Although ipsilateral proximal and shaft femoral fractures are not common, they present a diagnostic and therapeutic challenge for orthopedic surgeons. The majority of the patients in the reported case series were young males with high-energy trauma. Due to the frequency with which the injury is seen in vehicle crash front seat drivers and passengers, the typical damage mechanism has been postulated to be the result of a longitudinal compression force on a flexed and abducted hip. The femoral shaft fracture is typically comminuted, located in the middle third of the diaphysis, and open in 15-33% of cases. The femoral neck fracture is usually basicervical, vertically oriented, and nondisplaced in 60% of cases [20].
Diagnosis of proximal femoral fracture is easily delayed or missed. The incidence of delayed diagnosis is around 19-31%, and the incidence of missed diagnosis may be 13-31% [6]. Early diagnosis is generally difficult because the fracture is most often basilar and the symptoms are mild in the early phase of disease. Furthermore, surgeons pay more attention to the often life-threatening associated injuries (head, chest, or abdominal) [4]. Therefore, patients with femoral shaft fractures should undergo thorough radiography of the pelvis and both hips as a standard protocol. Additionally, CT scan examination should be performed if necessary. However, a nondedicated CT scan does not always reveal the femoral neck fracture preoperatively [21]. Objective sound waves can also be used as a diagnostic test or screening tool in the assessment of occult hip fractures [22]. Moreover, a recent study found that rapid limited-sequence pelvis MRI for patients with femoral shaft fractures could identify femoral neck fractures that were not diagnosed on thin-cut high-resolution CT [23]. In our present series, nine of the patients were young males (64.2%), two had open femoral shaft fractures (14.3%), seven had multisystem injuries (50.0%), and two had ipsilateral knee injuries (14.3%). Further, nine of the neck fractures were nondisplaced (75.0%), one was a subcapital fracture (8.3%), ten were basicervical fractures (83.3%), and one was a transcervical fracture (8.3%). Delayed diagnosis was observed in 3 cases (21.4%). The average delay time was 5.3 d (range, 5-6 d) and all of these cases were transferred from other departments to orthopedics. All of the results in our study are consistent with previous reports.
Non-operative treatment of either the proximal femoral fracture or shaft fracture is generally avoided except in extenuating circumstances, and poor results have been reported [24]. A series of surgical treatment strategies have been described for this combined injury. Orthopedic surgeons need to consider three issues for an optimal preoperative plan: 1) appropriate timing of surgical fixation, 2) which fracture to stabilize first, and 3) the optimal internal fixation for these complex fractures. The purpose of ipsilateral proximal and shaft femoral fracture surgical management is to achieve anatomical reduction of the proximal femoral fracture and rigid fixation of both fractures. Studies have recommended that the operation be performed within 8 h, 12 h, 24 h, 72 h, or 1 week [9,25-27]. It is generally accepted that early surgical treatment can reduce patient complications and morbidity and allow for earlier functional exercise and rehabilitation. Therefore, after the patient's general condition has stabilized, early reduction and fixation of this combined injury pattern is necessary. There is no consensus as to which fracture should be managed first. Some recommend that the femoral neck fracture should be always provisionally fixed first, either by closed or open methods, to avoid displacement of a nondisplaced or minimally displaced fracture and to ensure anatomic reduction and optimal stabilization of the neck, preventing osteonecrosis and nonunion [8]. Others advocate for fixation of the femoral shaft first to allow better control of the leg during the more technically challenging femoral neck reduction [28]. Generally speaking, we favored that the fixation should depend on the femoral neck fracture pattern. This therapeutic strategy is satisfactory with nondisplaced neck fractures, as neck fractures could be fixed in situ and further displacement is prevented. Otherwise, the femoral shaft should be fixed first to allow for better control of the leg during the reduction of the displaced femoral neck fracture.
Various constructs and surgical techniques have been described for the treatment of ipsilateral proximal and shaft femoral fractures, including single constructs or dual constructs for both fractures [4,6,7,29-31]. Single constructs include reconstruction intramedullary nails with interlocked screw fixation for the neck fracture via the nail, long proximal femoral nails (PFN-long) with anti-rotation, long sliding hip screws, and long proximal femoral locking plates [7,9,20]. Some favor the reconstruction nail, which allows possible closed reduction and biomechanical fixation with minimal incision, achieving biological fixation of both fractures and reduced intraoperative blood loss. However, this advantage may be outweighed by the high technical demand of accurately placing the proximal screws into the head and neck [7]. Additionally, reconstruction nailing should not be performed in displaced femoral neck fractures because it is difficult to achieve reduction [7]. PFN-long could stabilize and fix both fractures simultaneously, as described by Wang et al. [9]. Biomechanical studies have also shown that the helical blade could provide higher stability than the lag screw [32]. However, the availability of only three nail lengths and one diameter presents certain drawbacks [9].
Dual constructs include: 1) retrograde nailing combined with dynamic hip screw (DHS) or lag screws [6], 2) a dynamic compression plate (DCP) with DHS, cannulated cancellous screws, or a proximal femoral locking plate [2], and 3) antegrade femoral intramedullary nails with cannulated cancellous screws [27]. When compared with single constructs, dual constructs have many advantages, such as easier immobilization and superior biomechanical fixation [7,8]. However, their clinical application is limited by complications related to the knee, risk of fracture nonunion (particularly for retrograde nailing combined with DHS or lag screws), greater intraoperative trauma, and higher implant cost [28].
In order to minimize complications and trauma, all cases in our study were treated by BCFS in combination with MIPPO. The BCFS was comprised of clamps, connection rods, screws (set screw, locking screw, and cortical screw), and other accessory instruments (Supplemental material). Based on the patient needs, the surgeon chose different sizes of clamps and connection rods during the operation. When the set screw was screwed into the clamp, its nut tightened the connection rod and held the clamp tightly. Thus, the clamps, screws, and connection rods were locked as a whole to support firm and stable fixation of both the proximal and shaft femoral fractures. Compared to other treatment methods, the BCFS has relatively easy application and less trauma. Four different treatment methods (antegrade reamed intramedullary nailing and cancellous screw, DHS and low-contact dynamic compression plate (LCDCP), cancellous screw and LCDCP, and reconstruction nailing) were used for 43 patients with ipsilateral femoral neck and shaft fractures; these procedures had a mean surgery duration of 280 min and resulted in a mean blood loss of 428.6 ml [33]. The BCFS takes 179.6 min operation time with an average blood loss volume of 483.6 ml, reflecting the relative ease of manipulation. Furthermore, the curative effects, including fracture healing, complications, and postoperative functional indexes, are basically consistent with previous literature [33]. Moreover, BCFS has wide scope of application, even in the treatment of ipsilateral fractures of the femoral neck, shaft, and distal end cases (Fig. 3).