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Fractures of the femur
AO Principles Course
Leeds2005
Module : Principles of operative management of common fractures
David L ShawDavid L Shaw
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Fractures of the Femoral Fractures of the Femoral ShaftShaft (AO 3.2)(AO 3.2)
Why should I fix the #?Why should I fix the #? How should I fix it ?How should I fix it ? What complications can I expect ?What complications can I expect ?
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Paediatric fracturesPaediatric fractures
See articleSee article GallowsGallows Hip SpicaHip Spica TractionTraction
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Why fix the #Why fix the #
Save life Save life Poly traumaPoly trauma
Save limbSave limb
Preserve functionPreserve function Stabilisation with immediate rehabilitationStabilisation with immediate rehabilitation
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Choose a method ?Choose a method ?
PlatingPlating Rigid fixation Abs stability Rigid fixation Abs stability LISSLISS LCPLCP
Ext fixnExt fixn
IM NailIM Nail
•Consider absolute vs relative stabilityConsider absolute vs relative stability•Consider soft tissues and scarsConsider soft tissues and scars•Consider facilities and equipmentConsider facilities and equipment
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Choose a method 2Choose a method 2
Patient factorsPatient factors Facilities, time and polytraumaFacilities, time and polytrauma Damage control orthopaedicsDamage control orthopaedics
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““Get me a nail!”Get me a nail!”
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Rods & NailsRods & Nails
When is a nail not a nailWhen is a nail not a nail Hollow – Slotted – SolidHollow – Slotted – Solid
Why nails failWhy nails fail
Effects of ReamingEffects of Reaming
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Bones & NailsBones & NailsHollow structuresHollow structures
Hollow bones for strengthHollow bones for strength
Early nails were hollow & needed 3 point Early nails were hollow & needed 3 point fixationfixation
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Kuntcher - Clover leaf Kuntcher - Clover leaf nailnail
3 point fixation3 point fixation
Inserted open so no Inserted open so no guide wire requiredguide wire required
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GK & AOGK & AO – Slotted hollow nail – Slotted hollow nail
Allowed guide wire insertion Allowed guide wire insertion
Flat sheet manufactureFlat sheet manufacture
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Reaming to increase the Reaming to increase the contact areacontact area
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Lets talk about stiffnessLets talk about stiffness
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Bending StiffnessBending StiffnessSecond Moment of Inertia Second Moment of Inertia (I)(I)
TubeTube I=(RoI=(Ro44 – Ri – Ri44) * ) * ¶/4¶/4
Radius Radius cubedcubed
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Hollow structures are relatively strong for the volume of Hollow structures are relatively strong for the volume of materialmaterial
For a given increase in radius torsional and bending For a given increase in radius torsional and bending stiffness go up to the fourth powerstiffness go up to the fourth power
Torsional stiffness roughly 2x inc vs bending as radius Torsional stiffness roughly 2x inc vs bending as radius
At physiological loads torsional deformation more At physiological loads torsional deformation more clinically evidentclinically evident
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Slotted nails especially Slotted nails especially are weak in torsionare weak in torsion
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The advantage of The advantage of “Unreamed”“Unreamed”
Solid Ti nails are strong enough at Solid Ti nails are strong enough at diameters small enough to be inserted diameters small enough to be inserted without reaming without reaming
Not possible with SS nailsNot possible with SS nails
ExpensiveExpensive
The advantage of The advantage of SolidSolid
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““You be the Judge”You be the Judge”
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For For unreamedunreamed
Healing Healing 170 #170 # Equivalent healing time (19/52)Equivalent healing time (19/52) 55mins quicker55mins quicker = delayed unions= delayed unions Reynders Injury 2000Reynders Injury 2000
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General ResultsGeneral Results 164# retrospective series164# retrospective series 93% union rate with UFN93% union rate with UFN AO type C healed at 6.2mo (ave)AO type C healed at 6.2mo (ave) UFN “healing rates comparable with UFN “healing rates comparable with
historical standards”historical standards” Herscovici JOT 2000Herscovici JOT 2000
For For unreamedunreamed
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For For unreamedunreamed
Intramedullary pressureIntramedullary pressure Clinical trial 38 ptsClinical trial 38 pts 5x increased pressure in reamed group5x increased pressure in reamed group Pressure correlated with fat extravasationPressure correlated with fat extravasation Berger JOT 1997Berger JOT 1997
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Poly TraumaPoly Trauma Femur # in polytrauma pts managed by;Femur # in polytrauma pts managed by;
