Modul 12 PENANGANAN KONSERVATIF & OPERATIF FRAKTUR FEMUR

Bedah Orthopaedi 1/3/ TENGAH

(No. ICOPIM: 5-792, 8-362)

1. TUJUAN
1.1. Tujuan Pembelajaran Umum
Setelah mengikuti sesi ini peserta didik memahami dan mengerti tentang anatomi, patofisiologi dan
biomekanik fraktur femur, cara-cara diagnosis fraktur femur, cara-cara penanganan non operatif dan
operatif fraktur femur, komplikasi penanganan fraktur femur, Rehabilitasi dan penanganan lanjut
jangka panjang pasca penanganan fraktur femur dan tatacara sistem rujukan
1.2. Tujuan Pembelajaran Khusus
Setelah mengikuti sesi ini peserta didik akan memiliki kemampuan untuk:
1. Mampu menjelaskan tipe dan klasifikasi fraktur femur. (Tingkat Kompensasi K3,A3/ ak 2,3,6,7)
2. Mampu menjelaskan gejala klinis dan patofisiologi dan biomekanik dari masing-masing tipe dan
klasifikasi fraktur femur dan kemudian mendiagnosisnya. (Tingkat Kompensasi K3,A3/ ak 2,3,6,7)
3. Mampu melakukan komunikasi dengan pasien dan atau keluarga mengenai fraktur femur dan
penanganannya serta hal-hal yang mungkin terjadi selama atau sesudah penanganan. (Tingkat
Kompensasi K3,P3,A3/ ak 1-10)
4. Mampu menjelaskan metode penanganan pra-operatif, operatif dan pasca operasi sesuai dengan
tipe dan klasifikasinya, termasuk indikasi mutlak dan relatif, non-indikasi serta kontra-indikasi
operatif (Tingkat Kompensasi K3,A3/ ak 2,3,6,7)
5. Mampu melakukan penanganan operatif terhadap fraktur femur 1/3 tengah dan mampu melakukan
penanganan konservatif (non-operasi) optimal pada fraktur femur pada kasus yang tidak mau
dioperasi. (Tingkat Kompensasi K3,P3,A3/ ak 1-12)
6. Mampu menangani komplikasi yang terjadi tindakan. (Tingkat Kompensasi K3,P3,A3/ ak 1-12)
7. Mampu melaksanakan penanganan rehabiltasi pasca tindakan me!alui kerjasama tim. (Tingkat
Kompensasi K3,P3,A3/ ak 1-12)

2. POKOK BAHASAN / SUB POKOK BAHASAN

1. Anatomi, patofisiologi dan biomekanik fraktur femur, ldentifikasi sehubungan dengan patologinya.
2. Cara pemeriksaan klinis, radiologis dan laboratories pada fraktur femur.
3. Komunikasi bersifat empatik (diberikan dalam kuliah bedah dan praktek bedah pada umumnya.
4. Persiapan pre operatif dan perioperatif serta pasca operasi/ pasca tindakan konservatif pada fraktur
femur termasuk indikasi mutlak dan relatif, non serta kontra-indikasi tindakan operatif.
5. Metode penanganan operatif pada fraktur femur.
6. Komplikasi pasca penanganan fraktur femur dan penanganannya serta tatacara sistem rujukan
7. Rehabilitasi pasca penanganan fraktur femur

3. WAKTU
METODE A. Proses pembelajaran dilaksanakan melalui metode:
1) small group discussion
2) peer assisted learning (PAL)
3) bedside teaching
4) task-based medical education
B. Peserta didik paling tidak sudah harus mempelajari:
1) bahan acuan (references)
2) ilmu dasar yang berkaitan dengan topik pembelajaran
3) ilmu klinis dasar
C. Penuntun belajar (learning guide) terlampir
D. Tempat belajar (training setting): bangsal bedah, kamar
operasi, bangsal perawatan pasca operasi.

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4. MEDIA 1. Workshop / Pelatihan
2. Belajar mandiri
3. Kuliah
4. Group diskusi
5. Visite, bed site teaching
6. Bimbingan Operasi dan asistensi
7. Kasus morbiditas dan mortalitas
8. Continuing Profesional Development (P2B2)

5. ALAT BANTU PEMBELAJARAN

Internet, telekonferens, dll.

6. EVALUASI
1. Pada awal pertemuan dilaksanakan pre-test dalam bentuk MCQ, essay dan oral sesuai dengan
tingkat masa pendidikan, yang bertujuan untuk menilai kinerja awal yang dimiliki peserta didik
dan untuk mengidentifikasi kekurangan yang ada. Materi pre-test terdiri atas:
 Anatomi, patofisiologi dan biomekanik fraktur femur
 Penegakan Diagnosis
 Terapi ( tehnik pemasangan konservatif dan operasi )
 Komplikasi dan penanganannya
 Follow up
2. Selanjutnya dilakukan “small group discussion” bersama dengan fasilitator untuk membahas
kekurangan yang teridentifikasi, membahas isi dan hal-hal yang berkenaan dengan penuntun
belajar, kesempatan yang akan diperoleh pada saat bedside teaching dan proses penilaian.
3. Setelah mempelajari penuntun belajar ini, peserta didik diwajibkan untuk mengaplikasikan
langkah-langkah yang tertera dalam penuntun belajar dalam bentuk role-play dengan teman-
temannya (peer assisted learning) atau kepada SP (standardized patient). Pada saat tersebut,
yang bersangkutan tidak diperkenankan membawa penuntun belajar, penuntun belajar dipegang
oleh teman-temannya untuk melakukan evaluasi (peer assisted evaluation). Setelah dianggap
memadai, melalui metoda bedside teaching di bawah pengawasan fasilitator, peserta didik
mengaplikasikan penuntun belajar kepada nodel anatomik dan setelah kompetensi tercapai
peserta didik akan diberikan kesempatan untuk melakukannya pada pasien sesungguhnya. Pada
saat pelaksanaan, evaluator melakukan pengawasan langsung (direct observation), dan mengisi
formulir penilaian sebagai berikut:
 Perlu perbaikan: pelaksanaan belum benar atau sebagian langkah tidak dilaksanakan
 Cukup: pelaksanaan sudah benar tetapi tidak efisien, misal pemeriksaan terlalu lama atau
kurang memberi kenyamanan kepada pasien
 Baik: pelaksanaan benar dan baik (efisien)
4. Setelah selesai bedside teaching, dilakukan kembali diskusi untuk mendapatkan penjelasan dari
berbagai hal yang tidak memungkinkan dibicarakan di depan pasien, dan memberi masukan
untuk memperbaiki kekurangan yang ditemukan.
5. Self assessment dan Peer Assisted Evaluation dengan mempergunakan penuntun belajar
6. Pendidik/fasilitas:
 Pengamatan langsung dengan memakai evaluation checklist form / daftar tilik
(terlampir) Penjelasan lisan dari peserta didik/ diskusi
 Kriteria penilaian keseluruhan: cakap/ tidak cakap/ lalai.
7. Di akhir penilaian peserta didik diberi masukan dan bila diperlukan diberi tugas yang dapat
memperbaiki kinerja (task-based medical education)
8. Pencapaian
pembelajaran: Pre test
Isi pre test
Anatomi patofisiologi dan biomekanik fraktur femur
Diagnosis

