Trifocal femur fracture: where do I start?

Ipsilateral multifocal femoral fractures often present a challenge for the surgeon, as there is limited consensus in the literature regarding the optimal management of this rare type of fracture. In this clinical case, Dr Giovanni Longo highlights the issues he encountered while operating on this particularly challenging case. He won the Bonevoyage 2024 competition on myAO with this example case.

Non-contiguous ipsilateral femoral fractures involving the proximal femur, diaphysis, and distal femur are generally associated with high-energy trauma and are poorly described in the literature. Intracapsular femoral neck fractures and complete distal intra-articular fractures (AO/OTA type 33-C) [1] present a more complex clinical picture and are even more rarely documented. Given the rarity and complexity of these injuries, there is no consensus on their optimal surgical management. 

Case report, preoperative planning, and surgical management 

This case report describes a high-energy trifocal femoral fracture (intracapsular femoral neck, femoral shaft, and complete distal articular femur) treated with an intramedullary nail, free cannulated screws, and a LISS plate.

This combination of implants, not previously reported in the literature, allowed for an anatomical reduction with absolute stability of the distal periarticular fracture and a functional reduction with relative stability in the other two fractures (shaft and femoral neck).

The patient was a 72-year-old otherwise healthy man involved in a high-energy motor vehicle accident. On physical examination, he presented with pelvic tenderness, a shortened and externally rotated left lower limb, a swollen knee, and intact pulses.

Initial diagnostic tests revealed a left basal pneumothorax with bilateral pleural effusion, fractures of the left fifth to eighth ribs, xiphoid process fracture, nasal bone fractures, and a trifocal fracture of the left femur. He was admitted to the trauma unit at our hospital.

The trifocal femoral fracture (Figure 1) was classified as an obliquely oriented transcervical femoral neck fracture (AO/OTA 31-B2), a displaced shaft fracture (AO/OTA 32-A2), and a supracondylar fracture with intra-articular extension (AO/OTA 33-C2). 

The left lower limb was initially treated following the principles of Damage Control Orthopedics (DCO) with tibial traction and was later admitted to the Intensive Care Unit.

The patient also had a pulmonary contusion complicated by bacterial infection and a traumatic brain injury with a right temporobasal hematoma.

After resolving the pulmonary complications, the definitive surgery was performed in a single stage, step by step:

1. Kirschner wires were used to stabilize the femoral head, preventing further displacement
2. Cannulated screws were applied to fix the intra-articular distal femoral fracture
3. A nail with static distal locking was inserted 
4. A LISS plate was applied 
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Preoperative planning 

Postoperative Rehabilitation Protocol

The patient remained non-weight bearing for the first month post-surgery and immediately began physiotherapy to restore hip and knee range of motion and strengthen the quadriceps and gluteal muscles bilaterally.

Progressive weight-bearing was allowed afterward, as tolerated, until full weight-bearing was achieved. 

Results

As seen in the following images, all fracture sites healed with near-complete functional recovery, and no complications or deficits were reported. The full clinical case, including a video demonstrating the patient's functional recovery, can be accessed via this link. 

Discussion 

Trifocal femoral fractures involving the proximal, diaphyseal, and distal femur are extremely rare. Only nine cases of trifocal femoral fractures with AO/OTA type C distal fractures have been reported in the literature [^2-8], with only two cases including an intracapsular femoral neck fracture [^{2, 3}]. The case presented in this report is therefore one of the few published examples of trifocal femoral fractures comprising femoral neck, diaphyseal, and type C distal fractures [⁹].

Due to the rarity of this injury, there is little consensus on the surgical strategy and choice of implant. The first reported case of this injury, published by Käch in 1993, described a basicervical fracture treated with traction screws, a mid-diaphyseal fracture treated with an antegrade nail, and a type C distal femur fracture treated with a 95° blade plate, without complications [³].
In 2011, Dousa et al. reported a transcervical fracture treated with a dynamic hip screw, with mid-diaphyseal and type C distal femoral fractures treated with a 95° condylar plate, requiring reoperation for diaphyseal malunion [⁴].

We used an antegrade reconstruction nail for the femoral neck and diaphyseal fractures, cannulated screws for the distal intra-articular fracture, and a LISS plate for the supracondylar femur fracture. This combination prioritizes articular fractures with direct reductions and optimally treats the femoral shaft with intramedullary nailing.

However, it is important to note that the use of a single fixation device for both the femoral neck and shaft fractures may present a problem. If one of the two fractures failed to heal, it would have been necessary to revise the single fixation device, risking the healing of the other fracture sites.

Additionally, in our case, the intracapsular femoral fracture, whose fixation relied solely on the cephalic screw of the intramedullary nail, was at risk of rotational displacement.
Previous dogmas and reports have focused on prioritizing proximal and distal fractures, sometimes at the expense of the femoral shaft, under the premise that nonunion or malunion of the shaft is easier to treat than a problem in one of the terminal segments. While this may be true for the surgeon, the patient may still experience significant morbidity from this approach. With modern implants, it is possible to optimize the management of each fracture component, providing the patient with the best chance of healing without complications.

Conclusion 

This case report describes a trifocal femoral fracture with intracapsular femoral neck, diaphyseal, and complete distal articular fractures surgically treated with a combination of implants not yet described in the literature. This patient achieved a favorable clinical outcome and fracture healing without complications. We believe this case may be valuable for surgeons encountering and preparing to treat similarly complex injuries.