Bilateral intertrochanteric and femoral diaphyseal fractures with unilateral proximal tibial fracture: A case report and review of the literature

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InternationalJournalofSurgeryCaseReports5(2014)509–512

ContentslistsavailableatScienceDirect

International

Journal

of

Surgery

Case

Reports

j o u r n al ho m e p a g e :w w w . c a s e r e p o r t s . c o m

Bilateral

intertrochanteric

and

femoral

diaphyseal

fractures

with

unilateral

proximal

tibial

fracture:

A

case

report

and

review

of

the

literature

Ali

Seker

_,

_Adnan

_Kara

_,

_Mustafa

_Faik

_Seckin

_,

_Mesut

_Sonmez

_,

Erden

Erturer

_,

_Irfan

_Ozturk

a_{IstanbulMedipolUniversityMedicalFaculty,DepartmentofOrthopaedicsandTraumatology,Turkey} b_{IstanbulBilimUniversityMedicalFaculty,DepartmentofOrthopaedicsandTraumatology,Turkey} c_{SisliEtfalTrainingandResearchHospital,OrthopaedicsandTraumatologyClinic,Turkey}

d_{IstanbulUniversityIstanbulMedicalFaculty,DepartmentofOrthopaedicsandTraumatology,Turkey}

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Articlehistory: Received23April2014 Accepted2June2014 Availableonline16June2014

Keywords:

Intertrochantericfracture Femoraldiaphysealfracture Bilateral

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INTRODUCTION:Bilateralintertrochantericfemurfracturesarerelativelyrareinjuries.Thisstudyaims

topresentacaseofapatientwithsimultaneousbilateralintertrochantericfemurfracturesandfemoral

diaphysealfracturesandproximaltibialfracturewithhistwelveyearsfollow-up.

PRESENTATIONOFCASE:A44-year-oldmanpresentedtoemergencydepartmentafteramotorvehicle

accident.Bilateralintertrochantericfemurfractures(OTAclassification–31A.1.2)andbilateralfemoral

diaphysealfractures(OTAclassification–32A.2)andnondisplacedrightproximaltibialfracture(OTA

classification–41B.1)weredeterminedinradiographs.Followingclosedreduction,fractureswerefixed

withintramedullarynailsbilaterally.Proximaltibialfracturewasfixedwithcannulatedscrewsfollowing

openreduction.Attwelfthyearfollow-uphewasabletodohisdailyactivitieswithminimallimitation.

DISCUSSION:Highenergytraumas,stressfractures,systemicdisorders(osteomalacia,chronicrenal

fail-ure),steroidtreatments,seizuresandelectricinjuriesarepossiblecausesforbilateralhipfactures.

Howeverbilateralfemoraldiaphysealfracturesaremostlyduetohighenergytraumas.Long-term

biphos-phonateusemayalsocausebilateralfractures.Single-stagesurgeryshouldbeperformedinordertoavoid

secondarydamagesofsurgicalinterventions.Allfracturesofourpatientwerefixedinasinglesession.

Thispreventedfurtherdeteriorationofpatient’sstatusandmaderehabilitationeasy.

CONCLUSION:Carefulevaluationofallsystemsshouldbeperformedinmulti-traumapatientstofindout

concomitantinjuries.Singlestagedsurgicaltreatmentmaydecreasemorbidities.

©2014TheAuthors.PublishedbyElsevierLtd.onbehalfofSurgicalAssociatesLtd.Thisisanopen

accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/3.0/).

1. Introduction

Intertrochantericfemurfracturesandfemoraldiaphyseal frac-tures are frequently seen in emergency departments in daily practice.Simplefallsaremaincausesofthesefracturesinelderly patientsbut high energy traumas are leading causesin young population.1 _{Althoughbilateralfemoraldiaphysealfracturesare}

relativelycommonproblem, bilateralintertrochantericfractures arerare.

Thisarticleaimstoreportapatientwithsimultaneousbilateral intertrochantericfemurfractureswithbilateralfemoraldiaphyseal fracturesandunilateralproximaltibialfractureandhis12years follow-up.Toourknowledgethereisnosuchacaseinliterature.

∗ Correspondingauthorat:MedipolMegaHastane,TEMAvrupaOtoyoluGoztepe C¸ıkıs¸ıNo.1,Bagcilar,Istanbul,Turkey.Tel.:+905323262202;fax:+902124607070.

E-mailaddress:aliseker@doctor.com(A.Seker).

