Mismatch of short straight proximal femur nails with anterior bow of femur in Indian population- A radiological and functional analysis.

INTRODUCTION: Intra-medullary devices are the most common mode of fixation of inter-trochanteric fractures. Short proximal femur nails (PFN) used for fixing these fractures, unlike the long nails, are non-anatomic and are usually straight with no curvature in antero-posterior plane. As a result, there is always a chance of the nail tip impinging against the anterior cortex of femur. MATERIALS AND METHODS: A total of 80 patients with trochanteric fractures (AO 31A2 and 31A3), operated with short PFN, were followed up retrospectively and prospectively from 2019 to 2021, for a period of 6 months. All fractures were fixed with PFNs, with nails ranging from 170 to 250 mm. Radiological analysis was done on hip lateral X-rays (taken at 6 months) using Angle at Distant Axis (ADA) and Nail Tip Position (NTP). Functional outcome analysis was done using Harris Hip Score. Patients were graded into 2 groups according to ADA (ADA>4° and ADA<4°). Incidence of anterior thigh pain was noted in patients on follow up and was statistically evaluated with nail size, nail diameter, ADA and NTP. RESULTS: Mean ADA was 4.19° ± 1.45; mean NTP grade was 1.98 ± 1.11. Mean nail size was 201.87 mm with a mean nail diameter of 9.76 mm. Twenty patients complained of anterior thigh pain on follow-up. Twenty-five patients had NTP grade 3 or above of which 16 complained of anterior thigh pain (p < 0.001). Fifty-five patients had nail diameter of 10 mm or above of which 14 had anterior thigh pain (p < 0.01). Fifty-three patients had a nail length of 200 mm or above of which 16 patients complained of thigh pain on follow up (p < 0.01). CONCLUSION: There is a mismatch of short PFNs with anterior bow of femur. Use of shorter nails with narrow diameters will avoid this mismatch to an extent.

Anterior Hip Dislocation with Ipsilateral Subtrochanteric Femur Fracture in a Young Adult - A Rare Case Report.

INTRODUCTION: Combined subtrochanteric femur fracture with anterior dislocation of hip is a very rare injury to occur with subminimal reported cases available in the literature. This study report describes one such unusual case presentation. CASE REPORT: A 26-year-old gentleman presented to our emergency room following road traffic accident, complained of severe pain over his right hip and inability to move his right lower limb. The hip was diffusely swollen and the lower limb externally rotated, clinical and radiological evaluation revealed anterior dislocation of the right hip with ipsilateral subtrochanteric femur fracture. Emergency closed reduction of the right hip was performed using joystick maneuver with two Schanz pins and concomitantly the subtrochanteric fracture reduced, and uniplanar external fixator was applied on the same day of presentation. Following 2 days, external fixator removal and IMIL nailing were performed as an elective definitive procedure. The patient was regularly followed up both clinically and radiologically from the index procedure until now with 2 years as follow-up. CONCLUSION: Anterior hip dislocation with ipsilateral subtrochanteric femur fracture in a young adult requires early emergency evaluation and rapid intervention (reduction within 6 h) and early closed reduction of the joint helps decreasing the risk of complications such as avascular necrosis and chondrolysis and joint reduction with fracture fixation allows early rehabilitation.

Osteosynthesis in Neglected Femoral Neck Fracture in an Adolescent by Internal Fixation Alone - A Case Report.

INTRODUCTION: Femoral neck fractures are less frequent in adolescents. A neglected femoral neck fracture is one in which there has been a delay of more than 30 days from seeking medical attention from the time of injury [1]. The main complications are non-union and avascular necrosis (AVN) of femoral head. Various methods have been tried to successfully manage neglected femoral fractures. CASE REPORT: A 16-year-old boy presented with complains of pain over the right hip and inability to walk for the past 3 months, following a history of fall from a height of around 6 ft. He underwent native splinting from an indigenous native bone setter for 3 months. The splint was removed after 3 months, but the symptoms did not subside. He was diagnosed to have neglected femoral neck fracture and underwent open reduction and internal fixation with three 6.5 mm cannulated cancellous screws with washers. There were no post-operative complications. The patient recovered well. At 15 months follow-up, no clinical or radiological signs of AVN were observed with excellent functional outcome. CONCLUSION: The incidence of neglected femoral neck fractures is declining with improving health-care facilities in developing countries like India. Accurate anatomical reduction and internal fixation are important to reduce the incidence of AVN and non-union after a femoral neck fracture. Internal fixation of the fracture following valgus osteotomy is the most quoted technique in the literature.