murnau

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Hip Fractures Management with associated
Femoral Shaft Fractures
Andreas H. Ruecker
Trauma, Hand and Reconstructive
Surgery University Hospital Hamburg-Eppendorf
Hamburg, Germany
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Ipsilateral hip shaft fractures occur in 2.5
to 6 of all femoral shaft fractures
Mostly high energy trauma
78 MVA
Increasing (more survivors)
mean age 34yrs 78 male 44 multiple injuries
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Neck in most instances non- or minimally
displaced
30 - 50 missed on initial presentation 25
discovered during nailing
Watson JT, Clin Orthop Rel Res 2002
CT in high risk patients recommended
Yang KH, JBJS 1998

• High index of suspicion
• especially in high energy
• fractures

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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
HIP

• Vertical fracture line
• in up to 60 nondisplaced

60
Subcapital 2 Midcervical 21 Basicervical
39 Pertrochanteric 14 Intertrochanteric 24
40
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Shaft

• 80 occur in middle third
• of bone
• up to 67 open or
• comminuted

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Associated injuries
Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures

• Axial force along femur
• i.e. dashboard
• Fractures of
• Acetabulum
• Pelvis
• Knee Patella, femur condyle,
• tibia plateau, soft tissue
• Tibiashaft, distal tibia, ankle

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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Complications
nonunion Neck lt 3, - 14 (delay of diagnosis
or treatment) SHAFT! - 30 esp. with unreamed,
undersized nails Shaft fracture is the most
determining factor of outcome AVN (4 Bennett -
22 Swiontkowski) malrotation secondary fracture
dislocation
most of energy dissipated in causing shaft
fracture
Watson JT. Clin Orthop 2002 Bedi A. JOT 2009 Alho
A. J Am Acad Orthop Surg 1999
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Timing
Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
General consensus Early fixation
Decreases morbidity and mortality
Bone LB. JBJS 1991 Swiontkowski MF. JBJS
1984 Barei DP. J Trauma 2003 Hung SH. Injury 2004
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Treatment Options
more than 60 suggested options in the literature!
2 separate implants?
key decision
1 implant to fix both?
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Treatment Options
2 separate implants
Screws or SHS Screws or pins Screws/SHS/pins
Retrograde Nail Locking Plates Antegrade
Nail DCS, Ender nails, Rush pins LCDCP, Blade
plate .....

Reconstruction Nail Cephalomedullary
Nail Proximal Locking Plate
1 implant fix both
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Cancellous Screws Retrograde Nail
familiar neck fixation familiar shaft fixation
2 procedures no trochanteric
(40) repositioning

• 17 fractures
• 5 nonunions
• re-operated
• 1 avn

Oh Chan Wug et al, Arch Orthop Trauma Surg 2003
15 fractures 2 AVN
Swiontkowski MF et al, JBJS Am 1984
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Cancellous Screws Distal Locking Plates
familiar neck fixation familiar shaft
fixation positioning once on fracture table
possible in damage contr. orthop. (DCO) as
internal fixateur pc/mi/sm
no trochanteric
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Cancellous Screws Antegrade Nail
familiar shaft fixation positioning once on
fracture table
used in missed necks or iatrogenic fractures
problematic neck fixation problematic in
trochanteric

• 15 fractures over 8 years
• 33.3 re-operation
• delayed union, implant failure
• nonunion neck

Okcu et al, Arch Orthop Trauma Surg 2003
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
SHS Retrograde Nail
familiar neck fixation familiar shaft fixation
2 procedures no rotational stability limited in
trochanteric repositioning
14 fractures over 10 years 13 good results, 1 non
union
Chen et al, Injury 2000
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Reconstruction Nail
familiar shaft fixation single procedure positioni
ng once on fracture table
delicate neck fixation poor sliding
characteristics limited in trochanteric
75 complication rate
Bennett FS. Clin Orthop 1993
11 fractures, 1.8 y range 2 nonunion of neck and
shaft
Koldenhoven GA. South Med J 1997
33 fractures, 2 shaft non unions, 6 neck varus
nonunions, 2 FHN
Wiss DA. JOT 1992
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Cephalomedullary Nail
familiar shaft fixation good in trochanteric
single procedure positioning once on fracture
table
limited in neck
Significantly higher rate of malreduction 37
patients
Bedi A. JOT 2009
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Cephalomedullary Nail
new generation Intertan Smith and Nephew
works in neck stability in rotation controlled
compression dynamic implant
no data
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Cephalomedullary Nail Intertan
neck fracture fixation possible
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Proximal Locking Plate
single procedure positioning once on fracture
table
no sliding mechanism no data
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Long Stem Arthroplasty
single procedure
only in elderly patients (rare indication)
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
What to do how and when in a typical multiple
injured young patient?
fast and stable fixation after anatomic
reduction under biological aspects
2 different treatment options
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Management I, no DCO
M, 32y, MVA trochanteric fracture (38) 31 A 3.3
(24) ipsilateral fracture of femoral shaft mid
third associated fracture of the sacrum Denis
III elbow dislocation
Hight 6.43 ft (1.96m)
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Management I, no DCO
M, 32y, MVA trochanteric fracture 31 A 3.3
ipsilateral fracture of femoral shaft mid third
associated fracture of the sacrum Denis III
elbow dislocation
Options
first 12h
Hight 6.43 ft (1.96m)
SHS Retrograde Nail
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Management I, no DCO
M, 32y, MVA trochanteric fracture 31 A 3.3
ipsilateral fracture of femoral shaft mid third
associated fracture of the sacrum Denis III
elbow dislocation
Options
first 12h
Hight 6.43 ft (1.96m)
SHS Retrograde Nail
SHS performance low repositioning
Cephalomedullary nail
screw fixation of sacrum
Day 5 fixation of coronoid process
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
Management II
displaced neck fracture segmental femoral shaft
fracture articular supracondylar fracture open
tibia shaft fracture lung contusion head injury
Options
Cephalomedullary nail compromises in neck
fixation no stable distal fixation DCO
SHS retrograde nail intraarticular distal
fracture DCO, timing, positioning
Screws distal locking plate with targeter,
pc/mi/sm patient positioning once internal
fixateur no compromises in fixation
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
first 12h
ExFix tibia, wound debridement screw fixation of
neck fracture plating femur on fracture table
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Fractures Options Management
Hip Fractures with associated Femoral Shaft
Fractures
p.o.
12m
case from I. McFadyen
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Hip Fractures with associated Femoral Shaft
Fractures
Summary
the neck should be fixed early the shaft should
be reamed when nailed antegrade nailing and
screws only in missed or iatrogenic neck
fractures no compromise of reduction or fixation
of the other fracture the patient should be
positioned and scrubed only once
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Hip Fractures with associated Femoral Shaft
Fractures
Conclusion
Trochanteric shaft Cephalomedullary
Nail Alternatives in simple 31A1 distal
femoral fracture SHS Plate
Neck shaft Screws Distal Locking
Plate Alternatives in neck distal femoral
fracture SHS Plate in neck proximal
shaft fracture long SHS
no recon nail, no antegrade nailing screws
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Thank you for your attention!