International Journal of Surgery Case Reports 89 (2021) 106545

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Bilateral femoral neck fracture following a convulsion in the presence of

chronic kidney disease. A case report
Isam Sami Moghamis *, Aiman Mudawi, Elhadi Babikir, Mohamed Hafez Elsheikh Elamin,
Maamoun Abou Samhadaneh, Shamsi Abdul Hameed
Hamad Medical Corporation, Doha, Qatar

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction and importance: Bilateral femoral neck fractures in young adults are a rare entity. It is usually
Bilateral femoral neck fracture associated with pre-existing metabolic diseases, such as osteoporosis, renal osteodystrophy, or hypocalcemic
Seizure seizures. Hence, it is essential in such cases to look for other associated injuries following a traumatic event.
End stage renal disease
Missing associated injuries may lead to significant morbidities and poor functional outcomes.
Convulsions
Chronic kidney disease
Case presentation: A 37 years old male, who had chronic renal failure secondary to hypertension, and presented to
the emergency room following a seizure episode, in which he developed a generalized tonic-clonic convulsion
secondary to electrolyte imbalances with metabolic acidosis. As a result, he developed bilateral neck of femur
fracture.
Intervention and outcome: The medical team optimized electrolytes imbalance and then the patient underwent
surgical stabilization of both femur neck fracture, 1 year following the surgical fixation the patient had full range
of motion of both hips with radiological evidence of complete healing of the fracture.
Conclusion: In cases of fractures secondary to metabolic conditions, bilateral femoral neck fractures should be
suspected and investigated; especially in young patients who develop a generalized tonic-clonic seizure. The
etiology is multifactorial, and the treating surgeon should be aware of predisposing factors which may affect
bone quality, thereby raising the risk of fractures even with low-energy atraumatic events. Hip preservation
should always be the primary target when treating these patients.

1. Introduction and importance fixation or femoral head replacement. [9,10]

Presented here is a case of atraumatic bilateral femoral neck frac­
Femoral neck fractures are commonly sustained following low- tures following a tonic-clonic seizure in a 37 years old male with chronic
energy traumatic events in elderly osteoporotic patients. They may be kidney disease. We report this case in line with the updated consensus-
less commonly seen in younger patients following high-energy trauma. based surgical case report (SCARE) guidelines [11].
Although bilateral simultaneous involvement of femoral neck fractures
is relatively uncommon, it has been reported in association with meta­ 2. Case presentation
bolic bone diseases like renal osteodystrophy, rickets, osteomalacia, and
osteoporosis. [1–6] Bilateral femoral neck fractures are rare sequel of A 37-year-old Asian male, with a medical background of chronic
grand-mal seizure episodes, believed to be related to the unopposed kidney disease secondary to hypertension on oral antihypertensive
vigorous tonic-clonic muscle contractions, rather than as a result of drugs for 17 years, and without any family history of similar condition or
direct trauma to the limb, in the presence of an underlying metabolic genetic disorders. The patient presented to the emergency room (ER)
condition affecting bone quality due to an impairment in bone miner­ following a seizure attack that lasted for thirty minutes while he was
alization processes. [7,8] laying in bed and was witnessed and described by the patient's sister. No
Management of femoral neck fractures is surgical and, depending on post-ictal confusion or urinary incontinence was reported. The seizure
the patient's age, options are generally categorized into either surgical attack was initially localized to the face but eventually spread to the rest

* Corresponding author.
E-mail address: imoghamis@hamad.qa (I.S. Moghamis).

https://doi.org/10.1016/j.ijscr.2021.106545
Received 19 September 2021; Received in revised form 19 October 2021; Accepted 27 October 2021
Available online 2 November 2021
2210-2612/© 2021 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
I.S. Moghamis et al. International Journal of Surgery Case Reports 89 (2021) 106545

