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

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 involving the proximal femur, diaphysis, and distal femur are typically associated with high-energy trauma. • In the treatment of medial femoral neck fractures, especially in young patients, every effort should be made to preserve the femoral head and prevent avascular necrosis due to potential vascular injury. • In the presence of a simple lateral femoral fracture, a diaphyseal fracture, and a complex distal femoral fracture (AO type C), the ideal surgical sequence should begin distally and proceed proximally. • Coronal plane malalignment with fracture malunion and limb length discrepancies are the most commonly observed complications. • Patients presenting with this combination of fractures often require Damage Control Orthopedics (DCO), as Early Total Care (ETC) is frequently not feasible.