Simultaneous bilateral femoral neck fracture

Abstracts

Fratura simultânea bilateral do colo do fêmur é uma patologia rara e geralmente está relacionada a doenças metabólicas ou outras patologias prévias. Esse tipo de fratura pode passar despercebida, piorando o prognóstico desses pacientes. Neste relato, os autores apresentam o caso de um paciente do sexo masculino de 27 anos de idade com fratura simultânea bilateral do colo do fêmur após um episódio de convulsão. Serão discutidos aspectos sobre o mecanismo do trauma, os tipos de tratamento e a dificuldade no diagnóstico nesse tipo de fratura.

Fratura do colo do Fêmur; bilateral; simultânea; epilepsia

RELATO DE CASO

Simultaneous bilateral femoral neck fracture ^*

Carlos Roberto Schawartsmann^I; Gustavo Kaempf de Oliveira^II; Ricardo Kaempf de Oliveira^III; Douglas Carpes^III; Pablo Mariotti Werlang^IV

^ITitular Professor of ''Disciplina de Ortopedia e Traumatologia'' of ''Fundação Faculdade Federal de Ciências Médicas de Porto Alegre'' and Chief of the ''Serviço de Ortopedia e Traumatologia'' of ''Complexo Hospitalar Santa Casa de Porto Alegre''

^IIAssistant Doctor of the ''Serviço de Ortopedia e Traumatologia'' of ''Complexo Hospitalar Santa Casa de Porto Alegre''

^IIIResident in Orthopedics and Traumatology of ''Complexo Hospitalar Santa Casa de Porto Alegre''

^IVGraduation student of ''Fundação Faculdade Federal de Ciências Médicas de Porto Alegre''

SUMMARY

Simultaneous bilateral fractures of the neck of the femur is rare. Such fracture is usually associated with metabolic diseases or other previous pathologies. This fracture may pass unnoticed, a fact which would worsen its prognosis. In this report, the authors present the case of a twenty-seven year old male patient who, after having a convulsion, had a simultaneous bilateral femoral neck fracture. Aspect related to the trauma mechanism, its different treatments and the difficulty in diagnosing this fracture will be discussed.

Key Words: Femoral neck fracture; bilateral; simultaneous; epilepsy

INTRODUCTION

Meduna introduced pharmacological therapy of seizures in 1935 ⁽¹⁰⁾. Before 1950, strong muscle contractions happening during seizures induced by drugs or electroshock, mostly during psychiatric treatment occasionally resulted in simultaneous bilateral fracture of femoral neck ⁽¹⁵⁾. The first reports of bilateral fracture of femoral neck were in this kind of patient ⁽¹⁵⁾. In 1944, two Brazilians, Silva and Barros reported three cases of this kind of fracture in a Psychiatric magazine ⁽¹⁴⁾. Powell states that there is no recent publication on this injury related to this kind of treatment ⁽¹⁵⁾. However, the incidence of this kind of fracture was much reduced by the introduction of muscle relaxants as adjuvant therapy ^(2,19) .

Later other cases of this kind of injury were reported in previously healthy subjects ^(1,11,21) . Currently this kind of fracture is seen in patients with metabolic diseases such as chronic renal impairment, celiac disease, hiper-paratireoidism and others, causing bone changes. ^(2,9,19,23).

Are also reported in literature bilateral fractures of femoral neck after seizure caused by hypocalcaemia. ^(2,19)

CASE REPORT

A 27 years old male was admitted to the ''Serviço de Ortopedia e Traumatologia'' of the Complexo Hospitalar Santa Casa de Porto Alegre with pain in both hips and a history of seizures 15 days ago.

Under physical examination he had functional impairment of the lower limbs, which were in external rotation. Had also a retarded psycho and motor development, talking deficiency and bilateral blindness. According to the family report, he was diagnosed epilepsy for 23 years, and was under Phenobarbital since then.

Radiography was took demonstrating deep osteopenia of pelvian bones, and bilateral fracture of femoral neck, with a Garden IV displacement.

As treatment a cutaneous traction was placed for 7 days, when an open reduction was performed, and DHS type screws and tube plate placed. After the surgery a good post operative evolution was observed and the patient was discharged from the hospital at the seventh postoperative day, and is in ambulatory follow up without symptoms.