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 Terapi (Tehnik penanganan konservatif dan operasi)
Komplikasi dan penanggulangannya
Follow up
Bentuk pre test
MCQ, Essay dan oral sesuai dengan tingkat masa pendidikan
Buku acuan untuk pre test
1. Miller MD, Review of Orthopaedies Trauma, 4 ed, Saunders 2004
2. Swiontkwoski MF, Manual of Orthopaedics, 5 ed, Lippincott Williams and Wilkins
2001
3. Brinker RM, Review of Orthopaedics Trauma, WB Saunders Company, 2001
4. Salter RB, Texthook of Disorders and Injuries of the Musculoskeletal system, 3th
ed, Lippincott Williams and Wilkins 1999
5. Rasjad C, Pengantar Ilmu Bedah Ortopedi, Bintang Lamumpalue 2000
6. Greenspan A, Orthopaedics Radiology, 2nd ed, Lippincott-Raven, 1997
7. Brashear FIR, Shand’s Handbook of Orthopaedics Surgery, 9 ed, The CV Mosby
Company 1978
Bentuk Ujian / test latihan
 Ujian OSCA (K, P, A), dilakukan pada tahapan bedah dasar oleh Kolegium I.
Bedah.
 Ujian akhir stase, setiap divisi/ unit kerja oleh masing-masing senter pendidikan.
 Ujian akhir kognitif nasional, dilakukan pada akhir tahapan bedah lanjut (jaga II) oleh
Kolegium I. Bedah.
 Ujian akhir profesi nasional (kasus bedah), dilakukan pada akhir pendidikan oleh
Kolegium I. Bedah

7. REFERENSI:
1. Miller MD, Review of Orthopaedies Trauma, 4 ed, Saunders 2004
2. Swiontkwoski MF, Manual of Orthopaedics, 5 ed, Lippincott Williams and Wilkins 2001
3. Brinker RM, Review of Orthopaedics Trauma, WB Saunders Company, 2001
4. Salter RB, Texthook of Disorders and Injuries of the Musculoskeletal system, 3th ed, Lippincott
Williams and Wilkins 1999
5. Rasjad C, Pengantar Ilmu Bedah Ortopedi, Bintang Lamumpalue 2000
6. Greenspan A, Orthopaedics Radiology, 2nd ed, Lippincott-Raven, 1997
7. Brashear FIR, Shand’s Handbook of Orthopaedics Surgery, 9 ed, The CV Mosby Company 1978

8. URAIAN: FRAKTUR FEMUR

8.1. Introduksi
a. Definisi
Fraktur (fraktur) yang terjadi pada tulang femur. Mekanisme trauma yang berkaitan dengan
terjadinya fraktur pada femur antara lain : (I) pada jenis Femoral Neck fraktur karena kecelakaan lalu
lintas, jatuh pada tempat yang tidak tinggi, terpeleset di kamar mandi dimana panggul dalam
keadaan fleksi dan rotasi. Sering terjadi pada usia 60 tahun ke atas, biasanya tulang bersifat
osteoporotik, pada pasien awal menopause, alkoholism, merokok, berat badan rendah, terapi steroid,
phenytoin, dan jarang berolahraga, merupakan trauma high energy; (2) Femoral Trochanteric fraktur
karena trauma langsung atau trauma yang bersifat memuntir; (3) Femoral Shaft fraktur teijadi
apabila pasien jatuh dalam posisi kaki melekat pada dasar disertai putaran yang diteruskan ke femur.
Fraktur bisa bersifat transversal atan oblik karena trauma langsung atau angulasi. Fraktur patologis
biasanya terjadi akibat metastase tumor ganas. Bisa disertai perdarahan masif sehingga berakibat
syok
b. Ruang lingkup
Fraktur tulang femur terdiri atas : Femoral Head fraktur, Femoral Neck fraktur,
Intertrochanteric frakiur, Subtrochanteric fraktur, Femoral Shaft fraktur,
Supracondylar/Intercondylar Femoral fraktur (Distal Femoral fraktur)
• Femoral Head fraktur

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 Berdasarkan klasifikasi Pipkin : (I) Tipe I : fraktur dibawah fovea; (2) Tipe 2 fraktur diatas
fovea; (3) Tipe 3: tipe 1 atau tipe 2 ditambah fraktur femoral neck; (4) Tipe 4: tipe I atau tipe 2
ditambah fraktur acetabulum
• Femoral Neck fraktur
Berdasarkan klasifikasi Pauwel : (I) Tipe I : sudut inklinasi garis fraktur <30°;
(2) Tipe 2 : sudut inklinasi garis fraktur 30-50°; (3) Tipe 3 : sudut inklinasi garis fraktur > 70°
Berdasarkan klasiflkasi Garden (1) Garden 1: Fraktur inkomplet atau tipe abduksi/ valgus atau
impaksi; (2) Garden 2 fraktur lengkap, tidak ada pergeseran; (3) Garden 3 : fraktur lengkap, disertai
pergeseran tapi masih ada perlekatan atau inkomplet disertai pergeseran tipe varus; (4) Garden 4:
Fraktur lengkap disertai pergeseran penuh
• Trochanteric fraktur
Diklasifikasikan menjadi 4 tipe (1) Tipe 1: fraktur melewati trokanter mayor dan minor tanpa
pergeseran; (2) fraktur melewati trokanter mayor disertai pergeseran trokanter minor; (3) fraktur
disertai fraktur komunitif; (4) fraktur disertai fraktur spiral
• Femoral Shaft fraktur
Klasifikasi OTA : (1) Tipe A : Simple fraktur, antara lain fraktur spiral, oblik, transversal; (2) Tipe B
: wedge/butterfly comminution fraktur; (3) Tipe C : Segmental communition
Klasifikasi Winquist-Hansen : (1) Type 0 : no communition; (2) Tipe 1: 25% butterfly; (3) Tipe 2 :
25-50% butterfly; (4) Tipe 3 : >50% communition; (5) tipe segmental ; (6) Tipe 5 : segmental
dengan bone loss
• Supracondylar/Intercondylar Femoral fraktur (Distal Femoral fraktur)
Klasifikasi Neer, Grantham, Shelton (1) Tipe 1: fraktur suprakondiler dan kondiler bentuk 1; (2)
Tipe II A : fraktur suprakondiler dan kondiler dengan sebagian metafise (bentuk Y); Tipe II B :
bagian metafise lebih kecil; (3) fraktur suprakondiler komunitif dengan fraktur kondiler tidak total
Untuk penegakkan diagnosis diperlukan diperlukan pemeriksaan fisik. Pada fraktur tipe femoral neck
dan trochanteric, ditemukan pemendekkan dan rotasi eksternal. Selain itu ditemukan nyeri dan bengkak.
Juga dinilai gangguan sensoris daerah jan I dan II, juga pulsasi arteri distal. Untuk pemeriksaan
penunjang berupa foto roentgen posisi anteroposterior dan lateral. Sedangkan pemeriksaan laboratorium
antara lain hemoglobin, leukosit, trombosit, CT, BT.
c. Indikasi Operasi
Pada fraktur femur anak, dilakukan terapi berdasarkan tingkatan usia. Pada anak usia baru lahir
hingga 2 tahun dilakukan pemasangan bryant traksi. Sedangkan usia 2 sampal 5 tahun dilakukan
pemasangan thomas splint. Anak diperbolehkan pulang dengan hemispica.
Pada anak usia 5 sampai 10 tahun ditatalaksana dengan skin traksi dan pulang dengan hemispica
gips. Sedangkan usia 10 tahun ke atas ditatalaksana dengan pemasangan intamedullary nails atau
plate dan screw.
Untuk fraktur femur dewasa, tipe Femoral Head, prinsipnya adalah reduksi dulu dislokasi panggul.
Pipkin 1, II post reduksi diterapi dengan touch down weight-bearing 4-6 minggu. Pipkin I, 11
dengan peranjakan >1mm diterapi dengan ORIF. Pipkin 111 pada dewasa muda dengan ORIF,
sedangkan pada dewasa tua dengan endoprothesis. Pipkin IV diterapi dengan cara yang sama pada
fraktur acetabulum.
Tipe Femoral Neck, indikasi konservatif sangat terbatas. Konservatif berupa pemasangan skin traksi
selama 12-16 minggu. Sedangkan operatif dilakukan pemasangan pin, plate dan screw atau
arthroplasti (pada pasien usia >55 tahun), berupa eksisi arthroplasti, hemiarthroplasti dan
arthtroplasti total.
Fraktur Trochanteric yang tidak bergeser dilakukan terapi konservatif dan yang bergeser dilakukan
ORIF. Penanganan konservatif dilakukan pada supracondylar dan intercondylar, femur atau
proksimal tibia. Beban traksi 9 kg dan posisi lutut turns selama 12 minggu. Sedangkan untuk
intercondylar, untuk terapi konservatif, beban traksi 6 kg, selama 12-14 minggu.
Fraktur Shaft femur bisa dilakukan ORIF dan terapi konservatif. Terapi konsevatif hanya bersifat
untuk mengurangi spasme, reposisi dan immobilisasi. Indikasi pada anak dan remaja, level
fraktur terlalu distal atau proksimal dan fraktur sangat kominutif. Pada anak, Cast bracing
dilakukan bila terjadi clinical union.

