Trifocal Femoral Fracture Treated With an Intramedullary Nail Accompanied With Compression Bolts and Lag Screws: Case Presentation and Literature Review

Abstract

Ipsilateral combined fractures of the proximal femur, femoral shaft, and distal femur occur rarely with few published cases in the literature. These injures are classified as type 4 combined femoral fractures according to the classification of Lambiris et al. We present a rare case of a combined injury including an ipsilateral intertrochanteric fracture, a mid-shaft transverse femoral fracture, and a Y-shaped intra-articular fracture of distal femur in a 36-year-old man following a traffic accident. There was also an un-displaced extra-articular fracture of the ipsilateral patella. This combined injury has been reported only once, while our treatment strategy has never been reported in the literature. We used a single long Gamma-nail to treat all three fractures, while we locked the nail distally with compression bolts. The intra-articular part of the distal femoral fracture was managed with two cannulated percutaneous 6.5 mm lag screws. This modification of the nail allowed us to lock the nail and also to compress the metaphyseal part of the distal femoral fracture and secure this fracture to the nail. Our patient had an uneventful recovery, while the union was observed to all fractures four months postoperatively. As these combined femoral injuries are rare, there is no consensus of the management of such fractures. Many authors suggest an individualized approach to these rare cases based on the configuration of all fractures, especially the proximal and the distal one. By this case presentation we cite an alternative treatment of type 4 combined femoral fractures. Trauma surgeons may benefit from this Gamma-nail modification for such complicated injuries.

Keywords: combined femoral fractures; compression bolts; modification; nail; type 4.

Figure 1. Anteroposterior radiogram of the right femur demonstrates the mid-shaft femoral fracture (black arrow), while the ipsilateral proximal femoral fracture can be easily seen (yellow arrow).

Figure 2. Anteroposterior radiogram of right hip demonstrates the proximal intertrochanteric fracture (black arrows).

Figure 3. Profile and anteroposterior radiogram of distal femur and knee demonstrate the intra articular distal femoral fracture (yellow arrows), the fracture of the patella (blue arrow), the fibula (brown arrow), and the femoral shaft (red arrow).

Figure 4. Anteroposterior and profile postoperative X-rays demonstrate the long Gamma-nail accompanied with compression bolts (yellow arrows) and cannulated lag screws (blue arrow).

Figure 5. Postoperative anteroposterior X-ray of right femur at four months follow up demonstrates union of all three fractures (proximal femur-black arrow, femoral shaft-yellow arrow, and distal femur-blue arrow).

Figure 6. Postoperative profile X-ray of right femur at four months follow up demonstrates union of shaft (yellow arrow) and distal femur fracture (blue arrow).

Figure 7. Postoperative X-rays of right femur at one year follow up demonstrate union and remodeling of all fractures (proximal femur-black arrow, femoral shaft-blue arrow, distal femur-yellow arrows, and patella-brown arrow).