Outcomes Following the Urgent Surgical Management of Displaced Femoral Neck Stress Fractures.

OBJECTIVES: To review the clinical course, complication rates, and mid-term functional outcomes associated with the treatment of displaced femoral neck stress fractures (FNSFs). DESIGN: Retrospective Case Series. SETTING: Military Tertiary Referral Center. PATIENTS: Twenty-one operatively treated displaced FNSFs between 2002 and 2015. INTERVENTION: Urgent reduction and fixation was performed. If nonunion developed, an intertrochanteric osteotomy was performed. MAIN OUTCOME MEASUREMENTS: Nonunion, osteonecrosis (ON) of the femoral head, conversion to arthroplasty, modified Harris Hip Score, pain score, and Hip Outcome Score (HOS). RESULTS: Two (9.1%) patients developed nonunion. Both united after revision with intertrochanteric osteotomy. ON developed in one patient (4.8%) who was converted to arthroplasty. Average pain score at final follow-up was 2.0 (range 0-5). Average Modified Harris Hip Score was 84 (range 54-100). Average HOS Activities of Daily Living subscale was 80.9 (range 45.6-100). Average HOS Sport subscale was 69.8 (range 27.8-100). Larger displacement on injury films correlated with lower Modified Harris Hip Scores (P = 0.048) and lower HOS Sports Subscale Single Assessment Numeric Evaluation (P = 0.023). The need for an open reduction trended toward being a risk factor for nonunion (P = 0.081). CONCLUSIONS: This study represents the largest series of patients undergoing urgent surgery for displaced FNSFs. Nonunion and ON is found at a similar rate to what is reported in the young traumatic literature. Pain and outcome scores compare favorably to other hip pathology in young adults. Initial injury severity is variably correlated to final outcome scores. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The dangers of damage control orthopedics: a case report of vascular injury after femoral fracture external fixation.

BACKGROUND: Placement of external fixation frames is an expedient and minimally invasive method of achieving bone and joint stability in the setting of severe trauma. Although anatomic safe zones are established for placement of external fixation pins, neurovascular structures may be at risk in the setting of severe trauma. CASE REPORT: We present a case of a 21-year-old female involved in a high speed motorcycle accident who sustained a Type IIIB open segmental femur fracture with significant thigh soft tissue injury. Damage control orthopedic principals were applied and a spanning external fixator placed for provisional femoral stabilization. Intraoperative vascular examination noted absent distal pulses, however an intraoperative angiogram showed arterial flow distal to the trifurcation. Immediately postoperatively the dorsalis pedis pulse was detected using Doppler ultrasound but was then non-detectable over the preceding 12-hours. Femoral artery CT angiogram revealed iatrogenic superficial femoral artery occlusion due to kinking of the artery around an external fixator pin. Although the pin causing occlusion was placed under direct visualization, the degree of soft tissue injury altered the appearance of the local anatomy. The pin was subsequently revised allowing the artery to travel in its anatomic position, restoring perfusion. CONCLUSION: This case highlights the dangers associated with damage control orthopedics, especially when severe trauma alters normal local anatomy. Careful assessment of external fixator pin placement is crucial to avoiding iatrogenic injury. We recommend a thorough vascular examination pre-operatively and prior to leaving the operating room, which allows any abnormalities to be further evaluated while the patient remains in a controlled environment. When an unrecognized iatrogenic injury occurs, serial postoperative neurovascular examinations allow early recognition and corrective actions.