Anda di halaman 1dari 45

Fractures of the Femoral

Shaft

Dr. A. Pathak
Assistant Professor
Orthopaedics
Gandhi Medical college, Bhopal
http://www.esnips.com/web/apathak
Femur Fractures
 Common injury due to major violent trauma
 1 femur fracture/ 10,000 people
 More common in people < 25 yo or >65 yo
 Femur fracture leads to reduced activity for 107
days, the average length of hospital stay is 25
days
 Motor vehicle, motorcycle, auto-pedestrian,
aircraft, and gunshot wound accidents are most
frequent causes

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

http://www.esnips.com/web/apathak
MECHANISM OF INJURY

http://www.esnips.com/web/apathak
MECHANISM OF INJURY

High velocity In children


trauma in young Pathological
(<4) child
adults fracture in elderly
abuse is a
should be
possibility.
suspected

http://www.esnips.com/web/apathak
Femur Fractures- Associated
Injuries
 Struck by car- triad of femur
fracture, torso injuries, head injury
 Potential damage to physes of femur
and proximal tibia in children
 Head Injury – spasticity can make
traction and cast treatment difficult
 Abdominal injury – spica cast can
constrict abdomen and limit ability to
examine

http://www.esnips.com/web/apathak
Physical Exam
 Complete exam: head, chest,
abdomen, and other skeletal
segments
 Document distal neurologic and
vascular function
 Palpate all bones
 First Aid principles - Splint or
traction, especially prior to transfer
to another institution

http://www.esnips.com/web/apathak
Radiographic Evaluation
 AP Pelvis
 AP/Lat femur
 Visualize hip & knee joints

http://www.esnips.com/web/apathak
Classification
 Open or closed
 Location of fracture- subtrochanteric,
diaphyseal (proximal, mid, distal
third), supracondylar
 Fracture pattern- transverse, spiral,
oblique, comminuted, greenstick
 Amount of shortening
 Angular deformity

http://www.esnips.com/web/apathak
Decision Making
 Age
 Mechanism of injury
 Fracture pattern & location
 Associated Injuries
 Surgeon preference

http://www.esnips.com/web/apathak
Fracture pattern

http://www.esnips.com/web/apathak
Spiral fractures are seen where fall on a
fixed foot transmits an oblique twisting
force
http://www.esnips.com/web/apathak
Transverse or short oblique fractures are due to high
velocity direct trauma and are commonest in RTA

http://www.esnips.com/web/apathak
Segmntal or Communited fractures are due to a combination of
direct and twisting force

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

http://www.esnips.com/web/apathak
DISTAL THIRD FEMORAL FRACTURES
The proximal fragment may abduct or adduct while the distal
fragment is flexed by gastrocnemius

http://www.esnips.com/web/apathak
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
http://www.esnips.com/web/apathak
blood in the thigh
Traction Techniques
 Skin or skeletal
 Avoid physes if place skeletal traction
pins in children
 Place pin perpendicular to shaft to avoid
varus/valgus angulation
 Longitudinal in line traction for comfort
prior to definitive treatment
 Split Russells traction (90-90) if awaiting
early healing prior to casting

http://www.esnips.com/web/apathak
Classification
 Most femoral shaft fractures have some
degree of communition, although it may not
be readily apparent on x-ray.

 In closed communited fractures, the small


fagemnts are live bony pieces with intact
soft tissue attachments and blood supply

http://www.esnips.com/web/apathak
 This forms the basis of the Winquist
classification.

http://www.esnips.com/web/apathak
CLINICAL FEATURES
 PAIN
 SWELLING
 DEFORMITY
 INABILITY TO BEAR WEIGHT
 SHOCK AND ITS SYMPTOMS
 BEWARE! MULTISYSTEM INURY

http://www.esnips.com/web/apathak
X RAYS
 X rays can be postponed until shock is taken care
of.

 Remember to immobilize the facture first, the


attempt to take the radiographs

Never forget to X ray the pelvis.


- hip fractures and dislocation
- pelvic fractures and disruption
get a baseline chest X-ray done – ARDS and Fat
embolism may supervene

http://www.esnips.com/web/apathak
http://www.esnips.com/web/apathak
EMERGENCY CARE

http://www.esnips.com/web/apathak
Hare traction splint for initial
reduction of femur fractures prior to
OR or skeletal traction

http://www.esnips.com/web/apathak
COMPLICATIONS EXPECTED AT
THIS STAGE

SHOCK NOT
FAT EMBOLISM
RESONDING TO
AND ARDS
RESUSCITATION

http://www.esnips.com/web/apathak
FIXATION ?
 Best done at this stage with
interlocking intramedullary nailing

 Not always possible due to lack of


expertise, image intensifier, fracture
table, or instrumentation.

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

http://www.esnips.com/web/apathak
Gallows and Russel’s
tractions need a spica
apllication after 4-5 weeks

http://www.esnips.com/web/apathak
Hip spica

http://www.esnips.com/web/apathak
Surgical Options
 Plate & screw fixation
 External fixation
 Flexible nailing
 Rigid nailing

http://www.esnips.com/web/apathak
Gerhard Kuntscher
Technik der Marknagelung, 1945

Straight
nail with 3
point
fixation
First IM
nailing but
not locking
http://www.esnips.com/web/apathak
Klemm K, Schellman WD:
Veriegelung des marnagels,
1972

Locking IM nails in the


1980’s

Kempf I, Grosse A: Closed


Interlocking Intramedullary Nailing. Its
Application to Comminuted fractures
of the femur, 1985
http://www.esnips.com/web/apathak
Methods of internal fixation

http://www.esnips.com/web/apathak
Methods of internal fixation

http://www.esnips.com/web/apathak
Flexible Nailing
 Advantages – allows early mobilization
without cast, cosmetic scars, avoids
physes and blood supply to femoral head
 Disadvantages – later nail removal, ends
may irritate soft tissues, may not be
amenable to some fracture patterns (very
proximal or distal, comminution)

http://www.esnips.com/web/apathak
http://www.esnips.com/web/apathak
ORIF with Plates/Screws
 Advantages – rigid, technique familiar
to most surgeons, allows early
motion, favorable results reported in
children with associated head injuries
 Disadvantages- large scar, possible
refracture after plate removed, higher
infection rate in some earlier series

http://www.esnips.com/web/apathak
ORIF Plate Fixation

http://www.esnips.com/web/apathak
Methods of internal fixation

http://www.esnips.com/web/apathak
Percutaneous Bridge
Plating

http://www.esnips.com/web/apathak
Open Femur Fracture
Principles
 IV antibiotics, tetanus
prophylaxis
 emergent irrigation &
debridement
 skeletal stabilization
 External fixation best
option with severe
soft tissue injury
 soft tissue coverage

http://www.esnips.com/web/apathak
External fixation

http://www.esnips.com/web/apathak
Complications
 Early :
• Shock

• Fat embolism and ARDS

• Thromboembolism

http://www.esnips.com/web/apathak
Complications
 Late :
• Delyed or non union

• Malunion

• Joint stiffness

• Refracture and implant failure

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