stable fixation of both fractures
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6. econd level
• Due to the lack of successful salvage options for femoral head
osteonecrosis in the young adult, prioritization of formal ORIF of
the displaced neck fracture has been advocated
• Whereas the complications of femoral neck nonunion or
osteonecrosis are devastating, complications related to the
diaphyseal fracture are underreported with this injury pattern
• The shaft fracture is often highly comminuted, reflecting the
high-energy nature of this injury
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7. econd level
• Advocates of single-device fixation using a
cephalomedullary nail stress the advantages of
simultaneous fracture fixation and the potential for
reduced operative time and blood loss.
• This procedure however is technically demanding and
requires simultaneous fracture reductions.
• The femoral neck fracture may further displace with
nail insertion, potentially jeopardizing the tenuous
remaining head blood supply
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8. econd level
• The MFCA is the primary blood supply to the femoral head and may
be disrupted with a femoral neck fracture.
• If the MFCA is not disrupted at the time of fracture, it is anatomically
in close proximity to the piriformis fossa, and some authors
hypothesize there is increased risk to the femoral head blood supply
when nailing with a piriformis start point.
• Surgeons should take this into consideration when planning for
surgery
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9. econd level
Options
(1) Antegrade femoral nailing with cancellous screws placed around the
nail for the neck fracture,
(2) Cephalomedullary nailing using the proximal interlocking screws for
neck fixation,
(3) Plate fixation of the diaphyseal fracture with cancellous screw or
sliding hip screw fixation of the neck fracture, and
(4) Retrograde intramedullary nailing for shaft fixation with cancellous
screw or sliding hip screw fixation of the diaphyseal fracture
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10. Case Studies
Case 1
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11. econd level
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12. econd level
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13. econd level
After 30 months
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14. Case Series
Case 2
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15. econd level
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16. econd level
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