Trifocal femur fracture: Where should one begin? A case report and literature review.

Abstract

Introduction: Ipsilateral, non-contiguous femoral fractures involving the femoral neck, shaft, and distal articular region are extremely rare and typically result from high-energy trauma. Their complex nature and rarity contribute to a lack of consensus regarding optimal surgical management.

Case report: We report the case of a 72-year-old male involved in a high-energy motor vehicle accident who sustained a trifocal femoral fracture: an intracapsular femoral neck fracture (AO/OTA 31-B2, Pauwels type 3), a displaced diaphyseal fracture (AO/OTA 32-A2), and a complete intra-articular distal femoral fracture (AO/OTA 33-C2). Initial management included transtibial traction under a Damage Control Orthopaedics (DCO) protocol, followed by definitive fixation 10 days later using a single-stage stepwise surgical approach. Fixation consisted of an antegrade intramedullary nail (providing stabilization of the femoral neck and shaft fractures), 6.5-mm cannulated screws used exclusively for the intra-articular distal femoral fracture, and a LISS plate for the distal metaphyseal component.

Results: Postoperative recovery was uneventful, with radiographic evidence of full fracture union and no signs of post-traumatic osteoarthritis at final follow-up. Clinical recovery was excellent.

Discussion: This is one of the few reported cases in the literature involving a trifocal femoral fracture with this specific combination. Our surgical strategy allowed absolute stability of the distal articular fracture and relative stability for the shaft and femoral neck. A qualitative literature review revealed no standardized algorithm for implant selection or fixation sequence in such cases. Our experience supports a tailored approach based on fracture pattern, emphasizing the preservation of femoral head vascularity and anatomical reduction of joint surfaces.

Conclusion: Trifocal ipsilateral femoral fractures require individualized surgical planning. The described combination of implants-used here for the first time-proved effective and may serve as a reference in similar complex trauma cases.