A cascade of preventable complications following a missed femoral neck fracture after antegrade femoral nailing

BACKGROUND: Occult femoral neck fractures associated with femoral shaft fractures are frequently missed and may lead to adverse outcomes. CASE PRESENTATION: A 46-year old female presented to our institution with increasing groin pain one month after antegrade intramedullary nailing of a femoral shaft fracture at an outside hospital. Radiographic evaluation revealed a displaced ipsilateral femoral neck fracture, adjacent to the piriformis starting point of the nail. A revision fixation of the femoral shaft and neck fracture was performed. The patient sustained a series of complications requiring multiple revision surgeries, including a total hip arthroplasty. Despite the cascade of complications, the patient had an uneventful long-term recovery, without additional complications noted at one-year follow-up. CONCLUSION: This case report illustrates the necessity of increased awareness with a high level of suspicion for the presence of associated femoral shaft and neck fractures in any patient undergoing antegrade femoral nailing. Arguably, the cascade of complications presented in this paper could have been prevented with early recognition and initial stabilization of the occult femoral neck fracture. Standardized diagnostic protocols include “on table” pelvic radiographs to rule out associated femoral neck fractures. The diagnosis must be enforced in case of equivocal radiographic findings, either by computed tomography scan or magnetic resonance imaging.