Conservative treatment of a femoral neck fracture following nail removal
A 67-year-old woman was treated for a pertrochanteric fracture (AO classification 31-A1.2) following a low-energy fall at home with closed reduction and internal fixation with a locked IMN (Bi-Nail, Gruppo Bioimpianti, Peschiera Borromeo, Italy). At three weeks, she was walking with full weight bearing without support, and bony union had occurred by 12 weeks. Eighteen months after surgery, the fracture had clinical and radiographical signs of complete healing. Twenty months after the operation, the patient complained of continuous discomfort over the great trochanter; anteroposterior view documented the apex of the implant protruding proximally and the lag screw that was set in the center of the neck [].\nDue to this discomfort, the need for IMN removal was felt. The day after the removal of the hardware, the patient complained of a left inguinal pain that increased during weight bearing. No traumatic events occurred postoperatively. Standard X-rays were taken and no fracture signs were present. Due to persistence of pain, two days later, further plain radiographs were taken showing a dubious fracture of the femoral neck. In addition, a computed tomography (CT) scan was performed, documenting a subcapital femoral neck fracture, which was classified as Garden's grade II [].\nIn this condition, a stable osteosynthesis could hardly be achieved as screw-holding power would have been reduced by the recent removal of a lag screw, making it more prone to the risk of cutting out and consequent screw loosening, especially in an elderly patient. In view of the minimally displaced impacted fracture and the rapid reduction of the symptoms at rest, conservative management with medication and close X-ray monitoring was conducted. The patient was allowed to walk with bilateral crutches with no weight bearing on the left limb, and was discharged after 10 days. Antiosteoporotic therapy was started with calcium and vitamin D supplementation in addition to antiresorptive drugs. At the radiographic follow-up at 30 days, no displacement was detected and the fracture line was not visible any more. Six months postoperatively, radiographs showed complete healing of the fracture []. At the clinical follow-up at six months, the patient had returned to previous daily activities, and clinical assessment showed a satisfactory range of motion with no pain on walking.