of the body and involved jerky and repetitive movements. The charac­ outpatient clinic at the 6 weeks, 12 weeks, 6 months, 9 months, and 1-
teristics fit the description of a generalized tonic-clonic (grand-mal) year post-op marks, with regular imaging to assess for bone healing and
seizure. The patient was independent ambulatory without using any to monitor the femoral heads for any signs of avascular necrosis. A year
walking aids. Eventually, the patient was taken to the ER where he following surgical fixation, the patient demonstrated full range of mo­
developed another seizure, lasting for about 2 min. He was initially tion and was found to have radiographic evidence of complete bone
managed by the ER physicians and, as part of his initial treatment; he healing of the fracture with no signs of avascular necrosis of the femur
received a 1 g loading dose of levetiracetam (KEPPRA) intravenously. head as shown in Fig. 3. He also continued to follow up regularly in the
He noted that it was his first seizure attack with no history of previous epilepsy clinic, and was kept on maintenance doeses of levetiracetam
neurological conditions. 500 mg twice daily to keep his seizures under control.
On clinical examination, following his second attack in the ER, the
patient was conscious, alert, and oriented to time, place, and person, 3. Discussion
with no signs of any respiratory distress. He was hemodynamically
stable and his Glasgow Coma Scale was 15/15. His primary survey Femoral neck fractures in young patients are typically a result of
revealed a bilateral temporomandibular joint dislocation, which was high-energy traumatic events, and the vast majority is unilateral. In the
successfully reduced under conscious sedation by a maxillofacial sur­ presence of pre-existing medical conditions that affect bone strength
geon. His musculoskeletal examination revealed bilateral hip tenderness including, but not limited to: osteoporosis, renal osteodystrophy, hy­
with reduced range of motion and no obvious skin discoloration, pocalcemic convulsions with epileptic attacks, bilateral involvement
wounds, or soft-tissue swelling. Peripheral neurovascular assessments may be seen following low-energy trauma or even following no history
revealed normal findings bilaterally. Pelvic radiographs, shown in of trauma. [2,4,6,7,12]
Fig. 1, demonstrated bilateral transcervical femoral neck fractures, In 1956, Andreini proposed that the simultaneous contraction of
Garden type 4. Further Computed Tomography (CT) imaging revealed pelvic-trochanteric muscles is the main cause of fractures around the hip
no other fractures. following a convulsion. He demonstrated that only these muscles can
Laboratory data showed severe electrolyte imbalances, with hypo­ apply their force irrespective of the relative position of the femur and the
natremia (Sodium 114 mEq/L), hypokalemia (Potassium 2.8 mmol/L), pelvis. [4] Devkota et al. reported a similar case in which the patient
hypocalcemia (Calcium 1.49 mg/dL, Adjusted Calcium 0.43 mg/dL), suffered from chronic kidney disease and sustained an impacted femoral
elevated blood urea nitrogen (BUN 46.4 mmol/L), elevated creatinine neck fracture with no history of trauma nor a history of seizure attacks.
(Creatinine 1290 umol/L), and an absolute neutrophilic count (ANC) of They attributed the cause of this fracture to the changes that occur
8.1. Arterial blood gases revealed a picture of metabolic acidosis (PH secondary to chronic renal failure, which significantly affects bone
7.27, PO2 67, PCO2 25, BE -13.6, HCO3 116) and underlying secondary minerals and degrades bone structure. Consequently, this places the
hyperparathyroidism (PTH 1588 pg/mL). patient at an increased risk of atraumatic and/or pathological fractures.
The patient was referred to the medical team who gradually cor­ [13]
rected the patient's electrolytes and pre-surgically optimized him with In the presented case, a combination of these two factors including
hemodialysis. After medical optimization, the patient underwent a the chronic effect of renal failure on bone mineralization, and the onset
closed reduction of the femoral neck fracture with fluoroscopic guidance of a generalized tonic-clonic grand-mal seizure, resulted in bilateral
followed by fixation of bilateral neck of femur fractures using an femoral neck fractures. Other rare associated injuries have been re­
inverted triangle configuration of 8 mm cannulated screws as shown in ported in the literature, which includes: posterior shoulder dislocations,
(Fig. 2). A senior trauma surgeon at our institute performed the surgery. proximal humerus fractures, fractures of the scapula, Galeazzi fractures,
The patient was initially mobilized on post-op day 1 using a wheelchair, spine fractures, among others. Therefore, screening of the pelvis, spine,
which was changed to weight-bearing as tolerated using a walking frame and shoulder in patients who present following a tonic-clonic convul­
at 3 months post-surgical fixation. sion, is critically important. [14–17]
After discharging the patient, he was instructed to follow up in the Hip preservation should be the primary goal of treatment in young
patients. Different methods may be used to achieve this goal, including
fixation using cannulated screw (as done in this case), or the use of
dynamic hip screws. On the other hand, performing a hemiarthroplasty
may be a better choice for elderly patients with a low-demand lifestyle.
[7,8,12,18,19] Another factor, which should be considered in treating
such patients, is the ideal control of the seizures especially in-patient
with pre existing metabolic bone disorder as this may reduce the risk
for developing a pathological fracture.
Although osteonecrosis can develop following any femoral neck
fracture, it is much more frequently seen in displaced femoral neck
fractures Garden types 3 and 4, with estimated rates ranging from 11 to
40%. [20,21] Serious complications as such should always be discussed
with the patient, as this may lead to potential long-term morbidities and
poor outcomes which eventually necessitate arthroplasty.

4. Conclusion

In cases of fractures secondary to metabolic conditions, bilateral

femoral neck fractures should be suspected and investigated; especially
in young patients who develop a generalized tonic-clonic seizure. The
etiology is multifactorial, and the treating surgeon should be aware of
predisposing factors which may affect bone quality, thereby raising the
risk of fractures even with low-energy or atraumatic events. Hip pres­
Fig. 1. Initial radiograph showing an AP view of the pelvis with bilateral ervation should always be the primary target when treating these
Garden type 4 transcervical femoral neck fractures. patients.

2
I.S. Moghamis et al. International Journal of Surgery Case Reports 89 (2021) 106545

Fig. 2. Intraoperative fluoroscopic AP and frog lateral views of both femur necks showing in-situ fixation with cannulates screws.

Fig. 3. One-year post-operative x-ray of both hips AP and frog lateral views showing in-situ fixation with complete healing of the fractures.

Ethical approval Funding

Approved by the Medical Research Center at Hamad Medical Authors received no funding from any individual or institution and
Corporation. this work is completely a voluntary work.

3
I.S. Moghamis et al. International Journal of Surgery Case Reports 89 (2021) 106545

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