Concurrent ipsilateral fractures of the hip and shaft of the femur. A systematic review of 722 cases.

BACKGROUND AND AIMS: Ipsilateral fracture of the hip and femoral shaft is encountered in high-energy trauma, and warrants special diagnostic and therapeutic considerations, which are not available in any single report. Therefore, a meta-analysis was performed.

MATERIAL AND METHODS: Seven hundred and twenty-two cases of concurrent, ipsilateral fractures in the hip and femoral shaft reported in 65 publications were reviewed. This high-energy injury combination was rare in children, the median age of the patients being 34 years (range 3-76 years). 78% of them were men, 44% were multiply injured. Concurrent hip fractures were reported in 0.8 to 8.6% of all femoral shaft fractures.

RESULTS: The trauma force was found to cause buckling of the femur and shearing of the femoral neck. Hip fractures, divided into 5 subtypes, had the following distributions: subcapital-2%, midcervical-21%, basicervical-39%, pertrochanteric-14% and intertrochanteric-24%. The diagnosis of the hip fracture was delayed in 30% of the cases, but it healed in 99% with most operative methods with no deep infections. The average rate of avascular necrosis of the femoral head was 5.1%. Plate fixation of the shaft fracture was complicated by deep infection in 6.1%, by non-union in 9.8% and yielded a poor outcome in 11.0% of the cases. The respective figures for unlocked intramedullary nailing were 2.7%, 2.7% and 6.8% and for locked nailing 0%, 0% and 0%, respectively. Fixation of the hip fracture was bound with more complications (reoperations and malunions) in combination with nailing than plate fixation.

CONCLUSIONS: Early diagnosis of all injuries and operative treatment of all fracture components are the key factors in reducing complications and improving the outcome in ipsilateral hip and shaft fractures. Locked nails and hip screws yield improved results compared with plates and unlocked nails combined with hip screws. Cephalo-medullary nails have yielded results similar to the first-generation locked nails.