Parker et al. Journal of Medical Case Reports 2011, 5:219 http://www.jmedicalcasereports.com/content/5/1/219 pedal, or, with some designs, by twisting the cleat in sideways. Then, instead of loosening a toestrap or pull- ing a lever, the cyclist releases a foot from the pedal by twisting the heel outward. The force required to release the cleat from the pedal can be altered, by a tensioning mechanism, on the pedal. Competent cyclists, or those who have been using clipless pedal systems for a while, can usually find the right amount of tensioning to bal- ance the need for quick release of the foot in an emer- gency against the foot disengaging the pedal while pedaling forcefully. This is usually done by trial and error. Those new to the pedals have no guide to the amount needed to tensioning the pedal. Unlike skiing, where beginners have the bindings adjusted based on weight and ability, there is no such guide readily avail- able for bicycle pedals. As such users risk only finding out that they have over tightened the binding mechan- ism when they cannot release their foot in an emergency resulting in a fall and a potential injury [2,3]. Hip fractures are common in the elderly osteoporotic population following low energy falls. They can also occur in the young adult or even the child although they often involve a high energy type injury [4]. Intra- capsular femoral neck fractures have a high tendency (10-20%) to undergo non-union or avascular necrosis of the femoral head due to its blood supply [4-6]. The main blood supply to the femoral head in the adult is through the intra-osseous and capsular vessels, emanat- ing mainly from the medial circumflex femoral artery, a branch of the profunda femoris artery. When a dis- placed intra-capsular fracture occurs, the blood supply to the femoral head is compromised. In the elderly, this is dealt with by replacement of the femoral head with a metal prosthesis (hemi-arthroplasty or total hip arthro- plasty), with good functional outcomes [5]. However, in the active young patient, preservation of the femoral head offers a better functional outcome although survi- val of the head is not guaranteed [5]. It is, therefore, accepted practice that the fracture should be reduced and fixed as quickly as possible [4,5]. Should the frac- ture not heal or the head not survive then a total joint arthroplasty would then be needed. This would give the patient relief of pain but return to pre-injury activity levels is not guaranteed [7]. Conclusion Hip fractures in the young are serious, but thankfully rare, injuries. They carry the potential for high long- term morbidity. The use of clipless pedals has become widespread over the last 20 years. Most injuries from clipless pedals are minor. We have described an extreme injury resulting from inappropriately tensioned pedals, which, to the best of our knowledge, has only been described once before in the non-English literature. It Page 3 of 3 serves as a reminder of the importance of appropriate advice, especially from manufacturers and retailers, regarding the proper setup and dangers of using clipless pedals for the recreational cyclist. A system, similar to that used to adjust ski bindings, may help with the cor- rect setup of such pedals. Consent Written informed consent was obtained from the patient for publication of this case report and any accompany- ing images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Authors’ contributions JP was the operating surgeon and prepared a significant part of the manuscript. NP prepared a significant part of the manuscript. GD is the senior surgeon and is responsible for the ongoing management of our patient and helped in retrieving the required information for the preparation of the manuscript. Both authors have read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 3 July 2010 Accepted: 7 June 2011 Published: 7 June 2011 References 1. Leadbetter GW: Closed reduction of fractures of the neck of the femur. J Bone Joint Surg (Am) 1938, 20:108-113. 2. Slootmans FC, Biert J, de Waard JW, de Waal Malefijt MC, Schoots FJ: Femoral neck fractures in bicyclists due to clipless pedals. Ned Tijdschr Geneeskd 1995, 139(22):1141-1143, Dutch. 3. Patel ND: Mountain bike injuries and clipless pedals: a review of three cases. Br J Sports Med 2004, 38(3):340-341. 4. Swiontkowski MF, Winquist RA, Hansen ST Jr: Fractures of the femoral neck in patients between the ages of twelve and forty-nine years. J Bone Joint Surg Am 1984, 66(6):837-846. 5. Gerber C, Strehle J, Ganz R: The treatment of fractures of the femoral neck. Clin Orthop 1993, 292(10):77-86. 6. Harty M: Blood Supply of the Femoral Head. Br Med J 1953, 2(4848):1236-1237. 7. Palmer SJ, Parker MJ, Hollingworth MJ: The cost and implications of reoperation after surgery for fracture of the hip. J Bone Joint Surg (Br) 2000, 82(6):864-866. doi:10.1186/1752-1947-5-219 Cite this article as: Parker et al.: Proximal femoral fracture in a man resulting from modern clipless pedals: a case report. Journal of Medical Case Reports 2011 5:219. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color ﬁgure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit