Hip anterior dislocation with ipsilateral femoral neck fracture in young patients is a rare injury. In the present case, the right knee of the patient was injured in an accident, and the affected limb was in the abduction, external rotation, and hip flexion position. We analyzed that the violent impact initially resulted in hip anterior dislocation (obturator), followed by femoral neck fracture due to the obstruction of the pubic symphysis and shearing force. The residual violent impact finally caused a lower pubic fracture. The fracture line of the right femoral neck was vertical and involved part of the femoral head, which was also confirmed through intraoperative examination.
Reports on hip anterior dislocation and ipsilateral femoral neck fracture in young patients are limited. Previously, Jain et al reported a case using uncemented total hip arthroplasty for the treatment of hip dislocation with ipsilateral femoral neck fracture, achieving good hip mobility at week 6. They concluded that the choice of surgery should consider the time of injury, age, preference of the patient, and the size of the femoral head cartilage defect. Due to the moderate size of the femoral head cartilage and the preference of the patient, they did not choose an internal fixation and performed a joint replacement. However, hip replacement in young patients is associated with a potential risk of secondary or multiple revision surgeries. Hence, although the femoral head of this patient exhibited a small cartilage defect in the no weight-bearing area, we recommended and finally selected open reduction and internal fixation—rather than joint replacement—for this patient.
The healing of a femoral neck fracture requires good reduction and absolute stability. Robust stability can promote the revascularization of the femoral head, thereby promoting fracture healing and reducing the occurrence of femoral head avascular necrosis. Alternative internal fixation grafts for femoral neck fractures include parallel cannulated screws, dynamic hip screws, dynamic locking blade plates, etc. To our knowledge, a single graft cannot avoid the potential complications.[8–14] Recently, Allagui et al reported a patient with anterior hip dislocation and ipsilateral femoral neck fracture without avascular necrosis of the femoral head during the 3-year follow-up period after receiving dynamic hip screw fixation. However, significant femoral neck shortening and an increased neck shaft angle were observed at 12 weeks after surgery, which may be attributed to unstable fixation. Parallel cannulated screws possess the ability of flexible fixation along the axial direction of the femoral neck to promote fracture healing. However, they are also associated with a risk of femoral neck shortening. In this case, the femoral neck fracture was vertical with a large shear force. It was difficult to achieve a satisfactory fixation effect by simply using cannulated screws, which could compromise the stability of the fracture. Finally, the internal fixation was probably invalid. This further affected fracture healing and even led to femoral head necrosis. Liporace et al studied 75 patients with Pauwels type III femoral neck fracture. Of those, 37 patients underwent simple internal fixation with cannulated screws. The results showed that 19% of the patients had femoral neck fracture nonunion.
The combination of cannulated screws with a medial support plate may be an alternative method. In addition, a biomechanical study conducted by Kunapuli et al demonstrated that the treatment efficacy and feasibility of the combination of cannulated screws with a medial support plate of the femoral neck were better than those observed for the combination of dynamic hip screws with a support plate. On average, the medial support plate increased failure loads in both constructs by 83%. Femurs instrumented with cannulated screws exhibited a 26% higher failure load than those instrumented with dynamic hip screws. Therefore, 3 cannulated screws for intramedullary fixation were implanted for the reduction of the femoral neck fracture through a short version of the Smith–Petersen approach to fully expose the fracture site. Subsequently, a reconstructed steel plate was used on the inner side of the femoral neck. In addition, a femoral neck medial support plate was used for external fixation, which supported the medial femoral head and greatly reduced the shearing force. Furthermore, a single cortical screw was used at the proximal end of the medial supporting plate, which enhanced the fracture compression along the long axis of the femoral neck. The follow-up results at 6 months postoperatively showed satisfactory healing of the femoral neck fracture and hip joint activity, and absence of complications, such as femoral head necrosis and fracture displacement.
To be honest, our therapeutic schedule had a shortcoming of this therapeutic approach was the late weight loading in the lower limbs. Due to the severely fragmented left distal femur, we did not require the patient to bear weight early after surgery, and required partial weight-bearing activity at 6 months after surgery. Early-stage partial weight bearing may increase the axial pressure at the femoral neck and promote fracture healing, resulting in prompt recovery of the lower limb function.
We reported a rare case with hip obturator dislocation, femoral head and neck fracture, and pubic fracture. Cannulated screws and a medial support plate were used for the fixation of the femoral neck fracture. This treatment achieved a good fracture healing effect and satisfactory hip joint activity. There were no complaints (e.g., hip pain or discomfort) or femoral head necrosis observed. This case also provides a new reference for the treatment of vertical instability femoral neck fractures.
Conceptualization: Yuchen Hu, Chengdong Piao.
Data curation: Yuchen Hu, Feng Gao, He Liu, Yunlong Li, Zhengwei Li, Chao Huang.
Formal analysis: Feng Gao, Chao Huang.
Investigation: Zhengwei Li.
Resources: Yang Wang.
Software: He Liu, Liangshi Chen, Yunlong Li, Yang Wang.
Supervision: Chengdong Piao.
Visualization: Liangshi Chen.
Literature review: He Liu, Yun-long Li, Zheng-wei Li.
Data analysis: Zheng-wei Li, Yang Wang, Feng Gao.
Writing – original draft: Yuchen Hu.
Writing – review & editing: Chengdong Piao.
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Keywords:Copyright © 2019 the Author(s). Published by Wolters Kluwer Health, Inc.
femoral neck fracture; hip obturator dislocation; pubic fracture