fracture shaft femur

http://www.esnips.com/web/apathakhttp://www.esnips.com/web/apathak

Dr. A. PathakDr. A. PathakAssistant Professor Assistant Professor

OrthopaedicsOrthopaedicsGandhi Medical college, BhopalGandhi Medical college, Bhopal

Fractures of the Femoral Fractures of the Femoral Shaft Shaft


Femur FracturesFemur Fractures Common injury due to major violent traumaCommon injury due to major violent trauma 1 femur fracture/ 10,000 people1 femur fracture/ 10,000 people More common in people < 25 yo or >65 yoMore common in people < 25 yo or >65 yo Femur fracture leads to reduced activity for Femur fracture leads to reduced activity for

107 days, the average length of hospital 107 days, the average length of hospital stay is 25 daysstay is 25 days

Motor vehicle, motorcycle, auto-pedestrian, Motor vehicle, motorcycle, auto-pedestrian, aircraft, and gunshot wound accidents are aircraft, and gunshot wound accidents are most frequent causesmost frequent causes


The Proximal femoral shaft is well padded with powerful muscles

Advantage – This protects the femur from most forces

Disadvantages – This makes the reduction difficult, the displacement is often so severe


MECHANISM OF INJURYMECHANISM OF INJURY


MECHANISM OF INJURYMECHANISM OF INJURY

High velocity trauma in young

adults

Pathological fracture in elderly

should be suspected

In children (<4) child abuse is a possibility.


Femur Fractures- Associated Femur Fractures- Associated InjuriesInjuries

Struck by car- triad of femur fracture, Struck by car- triad of femur fracture, torso injuries, head injurytorso injuries, head injury

Potential damage to physes of femur Potential damage to physes of femur and proximal tibia in childrenand proximal tibia in children

Head Injury – spasticity can make Head Injury – spasticity can make traction and cast treatment difficulttraction and cast treatment difficult

Abdominal injury – spica cast can Abdominal injury – spica cast can constrict abdomen and limit ability to constrict abdomen and limit ability to examineexamine


Physical ExamPhysical Exam

Complete exam: head, chest, Complete exam: head, chest, abdomen, and other skeletal abdomen, and other skeletal segments segments

Document distal neurologic and Document distal neurologic and vascular functionvascular function

Palpate all bonesPalpate all bones First Aid principles - Splint or First Aid principles - Splint or

traction, especially prior to transfer traction, especially prior to transfer to another institutionto another institution


Radiographic Evaluation Radiographic Evaluation

AP PelvisAP Pelvis AP/Lat femurAP/Lat femur Visualize hip & knee jointsVisualize hip & knee joints


ClassificationClassification

Open or closedOpen or closed Location of fracture- subtrochanteric, Location of fracture- subtrochanteric,

diaphyseal (proximal, mid, distal diaphyseal (proximal, mid, distal third), supracondylarthird), supracondylar

Fracture pattern- transverse, spiral, Fracture pattern- transverse, spiral, oblique, comminuted, greenstickoblique, comminuted, greenstick

Amount of shorteningAmount of shortening Angular deformityAngular deformity


Decision MakingDecision Making

AgeAge Mechanism of injuryMechanism of injury Fracture pattern & locationFracture pattern & location Associated InjuriesAssociated Injuries Surgeon preferenceSurgeon preference


Fracture patternFracture pattern


Spiral fractures are seen where fall on a fixed foot transmits an oblique twisting

force


Transverse or short oblique fractures are due to high velocity direct trauma and are commonest in RTA


Segmntal or Communited fractures are due to a combination of direct and twisting force


MID SHAFT FEMORAL FRACTURES

Due to muscle pull the proximal fragment is abducted flexed and externally rotated d/t pull of illio-psoas and glutei

The distal fragement adducts


DISTAL THIRD FEMORAL FRACTURES

The proximal fragment may abduct or adduct while the distal fragment is flexed by gastrocnemius


Soft tissue bleed might be extensive

Upto 2 litres of blood may be lost in compound injuries

Closed fractures may pour as much as 1 litre of blood in the thigh


Traction TechniquesTraction Techniques

Skin or skeletalSkin or skeletal Avoid physes if place skeletal traction Avoid physes if place skeletal traction

pins in childrenpins in children Place pin perpendicular to shaft to Place pin perpendicular to shaft to

avoid varus/valgus angulationavoid varus/valgus angulation Longitudinal in line traction for Longitudinal in line traction for

comfort prior to definitive treatmentcomfort prior to definitive treatment Split Russells traction (90-90) if Split Russells traction (90-90) if

awaiting early healing prior to castingawaiting early healing prior to casting


ClassificationClassification

Most femoral shaft fractures have Most femoral shaft fractures have some degree of communition, some degree of communition, although it may not be readily although it may not be readily apparent on x-ray.apparent on x-ray.

In closed communited fractures, the In closed communited fractures, the small fagemnts are live bony pieces small fagemnts are live bony pieces with intact soft tissue attachments with intact soft tissue attachments and blood supply and blood supply


This forms the basis of the Winquist This forms the basis of the Winquist classification.classification.


