Boulton Christina L, Pollak Andrew N
Department of Orthopaedics, Division of Orthopaedic Traumatology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 South Greene Street, Baltimore, MD 21201, United States.
Department of Orthopaedics, Division of Orthopaedic Traumatology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 South Greene Street, Baltimore, MD 21201, United States.
Injury. 2015 Mar;46(3):478-83. doi: 10.1016/j.injury.2014.11.021. Epub 2014 Nov 28.
Ipsilateral fractures of the femoral neck and shaft are rare, high-energy injuries that typically occur in young polytrauma patients. The associated fracture of the neck is often vertical in nature and is more frequently non-displaced than in isolated femoral neck fractures. Historically the diagnosis of an associated femoral neck fracture was delayed or missed in approximately one third of cases. Studies have shown that detection can be significantly improved with the implementation of a protocolized approach to hip imaging in all patients with femoral shaft fractures. Prompt recognition of an associated femoral neck fracture allows for timely stabilization and may decrease the risks of non-union and avascular necrosis. In contrast, failure to recognize a non-displaced or minimally displaced associated neck fracture prior to fixation of the shaft can lead to displacement, a decrease in neck fixation options, a technically challenging secondary procedure and increased risk of long-term sequelae. A vast array of treatment strategies have been described for this combined injury. Published options range from spica casting to open reduction and internal fixation of both fractures and include almost all conceivable combinations in between. While timely surgical stabilization is now universally recommended for both shaft and neck, no consensus exists as to the most appropriate method of fixation for either fracture. Most authors recommend prompt, but not emergent, surgery with priority given to anatomic reduction and stabilization of the neck fracture by either closed or open methods. Fixation of the shaft fracture follows as patient condition allows. The rare nature of this injury makes it very challenging to study and most published series' are retrospective with very small sample sizes. In short, no scientificallycompelling study is available to definitively support any one implant choice or method of stabilzation over another for the treatment of associated fractures of the femoral neck and shaft.
同侧股骨颈和股骨干骨折是罕见的高能量损伤，通常发生于年轻的多发伤患者。与之相关的股骨颈骨折往往呈垂直型，相较于单纯股骨颈骨折，其无移位的情况更为常见。从历史上看，在大约三分之一的病例中，相关股骨颈骨折的诊断会被延迟或漏诊。研究表明，对所有股骨干骨折患者采用标准化的髋部成像方法，可显著提高骨折的检出率。及时识别相关股骨颈骨折能够实现及时固定，并可能降低骨不连和缺血性坏死的风险。相反，在固定股骨干之前未能识别出无移位或轻微移位的相关股骨颈骨折，可能会导致骨折移位、股骨颈固定选择减少、二次手术技术难度增加以及长期后遗症风险升高。针对这种复合伤，已经描述了大量的治疗策略。已发表的治疗方案从髋人字石膏固定到双骨折切开复位内固定，涵盖了几乎所有可能的组合方式。虽然目前普遍建议对股骨干和股骨颈及时进行手术固定，但对于哪种骨折的固定方法最为合适，尚无共识。大多数作者建议进行及时但非急诊的手术，优先通过闭合或开放方法对股骨颈骨折进行解剖复位和固定。待患者情况允许后，再对股骨干骨折进行固定。这种损伤的罕见性使得研究极具挑战性，大多数已发表的系列研究都是回顾性的，样本量非常小。简而言之，目前尚无科学上有说服力的研究能够明确支持在治疗股骨颈和股骨干联合骨折时，某一种植入物选择或固定方法优于另一种。