DISCUSSION

Bilateral simultaneous fracture of the femoral neck is extremely rare ^(1,4,9,15) . Dedichen⁽³⁾, reported in 1946 a case of bilateral fracture of femoral neck among 2428 patients. Fang⁽¹⁵⁾, in 1958, mentions two cases of this kind of injury among 1100 patients receiving electro-convulsivant therapy. Kelly⁽⁶⁾ reported in 1954 one case among 2200 patients who underwent electric therapy due to psychic problems. In Brazil, Silva and Barros⁽¹⁴⁾ reported in 1944 three cases of bilateral fracture among 1843 patients who undergone electron-convulsivant therapy or metrazol in a period of 55 months. In an evaluation of Rochester e Minnesota patients, between 1928 and 1982, 1701 proximal femur fractures were found, only one of them bilateral. Pathological fractures as a consequence of convulsivant therapy occur in 0.3 % of the cases ⁽¹⁶⁾.

As previously mentioned, bilateral simultaneous fractures of the femoral neck started to appear due to electron-convulsivant therapy due to psychic disorders. Later on, few reports of this kind of injury were demonstrated in previously healthy subjects ^(18,21,23). Atkinson mentions four bilateral fractures of the femoral neck which were secondary to a violent trauma, one after a vehicular accident, two due to fall of a heavy object over the femur and one due to fall from high ⁽¹⁾. In 1990, Slater reported one case of bilateral femoral neck fracture due to accidental electric shock, stressing that only found ten cases of this kind of fracture as a result of trauma, one of them from the same etiology ⁽¹⁸⁾. Later on, other cases of this kind of fracture were published ^(13,21). Currently most of the fractures of the femoral neck are due to previously existing bone metabolism diseases, among them late osteogenesis imperfecta ⁽²⁰⁾, ostemalacia due to aluminum and magnesium containing anti-acids ⁽¹²⁾, renal impairment and enterectomy inducing hypocalcemic convulsion ^(4,22), Marfan's syndrome ⁽⁷⁾, chronic alcoholism and hepatic cirrhosis ⁽⁵⁾, convulsion after paratireoidectomy ^(2,8), convulsion due to contrast used in mielography ⁽¹¹⁾.

In most of the patients diagnosis is delayed, usually for one week. ^(1,9,15). So, it is recommended a physical and radiographic examination after convulsivant therapy or a convulsive shock looking for possible fractures ⁽⁹⁾.

Injury mechanism is usually related to uncoordinated muscle contraction ⁽⁹⁾.

Treatment of this kind of patient depends on several issues, among them the time between the fracture and the surgery ⁽¹⁾. Morrey and O´Brien ⁽¹¹⁾ performed subtrocanteric valgisant osteotomy with fixation using plate and screws in a patient three weeks after the fracture. Nanda and Mohanti, treated one patient one week after the fracture with Smith-Petersen plate and nail ⁽¹⁾. Atkinson ⁽¹⁾ opted for Knowles pins in two patients with bilateral femoral neck. Taylor used internal fixation with compression ⁽¹⁹⁾ , and Madhok performed bipolar hip arthroplasty ⁽⁹⁾ in patients presenting the same injury.

As can be noticed, there are several kinds of treatment for this injury, being generally indicated a total or partial arthroplasty since chances of healing the fracture are usually poor and avascular necrosis is higher than in normal patients. Additionally life expectancy is limited. However, bone fixation is indicated in young patients with a longer life expectancy, and this led us to choose this more conservative option.

CONCLUSION

Simultaneous bilateral fracture of the femoral neck is extremely rare and a delayed diagnosis is usual. So, it is very important a history investigation of recent activities, nutritional habits and medicines and previous diseases, as well as clinical and radiological signs. The study of etiologic factors of this kind of fracture is essential to guide us in treatment choice. Early diagnosis and treatment are sometimes determinant of patient prognosis. Obviously patient's age, life expectancy as well as degree of fracture deviation have an influence over deciding treatment and results.

REFERÊNCIAS

Trabalho recebido em 10/11/2000. Aprovado em 12/06/2001

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*

This work was performed at the ''Serviço de Ortopedia e Traumatologia'' of ''Complexo Hospitalar Santa Casa de Porto Alegre''

Publication Dates

• Publication in this collection
  13 Oct 2005
• Date of issue
  Dec 2001

History

• Accepted
  12 June 2001
• Received
  10 Nov 2000