CLINICAL FEATURESCLINICAL FEATURES

PAINPAIN SWELLINGSWELLING DEFORMITYDEFORMITY INABILITY TO BEAR WEIGHTINABILITY TO BEAR WEIGHT SHOCK AND ITS SYMPTOMSSHOCK AND ITS SYMPTOMS BEWARE!BEWARE! MULTISYSTEM INURY MULTISYSTEM INURY


X RAYSX RAYS X rays can be postponed until shock is X rays can be postponed until shock is

taken care of.taken care of.

Remember to immobilize the facture first, Remember to immobilize the facture first, the attempt to take the radiographsthe attempt to take the radiographs

Never forget to X ray the pelvis.Never forget to X ray the pelvis.- hip fractures and dislocation- hip fractures and dislocation- pelvic fractures and disruption- pelvic fractures and disruption

get a baseline chest X-ray done – ARDS and get a baseline chest X-ray done – ARDS and Fat embolism may superveneFat embolism may supervene


EMERGENCY CAREEMERGENCY CARE


Hare traction splint for initial Hare traction splint for initial reduction of femur fractures prior to reduction of femur fractures prior to

OR or skeletal tractionOR or skeletal traction


COMPLICATIONS EXPECTED AT COMPLICATIONS EXPECTED AT THIS STAGETHIS STAGE

FAT EMBOLISM AND ARDS

SHOCK NOT RESONDING TO RESUSCITATION


FIXATION ?FIXATION ?

Best done at this stage with Best done at this stage with interlocking intramedullary nailinginterlocking intramedullary nailing

Not always possible due to lack of Not always possible due to lack of expertise, image intensifier, fracture expertise, image intensifier, fracture table, or instrumentation. table, or instrumentation.


Treatment in tractionTreatment in traction

Most femoral shaft fractures except those in upper third can be treated in skeletal traction.

Its ridden with problems, patient needs to stay in bed for 10 to 14 weeks , and all the complication of recumbancy for so long ensue.

It’s a poor choice in elderly, multiple injured and pathologic fractures

May be used when comorbidities prohibit anaethesia and surgery


Gallows and Russel’s tractions need a spica apllication after 4-5 weeks


Hip spicaHip spica


Surgical OptionsSurgical Options

Plate & screw fixationPlate & screw fixation External fixationExternal fixation Flexible nailingFlexible nailing Rigid nailingRigid nailing


Gerhard KuntscherGerhard KuntscherTechnik der Marknagelung, 1945Technik der Marknagelung, 1945

First IM First IM nailing but nailing but not lockingnot locking

Straight nail with 3 point fixation


Klemm K, Schellman WD:Klemm K, Schellman WD:Veriegelung des marnagels, Veriegelung des marnagels,

19721972

Kempf I, Grosse A: Closed Interlocking Intramedullary Nailing. Its Application to Comminuted fractures of the femur, 1985

Locking IM nails in the 1980’s


Methods of internal fixationMethods of internal fixation


Flexible NailingFlexible Nailing

Advantages – allows early Advantages – allows early mobilization without cast, cosmetic mobilization without cast, cosmetic scars, avoids physes and blood scars, avoids physes and blood supply to femoral headsupply to femoral head

Disadvantages – later nail removal, Disadvantages – later nail removal, ends may irritate soft tissues, may ends may irritate soft tissues, may not be amenable to some fracture not be amenable to some fracture patterns (very proximal or distal, patterns (very proximal or distal, comminution)comminution)


ORIF with Plates/ScrewsORIF with Plates/Screws

Advantages – rigid, technique Advantages – rigid, technique familiar to most surgeons, allows familiar to most surgeons, allows early motion, favorable results early motion, favorable results reported in children with associated reported in children with associated head injuries head injuries

Disadvantages- large scar, possible Disadvantages- large scar, possible refracture after plate removed, refracture after plate removed, higher infection rate in some earlier higher infection rate in some earlier seriesseries


ORIF Plate FixationORIF Plate Fixation


Methods of internal fixationMethods of internal fixation


Percutaneous Bridge Percutaneous Bridge PlatingPlating


Open Femur FractureOpen Femur FracturePrinciplesPrinciples

IV antibiotics, tetanus IV antibiotics, tetanus prophylaxisprophylaxis

emergent irrigation & emergent irrigation & debridementdebridement

skeletal stabilizationskeletal stabilization External fixation best External fixation best

option with severe option with severe soft tissue injurysoft tissue injury

soft tissue coveragesoft tissue coverage


External fixationExternal fixation


ComplicationsComplications

Early :Early :• ShockShock

• Fat embolism and ARDSFat embolism and ARDS

• ThromboembolismThromboembolism


ComplicationsComplications

Late :Late :• Delyed or non unionDelyed or non union

• MalunionMalunion

• Joint stiffnessJoint stiffness

• Refracture and implant failureRefracture and implant failure

fracture shaft femur

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