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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 17  |  Issue : 2  |  Page : 61-63

Simultaneous bilateral femoral neck fractures following electroconvulsive therapy


1 Department of Trauma and Orthopaedic Surgery, Ahmadu Bello University, Zaria, Nigeria
2 Department of Anaesthesia, Ahmadu Bello University, Zaria, Nigeria

Date of Web Publication16-Nov-2016

Correspondence Address:
Ismail Lawal Dahiru
Department of Trauma and Orthopaedic Surgery, Ahmadu Bello University, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1595-1103.194211

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  Abstract 

Fracture neck of femur occurs commonly among elderly people with osteoporosis being the risk factor favoring its occurrence. Its occurrence among young adults, though uncommon, follows high-energy trauma with multisystem affectation. Fracture neck of femur poses a management challenge to the surgeon in deciding on the best option of treatment, in achieving accurate reduction and fixation, and in dealing with complications which may be inevitable. Fracture neck of femur following electroconvulsive therapy is rare. Simultaneous bilateral femoral neck fractures following electroconvulsive therapy are even rarer. Simultaneous bilateral femoral neck fractures management is technically demanding, requiring considerable experience, appropriate instrumentation, and equipment. It is also associated with high morbidity which includes nonunion and avascular necrosis. These fractures can be prevented by the use of modified electroconvulsive therapy. This case seeks to reemphasize the rarity of simultaneous bilateral femoral neck fractures following electroconvulsive therapy, highlight the challenges of managing this condition and proffer ways of avoiding its occurrence.

Keywords: Electroconvulsive therapy, Fixation techniques, Modified electroconvulsive therapy, Simultaneous bilateral femoral neck fractures


How to cite this article:
Dahiru IL, Amaefule KE, Lawal YZ, Inuwa MM, Abdulgafar YA. Simultaneous bilateral femoral neck fractures following electroconvulsive therapy. Niger J Surg Res 2016;17:61-3

How to cite this URL:
Dahiru IL, Amaefule KE, Lawal YZ, Inuwa MM, Abdulgafar YA. Simultaneous bilateral femoral neck fractures following electroconvulsive therapy. Niger J Surg Res [serial online] 2016 [cited 2019 Mar 26];17:61-3. Available from: http://www.njsrjournal.org/text.asp?2016/17/2/61/194211


  Introduction Top


Femoral neck fractures account for 50% of hip fractures and are common in elderly people beyond the age of 70 years.[1],[2] About 80% of these fractures occur in women.[2] The incidence in the younger patients is low, and it is associated with high-energy trauma with comminution and other associated injuries.[2],[3],[4] Risk factors for fracture neck of femur include female sex, increasing age, poor health, tobacco and alcohol use, a previous fracture, and low estrogen level.[2],[5],[6] Femoral neck fractures are usually intracapsular and become progressively displaced following its occurrence. This forms the basis for the Gardens classification. They are associated with high chances of nonunion and avascular necrosis.[2]

Femoral neck fractures are treated with the sole aim of achieving early ambulation by obtaining early anatomical reduction and stable internal fixation or prosthetic replacement.[7] Nonoperative treatment for traumatic fractures is indicated only rarely for patients who are at extreme medical risk for surgery. In the young patients with normal bone, emergency closed/open reduction with internal fixation is required.[8],[9] Fracture neck of femur is associated with high rates of osteonecrosis and nonunion. Outcomes, however, depend on the severity of injury including the amount of displacement, comminution, and the extent of vascular compromise to the femoral head, as well as the timing and adequacy of the reduction and fixation.[2],[9] Even when surgery has been performed satisfactorily, 10–15% of patients develop complications of avascular necrosis and nonunion.

In the elderly patients also, the choice of treatment is between stable reduction and internal fixation or prosthetic replacement. The choice, however, depends on the age, preinjury functional status, quality of bone, and life expectancy. Fixation of this fractures is usually achieved with the use of cancellous or dynamic hip screws.[10] It is, therefore, obvious that fracture neck of femur poses a management challenge to the surgeon because it is technically demanding, requires careful review in deciding on the best option of management, and the complications that may follow treatment for which the surgeon has no control over. These complications are principally those of nonunion and avascular necrosis.[8],[9],[10]

Injuries have been reported to occur following electroconvulsive therapy, especially when given unmodified.[11] Fracture neck of femur following electroconvulsive therapy is however very rare.[11],[12] Simultaneous bilateral femoral neck fractures following electroconvulsive therapy are even rarer.[13] These fractures are technically demanding requiring considerable experience, appropriate instrumentations, and equipment. They are also associated with high morbidity, nonunion, and avascular necrosis. When it occurs in a young adult, the morbidity is even higher.[14] We report this case to emphasize the rarity of simultaneous bilateral femoral neck fractures following electroconvulsive therapy, highlight the challenges of managing this condition, and proffer ways of avoiding its occurrence.