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 d. Kontra indikasi Operasi
Pada pasien dengan fraktur terbuka, diperlukan debridement hingga cukup bersih untuk dilakukan
pemasangan ORIF. Kontraindikasi untuk traksi, adanya thromboplebitis dan pneumonia. Atau pada
pasien yang kondisi kesehatan tidak memungkinkan untuk operasie. Diagnosis Banding
f. Pemeriksaan Penunjang
Foto roentgen, CT — scan dan MRI. Jiku perlu dilakukan foto perbandingan.
Setelah memahami, menguasai dan mengerjakan modul ini maka diharapkan seorang dokter ahli bedah
mempunyai kompetensi konservatif dan operatif fraktur femur 1/3 tengah serta penerapannya dapat
dikerjakan di RS Pendidikan dan RS jaringan pendidikan serta tatacara sistem rujukan
8.2. Kompetensi terkait dengan modul/ list of skill
Tahapan Bedah Dasar ( semester I-III )
 Persiapan pra operasi :
Ο Anamnesis
Ο Pemeriksaan fisik
Ο Pemeriksaan Penunjang
Ο Informed consent
 Melakukan penanganan konservatif
 Assisten 2, assisten 1 pada saat operasi
 Follow up dan rehabilitasi
Tahapan Bedah Lanjut ( semester IV-VII ) dan chief residen ( semester VIII-IX )
 Persiapan pra operasi :
Ο Anamnesis
Ο Pemeriksaan fisik
Ο Pemeriksaan Penunjang
Ο Informed consent
 Penanganan terapi konservatif
 Melakukan operasi ( bimbingan , mandiri )
Ο Penanganan komplikasi
Ο Follow up dan komplikasi
8.3. Algoritma :
Algoritma

Fraktur diafisis Tanpa penyulit Penanganan konservatif

Shaft femur Atau operatif menggunakan
Daerah isthmus Kuntscher atau plate

Dengan Penyulit Rujuk spesialis

orthopaedi

Fraktur femur selain

yang terjadi pada Rujuk spesialis
isthmus diafisis Orthopaedi
shaft humerus

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8.4. Teknik Terapi Konservatif Operasi
 Pemasangan skeletal traksi
- Pasien berbaring posisi supine, Mikulicz line, dengan fleksi pada art genu.
- Prosedur aseptik/antiseptik
- Approach, pada distal femur linchi inferiot tubercie abduktor. Pada proximal tibia 1 inchi inferior
dan V inchi inferior tubercle tibia Anestesi lokal dengan lidokain 1 % . Anestesi disuntikkan hingga
ke periosteum.
- Insisi dengan pisau no.11. Approach dan bagian medial untuk distal femur dan lateral untuk
proksimal tibia
- Wire diinsersikan dengan menggunakan hand drill, untuk menghindari nekrosis tulang sekitar
insersi pm (bila menggunakan alat otomatis). Jenis wire yang bisa digunakan disini adalah
Kirschner wire No.5
 Pemasangan K-Nail (Kuntscher-Nail ) secara terbuka pada fraktur femur 1/3 tengah
- Pasien tidur miring ke sisi sehat dengan fleksi sendi panggul dan lutut
- Aprroach posterolateral dan trochanter mayor ke condylus lateral sepanjang 15 cm di atas daerah
fraktur
- Fascia lata dibelah dan m.vastus lateralis dibebaskan secara tajam dan septum intermuskularis dan
disisihkan ke anterior
- Ligasi a/v perforantes
- Bebaskan periosteum untuk mencapai kedua fragmen fraktur.
- Bebaskan kedua fragmen fraktur dari darah dan otot
- Ukur panjang K-nail. Pasang guide ke arab fragmen proksimal dan Ietakkan di tengah, dengan
posisi fleksi dan adduksi sendi panggul. Bagian kulit yang tertembus dibuat sayatan.
- K-nail dipasang dengan guide menghadap posteromedial
- Ujung proksimal K-nail dibenamkan 1-2 cm di atas tulang, jika terdapat rotational instability, ben
anti rotation bar, atau pakai cerelage wiring atau atau ganti K-nail
- Pemasangan K-nail sebaiknya setelah 7-14 hari pasca trauma. Cara lain pemasangan K- nail
dengan bantuan fluoroscopy.
 Plating pada fraktur fémur 1/3 tengah
- Pasien tidur miring ke sisi sehat dengan fleksi sendi panggul dan lutut
- Aprroach posterolateral dan trochanter mayor ke condylus lateral sepanjang 15 cm di atas daerah
fraktur
- Fascia lata dibelah dan m.vastus lateralis dibebaskan secara tajam dan septum intermuskularis dan
disisihkan ke anterior
- Ligasi a/v perforantes
- Bebaskan periosteum untuk mencapai kedua fragmen fraktur.
- Bebaskan kedua fragmen fraktur dari darah dan otot
- Reduksi fragmen fraktur
- Pemasangan plate (Broad Plate) pada permukaan anterior atau lateral dengan memakai 8 screw
pada masing-masing fragmen fraktur.
8.5. Komplikasi Operasi
Komplikasi pada fraktur femur, termasuk yang diterapi secara konservatif antara lain, bersifat segera:
syok, fat embolism, neurovascular injury seperti injury nervus pudendus, nervus peroneus,
thromboembolism, volkmann ischemic dan infeksi. Komplikasi lambat: delayed union, non union,
decubitus ulcer, ISK dan joint stiffhess. Pada pemasangan K- nail adventitious bursa, jika fiksasi terlalu
panjang dan fiksasi tidak rigid jika terlalu pendek.
8.6. Mortalitas
Mortitas berkaitan dengan adanya syok dan embolisme.
8.7. Perawatan Pasca Bedah
Pasien dengan pernasangan traksi, rawat di ruangan dengan fasilitas ortopedi. Sedangkan pada pasien
dengan pemasangan OR1F, rawat di ruangan pemulihan, cek hemoglobin pasca operasi.

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8.8. Follow up
Untuk Follow up pasien dengan skeletal traksi, lakukan isometric exercise sesegera mungkin dan jika
udem hilang, lakukan latihan isotonik. Pada fraktur femur 1/3 proksimal traksi abduksi >30˚ dan
exorotasi. Pada 1/3 tengah posisi abduksi 30˚ dan tungkai mid posisi, sedangkan pada 1/3 distal,
tungkai adduksi < 30˚ dan kaki mid posisi. Pada fraktur distal perhatikan ganjal lutut, berikan fleksi
ringan, 15°. Setiap harinya, perhatikan arah, kedudukan traksi, posterior dan anterior bowing. Periksa
denan roentgen tiap 2 hari sampai accepted, kemudian tiap 2 minggu. Jika tercapai klinikal union, maka
dilakukan weight bearing, half weight bearing dan non weight bearing dengan jarak tiap 4 minggu.
Sedangkan untuk follow up pasca operatif, minggu 1 hari pertama kaki fleksi dan ektensi, kemudian
minggu selanjutnya miring-miring. Minggu ke-2 jalan dengan tongkat dan isotonik quadricep. Fungsi
lutut harus pulih dalam 6 minggu.
Pada pasien anak, follow up dengan roentgen, jika sudah terjadi clinical union, pasang hemispica dan
pasien boleh kontrol poliklinik.
8.9. Kata Kunci: Fraktur Femur, Nailing, Plating, skeletal traksi

