Overlooked or delayed diagnoses are commonly reported in literature when treating polytraumatized patients (1.3 to 39%) [
23,
24]. In case of ipsilateral femoral neck and shaft fractures, the delayed diagnosis of the femoral neck fracture occurs in 19 to 50% of patients during the initial examination [
2,
7,
8,
11,
12,
19,
25‐
28]. According to the literature, several factors may account for the pre-operative mis- or delayed diagnosis of ipsilateral femoral shaft and neck fractures. Among others, the main factor includes the type of fracture (nondisplaced or minimally displaced in 26 to 59% of cases) [
2,
29], as in our case. The pre-operative hip and pelvic radiographic exams were initially deemed negative for a femoral neck fracture since no displacement was evident. As the patient was already intubated upon arrival, collection of symptoms supporting suspicion of a femoral neck fracture was minimal during early clinical examination. The treatment was focused on life-threatening and obvious injuries. The particularities of the treatment of a multiply injured patient, in addition, may play a role in the delayed diagnosis [
11,
12,
27]. Several studies show that an insufficient radiological protocol seems to affect the incidence of mis- or delayed diagnosis [
2,
4,
11‐
14,
18,
26,
28,
30‐
33].
In our case the patient was evaluated with a pre-operative AP pelvis, which was negative. It is unclear whether a lateral view of the hip could have been more sensitive in detecting the femoral neck fracture. Nonetheless, we tend to agree with the statement that a dedicated antero-posterior internal rotation hip radiograph, performed intra-operatively or immediately after the reduction and stabilization of the femoral shaft fracture, could have improved the likelihood of detecting the fracture of the femoral neck, by minimally displacing the femoral neck fracture and making the diagnosis less difficult [
28].
The diagnostic value of the preoperative CT scan is still controversial. Some authors claim that its use helps reducing the delay in diagnosis of femoral neck fracture (from 57 to 6.3%) [
26,
28,
29,
34,
35]. Others claim that the significance of CT is equivalent of that of the plain radiography (sensitivity of only 56% to 64) [
29,
36,
37]. In our case the emergency CT scan available offered coronal and axial views with thickness of 3 mm. Perhaps using thin-cut computer tomography CT scan (thickness 1–2 mm) could have improved the ability to detect the non-displaced femoral neck fractures. Combining different preoperative (thin-cut computed tomography CT scan and dedicated antero-posterior internal rotation radiographs of the femoral neck, including 2D CT reconstructions), intraoperative (lateral hip fluoroscopic view by angulation of the radiographic beam before reducing the shaft fracture or plain radiograph view centered at the hip with 10° to 15° of hip internal rotation following fixation) and postoperative (dedicated AP internal rotation views of the hip) clinical and radiological measures should help reduce the incidence of a missed femoral neck fracture.
Variable rates of complications and results have been reported in patients suffering from ipsilateral femoral neck and shaft fracture [
3,
9,
13,
16,
38]. Common complications (incidence 4 to 22%) of the femoral head are aseptic necrosis [
5,
11,
12,
31] and nonunion [
11,
12,
31,
39‐
41]. Complications of the shaft fractures are nonunion caused by an open fracture, inadequate implant (nail diameter too small), no reaming and prolonged delay to weight bearing [
2,
3]. Clear evidence that a delayed diagnosis of femoral neck fracture in these complex injuries affects the incidence of complications such as non-union and avascular necrosis [
2,
3,
7,
8,
19] is still lacking. According to some authors, the delayed diagnosis of femoral neck fracture in these complex injuries does not seem to affect the incidence of complications such as non-union and avascular necrosis [
2,
19]. Conversely others report that the risk of healing complications is higher in late surgery compared to early surgery and in combined shaft and neck fractures compared to one-level-injuries [
3]. In the present case report the delay between diagnosis and treatment of the ipsilateral femoral neck and shaft fracture was 2 days, making it impossible to state with certainty whether or not the delay in diagnosis is responsible for the non-union. Timely recognition and early surgical treatment of ipsilateral femoral shaft and neck fractures are crucial for early mobilization and rehabilitation, allowing overall good functional outcomes [
6,
17] and reduces mortality and morbidity [
25]. Deciding on the appropriate therapy remains challenging [
3]. Different strategies for the treatment of ipsilateral femoral neck and shaft fractures have been proposed: cannulated screws for the femoral neck and a retrograde locking nail for the femoral shaft [
4,
35,
42], cephalomedullary implant [
7‐
9,
20,
43], antegrade nail with one neck screw [
6,
13,
20,
22,
44,
45], long proximal femoral nail [
46,
47]. At the present time, however, there is still no consensus on the superiority of a treatment protocol [
17,
48,
49]. In the present case, we opted to treat both fractures with antegrade nail with one neck screw and the timing for the surgery was within one week from the traumatic event. The intra- and post-operative radiographs excluded the presence of a reduction in varus and implant placement was deemed satisfactory, although a smaller tip-apex distance could have provided a better purchase in subchondral bone and therefore possibly reduce the risk of early cut-out [
28].