Amala Institute of Medical Sciences

Dr. Libin Thomas Manathara

Prof. C. Jayaprakash

Dr. Kishore P.1

Case Presentation A 55-year-old woman fell by slipping in the bathroom,

with left hip twisting, resulting in immediate pain.

She could not walk after the fall and was carried to theemergency department

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Case Presentation The patient had no other injuries and the left leg was

shortened and externally rotated.

Radiographs of the left hip showed intra-capsularFracture Neck of Femur (FNF).

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Case Presentation Though she was advised to undergo surgical fixation of

the fracture, she refused surgery as she had to take careof a child with disability and was later discharged atrequest from the hospital.

Ten years later she came to visit and was ableto walk with out much difficulty and able tosquat and sit cross-legged.

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Case Presentation X Ray of the Pelvis showed an unusual form of

Pseudoarthroses of the left Hip with a Pelvi FemoralBony Bridge.

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Case Presentation An MRI of the Pelvi Femoral and Hip region was done

which showed progressive ossification of the Ilio PsoasTendon up to the lesser trochanter

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Case Presentation The ossification begins at the musculo tendinous

junction of the Ilio Psoas Muscle

The MRI also reveals that the remaining part of Head of Femur is Vascular

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Case Presentation Computerized Tomography evaluation, detailed a

pelvi-femoral bone bridge formation in the left hipwith nonunion FNF.

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Computerized Tomography reconstruction image showing anteroposterior view of the ununited fracture neck of femur left with a pelvi-femoral bony bridge.

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ComputerizedTomographyreconstructionimage showingposterior view ofthe ununitedfracture neck offemur left with apelvi-femoralbony bridge.

Computerized Tomography cross-section imageshowing nonunion of left neck of femur withrelatively preserved head of femur.

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Case Presentation As the patient was asymptomatic, no treatment was

offered.

She is using a Raised Footwear to compensate for shortening.

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Discussion

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Discussion There are only limited descriptions of the different

pathological outcomes of untreated fracture neck offemur.

To the best of our knowledge, pelvi-femoral bonebridge formation with non-union at fracture site inuntreated fracture neck of femur has heretofore notbeen reported in the biomedical literature.

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Discussion FNF is still regarded as unsolved fracture.

Most common complications after FNF are non-unionand avascular necrosis (AVN).

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Discussion Review of the specimens in the Galler Collection by

Solomon et al had illustrated the possible outcomesfollowing FNF non union.

In non-union FNF, head of femur can either go forFragmentation with resultant functional girdlestone orAcetabularisation without femoral headfragmentation.

Acetabularisation occurs with either preservation offemuro-acetabular joint or with ankylosis of the same.

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Ankylosis of FAJPreservation of FAJ

AcetabularisationFunctional Girdlestone

Head FragmentationNo Head

Fragmentation

Non UnionUnion

FNF

Discussion• In a prospective study of 236 patients, Sandhu et al

classified untreated FNF in to three stages based onthe radiologic changes that occur at the site of thefracture.

• The radiological changes included smoothening of thefracture surfaces, decrease in the size of the proximalfragment, increase in the gap between the fracturefragments due to neck resorption and AVN.

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Discussion• In the case that we describe in this report, the patient

had fallen by slipping in the bathroom with twistinginjury to the left hip resulting in FNF.

• She refused to take any treatment.

• When evaluated 10 years later, she was relativelyasymptomatic and radiological evaluation detailed apelvi-femoral bone bridge formation in the left hipwith stage 3 nonunion FNF.

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Discussion Size and shape head of femur was relatively preserved,

which is consistent with Galler collection findings

This illustrates that posttraumatic AVN of the femoralhead does not necessarily lead to head collapse.

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Discussion We believe that this radiological outcome in an

untreated FNF is unusual and that the patientdescribed in this article represents the first such casedescribed in the literature.

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