2. Presentationofcase

A44-year-oldman waspresented toemergency department afteramotorvehicleaccident.Onphysicalexaminationlocal ten-dernessandswellingwaspresentoverboththighsandrightknee. His vital signs were 90/60mmHg blood pressure and 130/min pulserate.Thehemoglobinlevelwas10.2g/dlinitially.Bilateral intertrochantericfemurfractures(OTAclassification–31A.1.2)and bilateralfemoraldiaphysealfractures(OTAclassification–32A.2) and nondisplaced right proximaltibial fracture (OTA classifica-tion – 41B.1)were determinedin radiographs (Fig. 1).He was operatedonthefifthdayofadmissionafterhemodynamic stabi-lization.Transtibialskeletaltractionswereappliedforbothsides uptosurgery.Inasinglesession,lockedintramedullarynailswere usedforthefixationofintertrochantericanddiaphysealfemoral fracturesafterclosedreductionforbothextremities.Open reduc-tionandinternalfixationwithcannulatedscrewswereperformed forrightproximaltibialfracture.Fourunitsofpackedredblood

http://dx.doi.org/10.1016/j.ijscr.2014.06.001

2210-2612/© 2014TheAuthors. Publishedby ElsevierLtd.on behalfof SurgicalAssociates Ltd.Thisis an openaccessarticle underthe CCBY-NC-ND license

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Fig.1.Radiographsshowfracturesofbothfemur.

cells and two units of fresh frozen plasma were given to the patienttotally.Arehabilitationprogramwasstartedimmediately aftersurgery.Oneweekaftersurgeryseropurulentdischargewas observedfromtheincisionofrighttibia.Staphylococcusaureuswas cultivated.Infectionwastreatedwithoralantibiotics.Patientwas discharged12daysafteroperation.Weightbearingwasallowed6 weeksaftersurgeryforbothsides.Dynamizationofbothnailswere performedat4thmonthduetodelayedunion.(Fig.2)Complete unionoffractureswereshowedwithradiographsat8th month followup.Implantswereremovedthreeyearslater.Patienthad mildpain,especiallyinhisrighthip,andlimpat12thyearcontrol. Degenerativechangeswereobservedatrighthiponradiographs. (Fig.3)Althoughmovementsofrighthipwererestricted,hewas abletodohisdailyactivitieswithminimallimitationandwithout medication(Fig.4).

3. Discussion

Althoughproximalfemoralfracturesarefrequentlyseenindaily practice,bilateralfracturesarerare.Casereportsinliteratureare mostlyrelatedwithbilateralfemoralneckfracturesorfractures

Fig.2. Atpostoperative4thmonthcompleteunionwasnotachievedand dynamiza-tionofnailswereperformedbilaterally.

Fig.3.Degenerativechangeswereobservedinrighthipat12thyearcontrol radio-graph.

withmixedpatterns.Onlyfewpapersarereportingsimultaneous bilateralintertrochantericfemurfractures.Ourcaseisthefirstfor simultaneous bilateralintertrochantericand femoraldiaphyseal fractures.

High energy traumas, stress fractures, systemic disorders (osteomalacia,chronicrenalfailure),steroidtreatments,seizures andelectricinjuriesarepossiblecausesforbilateralhipfactures.2–7

Howeverbilateralfemoraldiaphysealfracturesaremostlydueto highenergytraumas.Long-termbiphosphonateusemayalsocause bilateralfractures.8

Grisoni et al.1 _{reported 8 bilateral cases (0.3%) in 2426}

hipfractures and only two patients had simultaneous bilateral intertrochantericfractures.Themechanism ofinjurywasmotor vehicleaccidentfora patientand simplefallfortheother.First patientwasa53-year-oldmaleandhadadditionaltibiaandpatella fractures.Secondpatientwasa88-year-oldwomanwithout addi-tionalinjury.Bothpatientswereoperatedinasinglesessionand dynamichipscrews (DHS)werepreferredfor fixation.Younger patientwasdischargedtohomebutelderonewasdeadat post-operativeseventhday.

Dendrinosetal.9_{reportedthreecaseswithsimultaneous}

bilat-eralhipfractures.One ofthesepatientswasa 53-year-oldguy withbilateralcomminutedpertrochantericfractures.Mechanism ofinjurywasamotorvehicleaccident.Duetothevisceralinjuries bothhipswerefixedwithslidingscrew-platesystemfivedaysafter laparatomy.Mildpaininrighthipandslightlimp wasnotedat the26thmonthfollow-up.Othertwopatientshadbilateral sub-trochantericfractures.

Panagopoulosetal.2_{reporteda44-year-oldpatientwith}

bilat-eral intertrochanteric femur fractures. He had additional left acetabularandleftdistalradiusfractures.Patientwastreatedwith proximalfemoralnailinginsinglesession. Distalradiusfracture wasoperatedatthesametime.Conservativetreatmentwas cho-senforacetabularfracture.Authorsgave18monthsfollow-upwith goodresults.

