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

Figure 1 Flow diagram of patient inclusion and classification. Flowchart illustrating the selection process of 1342 patients undergoing femoral shaft nailing, with identification of 18 cases of iatrogenic ipsilateral femoral neck fractures. Cases are stratified by timing of diagnosis and fracture etiology.

Figure 2 Algorithm for management of iatrogenic femoral neck fractures. Decision-making flowchart outlining management strategies based on fracture displacement, timing of diagnosis, and implant status. Includes options for long proximal femoral nail, cannulated cancellous screw fixation, and salvage techniques. PFN: Proximal femoral nail; CCS: Cannulated cancellous screw.

Figure 3 Case of iatrogenic neck fracture due to erroneous entry point. A: Preoperative radiograph showing femoral shaft fracture (Arbeitsgemeinschaft für Osteosynthesefrage 32-A3); B: Intraoperative detection of neck fracture caused by medialized entry point; managed with long proximal femoral nail; C: One-year follow-up showing union at both shaft and neck fracture sites.

Figure 4 Neck fracture induced by inadvertent jig hammering. A: Preoperative radiograph of femoral shaft fracture (Arbeitsgemeinschaft für Osteosynthesefrage 32-A2); B: Iatrogenic neck fracture resulting from forceful jig impaction; nail removed and long proximal femoral nail inserted; C: One-year follow-up showing shaft union with incomplete neck healing.

Figure 5 Missed neck fracture diagnosed postoperatively. A: Two-week postoperative radiograph revealing displaced femoral neck fracture missed during initial evaluation; B: Fixation using two cannulated cancellous screws via “miss-the-nail” technique.

Figure 6 Delayed hoop stress fracture presentation. A: Immediate postoperative radiograph showing no neck fracture; B: Four-week follow-up revealing fracture at femoral neck due to hoop stress, without intervening trauma.

Figure 7 Salvage management with hemiarthroplasty and plate fixation. A: Displaced neck fracture diagnosed at four weeks in an osteoporotic patient; B: Managed with bipolar hemiarthroplasty for the neck and limited contact dynamic compression plate for the shaft.