Management and prevention of iatrogenic ipsilateral femoral neck fracture during intramedullary nailing of femoral shaft

Abstract

BACKGROUND

Iatrogenic ipsilateral femoral neck fractures are rare but significant complications associated with intramedullary nailing of femoral shaft fractures. These injuries may occur intraoperatively due to technical errors or be diagnosed postoperatively, often with delayed recognition.

AIM

To identify etiological factors contributing to iatrogenic femoral neck fractures during femoral shaft nailing and to propose a structured management algorithm for prevention and treatment.

METHODS

A retrospective analysis was conducted on 1342 femoral interlocking nail procedures performed between 2017 and 2021. Eighteen cases (1.3%) of iatrogenic femoral neck fractures were identified. Clinical data, imaging findings, surgical techniques, and fixation methods were reviewed. Fractures were classified based on timing of diagnosis (intraoperative vs postoperative) and displacement status.

RESULTS

The most common causes included erroneous entry points (6 cases), inadvertent jig hammering (5 cases), misdirected nail manipulation (3 cases), and hoop stress-related fractures (3 cases). Fourteen fractures were diagnosed intraoperatively, while four were identified postoperatively. Fixation strategies included long proximal femoral nails (10 cases), cannulated cancellous screws (6 cases), and salvage techniques such as hemiarthroplasty (1 case). Delayed diagnosis correlated with increased operative time and poorer outcomes (P < 0.05), though union rates at 6 months and 12 months were statistically comparable across fixation methods.

CONCLUSION

Iatrogenic femoral neck fractures during femoral nailing are preventable with meticulous technique, appropriate implant selection, and vigilant intraoperative imaging. A standardized preoperative and intraoperative protocol can reduce incidence and improve outcomes.

Keywords: Femur; Interlock nail; Femoral neck fracture; Femoral shaft fracture; Iatrogenic

Core Tip: Iatrogenic femoral neck fractures, though rare, are a notable complication during or after femoral shaft fixation with interlocking nails. This study highlights key technical errors-erroneous entry points, misdirected nail manipulation, and forceful jig hammering-as primary causes. Early recognition and adherence to surgical precision can prevent such fractures. Timely diagnosis and appropriate fracture management are essential to optimize patient outcomes and reduce postoperative morbidity.