Session IX - Femur
Sat, 10/9/04 Femur, Paper #49, 3:57 pm
Avoiding Missed Femoral Neck Fractures: Improvement by Using a Standard Protocol in Cases of Femoral Shaft Fractures
Purpose: Ipsilateral associated femoral neck fractures are seen in 1% to 9% of femoral shaft fractures. It is estimated that 20% to 50% of these injuries are missed, many because the fractures are non- or minimally displaced in up to 60% of patients. However, even nondisplaced fractures are at risk for displacement during or after femoral fixation with intramedullary nailing or plating. It is imperative that all efforts are made to recognize and treat associated femoral neck fractures during the first operative session to avoid severe late complications, particularly because femoral shaft fractures are most common in young adults. The purpose of this study was to describe a program of quality improvement and a subsequent protocol that have resulted in a reduction of missed femoral neck fractures in patients with femoral shaft fractures treated in a level-one trauma center.
Methods: Over a 1-year period, seven (8.5%) of 82 patients with femoral shaft fractures had associated femoral neck fractures. Four of these fractures were missed during the preoperative workup and operative session; the diagnosis was made only after the patient left the operating room. Three of four fractures were displaced, and all required repeat surgical intervention. At that time the workup for femoral neck fracture was left to the operating surgeon, with no guidelines. Because of these missed injuries, a best-practice protocol was developed by the attending trauma surgeons for the evaluation of the femoral neck in patients with femoral shaft fractures. This includes a dedicated IR plain radiograph, a fine cut (2 mm) CT through the femoral neck, and a fluoroscopic lateral in all cases of femoral shaft fracture prior to fixation. This is followed by postoperative AP and lateral radiographs of the hip in the operating room prior to awakening the patient to look for femoral neck fracture.
Results: A consecutive series of patients with 268 femoral shaft fractures were seen after initiation of the evaluation protocol. Of these, 254 patients were observed for a minimum of 1 month (assumed time needed for a late fracture to show up). Nineteen of the 254 patients had an ipsilateral associated femoral neck fracture. One (5%) fracture was missed, and there was one iatrogenic nondisplaced fracture (5%). In retrospect, the one missed injury was seen on only two CT cuts as a nondisplaced crack and was not visible on the plain radiographs. This fracture displaced completely in a rehabilitation center. One case was seen in the operating room after nailing and was treated during the same operative session. All other fractures (16) were found preoperatively and treated. The best screening tool for this group of patients was CT scanning, which can easily be added to the standard abdominal-pelvic trauma CT scan protocol for patients with femoral shaft fractures.
Conclusions: The use of a consistent method of preoperative and postoperative evaluation of the femoral neck in cases of femoral shaft fractures is effective in diminishing the rate of missed injury. The addition of a fine cut CT of the femoral neck prior to fixation was the most important component of the improvement process.