9. DAFTAR CEK PENUNTUN BELAJAR PROSEDUR OPERASI

Sudah Belum
No Daftar cek penuntun belajar prosedur operasi dikerjakan dikerjakan
PERSIAPAN PRE OPERASI
1 Informed consent
2 Laboratorium
3 Pemeriksaan tambahan
4 Antibiotik propilaksis
5 Cairan dan Darah
6 Peralatan dan instrumen operasi khusus
ANASTESI
1 Narcose dengan general anesthesia
PERSIAPAN LOKAL DAERAH OPERASI
1 Memposisikan penderita
2 Lakukan desinfeksi dan tindakan asepsis / antisepsis pada
daerah operasi.
3 Lapangan pembedahan dipersempit dengan linen steril.
TINDAKAN OPERASI
1 Insisi kulit sesuai dengan indikasi operasi .
2 Insisi diperdalam dengan diseksi jaringan lunak
3 Reduksi fragmen fraktur
4 Pemasangan Intramedulary Nail atau Plate dan screw
PERAWATAN PASCA BEDAH
1 Komplikasi dan penanganannya: A,V,N
2 Pengawasan terhadap ABC
3 Perawatan luka operasi

Catatan: Sudah / Belum dikerjakan beri tanda 

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10. DAFTAR TILIK

Berikan tanda dalam kotak yang tersedia bila keterampilan/tugas telah dikerjakan dengan memuaskan (1);
tidak memuaskan (2) dan tidak diamati (3)
1. MemuaskanLangkah/ tugas dikerjakan sesuai dengan prosedur standar atau penuntun
2. TidakTidak mampu untuk mengerjakan langkah/ tugas sesuai dengan prosedur
memuaskanstandar atau penuntun
3. Tidak diamati Langkah, tugas atau ketrampilan tidak dilakukan oleh peserta latih selama
penilaian oleh pelatih

Nama peserta didik Tanggal

Nama pasien No Rekam Medis

DAFTAR TILIK
Penilaian
No Kegiatan / langkah klinik
1 2 3
1 Persiapan Pre-Operasi

2 Anestesi

3 Tindakan Medik/ Operasi

4 Perawatan Pasca Operasi & Follow-up

Peserta dinyatakan : Tanda tangan pelatih

 Layak
 Tidak layak
melakukan prosedur

Tanda tangan dan nama terang

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FRACTURES OF THE FEMORAL NECK
The femoral neck is the commonest site of fractures in the elderly. The vast majority of patients are Caucasian
women in the seventh and eighth decades, and the association with osteoporosis is so manifest that the
incidence of femoral neck fractures has been used as a measure of age-related osteoporosis in population
studies. Other risk factors include bone-losing or bone-weakening disorders such as osteomalacia, diabetes,
stroke (disuse), alcoholism and chronic debilitating disease. In addition, old people often have weak muscles
and poor balance resulting in an increased tendency to fall.

The association of femoral neck fracture with post-menopausal bone loss has stimulated renewed interest in
screening for osteoporosis and prophylactic measures in the ‘at risk’ population. By contrast, this injury is
much less common among people whose bone mass is above that of the population average, e.g. those with
osteoarthritis of the hip.

Femoral neck fractures are also much less common in black (Negroid) peoples than in whites and Asians. The
reasons for this phenomenon are poorly understood. Slightly higher bone mass and a slower rate of bone loss
after the menopause may be significant, but a qualitative difference in bone structure has also been suggested:
even among people with the same bone mass, those with greater loss of trabecular interconnectivity (typical in
elderly whites) will suffer fractures more easily than those with firmer structure. The incidence of femoral
neck fractures is set to double over the next 30 years; this is a reflection of a higher number of individuals
living beyond 65 years and a parallel rise in those affected with osteoporosis. The economic impact of
treating, rehabilitating and caring for this group of patients is increasingly being recognized, with many
governments and healthcare administration bodies focusing on preventive strategies.

Mechanism of injury
The fracture usually results from a simple fall; however, in very osteoporotic people, less force is required ––
perhaps no more than catching a toe in the carpet and twisting the hip into external rotation. Some patients
may have experienced minor symptoms of a preceding stress fracture of the femoral neck.

In younger individuals, the usual cause is a fall from a height or a blow sustained in a road accident. These
patients often have multiple injuries and in 20 per cent there is an associated fracture of the femoral shaft.
Occasionally, stress fractures of the femoral neck occur in runners or military personnel.

Pathological anatomy and classification

The most useful classification is that of Garden, which is based on the amount of displacement apparent in the
pre-reduction x-rays (Garden 1961). Once fractured, the head and neck become displaced in progressively
severe stages. Stage I is an incomplete impacted fracture, including the so-called abduction fracture in which
the femoral head is tilted into valgus in relation to the neck. Stage II is a complete but undisplaced fracture.
Stage III is a complete fracture with moderate displacement. And Stage IV is a severely displaced fracture.
This is essentially a radiographic classification; the distinctive x-ray features are described below.

Garden I and II fractures, which are only slightly displaced, have a much better prognosis for union and for
viability of the femoral head than the more severely displaced Garden III and IV fractures (Barnes, Brown et
al. 1976). This has an important influence on the choice of treatment for the various stages. However, there is
little room for complacency with any of these fractures; left untreated, a comparatively benign-looking Stage I
fracture may rapidly disintegrate to Stage IV.

Healing of femoral neck fractures is bedevilled by two problems: the threat of bone ischaemia and tardy
union. The femoral head gets its blood supply from three sources: (1) intramedullary vessels in the femoral
neck; (2) ascending cervical branches of the medial and lateral circumflex anastomoses, which run within the
capsular retinaculum before entering the bone at the articular margin of the femoral head; and (3) the vessels
of the ligamentum teres. The intramedullary supply is always interrupted by the fracture; the retinacular
vessels, also, may be kinked or torn if the fracture is displaced. In elderly people, the remaining supply in the
ligamentum teres is at best fairly meagre and, in 20 per cent of cases, nonexistent. Hence the high incidence of
avascular necrosis in displaced femoral neck fractures.

Transcervical fractures are, by definition, intracapsular. They have a poor capacity for healing because: (1) by
tearing the retinacular vessels the injury deprives the head of its main blood supply; (2) intra-articular bone
has only a flimsy periosteum and no contact with soft tissues which could promote callus formation; and (3)
synovial fluid prevents clotting of the fracture haematoma. Accurate apposition and impaction of bone
fragments are therefore of more importance than usual. There is evidence that aspirating a haemarthrosis
increases the blood flow in the femoral head by relieving tension in the capsule, and the practice is encouraged
at the time of surgery (Harper, Barnes et al. 1991; Bonnaire and Weber 2002).

Clinical features
There is usually a history of a fall, followed by pain in the hip. If the fracture is displaced, the patient lies with
the limb in lateral rotation and the leg looks short.

Beware, not all hip fractures are so obvious. With an impacted fracture the patient may still be able to walk,
and debilitated or mentally handicapped patients may not complain at all – even with bilateral fractures.

In contrast, femoral neck fractures in young adults result from road traffic accidents or falls from heights and
are often associated with multiple injuries. A good rule is that young adults with severe injuries – whether they
complain of hip pain or not – should always be examined for an associated femoral neck fracture.

X-ray
Two questions must be answered: is there a fracture, and is it displaced? Usually the break is obvious, but an
impacted fracture can be missed by the unwary. Displacement is judged by the abnormal shape of the bone
outlines and the degree of mismatch of the trabecular lines in the femoral head and neck and the supra-
acetabular (innominate) part of the pelvis (Figure 29.5). This assessment is important because impacted or
undisplaced fractures do well after inter nal fixation, whereas displaced fractures have a high rate of non-union
and avascular necrosis.

In Garden I fractures the femoral head is in its normal position or tilted into valgus and impacted on the
femoral neck stump. The medial cortex may be intact. The femoral head stress trabeculae are normally aligned
with the innominate trabeculae.

In Garden II fractures the femoral head is normally placed and the fracture line may be difficult to discern.