  Case Report Top


M.A. is a 31-year-old schizophrenic who was admitted in our hospital with 2 weeks history of pain in both hips and inability to walk, which was noticed after having an unmodified electroconvulsive therapy. He had no other systemic complaints. Examination of the lower limbs revealed them being in attitude of external rotation. The patient could not straight leg raise and had tenderness in both hips. He had X-rays of the pelvis and hips, which revealed displaced bilateral subcapital fracture neck of femur (Stage iv Gardens) [Figure 1]. He had closed reduction and internal fixation with two cancellous screws under image intensification on the left due to difficulties getting cannulated screws and had open reduction and internal fixation with two cancellous screws for right hip fracture because the image intensifier broke down while attempting closed reduction. Patient did well postoperatively. He remained on admission for 16 weeks to avoid risking loss of fixation as we did not have dynamic hip screws at that time, which provides better stability. X-rays were repeated at 16 weeks which revealed fractures to have united [Figure 2]. He was thereafter gradually ambulated and discharged at twenty weeks. Patient continued to attend follow-up at our outpatient clinic for about 3 years after which he defaulted. There was no significant hip pain as at the last visit and has continued to attend follow-up visits at psychiatry clinic.
Figure 1: Preoperative pelvic X-ray showing Stage IV bilateral femoral neck fractures

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Figure 2: Postoperative X-ray at 16 weeks confirming union of fractures

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  Discussion Top


Simultaneous bilateral femoral neck fractures following electroconvulsive therapy or other causes are rare with a number of cases reported in the last 60 years being <30.[15] Electrical shock whether accidental or controlled account for about 50%, whereas violent injury and epilepsy account for the remainder.[13] The number of reported cases arising from electroconvulsive therapy has declined dramatically as <10 cases have been reported in the last forty years.[16] The introduction of modified electroconvulsive therapy has been largely responsible for this.[16] Modification of the electroconvulsive therapy entails the use of general anesthesia that is characterized by its briefness and repetitiveness resulting in several imperatives: Anesthesia of short duration, deep narcosis with muscular relaxation, and ambulatory character.[17],[18] Thus, anesthetic drugs to be used should have a fast onset of action, to obtain a rapid and as alert as possible postanesthesia awakening.[18] Suitable anesthetic drugs being used include thiopentone, propofol, and methohexitone.[19] Modified electroconvulsive therapy is now the gold standard. In Nigeria, its use among psychiatrists still remains low with many centers still administering the unmodified electroconvulsive therapy. Reasons proffered included lack of awareness and shortage of physician anesthetist.[20] This case resulted from an unmodified electroconvulsive therapy with this report serving as a reminder of propagating the benefits of modified electroconvulsive therapy.

Our patient presented late after 2 weeks of fracture and still had closed/open reduction and internal fixation with cancellous screws. Fracture neck of femur and indeed Gardens Stage IV requires and immediate treatment if complications of nonunion and avascular necrosis are to be averted. Delays of over 48 h are associated with increased incidence of this complications.[21] It is advocated that with such delays, the best option of treatment would have been a bipolar hemiarthroplasty.[22] This is true, especially in the elderly. In the young adult, the best option of treatment modality is reduction and internal fixation.[23] Factors to be considered are those of age, functional demands, and comorbidities.[23] Good outcome with internal fixation after delayed presentation has been reported.[24] Our patient achieved union within 16 weeks and follow-up of 3 years duration did not reveal evidence of avascular necrosis. Internal fixation of femoral neck fracture in the young is better than hemiarthroplasty which carries high chances of dislocation and reduced survivability.[25] We therefore also advocate reduction and internal fixation of fracture neck of femur in the young adult even after moderate delay in presentation.


