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Treatment of Open Proximal Femoral Fractures Sustained in Combat
Andrew W. Mack, MD1; Brett A. Freedman, MD2; Adam T. Groth, MD3; Kevin L. Kirk, DO4; John J. Keeling, MD1; Romney C. Andersen, MD1
1 Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889. E-mail address for A.W. Mack: amack2@caregroup.harvard.edu
2 Landstuhl Regional Medical Center, AE, 09180-0402
3 Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI 96859-5000
4 Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234
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Investigation performed at Walter Reed Army Medical Center, Washington, D.C., and National Naval Medical Center, Bethesda, Maryland

Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Army, the Department of the Navy, the Department of Defense, or the United States Government. This work was prepared as part of their official duties and, as such, there is no copyright to be transferred.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Feb 06;95(3):e13 1-8. doi: 10.2106/JBJS.K.01568
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Open proximal femoral fractures are rare injuries that often result from wartime high-energy causes. Limited data exist regarding the treatment and complications of these injuries.


We retrospectively reviewed the records of combat casualties treated at two institutions between March 2003 and March 2008. The casualty patient databases, medical records, radiographs, and laboratory data were reviewed to determine time to union, complication rates, and patient outcomes.


Forty-one patients (thirty-nine men and two women) with a mean age of 25.7 years were identified as receiving treatment for open proximal femoral fractures. The mechanisms of injury for these forty-one patients were blast (twenty-nine patients [71%]), gunshot wound (eight patients [20%]), motor vehicle crash (three patients [7%]), and helicopter crash (one patient [2%]). There were thirty Type-IIIA, six Type-IIIB, and five Type-IIIC open fractures. The predominant method of definitive fixation was a cephalomedullary or reconstruction nail in thirty-four patients (83%). Thirty-nine patients had at least two years of follow-up data available for assessment of complications and radiographic union. The mean time to union was 5.1 months (range, 2.8 to 16.0 months). Complications requiring reoperation occurred in twenty-two (56%) of thirty-nine patients. Wound infection (twelve patients [31%]) and symptomatic heterotopic ossification (ten patients [26%]) were the most common complications.


Cephalomedullary nail fixation of open Type-III wartime subtrochanteric and pertrochanteric femoral fractures can be reliably used to effect fracture union in a timely manner. The most frequent complications of treatment are wound infection and symptomatic heterotopic ossification.

Level of Evidence: 

Therapeutic Level IV. See Instructions for 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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