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

## TL;DR

This paper presents a rare case of a trifocal femur fracture and discusses the surgical approach and outcomes for managing such complex injuries.

## Contribution

The paper introduces a novel surgical strategy using a combination of implants for trifocal femoral fractures.

## Key findings

- The described surgical approach achieved full fracture union and no post-traumatic osteoarthritis.
- A tailored approach based on fracture pattern is emphasized for optimal outcomes.
- No standardized algorithm exists for implant selection or fixation sequence in trifocal femoral fractures.

## Abstract

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.

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.

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.

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.

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.

•Non-contiguous ipsilateral femoral fractures of proximal, diaphyseal, and distal segments follow high-energy trauma.•In medial femoral neck fractures, especially in young patients, preserve the femoral head to prevent avascular necrosis.•With simple lateral, diaphyseal, and complex distal (AO type C) femoral fractures, surgery should start distally and proceed proximally.•Coronal malalignment, fracture malunion, and limb length discrepancy are the most common complications.•Patients with this fracture pattern often require Damage Control Orthopedics, as Early Total Care is often not feasible.

Non-contiguous ipsilateral femoral fractures of proximal, diaphyseal, and distal segments follow high-energy trauma.

In medial femoral neck fractures, especially in young patients, preserve the femoral head to prevent avascular necrosis.

With simple lateral, diaphyseal, and complex distal (AO type C) femoral fractures, surgery should start distally and proceed proximally.

Coronal malalignment, fracture malunion, and limb length discrepancy are the most common complications.

Patients with this fracture pattern often require Damage Control Orthopedics, as Early Total Care is often not feasible.