This patient clearly sustained major trauma and the management should proceed along an ATLS protocol. Mention is made of fluid resuscitation, however management priorities could be clearer. The abdomen is a source of major bleeding in this patient and it is not the time to be considering plates and screws to the femur until the patient is stablised and in a better physiological condition. An opportunity to discuss damage control orthopaedics and external fixation has been missed.

The mechanism of injury described begins with a high velocity impact from a vehicle. Looking at the radiographs, I doubt very much that this resulted in the trochanteric fracture which appears to be a 2 part fracture with little displacment seen in the films available. The supracondylar fracture however is a multipart displaced fracture, likely to be more consistant with a high energy impact. We should also consider the size of the "truck" is not mentioned. It is possible that in an adult, the bumper of  said truck will impact with the supracondylar region resulting in this injury. The tertiary impact with the ground is more likely to have resulted in the proximal femur injuries.

The quality of diction is acceptable however, it could be more scientific, for example "The subsequent hit with the wall," would be better phrased as "The subsequent impact against the wall."

This is an interesting case and provokes thought.

I have worked in Orthopaedics and Trauma in the UK for several years treating both civilian and military casualties.  I have also worked in Accident and Emergency Medicince 

Thanks for giving me an opportunity to review the article titled “Ipsilateral Fracture of the Femoral Neck, Trochanter And Shaft: A Unique Case” by the authors:

Dr. Nasir Muzaffar  , Dr. Naveed Bashir  , Dr. Aejaz Ahmad  , Dr. Nawaz Ahmad  , Dr. Arifa Hafeez  
Corresponding AuthorDr. Nasir Muzaffar   

I agree with the authors that such a plethora of fractures in a single bone is rarely reported in literature. In my entire career of 11 years as an orthopaedic surgeon I have never seen a case with the above mentioned combination of fractures in femur; however I have experience of fixing two cases of proximal femoral fractures involving a combination of fracture neck of femur and a fracture trochanter in one case¹  and a fracture subtrochanter in the other case (unreported). However, I would like to differ so as the mechanism of injury and the initial proposed treatment by the authors in this particular case as mentioned in the discussion.

So far as the mechanism of fracture is concerned I presume that the initial impact might have caused the fracture of the supra condylar area of femur as is evident from the figs- 3 and 4 that the fracture is highly communited. Hit by a speeding truck as the initial impact would generate a high velocity trauma to the bone causing fracture of the supra condylar area of the femur that is communited. The second impact, a lesser velocity trauma while she was flung to the wall and a bounce would cause the fracture trochanter and the neck of femur fracture as is evident from the figs- 1 and 2, uncommunited fractures.

So far as the initial proposed treatment for such fractures in a poly trauma patient, the wiser decision would be to follow the protocols of “Damage control Orthopedics”. Initially the patient should have been planned for minimal invasive stabilization of her fractures using external fixators for the supra condylar part of femur as well as the same modality to stabilize the of trochanter and neck, as it is evident from the figs-1 and 2 that the fractures are             un displaced. Once the patient’s condition is stabilized haemodynamically and other injuries taken care of, we could definitely use other definitive measures as mentioned by the authors to achieve union and function.

 1. Butt MF, Dhar SA, Hussain A, Gani NU, Kangoo KA, Farooq M. Femoral neck fracture with ipsilateral trochanteric fracture: Is there room for osteosynthesis? The Internet Journal of Orthopedic Surgery 2007:5/1

i have been working as an orthopedician in a teaching institution for 10 years and have dealt with such fractures twice.