Simultaneous bilateral traumatic
inter-trochanteric fractures: A case report

A. PANAGOPOULOS, A.Χ. PAPADOPOULOS, D. GIANNIKAS, M. TYLLIANAKIS
Orthopaedic department of Patras University

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ABSTRACT
A case of simultaneous bilateral inter-trochanteric fractures of the femur, caused by traffic accident, managed with one-stage proximal femoral nailing, is reported. This combined type of fracture is severe and a potentially life-threatening injury associated with high morbidity. Adequate resuscitation, early one-stage stabilization and subsequent mobilization of the patient are the major determinants of successful outcome.
Key words: bilateral intertrochanteric fractures, proximal femoral nailing

Figure 1. Anteroposterior radiographs of both hips demonstrated comminuted inter-trochanteric fractures.

INTRODUCTION
Simultaneous bilateral fractures of the proximal end of the femur are very rare and various etiologic factors have been identified. Most cases concern patients with stress fractures, due to local destructive disease, steroid treatment, epileptic or drug-induced convulsions and high voltage electric injuries[1,4,6,7]. Simultaneous bilateral inter-trochanteric femoral fractures caused by violent injury to normal structures appear to be considerably rare. In fact to our knowledge there is only one report of traumatic bilateral inter-trochanteric fractures[2].

CASE REPORT
A 44-year-old man was a victim of a traffic accident. His wife was driving their car when it collided with a truck coming from the opposite direction. The crash impact was mainly absorbed by the right door and bumper, which gave way and squeezed the patient toward the left door. He was transferred to our hospital and arrived approximately 30 minutes after the crash. On admission he was slightly confused with temporary memory loss. Initial vital signs were systolic blood pressure 100mm Hg and pulse rate 120/min. He complained of pain in his head, right wrist and both hips and thighs. He had multiple small lacerations and bruises to the face, right forearm and both legs. Clinical examination demonstrated fractures in the right wrist and in both hips and no other injuries to the locomotor system or to the viscera. Radiographs revealed bilateral intertrochanteric fractures(R Tronzo IV, L Tronzo II - Figure 1), left acetabular fracture and intra-articular fracture of the distal end of his left radius. Initial hemoglobin level was 8.9g/dl, PO2 82.5mmHg and PCO2 33.2mmHg. On the basis of this findings oxygen 30% was administered by mask. Before transfer to the ward fluid resuscitation was initiated and via central and peripheral lines 2 units of blood and adequate crystalloids were transfused in order to stabilize his hemodynamic status. GCS on admission was 15 and the CT scan of his brain, was normal. Bilateral skin traction and a short forearm cast was applied and 3 hours after his admission he was transferred to the ward. The patient had been operated 4 years ago for subarachnoid hemorrhage. Clipping of an anterior anastomotic artery aneurysm had been done through a right interpterygoid craniotomy. Left hemiparesis and mixed (mainly of emission type) aphasia was his residual neurological status.
The next day the patient was taken to the operating theater and under general anesthesia the same surgical team performed internal fixation of both intertrochanteric fractures consecutively, first in the right and then in the left hip. Standard AO/ASIF proximal femoral nailing systems (Synthes¨) were applied bilaterally. Since the displacement of the acetabular fracture was considered minimal no attempt at internal fixation was made and only skin traction was applied in the left leg. An intra-articular fracture of the left radius with TFCC rupture was found and K-W fixation was used to stabilize the fracture while TFCC restoration was done using one mini Mitec anchor. The overall operating time was 3 hours and the estimated blood loss two units, which were replaced postoperatively.
His total hospital stay was 10 days and his recovery was uncomplicated. He was allowed to do partial weight bearing 8 weeks after the hip operations and full weight bearing after 4 months. On 18 months follow up he complained of slight pain in the right hip and mild limitation of right wrist motion. His roentgenograms showed solid union of both femoral fractures (figure 2).

Figure 2. Radiographic evaluation at 18 months follow up, showing
solid union of both inter-trochanteric fractures.

DISCUSSION
Simultaneous bilateral intertrochanteric fractures are very rare, in contrast with the number of patients treated for unilateral fractures, and pose completely different problems from the unilateral ones, especially with respect to mechanism, severity and management[5].
In contrast to unilateral fractures, which are usually caused by relative minor forces, bilateral trochanteric fractures are always the result of a violent injury and the combination of strong forces, including rotation acting on both legs simultaneously or consecutively. Our patient was vehicle occupant (co-driver) and he had his lower limbs trapped in the front part of the vehicle, while his trunk was thrown backward and forced to twist around the immobilized thighs. The presence of associated multiple major or minor injuries indicate that a high energy transfer occurred at the time of the impact. Our assumption that bilateral simultaneous trochanteric fractures pose a threat to life is based on the fact that our patient required at least fluid resuscitation, a large amount of blood transfusion and closed preoperative and postoperative monitoring.
Questions may arise about the ideal timing for the surgical procedure. Fractures fixation should be undertaken as soon as the general condition of the patient is stable, preferably in the first 24 hours[3]. Early surgery decreases the incidence of respiratory distress syndrome, the possibility of fat embolism and also may reduce the incidence of complications related to the fracture and to the prolonged time of hospitalization.
We are in favor of the one-stage surgical procedure provided that the general condition of the patient allows it and preferable under general anesthesia which offering adequate operating time and improving the already impaired oxygenation of the patient. Three to four units of blood must be available for the surgical procedure. Considering the technical aspects of the osteosynthesis of these fractures, in our department we routinely use the sliding-screw plating systems. However in this particular case we used the proximal femoral nail system. The latter provides safer rigidity than the screw plate system, is performed faster, is related with less blood loss and allows earlier ambulation of the patient[8].
In conclusion, simultaneous bilateral trochanteric fractures are rare and potentially life-threatening injuries, associated with high morbidity. Early one-stage internal fixation, preferably with intramedullary nailing and closed monitoring of the patient are the major determinants for a good final outcome.

REFERENCES
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