Loupasis et al. Journal of Medical Case Reports 2010, 4:363 http://www.jmedicalcasereports.com/content/4/1/363 Page 2 of 4 Figure 1 Pertrochanteric fracture combined with subcapital fracture on preoperative anteroposterior radiograph of the left hip. anti-rotational cannulated screw (Figure 2). To prevent the development of rotational forces to the femoral head during drilling or lag screw insertion, an eccentric tem- porary guide wire was inserted into the femoral head and the acetabulum before drilling, and removed after the insertion of the lag screw. Our patient’s post-operative rehabilitation protocol included immediate walking with crutches in a touch weight-bearing fashion for eight weeks. Partial to full weight-bearing commenced two months postoperatively. Follow-up included fracture clinic visits at six-month intervals, where the patient was clinically and radiogra- phically assessed and hip functional scores were obtained; Harris hip scores at 12 and 24 months were 88.66 and 93.0, respectively. About one month after the accident, dual energy X-ray absorptiometry was per- formed at the femoral neck region of the opposite femur, and bone mineral density values were found to be within normal limits. At the last follow-up, two years after the accident, the patient was asymptomatic and had returned to his previous activities, and the fractures were solidly united without evidence of avascular necro- sis in the radiographs (Figure 3). Discussion Neck and intertrochanteric fractures of the proximal femur occur predominantly after low-energy trauma in older patients with osteoporosis. The same type of frac- ture in young patients is usually associated with high- energy trauma. Although these injuries are one of the most common causes of admission, mainly of older people, to ortho- paedic departments, simultaneous occurrence of these fractures on the same side is an extremely rare situation, and only four cases have been reported previously in the literature [5-8]. All four cases concerned older patients who had sustained this unusual combination of fractures after a simple fall. In three of the four cases, the subca- pital fracture was either not displaced or only slightly displaced, and the intertrochanteric fracture was dis- placed but could be classified as a stable injury (AO/ OTA 31-A1) [6-8]. All four cases were managed either with closed reduction and osteosynthesis with DHS fixa- tion combined with a cannulated screw, or with DHS fixation alone, with a good final result. In the fourth case, there was a combination of a comminuted inter- trochanteric and displaced subcapital fracture, which was treated with a bipolar hemiarthroplasty and cerclage wires with a satisfactory outcome [5]. Our case is of interest because of the occurrence of such unusual combinations of fractures in a younger adult without osteoporosis occurring after high-energy trauma, a contrast to the previously reported cases, which have occurred in patients with osteoporosis. Full preservation of the femoral head should be the main goal of treatment of this complex injury in younger patients. Fixation with DHS supplemented with an anti- rotational cannulated screw should achieve this. The healing process of the subcapital component of this complex fracture should not be expected to differ from that of an isolated femoral neck fracture. Both fracture lines in our case had an unusual pattern, indi- cating a different mechanism of injury from that of iso- lated subcapital or intertrochanteric fracture. Although we can only speculate as to the mechanism of this rare injury, it is likely that the subcapital fracture occurs first when the femoral neck impinges against the acetabulum as a result of an excessive flexion/external rotatory force to the hip. At this stage, if the forces are still not dissi- pated, a fracture in the intertrochanteric region can occur. There have been some sporadic reports in the litera- ture about non-concomitant combinations of both frac- ture types: a primary healed intertrochanteric fracture treated by various methods of fixation, with re-fractur- ing of the same hip through the femoral neck some time later [1-4]. Several theories have been postulated