Multiple fractures of the femur: Case report, literature review, and proposal for a shared algorithm of treatment

Abstract

Multiple fractures of the femur, defined for the purposes of this study as the association of three or more non-contiguous fractures on the same bone segment, is an exceedingly rare condition with an unknown incidence in the literature. A limited number of studies, mainly consisting of case reports or small case series, have addressed this topic, and no shared consensus or guidelines exist on what the ideal timing and sequence of multiple fracture fixation is. The present paper reports the clinical case of a 36 years old man who sustained a blunt chest injury, a non-concussive head injury, a displaced intracapsular fracture of the left femur (AO 31B2), a left diaphyseal multifragmentary fracture (AO 32B3), a supradiacondylar fracture of the distal end of the left femur (AO 33C1.1), a Hoffa fracture of the lateral left femoral condyle (AO 33B3.2 f), and a multifragmentary fracture of the left patella with bone loss (AO 34C3) due to a vehicular high-energy trauma. The patient was surgically treated by open reduction and internal fixation according to a proposed algorithm of treatment and reported excellent clinical and radiological outcomes at 32 months follow-up. The primary aim of this study is to describe our experience in the treatment of such complex fractures, by presenting our clinical and radiological results, and to propose a treatment algorithm. The secondary aim is to provide a comprehensive review of the literature on this topic.

Keywords: Multiple femur fracture; distal femur fracture; femur fixation; polytrauma; proximal femur fracture.

Figure 1.

The figure shows the combination of multiple non-contiguous fractures of the left femur: displaced intracapsular fracture of the left femur (AO 31B2), a left diaphyseal multifragmentary fracture (AO 32B3), a supradiacondylar fracture of the distal end of the left femur (AO 33C1.1), a Hoffa fracture of the lateral left femoral condyle (AO 33B3.2 f), and a multifragmentary fracture of the left patella with bone loss (AO 34C3).

Figure 2.

The post-operative X-ray: an 11-hole less invasive stabilization system plate and screws, a 3.5-mm anteroposterior screw, 6.5-mm cannulated screws for the femoral neck, and intercondylar fracture fixation were used.

Figure 3.

The figure shows the fractures healing and the removal of the patellar tension banding cerclage wire, condylar cannulated screws, and distal less invasive stabilization system condylar screws.

Figure 4.

The figure shows the X-rays after hardware removal 24 months after the original trauma.

Figure 5.

Clinical results at the last follow-up visit (32 months).

Figure 6.

PRISMA flowchart for literature review.

Figure 7.

Algorithm flowchart proposal.