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A.Sekeretal./InternationalJournalofSurgeryCaseReports5(2014)509–512 511

Fig.4.Despitedegenerativechangesintheradiographspatientwasabletodohisdailyactivitieswithminimalrestriction.

Harshvardhan3 _{reported a 40-year-old man with bilateral}

intertrochantericfemurfractureswithoutadditional injury.The mechanismof injurywasamotor vehicleaccident.Patientwas treatedwithtwo-stageinternalfixationwithDHSinonesideand DynamicCondylarScrewintheother.Postoperativefollow-ups werenotincludedinthetext.

Balietal.4_{reportedapatientwithbilateralpertrochanteric}

frac-tureswithbilateralpatellarfracturesandunilateralmedialtalar processfracture.HipfracturesweretreatedwithDHSand bilat-eralpatellarfractureswithORIFinasinglestagedsurgery.Atthe endoftheoneandhalfyear-follow-uppatientreturnedtohisdaily activitieswithminimaldifficulties.

Suhetal.5_{reportedapatientwithbilateralfemoralneck}

frac-turessecondarytohypocalcemicconvulsion.Patientwastreated withmultiplecannulatedscrews.Duringpostoperative rehabili-tationpatientadmittedtohospitalafterconvulsionandbilateral intertrochantericfemurfractureswerediagnosed.Theauthors pre-ferredrevisionofonesidewithDHSandconservativetreatmentfor otherside.Completeunionoffractureswithoutavascular necro-sisoffemoralheadswerereportedathispostoperative2.5years follow-up.

Optimaltimingforsurgeryofpolytraumapatientsaredecided according to “Damage Control Orthopaedics’ principles. 10 _Our

patientwasoperatedfivedaysaftertrauma.Bringingpatientto optimallevelforsurgerywasthecauseofdelay.Itisacceptedthat polytraumapatientswithhemodynamicstabilitycouldbeoperated early.Operationsofpatientsinborderline,unstableandextremis groupshouldbedelayed.Injuryseverityscoreofourpatientwas 32_{=9pointsandhewasinstablegroup.Hewouldbeoperated}

early.

Despiteexceptionsinliterature,3 _{ifit ispossiblesingle-stage}

surgeryshouldbeperformedinordertoavoidsecondarydamages ofsurgicalinterventions.Allfracturesofourpatientwerefixedin asinglesession.Thispreventedfurtherdeteriorationofpatient’s statusandmaderehabilitationeasy.

Although the primary goal of hip fracture treatment is fix-ation in acceptable position with closed reduction, it cannot be achieved always. In such cases open reduction should be performed.Intramedullary nails,dynamic hipscrews, proximal femurplatesandexternalfixatorscanbeusedinthetreatmentof intertrochantericfemurfractures.Duetoipsilateralfemoral dia-physealfracturesintramedullarynailswereourchoiceinthiscase. Inordertopreventhemodynamicdeteriorationofpatient,fractures werereducedinclosedmannerbutfemoraldiaphysealfractures madereduction difficult.Fixation in varusmalposition wasthe endresultforbothhips.Theaimofintramedullarynailingwasto allowearlyweightbearing.Withoutproperfracturereductionnail causedvarusangulationoffracture.Applicationofnailafteropen

reductionorfixationofhipandfemoraldiaphysiswithdynamic hipscrewwithlongplateafteropenreductionwouldbebetter.

Atfinalcontrol,arthroticchangeswereobservedinradiographs. Patientwasabletodohisdailyactivitieswithmildpainand with-outpainkiller.Harrishipscorewas81pointswithgoodresult.If openreductionwasperformed,suchacomplicationwouldnotbe observedandbetterfunctionaloutcomewouldbegot.

4. Conclusion

Bilateralhipfracturesareveryrare.Carefulevaluationofother systemsshouldbeperformedinsuchcasestofindoutconcomitant injuries.Singlestagedsurgicaltreatmentmaydecreasemorbidities. Openreductionshouldbekeptinmindifclosedreductioncouldnot beperformed.

Conflictofinterest

Theauthorsdeclarethatthereisnoconflictofinterest Funding

Thereisnosponsorforthisstudy. Ethicalapproval

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereport.Acopyofthewrittenconsentis avail-ableforreviewbytheEditor-in-Chiefofthisjournalonrequest. Authorcontributions

AliSeker,studyconceptordesign,datacollection,writingthe paper;AdnanKara,datacollection;MustafaFaikSeckin,data col-lection;MesutSonmez,datacollection;ErdenErturer,writingthe paper;IrfanOzturk,writingthepaper.

Keylearningpoints

• Bilateralintertrochantericfracturewithbilateralfemoral diaphy-sealfractureisveryrare.

• Managementofsuchinjuriesischallenging.

• Thequalityofreductionandfixationaregoingtoaffectthefinal results.

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