Ipsilateral proximal femur and shaft fractures treated with hip screws and a reamed retrograde intramedullary nail

Abstract

Background: Although not common, proximal femoral fractures associated with ipsilateral shaft fractures present a difficult management problem. A variety of surgical options have been employed with varying results.

Questions/purposes: We investigated the use of hip screws and a reamed retrograde intramedullary (IM) nail for the treatment of this combined fracture pattern in terms of postoperative alignment (malunion), nonunion, and complications.

Methods: Between May 2002 and October 2011, a total of 95 proximal femoral fractures with associated shaft fractures were treated at three participating Level 1 trauma centers; all were treated with hip screw fixation (cannulated screws or sliding hip screws) and retrograde reamed IM nails. The medical records of these patients were reviewed retrospectively for alignment, malunion, nonunion, and complications. Followup was available on 92 of 95 (97%) of the patients treated with hip screws and a retrograde nail. Forty were treated with a sliding hip screw, and 52 were treated with cannulated screws.

Results: There were five proximal malunions in this series (5%). The union rate was 98% (90 of 92) for the femoral neck fractures and 91.3% (84 of 92) for the femoral shaft fractures after the initial surgery. There were two nonunions of comminuted femoral neck fractures after cannulated screw fixation. There was no difference in femoral neck union or alignment when comparing cannulated screws to a sliding hip screw. Four open comminuted femoral shaft fractures went on to nonunion and required secondary surgery to obtain union, and one patient developed symptomatic avascular necrosis.

Conclusions: The treatment of ipsilateral proximal femoral neck and shaft fractures with hip screw fixation and a reamed retrograde nail demonstrated a high likelihood of union for the femoral neck fractures and a low risk of malunion. Comminution and initial displacement of the proximal femoral fracture may still lead to a small incidence of malunion or nonunion, and open comminuted femoral shaft fractures still may progress to nonunion despite appropriate surgical management.

Level of evidence: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Fig. 1A–B

(A) A radiograph shows a segmental femur fracture in a 70-year-old man. (B) A CT scan shows a nondisplaced basicervical femoral neck fracture (arrow).

Fig. 2A–C

(A) An initial radiograph shows a comminuted vertical basicervical femoral neck fracture with an associated ipsilateral shaft fracture in a 42-year-old woman. (B) A radiograph shows the fracture 1 month after an open reduction and fixation of the femoral neck fracture. (C) A 7-month radiograph demonstrates that there is subsequent shortening of the femoral neck on the sliding hip screw due to comminution.

Fig. 3A–D

(A) A radiograph shows a displaced intertrochanteric hip fracture and a segmental Grade IIIB open femur fracture in a 30-year-old man. (B) At 3 months, the hip fracture has drifted into 5° of varus with slight compression of the lag screw in the barrel. The femoral shaft fracture showed no signs of union, and bone graft and plating were performed around the IM nail. Radiographs taken at 7 months postoperatively show final union of (C) the femoral shaft and (D) the hip fracture.

Fig. 4A–D

(A) A radiograph shows a femoral shaft fracture in a 25-year-old woman. (B) A radiograph shows a minimally displaced basicervical femoral neck fracture. (C) A radiograph shows the appearance of the femoral neck fracture at 7 months. (D) Radiographic union of the femoral neck fracture at 14 months after injury is shown.