Simultaneous bilateral femoral neck fractures in a dialysis-dependent patient: case report and literature review

Bilateral simultaneous proximal femoral fractures on dissimilar anatomical regions

Simultaneous presentation of bilateral proximal femoral fractures following a traumatic event are considered very rare injuries. A literature search revealed that the fracture pattern in bilateral simultaneous proximal femoral fractures is most commonly similar to the anatomical region. We report a case of traumatic bilateral proximal femoral fractures with dissimilar pattern and anatomical location following a low energy trauma. A 90-year-old female presented with a right extracapsular - intertrochanteric neck of femur fracture and a left intracapsular - subcapital neck of femur fracture following a fall. The surgical plan was to fix the right side with a dynamic hip screw (DHS), directly followed by left cemented hip hemiarthroplasty on the left. Anesthetic concerns were raised towards the end of the first procedure hence the hemiarthroplasty was postponed. Following medical optimization, a bipolar cemented hip hemiarthroplasty was performed 4 days later. The patient was discharged after 16 days with carers support at home. Careful planning should take place in cases of simultaneous bilateral hip fracture given increased morbidity and mortality. Operation of both sides in a single stage is acceptable to reduce the risk of anesthetic complications and reduce costs. Dissimilar or asymmetrical bilateral hip fractures present a unique challenge, primarily because of the need to change the patient's position. Communication between the surgical and the anesthetic team throughout any procedure is important, but even more so in high-risk cases. To our knowledge, dissimilar or asymmetrical bilateral proximal hip fractures in the elderly presenting simultaneously have only been described twice in literature. Their rarity necessitates careful preoperative planning. The aim should be to address both injuries in a single operation, however contingency planning is important.

Non-traumatic Simultaneous Bilateral Femur Neck Fracture in a Young Female Unraveling End-Stage Renal Disease: A Case Report and Literature Review

Introduction

Spontaneous femur neck fracture is rare, especially when they occur bilaterally. Renal osteodystrophy is among the causes of these fractures that should be kept in mind. We report a case of a young female who presented with bilateral hip pain and was found to have bilateral femur neck fracture due to renal osteodystrophy. This was the first presentation of an undiagnosed end-stage kidney disease. This case report aims to highlight the importance of investigating the cause of these rare fractures in young patients and discuss available surgical options.

Case Report

A 19-year-old female presented complaining of bilateral hip pain. On physical examination, there was tenderness on palpation of both thighs. Her workup was significant for anemia, a high level of creatinine, hypocalcemia, elevated alkaline phosphatase, and parathyroid hormone. A pelvis radiograph showed bilateral femur neck fracture. Considering her very young age, the metabolic derangements she had and to avoid exposing her to a major surgery, we treated her fractures by fixation using three cannulated screws on each side. We aimed to report this case as it is an unusual presentation of a previously undetected stage 5 chronic kidney disease (CKD) in a very young patient.

Conclusion

Renal osteodystrophy due to CKD can present with spontaneous bilateral femur neck fracture. Physicians should have a high index of suspicion for this condition not to miss a chronic disease with multiple sequelae. Furthermore, these fractures carry a high risk of complications and mortality, so they should be addressed promptly.

Bilateral Intertrochanteric Femur Fractures in a Paraplegic Patient: A Case Report

Bilateral intertrochanteric (IT) femur fractures are rare, and appropriate evaluation and treatment can vary depending on concurrent patient comorbidities. Even less has been described for patients with bilateral IT fractures with pre-existing paraplegia. This case report describes the unique case of a 72-year-old paraplegic female who presented with bilateral IT femur fractures due to a wheelchair accident. The patient was treated with single-stage bilateral cephalomedullary nail fixation so she could effectively transfer to and from the wheelchair with less pain and a greater chance of fracture union. At the last follow-up, the patient's pain had resolved and she was able to transfer as effectively and safely as her pre-injury baseline. Single-stage cephalomedullary fixation of bilateral IT femur fractures is indicated in the paraplegic population to relieve pain and improve effective safe transfers for daily activities.