In Garden III fractures the anteroposterior x-ray shows that the femoral head is tilted out of position and the
trabecular markings are not in line with those of the innominate bone; this is because the proximal fragment
retains some contact with the neck stump and is pushed out of alignment.

In Garden IV fractures the femoral head trabeculae are normally aligned with those of the innominate bone;
the reason is that the proximal fragment has lost contact with the femoral neck and lies in its normal position
in the acetabular socket.

Diagnosis
There are four situations in which a femoral neck fracture may be missed, sometimes with dire consequences.
• Stress fractures The elderly patient with unexplained pain in the hip should be considered to have a stress
fracture until proved otherwise. A similar cautionary note is raised for young athletes who do regular impact-
loading sports and military personnel on marching routines. The x-ray is usually normal but a bone scan, or
better still an MRI, will show the lesion (Figure 29.6).
• Undisplaced fractures Impacted fractures may be extremely difficult to discern on plain x-ray. If there is a
fracture it will show up on MRI or a bone scan after a few days.
• Painless fractures A bed-ridden patient may develop a ‘silent’ fracture. Even a fit patient occasionally walks
about without pain if the fracture is impacted. If the context suggests an injury, investigate – whether the
patient complains or not.
• Multiple fractures The patient with a femoral shaft fracture may also have a hip fracture, which is easily
missed unless the pelvis is x-rayed.

Treatment
Initial treatment consists of pain-relieving measures and simple splintage of the limb. If operation is delayed, a
femoral nerve block may be helpful.

A case for non-operative treatment of undisplaced (Garden Stages I and II) fractures can be made in treating
patients with advanced dementia and little discomfort. For all others, operative treatment is almost mandatory.
Displaced fractures will not unite without internal fixation, and in any case elderly people should be got up
and kept active without delay if pulmonary complications and bed sores are to be prevented. Impacted
fractures can be left to unite, but there is always a risk that they may become displaced, even while lying in
bed, so fixation is safer.

Another indication for non-operative management is an impacted Garden I fracture that is an ‘old’ injury,
where the diagnosis is made only after the patient has been walking about for several weeks without
deleterious effect on the fracture position.

When should the operation be performed? In young patients operation is urgent; interruption of the blood
supply will produce irreversible cellular changes after 12 hours and, to prevent this, an accurate reduction and
stable internal fixation is needed as soon as possible. In older patients, also, the longer the delay, the greater is
the likelihood of complications. However, here speed is tempered by the need for adequate preparation,
especially in the very elderly, who are often ill and debilitated.
What if operation is considered too dangerous? Lying in bed on traction may be even more dangerous, and
leaving the fracture untreated too painful; the patient least fit for operation may need it most.

Internal fixation Notwithstanding the advances in joint replacement, for most patients the principles of
treatment are as of old: accurate reduction, secure internal fixation and early activity. Displaced fractures must
first be reduced: with the patient under anaesthesia, the fracture is disimpacted by applying traction with the
hip held in 45 degrees of flexion and slight abduction; the limb is then slowly brought into extension and
finally internally rotated; as traction is released, the fracture re-impacts in the reduced position.

The reduction is assessed by x-ray. The femoral head should be positioned correctly with the stress trabeculae
in the femoral head and those in the femoral neck aligned close to their normal position in both anteroposterior
and lateral views, as shown in Figure 29.7. In the AP x-ray the trabeculae in the femoral head and a line along
the medial border of the femoral shaft should subtend an angle of 155–180 degrees.

To fix an imperfectly reduced fracture is to risk failure. If a stage III or IV fracture cannot be reduced closed,
and the patient is under 60 years of age, open reduction through an anterolateral approach is advisable.
However, in older patients (and certainly in those over 70) this may not be justified; if two careful attempts at
closed reduction fail, prosthetic replacement is preferable. Some may even argue that prosthetic replacement is
always a preferable option for this older group as it carries a much lower risk of needing revision surgery.

Once the fracture is reduced, it is held with cannulated screws or a sliding screw and side-plate which attaches
to the femoral shaft. A lateral incision is used to expose the upper femur. When using cannulated screws,
guide wires –– inserted under fluoroscopic control – are used to ensure correct placement of the fixing device.
Usually three cannulated screws will suffice; they should lie parallel and extend to within 5 mm of the
subchondral bone plate. It is usual to start with an inferior screw that skirts the inferior cortex of the neck but
remains centred in the lateral x-ray view. This screw should be inserted through the lateral cortex of the femur
at a level proximal to the lesser trochanter lest a stress riser is created and produces a subtrochanteric fracture.
Two further screws are inserted more proximally, this time centred in the femoral neck on the anteroposterior
x-ray but straddling the anterior and posterior margins of the femoral neck on the lateral x-ray (Figure 29.8). If
a sliding screw is used, the femoral neck will first have to be reamed; a temporary guidewire should always be
introduced before reaming so as to prevent the femoral head from rotating with the reamer and tearing the
remaining soft-tissue attachments. Once the sliding screw is fixed, the guidewire is replaced by a single screw
to reduce the risk of femoral head rotation during fracture healing – this screw must be parallel to the sliding
screw or else impaction of the fracture will not occur!

From the first day patients should sit up in bed or in a chair. They are taught breathing exercises, and
encouraged to help themselves and to begin walking (with crutches or a walker) as soon as possible. To delay
weightbearing may be theoretically appropriate but is rarely practicable.

Prosthetic replacement This procedure carries a longer operating time, greater blood loss and a higher
infection rate than internal fixation. However, in its favour is a much lower need for revision surgery (nearly
four times less) when compared to internal fixation for stage III and IV fractures. The mortality rates are
equivalent for the two groups but there is insufficient data to be certain there is a difference in morbidity
(Masson, Parker et al. 2003). Some argue that prosthetic replacement is always preferable for stage III and IV
fractures so that patients, particularly the elderly, are subject to one single surgical intervention (Figure 29.9).
This is also true for patients with pathological fractures and those in whom closed reduction cannot be
achieved.

Hip prostheses used for femoral neck fractures are usually of the femoral part only (hemiarthroplasty) and
may be inserted with or without cement. Cemented prostheses have better mobility and less thigh pain;
uncemented prostheses should be reserved for the very frail where the pre-injury status suggests that mobility
is unlikely to be attained after operation and those who will benefit significantly from the reduced operating
time. There is little evidence to support use of bipolar prostheses over unipolar types for the elderly group; the
mortality, morbidity and functional recovery following use of either are similar.
However, some studies suggest a longer survivorship of bipolar implants and an argument can be made for
their use in younger patients.

Total hip replacement for femoral neck fractures may be indicated: (1) if treatment has been delayed for some
weeks and acetabular damage is suspected, or (2) in patients with metastatic disease or Paget’s disease. Hip
function and quality of life are reported to be better with total hip replacement, even when compared with
hemiarthroplasty, and there is some justification for using this as a preferred option in the healthy, active
person who needs treatment for a stage III or IV fracture (Keating, Grant et al. 2006).

Postoperatively, breathing exercises and early mobilization are important. Speed of recovery depends largely
on how active the patient was before the fracture; after 2–4 months, further improvement is unlikely.

Complications
General complications These patients, most of whom are elderly, are prone to general complications such as
deep vein thrombosis, pulmonary embolism, pneumonia and bed sores; not to mention disorders that might
have been present before the fracture and which lead to death in a substantial proportion of cases.
Notwithstanding the advances in perioperative care, the mortality rate in elderly patients may be as high as 20
per cent at 4 months after injury. Among the survivors over 80 years, about half fail to resume independent
walking.