  Conclusion Top


Fracture neck of femur following electroconvulsive therapy is rare. Simultaneous bilateral femoral neck fractures following electroconvulsive therapy are even rarer. Simultaneous bilateral femoral neck fractures management is technically demanding and associated with high morbidity. These fractures can be prevented by the use of modified electroconvulsive therapy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Park JH, Jeong H, Shin H, Kim E, Ko TS, Choi Y. Simultaneous bilateral fracture of femoral neck in Korea: A case report. Hip Pelvis 2015;27:53-6.  Back to cited text no. 1
    
2.
Ly TV, Swiontkowski MF. Management of femoral neck fractures in young adults. Indian J Orthop 2008;42:3-12.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
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Gao YS, Zhu ZH, Zhang CQ. Simultaneous bilateral fractures of the femoral neck caused by high energy: A case report and literature review. Chin J Traumatol 2015;18:304-6.  Back to cited text no. 3
    
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Hootkani A, Moradi A, Vahedi E. Neglected simultaneous bilateral femoral neck fractures secondary to narcotic drug abuse treated by bilateral one-staged hemiarthroplasty: A case report. J Orthop Surg Res 2010;5:41.  Back to cited text no. 4
    
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Schröder J, Marti RK. Simultaneous bilateral femoral neck fractures: Case report. Swiss Surg 2001;7:222-4.  Back to cited text no. 5
    
6.
McGoldrick NP, Dodds MK, Green C, Synnott K. Management of simultaneous bilateral neck of femur fractures in an elderly patient. Geriatr Orthop Surg Rehabil 2013;4:71-3.  Back to cited text no. 6
    
7.
Koval KJ, Zuckerman JD. Hip fractures: I overview and evaluation and treatment of femoral-neck fractures. J Am Acad Orthop Surg 1994;2:141-9.  Back to cited text no. 7
    
8.
Naranje S, Sezo N, Trikha V, Kancherla R, Rijal L, Jha R. Simultaneous bilateral femoral neck stress fractures in a young military cadet: A rare case report. Eur J Orthop Surg Traumatol 2012;22 Suppl 1:103-6.  Back to cited text no. 8
    
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Shah AK, Eissler J, Radomisli T. Algorithms for the treatment of femoral neck fractures. Clin Orthop Relat Res 2002;399:28-34.  Back to cited text no. 9
    
10.
Sandhu HS. Management fracture neck of femur. Indian J Orthop 2005;39:130-6.  Back to cited text no. 10
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12.
Sohal HS, Goyal D. Simultaneous bilateral femoral neck fractures after electrical shock injury: A case report. Chin J Traumatol 2013;16:126-8.  Back to cited text no. 12
    
13.
Shaheen MA, Sabet NA. Bilateral simultaneous fracture of the femoral neck following electrical shock. Injury 1984;16:13-4.  Back to cited text no. 13
    
14.
Estrada LS, Volgas DA, Stannard JP, Alonso JE. Fixation failure in femoral neck fractures. Clin Orthop Relat Res 2002;399:110-8.  Back to cited text no. 14
    
15.
Marsh JP, Leiter JR, Macdonald P. Bilateral femoral neck fractures resulting from a grand mal seizure in an elderly man with Down syndrome. Orthop Rev (Pavia) 2010;2:e10.  Back to cited text no. 15
    
16.
Schawartsmann CR, de Oliveira GK, de Oliveira RK, Caepes D, Werlang PM. Simultaneous bilateral femoral neck fracture. Acta Ortop Bras 2001;9:58-61.  Back to cited text no. 16
    
17.
Lee M. Anaesthesia for electroconvulsive therapy. Anaesthesia 1996;51:583-4.  Back to cited text no. 17
    
18.
Harti A, Hmamouchi B, Idali H, Barrou L. Anesthesia for electroconvulsive therapy: Propofol versus thiopental. Encephale 2001;27:217-21.  Back to cited text no. 18
    
19.
Lee D, Kenny M, Harrop-Griffiths W. Anaesthesia for electroconvulsive therapy. Anaesthesia 1960;51:583-4.  Back to cited text no. 19
    
20.
James BO, Inogbo CF. Implementing modified electroconvulsive therapy in Nigeria: Current status and psychiatrists' attitudes. J ECT 2013;29:e25-6.  Back to cited text no. 20
    
21.
Kofoed H. Femoral neck fractures in young adults. Injury 1982;14:146-50.  Back to cited text no. 21
    
22.
Florschutz AV, Langford JR, Haidukewych GJ, Koval KJ. Femoral neck fractures: Current management. J Orthop Trauma 2015;29:121-9.  Back to cited text no. 22
    
23.
Grimaldi M, Vouaillat H, Tonneti J, Merloz P. Simultaneous bilateral femoral neck fractures secondary to epileptic seizures: Treatment by bilateral total hip arthroplasty. J Ortop Surg Res 2009;95:555-7.  Back to cited text no. 23
    
24.
Rahman MM, Awada A. Bilateral simultaneous hip fractures secondary to an epileptic seizure. Saudi Med J 2003;24:1261-3.  Back to cited text no. 24
    
25.
Bonnaire F, Lein T, Engler KJ. Treatment of femoral neck fractures. Chirurg 2008;79:595-611.  Back to cited text no. 25
    


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