Malunited Right and Ununited Left Fracture Neck Femur in Autism with Seizures Treated with Valgus Osteotomy: A Case Report

CASE

An 18-year-old autistic boy with seizure disorder had a 4-month-old hip injury with a similar right hip injury 6 months earlier. X-rays revealed an ununited fracture neck femur on the left and a malunited fracture neck femur on the right hip. Magnetic resonance imaging indicated preserved head vascularity. Valgus osteotomy and double-angle plate fixation of both hips were performed at an interval of 2 months.

CONCLUSION

Delayed presentation bilateral neck fractures are rare. X-rays showed healed fractures with no avascular necrosis in both hips at 2-year 6-month follow-up. Valgus osteotomy is ideal and relevant for osteosynthesis in selected ununited femur neck fractures.

Simultaneous bilateral basicervical femoral neck fractures in a patient with osteomalacia: A case report and literature review

A thin patient with a history of eating disorders developed basicervical femoral neck fracture bilaterally and simultaneously due to vitamin D deficiency osteomalacia. A careful evaluation in thin patients with thigh pain, including bone biopsy, is required to avoid overlooking osteomalacia.

Energy, Waves, and Forces in Bilateral Fracture of the Femoral Necks: Two Case Presentations and Updated Critical Review

Two case reports and an updated critical review on bilateral fractures of the femoral neck are presented. Bilateral fractures of the femoral neck have been investigated for at least 80 years and are treated as rare cases. The primary cause is usually considered an external shock; however, aside from high energy shocks (e.g., falling and impact with hard, rigid surfaces, traffic accidents, etc.) the underlying causes of femoral neck frailty have not yet been fully understood. Although not exhaustive, the review spans cases reported as early as 1944 and compares their conclusions in line with medicine developments at the time of the reports until present. The discussion is perhaps controversial at times; it brings to the fore the energy balance between shock waves and stress waves. The two cases reported here add to the review, one highlighting the biomechanics, and the other supporting more recent findings on metabolic disorders, which ultimately lead to enhanced frailty of the femoral neck. Investigation of the fractures has been performed with X-ray radiographs, MRI, and CT, with a follow up using a Doppler US to check blood flow in the lower zone of the limbs. The second case was investigated both for fractures and metabolic diseases, e.g., type I diabetes and kidney failure (dialysis). In Case 1 the second fracture was not observable at the time of admission, and therefore two surgery operations were performed at seven days interval. Taperloc Complete prostheses (Zimmer Biomet) were applied. Case 2 suffered a second fracture in the right hip in the segment above the knee and required better fixation with cables. Despite this, she returned one month later with a new crack in the femur. Case 1 is a typical case of wear consequences on the biomechanics of the hill pad-tibia-femur-femoral neck system, where tension of the neck occurred due to a stress wave rather than a shock wave. This can be proven by the absence of a second fracture from the images first acquired, the only evidence being pain and walking difficulty. Case 2 shows that metabolic diseases can dramatically enhance the frequency of bilateral femoral neck fractures.

Bilateral simultaneous asymmetric hip fracture without major trauma in an elderly patient: a case report

BACKGROUND

Simultaneous bilateral hip fractures without major trauma in the elderly are rare and usually symmetrical. To the best of our knowledge, only two cases of bilateral simultaneous asymmetric hip fracture in the elderly without major trauma have been reported.

CASE PRESENTATION

We present the case of a 90-year-old Japanese man with simultaneous bilateral asymmetric hip fractures with trochanteric fracture on the right side and greater trochanteric fracture on the left side. He complained of dyspnea at midnight and was referred to our emergency department. He was admitted to the internal medicine department for bacterial pneumonia treatment. On the 8th day of hospitalization, he was referred to our orthopedic surgery department for hip pain and was found to have fractures of both hips. Computed tomography findings showed that the left femoral neck fracture was an old fracture, while the left greater trochanteric fracture and the right trochanteric fracture were fresh fractures. He was surgically treated through open reduction and internal fixation with an intramedullary nail on the right and hemiarthroplasty on the left in supine position, performed during the same surgical sessions on the 12th day of hospitalization.