Avascular necrosis Ischaemic necrosis of the femoral head occurs in about 30 per cent of patients with
displaced fractures and 10 per cent of those with undisplaced fractures. There is no way of diagnosing this at
the time of fracture. A few weeks later, an isotope bone scan may show diminished vascularity. X-ray changes
may not become apparent for months or even years. Whether the fracture unites or not, collapse of the femoral
head will cause pain and progressive loss of function (Figure 29.10). In patients over 45 years, treatment is by
total joint replacement.
In younger patients, the choice of treatment is controversial. Core decompression has no place in the
management of traumatic osteonecrosis. Realignment or rotational osteotomy is suitable for those with a
relatively small necrotic segment. Arthrodesis is often mentioned in armchair discussions, but in practice it is
seldom carried out. Provided the risks are carefully explained, including the likelihood of at least one revision
procedure, joint replacement may be justifiable even in this group. Non-union More than 30 per cent of all
femoral neck fractures fail to unite, and the risk is particularly high in those that are severely displaced. There
are many causes: poor blood supply, imperfect reduction, inadequate fixation, and the tardy healing that is
characteristic of intra-articular fractures. The bone at the fracture site is ground away, the fragments fall apart
and the screw cuts out of the bone or is extruded laterally. The patient complains of pain, shortening of the
limb and difficulty with walking. The x-ray shows the sorry outcome. The method of treatment depends on the
cause of the non-union and the age of the patient. In the relatively young, three procedures are available: (1) if
the fracture is nearly vertical but the head is alive, subtrochanteric osteotomy with internal fixation changes
the fracture line to a more horizontal angle; (2) if the reduction or fixation was faulty and there are no signs of
necrosis, it is reasonable to remove the screws, reduce the fracture, insert fresh screws correctly and also to
apply a bone graft across the fracture, either a segment of fibula or a muscle pedicle graft; and (3), if the head
is avascular but the joint unaffected, prosthetic replacement may be suitable; if the joint is damaged or
arthritic, total replacement is indicated. In elderly patients, only two procedures should be considered: (1) if
pain is considerable then the femoral head, no matter whether it is avascular or not, is best removed and
(provided the patient is reasonably fit) total joint replacement is performed; (2) if the patient is old and infirm
and pain not unbearable, a raised heel and a stout stick or elbow crutch are often sufficient.

Osteoarthritis Avascular necrosis or femoral head collapse may lead, after several years, to secondary
osteoarthritis of the hip. If there is marked loss of joint movement and widespread damage to the articular
surface, total joint replacement will be needed.

Combined fractures of the neck and shaft

Young patients with high-energy fractures of both the femoral neck and the ipsilateral femoral shaft present a
special problem. Both fractures must be fixed, and there are several ways of doing this. The femoral neck
fracture takes priority as complications following this fracture are generally more difficult to address than
those of the shaft fracture. Anatomic reduction and stable fixation of the femoral neck fracture must not be
compromised in order to accommodate fixation of the shaft fracture. The femoral neck fracture is reduced
using closed or, if necessary, open methods. The fracture is fixed using multiple screws. The femoral shaft
fracture can then be managed with a retrograde locked intramedullary nail (inserted through the knee) or by a
lateral plate inserted in a submuscular fashion.

FEMORAL SHAFT FRACTURES

The femoral shaft is circumferentially padded with large muscles. This provides advantages and
disadvantages: reduction can be difficult as muscle contraction displaces the fracture; however, healing
potential is improved by having this well-vascularized sleeve containing a source of mesenchymal stem cells,
and open fractures often need no more than split thickness skin grafts to obtain satisfactory cover. Mechanism
of injury This is usually a fracture of young adults and results from a high energy injury. Diaphyseal fractures
in elderly patients should be considered ‘pathological’ until proved otherwise. In children under 4 years the
possibility of physical abuse must be kept in mind. Fracture patterns are clues to the type of force that
produced the break. A spiral fracture is usually caused by a fall in which the foot is anchored while a twisting
force is transmitted to the femur. Transverse and oblique fractures are more often due to angulation or direct
violence and are therefore particularly common in road accidents. With severe violence (often a combination
of direct and indirect forces) the fracture may be comminuted, or the bone may be broken in more than one
place (a segmental fracture).

Pathological anatomy
Most fractures of the femoral shaft have some degree of comminution, although it is not always apparent on x-
ray. Small bone fragments, or a single large ‘butterfly’ fragment, may separate at the fracture line but usually
remain attached to the adjacent soft tissue and retain their blood supply. With more extensive comminution
there is no point of firm contact between proximal and distal fragments and the fracture is completely unstable
(Figure 29.20). This is the basis of a helpful classification (Winquist, Hansen et al. 1984). Fracture
displacement often follows a predictable pattern dictated by the pull of muscles attached to each fragment.
• In proximal shaft fractures the proximal fragment is flexed, abducted and externally rotated because of
gluteus medius and iliopsoas pull; the distal fragment is frequently adducted.
• In mid-shaft fractures the proximal fragment is again flexed and externally rotated but abduction is less
marked. • In lower third fractures the proximal fragment is adducted and the distal fragment is tilted by
gastrocnemius pull.

The soft tissues are always injured and bleeding from the perforators of the profunda femoris may be severe.
Over one litre may be lost into the tissues and, in the case of bilateral femoral shaft fractures, the patient can
become hypotensive quickly if not adequately resuscitated. Beware of the fracture at the junction of the
middle and distal thirds of the femoral shaft – it can be responsible for damaging the femoral artery in the
adductor canal.

Clinical features
There is swelling and deformity of the limb, and any attempt to move the limb is painful. With the exception
of a fracture through pathological bone, the large forces needed to break the femur usually produce
accompanying injuries nearby and sometimes further afield. Careful clinical scrutiny is necessary to exclude
neurovascular problems and other lower limb or pelvic fractures. An ipsilateral femoral neck fracture occurs
in about 10 per cent of cases and, if present, there is a one in three chance of a significant knee injury as well.
The combination of femoral shaft and tibial shaft fractures on the same side, producing a ‘floating knee’,
signals a high risk of multi-system injury in the patient. The effects of blood loss and other injuries, some of
which can be life-threatening, may dominate the clinical picture

X-ray
It may be difficult to obtain adequate views in the Accident and Emergency Room setting, especially views
that provide reliable information on proximal or distal fracture extensions or joint involvement; these can be
postponed until better facilities and easier patient positioning are possible. But never forget to x-ray the hip
and knee as well (Figure 29.21). A baseline chest x-ray is useful as there is a risk of adult respiratory distress
syndrome (ARDS) in those with multiple injuries. The fracture pattern should be noted; it will form a guide to
treatment.

Emergency treatment
Traction with a splint is first aid for a patient with a femoral shaft fracture. It is applied at the site of the
accident, and before the patient is moved. A Thomas’ splint, or one of the modern derivations of this practical
device, is ideal: the leg is pulled straight and threaded through the ring of the splint; the shod foot is tied to the
cross-piece so as to maintain traction and the limb and splint are firmly bandaged together. This temporary
stabilization helps to control pain, reduces bleeding and makes transfer easier. Shock should be treated; blood
volume is restored and maintained, and a definitive plan of action instituted as soon as the patient’s condition
has been fully assessed.

Definitive treatment
The patient with multiple injuries The association of femoral shaft fractures with other injuries, including
head, chest, abdominal and pelvic trauma, increases the potential for developing fat embolism, ARDS and
multi-organ failure. The risk of systemic complications can be significantly reduced by early stabilization of
the fracture, usually by a locked intramedullary nail. However, surgery to introduce a reamed intra - medullary
nail may produce untoward effects in those with severe chest injuries, especially when carried out within 24
hours of the fracture. It is thought the trauma of surgery and blood loss induces inflammatory changes that
may increase both morbidity and mortality – this phenomenon is called ‘the second hit’, referring to a second
episode of trauma, albeit surgical, on the patient. Consequently, in the multiply injured patient, particularly
one with severe chest trauma, prompt stabilization with an external fixator may be wise; the fixator can be
exchanged for an intramedullary nail when the patient’s condition stabilizes. The timing of this second
procedure is problematic. Some guidance can be sought from measurement of circulating levels of interleukin-
6, a pro-inflammatory cytokine (Pape, van Griensven et al. 2001); when the levels start to decrease, it should
be safe to perform ‘second hit’ interventions. Clinically this occurs around 5–7 days after admission, but this
window is by no means applicable to all patients nor is it conclusive at this time. Performing the exchange to
an intramedullary nail also carries the risk of transferring contaminants from pin sites to the intramedullary
nail; the earlier the operation is performed, the lower the risk. In the patient who spends a protracted period in
the intensive care unit, it may be safer to use external fixation as definitive treatment, perhaps with a return to
theatre later to allow insertion of new pins to increase the stability of the construct.

