This prospective cohort study tested whether a mandatory four-step diagnostic protocol could reduce missed ipsilateral femoral neck fractures in patients with femoral shaft fractures. 268 consecutive patients were enrolled at a single Level I trauma center after protocol institution. The protocol added a dedicated AP internal rotation hip radiograph, fine-cut 2-mm CT, intraoperative fluoroscopic lateral, and postoperative OR hip films to every femoral shaft fracture workup.
Roughly 1 in 13 femoral shaft fractures hides an ipsilateral femoral neck fracture. Without a systematic workup, more than half are missed — often not caught until the neck displaces and the patient needs reoperation for osteonecrosis or nonunion.
When you see a femoral shaft fracture, this workup is mandatory: Order a dedicated AP internal rotation hip radiograph Order fine-cut 2-mm CT through the femoral neck as part of the initial trauma scan (standard CT slice thickness is not sufficient) Obtain an intraoperative fluoroscopic lateral of the hip before you nail Before waking the patient, get AP and lateral hip films in the OR
If the piriformis portal feels unusually resistant during antegrade nailing, stop and image the neck. The iatrogenic case in this series was telegraphed by exactly that sign. This paper is the evidentiary foundation for why systematic femoral neck screening is now standard of care at Level I trauma centers. It turned a historically 57% miss rate into a manageable 6.3%.
This prospective cohort study tested whether a mandatory four-step diagnostic protocol could reduce missed ipsilateral femoral neck fractures in patients with femoral shaft fractures. 268 consecutive patients were enrolled at a single Level I trauma center after protocol institution. The protocol added a dedicated AP internal rotation hip radiograph, fine-cut 2-mm CT, intraoperative fluoroscopic lateral, and postoperative OR hip films to every femoral shaft fracture workup.
Roughly 1 in 13 femoral shaft fractures hides an ipsilateral femoral neck fracture. Without a systematic workup, more than half are missed — often not caught until the neck displaces and the patient needs reoperation for osteonecrosis or nonunion.
When you see a femoral shaft fracture, this workup is mandatory: Order a dedicated AP internal rotation hip radiograph Order fine-cut 2-mm CT through the femoral neck as part of the initial trauma scan (standard CT slice thickness is not sufficient) Obtain an intraoperative fluoroscopic lateral of the hip before you nail Before waking the patient, get AP and lateral hip films in the OR
If the piriformis portal feels unusually resistant during antegrade nailing, stop and image the neck. The iatrogenic case in this series was telegraphed by exactly that sign. This paper is the evidentiary foundation for why systematic femoral neck screening is now standard of care at Level I trauma centers. It turned a historically 57% miss rate into a manageable 6.3%.