we report a case of a 43-year - old male who sustained an electrical shock injury following which he fell from a height of around 4 feet .
laboratory investigations revealed the patient had extremely low levels of vitamin d ( 11.1ng / ml ) .
we report this case as a rare etiological combination of hypovitaminosis d and electrical injury causing bilateral neck of femur fracture .
such injuries should be diagnosed at the earliest and goal of treatment should be to preserve both the hip joints . early management would avoid potential complications like non - union and avascular necrosis .
the reasons behind such injuries are varied . electrical shock forms an exceedingly rare cause of bilateral neck of femur fracture .
the reason for such an injury is due to violent unopposed muscle contractions rather than the trauma of fall per se .
we report a case of simultaneous bilateral fractures of neck of femur occurring due to a rare etiological combination ofhypovitaminosis - d and electrical shock injury .
a 43-year - old male patient presented to the emergency department with a fall from a height of 4 feet .
he gave a history of charging his mobile , standing on a shelf of four feet height following which he suffered an electrocution injury .
he fell down from the shelf , after which he was unable to stand up on his feet or move his legs due to pain . on examination ,
1 ) . investigations revealed his vitamin d levels were low ( 11.1ng / ml ) .
the patient was taken up for surgery , closed reduction and internal fixation by 6.5 mm cannulated cancellous screws .
surgical technique : pre - operative x - ray showing bilateral transcervical neck of femur fracture .
the fracture was reduced by leadbetter s technique and reduction was maintained using traction table . using the lateral approach ,
the tensor fascia lata was dissected and the area 2.5 cm distal to the vastus ridge was chosen for inserting three 6.5 mm cannulated cancellous screws with washers .
after screws were inserted , reduction was checked again with the aid of c - arm .
the left hip was fixed by the inverted triangle pattern of screw fixation , whereas the right hip was fixed with upright triangle pattern of fixation ( fig .
the patient was taught static quadriceps exercises and active knee and ankle range of movements 5 days after surgery .
patient was ambulated using a four stand walker at the end of 12 weeks . at the end of 16 weeks
, patient was independently ambulatory and had good range of movements ofboth the hips ( fig . 3 , 4 , 5 ) post - operative x - ray showing fixation of bilateral neck of femur with 6.5 cannulatedcancellous screws post - operative active bilateral hip flexion . bilateral active bilateral hip abduction .
less than ten cases have been reported in our review of literature [ 1 - 6 ] .
most authors equivocally attribute this unique injury due to unopposed violent contractions of the musclesrather than the fall per se . in 1960 , powell explained that the fractures occur specifically during the tonic phase of contractions of the muscles .
this is evident by the fact that our patient fell from a height of less than 4 feet .
this is not a sufficient force to cause fracture of bilateral neck of femur . in 1956 , andreini suggested that simultaneous contraction of pertrochanteric muscles is the main cause of fractures around the hip following an electrical shock injury .
he explained that only these muscles can apply their force irrespective of the position of pelvis and femur .
he went on to conclude that if a person sustains an electrical injury when his legs are adducted , it would lead to central dislocation of bilateral hip joints .
when the legs are abducted , it would lead to bilateral neck of femur fractures . in 1938 , satta suggested that men are more prone to bilateral neck of femur fractures following an electrical shock due to the fact that muscles are stronger and well - toned as compared to women .
bone is the poorest conductor of electric current among all the living tissues in our body .
consequently , it provides the greatest resistance to flow of electric current resulting in it absorbing all the energy of the conducted current . in experimental studies , it has been observed that muscle contractions result from direct current of at least 20maand alternating current of 10ma .
authors have suggested that electroconvulsive therapy , drug induced epilepsy , chronic renal failure and metabolic conditions like hypocalcemia , osteomalacia are other causes of similar injuries in order of their frequency of presentation [ 8 - 15 ] . in 1947 , santagali explained that bilateral neck of femur fractures tend to occur in metabolic conditions like osteomalacia and osteoporosis .
our patient had very low levels of serum vitamin d , which could also contribute to the grievous nature of the injury .
accidental electrical injuries are rare and often the patient is unconscious or in a confused state of mind .
initial sequelae of electric shock include thermal myonecrosis which leads to acute renal failure which complicates to cardiac arrest or cardiac arrhythmias .
hence , in the emergency room ( er ) , the patient must be critically screened for cardiac and renal anomalies .
electrocardiogram with renal function tests with 24 hour monitoring is usually sufficient to rule out such complications [ 18 , 19 , 20 ] .
screening of pelvis , spine and shoulder is essential in order to avoid missing these rare injuries [ 8,16 , 17 ] . in our review of literature ,
posterior shoulder dislocations , fractures of the proximal humerus and fracture of scapula have been reported following electric shock injuries due to vigorous muscle contractions around the shoulder[18 , 21 , 22 ] . in the forearm , galeazzi and
distal radius fractures have been reported [ 18 , 23 , 24 ] . in the spine , l4 burst fractures and
if the patient is conscious , a thorough clinical examination should suffice to rule out the above mentioned injuries . in our case , the patient was conscious and unable to lift both legs with painful range of movement of both hips .
hence , it was relatively easy to confirm the diagnosis after radiological studies . if the patient is not conscious , it becomes critical to screen the spine , pelvis and shoulders .
hip preservation should be the goal of treatment in young patients such as in our case .
we took a decision of fixing both the femurs with three cannulated cancellous screws each .
dynamic hip screw can also be used as an alternative to treat such injuries . in older patients with a sedentary life style , bilateral hemiarthroplasty
anesthetic complications like difficult intubation due to spasm or persisting cardiac abnormalities like arrhythmias are usually encountered . in such cases , surgery is deferred until the patient is stabilized . in our case
complications like non - union and avascular necrosis are very common if neglected and hence the need to diagnose such injuries at the earliest [ 7 , 8 ] .
he was ambulatory and had good range of movements of the hip , knee and ankle to continue his normal life .
we report this case as a rare etiological combination of hypovitaminosis d and electrical injury causing bilateral neck of femur fracture .
such injuries should be diagnosed at the earliest and goal of treatment should be to preserve both the hip joints . early management would avoid potential complications like non - union and avascular necrosis the goal of the treatment should be to preserve both the hip joints with prior importance in treating hypovitaminosis - d , which would help in early healing of fracture and also prevent further pathlogical fractures following trivial trauma .
 introduction : simultaneous bilateral fractures of the neck of femur is rare . 
 hypocalcemia , epilepsy , osteoporosis and electrical injuries are known to cause similar injuries.case report : we report a case of a 43-year - old male who sustained an electrical shock injury following which he fell from a height of around 4 feet . 
 radiological studies confirmed bilateral transcervical neck of femur fracture . 
 laboratory investigations revealed the patient had extremely low levels of vitamin d ( 11.1ng / ml ) . 
 patient was treated with three 6.5 mm cannulated cancellous screws on each side . 
 patient had good functional outcome at the end of one year.conclusion:we report this case as a rare etiological combination of hypovitaminosis d and electrical injury causing bilateral neck of femur fracture . 
 such injuries should be diagnosed at the earliest and goal of treatment should be to preserve both the hip joints . early management would avoid potential complications like non - union and avascular necrosis . 