CONCLUSIONS

We report a new form of simultaneous bilateral asymmetric hip fracture in the elderly. The fracture types of the case were femoral trochanteric fracture and greater trochanteric fracture of the femur, which were different from the fracture types in the previously reported two cases. Clinicians should be aware of the possibility of simultaneous bilateral hip fractures, especially in the elderly.

Rapidly destructive coxopathy due to dialysis amyloidosis: a case report

Rapidly destructive coxopathy (RDC) is a disease that is sometimes seen in geriatric patients. A total hip arthroplasty (THA) is mostly chosen to treat the RDC, but few cases are known that received THAs due to RDC associated with dialysis amyloidosis. We report a case of RDC due to dialysis amyloidosis with special references to its pathophysiology. The case involved a 61-year-old male who had been on dialysis for seven years due to diabetic nephropathy. At his first visit, the radiographs showed collapse and flattening of the femoral head, which progressed within a month. Magnetic resonance imaging for the hip disclosed bone marrow edoema of the acetabulum and sclerosis of the subchondral bone of the femoral head. Biochemical analyses for the blood revealed high inflammatory reactions with elevated C-reactive protein and white blood cell count, but the joint fluid cultures were negative for general bacteria, tubercle bacillus, and nontuberculous mycobacteria. As he did not have gastrointestinal disorders or inflammatory arthritis other than the left hip and no disease that caused elevated inflammatory reactions was observed, we diagnosed the patient with RDC due to dialysis amyloidosis, and a THA was performed. Pathological findings for the synovium collected during surgery showed infiltration of the inflammatory mononuclear cells and vascular hyperplasia. The synovial tissues were extensively stained with an antibody to β2-microglobulin. Many tartrate-resistant acid phosphatase-positive multinucleated cells were also observed in the synovium. One year after surgery, his left hip pain disappeared and he returned to work.

A simultaneous bilateral asymmetric hip fracture in an elderly patient: A case report and review of the literature

•

Simultaneous bilateral hip fractures in the elderly are rare and usually have a symmetric pattern.

•

Intracapsular fractures on one side and trochanteric on the other are even rarer.

•

They are caused by a spontaneous fracture which causes a fall on the contralateral side.

•

The trochanteric fracture should be operated first to avoid possible complications.

Introduction

Simultaneous bilateral hip fractures are usually associated with high energy trauma, seizures, metabolic diseases and bisphosphonates use. They are observed rarely in the elderly population after simple trauma and usually have the same fracture pattern (symmetric). We report a rare case of asymmetric fracture and discuss mechanism of injury and treatment, analyzing the literature.

Presentation of case

We report a case of an 86-year old woman with a simultaneous bilateral asymmetric hip fracture (trochanteric on the right side and subcapital on the left), occurred after a fall at home. The patient was surgically treated by open reduction and internal fixation with an intramedullary nail on the right and by hemiarthroplasty on the left performed during the same surgical session, with good results.

Discussion

Simultaneous bilateral hip fractures in the elderly are rare and usually are symmetric. In the majority of the cases these fractures are intracapsular and are treated by hemiarthroplasties. On the contrary, simultaneous bilateral hip fractures with a different pattern, as the described case, are extremely rare. The possible mechanism of injury is a spontaneous fracture on one side, which causes a fall the contralateral side. The surgical treatment may be performed bilaterally, treating first the trochanteric fracture.

Conclusion

Simultaneous bilateral asymmetric hip fracture are extremely rare and may occur in elderly patient with a specific mechanism of injury. We believe that the trochanteric fracture should be operated first to avoid possible complications.