*Pankaj Kumar,
G.K.Singh, M.P.Singh
*Department of Orthopaedics,
B.P.Koirala Institute of Health Sciences, Dharan, Nepal.
Address for Correspondence
Dr Pankaj Kumar
Assistant Prof., Department of Orthopedics,
B.P.Koirala Institute of Health Sciences, Dharan, Nepal
Phone: +97-25-525555-3260,2016
Fax:+977-25-520251
E-mail:drpankaj06@yahoo.co.in |
Abstract We report the
third case in medical literature reviewed of bilateral fracture
neck femur in a young female child and describe the possible
mechanism.
Key words: Fracture neck of femur, Bilateral, Mechanism
of injury
J.Orthopaedics 2006;3(3)e5
Introduction:
Bilateral
fractures of the femoral neck in children mostly occur due to
high - energy impact. [4] These fractures involve mostly
osteopenic bones of the elderly. Bilateral femoral neck
fractures in a disease-free bone of a child are very rare. [2]
We retrieved only two cases from medical literature where the
mechanism is described in detailed. We report the third such
case and suggest a possible mechanism, different to the one
described in literature, which was possibly operating in this
case.
Case report:
An
11-year-old female reported with a fall from the tree 20 ft
height. Firstly the right thigh struck a branch before she
landed on the ground with the left lower limb extended. She
lost consciousness for a few minutes and was brought to the
emergency department of BPKIHS 4 hours following injury. At the
time of admission she was complaining of difficulty in
breathing, abdominal pain and pain around bilateral hip region.
On examination chest compression test was positive, abdomen was
soft and the abdomen was tender and mildly distended. On
auscultation of chest bilateral air entry was equal with normal
vesicular breathing without additional sounds. Bowel sounds
were normally heard. USG revealed collection in peri-splenic
area, pelvic region and free fluid in the left pleural space.
X-ray of the abdomen revealed dilated small bowel loop and X-ray
of hip joints revealed bilateral fracture neck of femur. (Fig 1)
The patient was kept on conservative management with Ryles tube
and bilateral skin traction, upon which he recovered slowly over
a period of 10 days. After that she underwent opened reduction
and internal fixation of her fractures with canulated cancellous
screws. Bilateral skin traction was applied for 3 weeks for
immobilization and gradual active assisted hip mobilization on
bed was started after 1 week. Both the fractures united
completely at 14 weeks and the patient returned to full activity
at 20 months. At 30 months later there were no signs of
avascular necrosis of the head of femur.
Discussion :
Fractures of the femoral neck in children are
rare and such cases result from severe trauma. [4] Although
cases of simultaneous bilateral fractures of the femoral neck
are reported in young adults and elderly with osteopenic bones,
there have been two such cases reported in children having
normal bones. Most of the concurrent bilateral fractures are
caused by violent trauma resulting from electric shock, either
accidental or during electro-convulsive therapy. [1], [3], [5]
High-energy trauma is the accepted mechanism of injury for
childhood femoral neck fractures. [1] This usually occurs
following a fall from a height (a tree, ladder or a wall). In
such cases, initially they fall on edge of the roof or on branch
of tree fracturing one neck of femur before falling to the
ground to fracture the other. During this process possibly one
limb is forced into abduction, extension and external rotation
and a further continuation of these forces causes the neck to
break. This mechanism would normally result in an obturator type
anterior dislocation of the hip6 but the tight iliopsoas from
hip extension and the tight rectus femoris from knee flexion
along with the anterior capsule and the Y shaped ligament of
Bigelow prevent this from happening. Thus, femoral necks
fracture rather than an anterior dislocation of the hip results.
Following this the other side impacts the ground causing the
classical indirect flexion, adduction external rotation force at
hip to fracture the neck of the opposite side. Fig 2.
Reference :
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Atkinson R, Kinnett JG, Arnold
WD. Simultaneous fractures of both femoral necks: review of
the literatures and report of two cases. Clin Orthop Rel Res
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Ashish Upadhyay, Lalit Maini,
Sumit Batra, et al Simultaneous bilateral fractures of femoral
neck in children-mechanism of injury.JINJ 2045 1–3
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Chadha M, Balain B, Maini L, et
al. Spontaneous bilateral displaced femoral neck fractures in
nutritional osteomalacia: a case report. Acta Orthop Scand
2001; 72(1): 94—6.
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Canale ST, Beaty JH, Pelvic and
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Nanda S, Mohanti RC. Bilateral
fracture of the neck of the femur. J Indian Med Assoc 1968;
51:185—6.Shaheen MA, Sabet NA. Bilateral simultaneous fracture
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