THE ISOLATED FEMORAL SHAFT FRACTURE

Traction, bracing and spica casts Traction can reduce and hold most fractures in reasonable alignment, except
those in the upper third of the femur. Joint mobility can be ensured by active exercises. The chief drawback is
the length of time spent in bed (10–14 weeks for adults) with the attendant problems of keeping the femur
aligned until sufficient callus has formed plus reducing patient morbidity and frustration. Some of these
difficulties are overcome by changing to a plaster spica or – in the case of lower third fractures – functional
bracing when the fracture is ‘sticky’, usually around 6–8 weeks.

The main indications for traction are (1) fractures in children; (2) contraindications to anaesthesia; and (3) lack
of suitable skill or facilities for internal fixation. It is a poor choice for elderly patients, for pathological
fractures and for those with multiple injuries. The various methods of traction are described in Chapter 23. For
young children, skin traction without a splint is usually all that is needed. Infants less than 12 kg in weight are
most easily managed by suspending the lower limbs from overhead pulleys (‘gallows traction’), but no more
than 2 kg weight should be used and the feet must be checked frequently for circulatory problems. Older
children are better suited to Russell’s traction (Chapter 23) or use of a Thomas’ splint. Fracture union will
have progressed sufficiently by 2–4 weeks (depending on the age of the child) to permit a hip spica to be
applied and the child is then allowed up. Consolidation is usually complete by 6–12 weeks. Adults (and older
adolescents) require skeletal traction through a pin or a tightly strung Kirschner wire behind the tibial tubercle.
Traction (8–10 kg for an adult) is applied over pulleys at the foot of the bed. The limb is usually supported on
a Thomas’ splint and a flexion piece allows movement at the knee (Figure 29.22). However, a splint is not
essential; indeed, skeletal traction without a splint (Perkins’ traction) has the advantages of producing less
distortion of the fracture and allowing freer movement in bed (Figure 29.23). Exercises are begun as soon as
possible.

Once the fracture is sticky (at about 8 weeks in adults) traction can be discontinued and the patient allowed up
and partial weightbearing in a cast or brace. For fractures in the upper half of the femur, a plaster spica is the
safest but it will almost certainly prolong the period of knee stiffness. For fractures in the lower half of the
femur, cast-bracing is suitable. This type of protection is needed until the fracture has consolidated (16–24
weeks).

Plate and screw fixation

Plating is a comparatively easy way of obtaining accurate reduction and firm fixation. The method was
popular at one time but went out of favour because of a high complication rate. This occurred when plates
were applied through a wide open exposure of the fracture site and perfect anatomical reduction of all bone
pieces. Such extensive surgery damaged the healing potential and led to tardy union and implant failure.
However, plates have encountered resurgence: today, they are inserted through short incisions and placed in a
submuscular plane, rather than deep to periosteum; an indirect (closed) reduction of the fracture is done; fewer
screws are used, and usually placed at the ends of the plate, leading to a less rigid hold on the fracture. This
technique of minimally invasive plate osteosynthesis (MIPO) has led to better union rates. However,
postoperative weightbearing will need to be modified as the implant is not as strong as an intramedullary nail.
The main indications for plates are (1) fractures at either end of the femoral shaft, especially those with
extensions into the supracondylar or pertrochanteric areas, (2) a shaft fracture in a growing child, and (3) a
fracture with a vascular injury which requires repair (Figure 29.24).

Intramedullary nailing
Intramedullary nailing is the method of choice for most femoral shaft fractures. However, it should not be
attempted unless the appropriate facilities and expertise are available. The basic implant system consists of an
intramedullary nail (in a range of sizes) which is perforated near each end so that locking screws can be
inserted transversely at the proximal and distal ends; this controls rotation and length, and ensures stability
even for subtrochanteric and distal third fractures (Figure 29.25).
These important details should be remembered when using locked intramedullary nails:
1. Reamed nails have a lower need for revision surgery when compared to unreamed nails.
2. Select a nail that is approximately the size of the medullary isthmus so that it fills the canal reasonably well
(after reaming) and adds to stability – small diameter nails are quicker to insert but more frequently lead to the
need for revision surgery.
3. Consider alternative means of fracture fixation if the isthmus is so narrow that a large amount of canal
reaming will have to be done in order to fit the smallest diameter nail available.
4. Use a nail of sufficient length to fully span the canal.
5. Antegrade insertion (through either the piriformis fossa or the tip of the greater trochanter, depending on the
design of nail) or retrograde insertion (through the intercondylar notch distally) are equally suitable techniques
to use; there is a small incidence of hip and thigh pain with antegrade nails, whereas there is a small problem
with knee pain with retrograde nails. Retrograde insertion of intramedullary nails is particularly useful for:
obese patients; when there are bilateral femoral shaft fractures (as the procedure can be performed without the
need for a fracture table and the added time for setting up for each side); when there is a tibial shaft fracture on
the same side; and if there is a femoral neck fracture more proximally, as screws can be inserted to hold this
fracture without being impeded by the nail.

Stability is improved by using interlocking screws; all locking holes in the nail should be used. Often there is
enough shared stability between the nail and fracture ends to allow some weightbearing early on. The fracture
usually heals within 20 weeks and the complication rate is low; sometimes malunion (more likely malrotation)
or delayed union (from leaving the fracture site over-distracted) occurs.
Open medullary nailing is a feasible alternative where facilities for closed nailing are lacking. A limited lateral
exposure of the femur is made; the fracture is reduced and a guidewire is passed between the main proximal
and distal fragments. A small exposure to achieve reduction does not significantly affect the risk of
complications or fracture healing as compared to ‘closed’ nailing.

External fixation The main indications for external fixation are (1) treatment of severe open injuries; (2)
management of patients with multiple injuries where there is a need to reduce operating time and prevent the
‘second hit’; and (3) the need to deal with severe bone loss by the technique of bone transport. External
fixation is also useful for (4) treating femoral fractures in adolescents (Figure 29.26). Like closed
intramedullary nailing, it has the advantage of not exposing the fracture site and small amounts of axial
movement can be applied to the bone by allowing a telescoping action in the fixator body (with some designs
of external fixator). As the callus increases in volume and quality, the fixator can be adjusted to increase stress
transfer to the fracture site, thus promoting quicker consolidation. However, there are still problems with pin-
site infection, pin loosening and (if the half-pins are applied close to joints) limitation of movement due to
interference with sliding structures.

The patient is allowed up as soon as he or she is comfortable and knee movement exercises are encouraged to
prevent tethering by the half pins. Partial weightbearing is usually possible immediately but this will depend
on the x-ray appearance of callus – this may take some time (more than 6 weeks) if the fixator is a rigid
device. Most femoral shaft fractures will unite in under 5 months but some take longer if the fracture is badly
comminuted or contact between fracture ends is poor.

Treatment of open fractures Open femoral fractures should be carefully assessed for (1) skin loss; (2) wound
contamination; (3) muscle ischaemia; and (4) injury to vessels and nerves. The immediate treatment is similar
to that of closed fractures; in addition, the patient is started on intravenous antibiotics. The wound will need
cleansing: it should be extended to give unhindered access, contaminated areas and dead tissue must be
excised and the entire area should be washed thoroughly. Stabilization of open femoral shaft fractures is best
achieved with locked intramedullary nails unless there is heavy contamination or bone loss – in which case
external fixation (if necessary with the capacity to deal with bone loss through distraction osteogenesis) is
preferable.

