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Diagnosis of Femoral Neck Fractures in Patients with a Femoral Shaft FractureImprovement with a Standard Protocol
Paul TornettaIII, MD1; Michael Sean Hillegass Kain, MD1; William R. Creevy, MD1
1 Department of Orthopaedics, Boston Medical Center, 850 Harrison Avenue, Dowling 2 North, Boston, MA 02118. E-mail address for P. Tornetta: ptornetta@pol.net. E-mail address for M.S.H. Kain: mikain@bmc.org
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Disclosure: The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedics, Boston Medical Center, Boston, Massachusetts

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Jan 01;89(1):39-43. doi: 10.2106/JBJS.F.00297
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Background: An ipsilateral fracture of the femoral neck is seen in association with 1% to 9% of femoral shaft fractures, and 20% to 50% of these injuries are missed initially. Recognition of an associated femoral neck fracture prior to stabilization of the femoral shaft fracture is imperative to avoid or minimize complications of displacement and osteonecrosis.

Methods: A protocol to look for a femoral neck fracture in all patients with a femoral shaft fracture was instituted at a single level-I trauma center. This protocol consisted of a dedicated anteroposterior internal rotation plain radiograph, a fine (2-mm) cut computed tomographic scan through the femoral neck, and an intraoperative fluoroscopic lateral radiograph prior to fixation as well as postoperative anteroposterior and lateral radiographs of the hip in the operating room prior to awakening the patient. A chi-square analysis comparing pre-protocol and post-protocol fracture prevalences was used to assess the relative risk of missing an associated femoral neck fracture.

Results: Two hundred and sixty-eight consecutive patients with a femoral shaft fracture formed the basis of the study group. Of 254 who were followed for at least two months, sixteen were identified as having an associated ipsilateral femoral neck fracture with use of the protocol. Thirteen associated femoral neck fractures were identified before the patient entered the operating room for definitive fixation, and twelve of them were identified with the fine-cut computed tomographic scan. One fracture was identified intraoperatively. There was one iatrogenic fracture and one delayed diagnosis of a femoral neck fracture. With this protocol, we reduced the delay in diagnosis by 91% as compared with our experience in the year prior to the initiation of the protocol.

Conclusions: In the presence of a femoral shaft fracture, evaluation of the femoral neck with fine-cut computed tomography and dedicated internal rotation hip radiographs significantly improves the ability to diagnose an associated femoral neck fracture.

Level of Evidence: Diagnostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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