Complex injuries
FRACTURES ASSOCIATED WITH VASCULAR INJURY
Warning signs of an associated vascular injury are (1) excessive bleeding or haematoma formation; and (2)
paraesthesia, pallor or pulselessness in the leg and foot. Do not accept ‘arterial spasm’ as a cause of absent
pulses; the fracture level on x-ray will indicate the region of arterial damage and arteriography may only delay
surgery to re-establish perfusion. Most femoral fractures with vascular injuries will have had warm ischaemia
times greater than 2–3 hours by the time the patient arrives in the operating theatre; when this exceeds 4– 6
hours, salvage may not be possible and the risk of amputation rises. This means that diagnosis must be prompt
and re-establishing perfusion a priority; fracture stabilization is secondary.

A recommended sequence for treatment, particularly if the warm ischaemia time is approaching the salvage
threshold, is (a) to create a shunt from the femoral vessels in the groin to beyond the point of injury using
plastic catheters; (b) to stabilize the fracture (usually by plating or external fixation) and then (c) to carry out
definitive vascular repair. This sequence establishes blood flow quickly and permits fracture fixation and
vascular repair to be carried out without pressure of time.

FRACTURE ASSOCIATED WITH KNEE INJURY

Femoral fractures are frequently accompanied by injury to the ligaments of the knee. Direct blows to the knee
from the dashboard of a car in an accident will damage knee ligaments as well as break the femoral shaft and
femoral neck – this triad of problems should be recognized. With attention focused on the femur, the knee
injury is easily overlooked, only to re-emerge as a persistent complaint weeks or months later. As soon as the
fracture has been stabilized, the knee should be carefully examined and any associated abnormality treated.

‘FLOATING KNEE’
Ipsilateral fractures of the femur and tibia may leave the knee joint ‘floating’. This is a very serious situation,
and other injuries are often present. Both fractures will need immediate stabilization – an anterior approach to
the knee joint will allow both fractures to be stabilized by intramedullary nails – retrograde for the femur and
antegrade for the tibia. It is usual to fix the femur first.

COMBINED NECK AND SHAFT FRACTURES

This is dealt with on page 850. The most important thing is diagnosis: always examine the hip and obtain an x-
ray of the pelvis. Both sites must be stabilized, first the femoral neck and then the femur. Parallel screw
fixation of the femoral neck followed by retrograde femoral nailing is a useful way to treat this problem.

PATHOLOGICAL FRACTURES
Fractures through metastatic lesions should be fixed by intramedullary nailing. Provided the patient is fit
enough to tolerate the operation, a short life expectancy is not a contraindication. ‘Prophylactic fixation’ is
also indicated if a lytic lesion is (a) greater than half the diameter of the bone; (b) longer than 3 cm on any
view, or (c) painful, irrespective of its size. Paget’s disease, fibrous dysplasia or rickets may present a
problem. The femur is likely to be bowed and, in the case of Paget’s disease, abnormally hard. An osteotomy
to straighten the femur may be necessary to allow a nail to be inserted fully (Figure 29.27).

PERIPROSTHETIC FRACTURES
Femoral shaft fractures around a hip implant are uncommon; they may happen during primary hip surgery
when reaming or preparing the medullary canal, or when forcing in an over-sized uncemented prosthesis, or
during revision surgery while extracting cement or attempting to dislocate the hip if the soft tissue release has
been insufficient. Sometimes the fracture occurs much later, and there are usually x-ray signs of osteolysis or
implant loosening suggesting a reason for bone weakness.
If the prosthesis is worn or loose, it should be removed and replaced by one with a long stem, thereby treating
both problems. If the primary implant is neither loose nor worn it can be left in place and the fracture treated
by plate fixation with structural allografts bridging the fracture (Figure 29.28).

Complications of femoral shaft fractures

All the complications described in Chapter 23, with the exception of visceral injury and avascular necrosis, are
encountered in femoral shaft fractures. The more common ones are as follows.

EARLY
Shock One or two litres of blood can be lost even with a closed fracture, and if the injury is bilateral shock
may be severe. Prevention is better than cure; most patients will require a transfusion.

Fat embolism and ARDS Fracture through a large marrow-filled cavity almost inevitably results in small
showers of fat emboli being swept to the lungs. This can usually be accommodated without serious
consequences, but in some cases (and especially in those with multiple injuries and severe shock, or in patients
with associated chest injuries) it results in progressive respiratory distress and multi-organ failure (adult res
piratory distress syndrome). Blood gases should be measured if this is suspected and signs such as shortness of
breath, restlessness or a rise in temperature or pulse rate should prompt a search for petechial haemorrhages
over the upper body, axillae and conjunctivae. Treatment is supportive, with the emphasis on preventing
hypoxia and maintaining blood volume.

Thromboembolism Prolonged traction in bed predisposes to thrombosis. Movement and exercise are important
in preventing this, but high-risk patients should be given prophylactic anticoagulants as well. Vigilance is
needed and full anticoagulant treatment is started immediately if thigh or pelvic vein thrombosis is diagnosed.

Infection In open injuries, and following internal fixation, there is always a risk of infection. Prophylactic
antibiotics and careful attention to the principles of fracture surgery should keep the incidence below 2 per
cent. If the bone does become infected, the patient should be treated as for an acute osteomyelitis. Antibiotic
treatment may suppress the infection until the fracture unites, at which time the femoral nail can be removed
and the canal reamed and washed out. However, if there is pus or a sequestrum, a more radical approach is
called for: the wound is explored, all dead and infected tissue is removed and the nail as well; the canal is
reamed and washed out and the fracture is then stabilized by an external fixator. Replacement of the external
fixator by another intramedullary nail can be risky, and much depends of the nature of the infecting organism
(its sensitivity or resistance to antibiotics), the length of time during which the infection has been present and
the quality of the surgical debridement. The long-term management of chronic osteo - myelitis is discussed in
Chapter 2.
LATE
Delayed union and non-union The time-scale for declaring a delayed or non-union can vary with the type of
injury and the method of treatment. If there is failure to progress by 6 months, as judged by serial x-rays, then
intervention may be needed. A common practice is to remove locking screws from the intramedullary nail to
enable the fracture to ‘collapse’ (‘dynamise’ in modern orthopaedic parlance). This can be successful in a
small proportion of cases; more often it fails and results in pain as rotational control of the fracture is lost (the
femur is often subject to torsional forces in walking). A better course is to remove the nail, ream the medullary
canal and introduce a larger diameter nail – exchange nailing. Bone grafts should be added to the fracture site
if there are gaps not closed at the revision procedure.

Malunion Fractures treated by traction and bracing often develop some deformity; no more than 15 degrees of
angulation should be accepted (Figure 29.29). Even if the initial reduction was satisfactory, until the x-ray
shows solid union the fracture is too insecure to permit weightbearing; the bone will bend and what previously
seemed a satisfactory reduction may end up with lateral or anterior bowing.

Malunion is much less likely in those treated with static interlocked nails; yet it does still occur – especially
malrotation – and this can be prevented only by meticulous intra-operative and post-operative assessment
followed, where necessary, by immediate correction. Shortening is seldom a major problem unless there was
bone loss; if it does occur, treatment will depend on the amount and its clinical impact – sometimes all that is
needed is a built-up shoe.

Joint stiffness The knee is often affected after a femoral shaft fracture. The joint may be injured at the same
time, or it stiffens due to soft-tissue adhesions during treatment; hence the importance of repeated evaluation
and early physiotherapy.

Refracture and implant failure Fractures which heal with abundant callus are unlikely to recur. By contrast, in
those treated by internal fixation, callus formation is often slow and meagre. With delayed union or non union,
the integrity of the femur may be almost wholly dependent on the implant and sooner or later it will fail. If a
comminuted fracture is plated, bone grafts should be added and weightbearing delayed so as to protect the
plate from reaching its fatigue limit too soon. Intramedullary nails are less prone to break. However,
sometimes they do, especially with a slowhealing fracture of the lower third and a static locked nail; the break
usually occurs through the screw-hole closest to the fracture. Treatment consists of replacing the nail and
adding bone grafts. In resistant cases, the fracture site may need excising (as viability of the bone ends is poor)
followed by distraction osteogenesis which simultaneously stabilizes the limb and deals with the length
discrepancy (Figure 29.30).