Early Total CareEarly Total Care Intermediate Stabilisation Intermediate Stabilisation ““Damage Control Surgery”Damage Control Surgery” ““A significant reduction in the incidence of A significant reduction in the incidence of
complications was found ..regardless of the type complications was found ..regardless of the type of fixation”of fixation”
Garapati & Krettek J of T 2002Garapati & Krettek J of T 2002
For For unreamedunreamed
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Against unreamed Against unreamed methodmethod
Healing Healing 147#147# 6 weeks longer to heal 6 weeks longer to heal Giannoudis Injury 1997Giannoudis Injury 1997
172#172# 4 weeks longer to heal4 weeks longer to heal More “technical complications”More “technical complications” Tornetta JOT 2000Tornetta JOT 2000
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Against unreamed Against unreamed methodmethod
Stimulation of the inflammatory systemStimulation of the inflammatory system IL6, CD11b, s-ICAM-1, E-selectin & elastaseIL6, CD11b, s-ICAM-1, E-selectin & elastase Reamed vs Unreamed Reamed vs Unreamed Evidence of a “second hit” to the immune Evidence of a “second hit” to the immune
systemsystem No difference reamed vs unreamed No difference reamed vs unreamed
Giannoudis JBJS(B) 1999Giannoudis JBJS(B) 1999
• If you don’t ream you still get a second If you don’t ream you still get a second hit to the immune systemhit to the immune system
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Against unreamed Against unreamed methodmethod
ComplicationsComplications 100 randomised pts 100 randomised pts
2x iatrogenic comminution in unreamed2x iatrogenic comminution in unreamed Reaming was “required” in the unreamed Reaming was “required” in the unreamed
group in 3group in 3 Shepherd J Orthop Trauma 2001Shepherd J Orthop Trauma 2001
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For unreamedFor unreamed QuickerQuicker SimplerSimpler Less equipmentLess equipment Equivalent healing rateEquivalent healing rate Less fat embolusLess fat embolus Less H-OLess H-O Lower immune “hit”Lower immune “hit”
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For reamedFor reamed
Faster unionFaster union Fewer implant Fewer implant
related complicationsrelated complications Lung injury not Lung injury not
directly & only directly & only caused by reamingcaused by reaming
““Second hit” not Second hit” not specifically caused specifically caused by reamingby reaming
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It’s all about techniqueIt’s all about technique
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Reaming is a Reaming is a techniquetechnique
Solid nails are implantsSolid nails are implants
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Solid nail ?Solid nail ?
Who would put a Who would put a 9mm nail in this pt!9mm nail in this pt!
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Summary & “Verdict”Summary & “Verdict”
Reaming is a technique Reaming is a technique
Solid vs Slotted vs Cannulated Solid vs Slotted vs Cannulated is a design / manufacturing processis a design / manufacturing process
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““I always do reamed I always do reamed nails”nails”
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SummarySummary
Chose the smallest nail which is strong Chose the smallest nail which is strong enough for the patient and his/her injuryenough for the patient and his/her injury
Ream if necessary to put the appropriate Ream if necessary to put the appropriate size of nail in for the patient & injurysize of nail in for the patient & injury
Don’t confuse implants with techniqueDon’t confuse implants with technique
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Other peoples’ Other peoples’ complicationscomplications
•General complicationsGeneral complications
•Specific # related comlpicationsSpecific # related comlpications
•MalunionMalunion
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Cambell’s Operative Cambell’s Operative OrthopaedicsOrthopaedics
““Malunions after closed treatment are the Malunions after closed treatment are the rule”rule”
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MalrotationMalrotation
> 10 degrees in 8-19% of fractures> 10 degrees in 8-19% of fractures
JBJS 75 (B) 799-803JBJS 75 (B) 799-803 JBJS 66 (A) 529-39JBJS 66 (A) 529-39
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Cambell’s Operative Cambell’s Operative OrthopaedicsOrthopaedics
““..become significant only if they result in..become significant only if they result in shortening of more than 2.5 cmshortening of more than 2.5 cm angulated more than 10 degreesangulated more than 10 degrees internally or externally rotated to the point internally or externally rotated to the point
that the knee cannot be aligned with that the knee cannot be aligned with forward motion during gait.”forward motion during gait.”
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? How much rotation ?? How much rotation ?
External rotation less well compensated External rotation less well compensated
than internalthan internal 15 degree limit15 degree limit Based on functional assessments and Based on functional assessments and
FPAFPA Nijmegen group: Injury 35 1270-1278 2004Nijmegen group: Injury 35 1270-1278 2004
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Malunion Malunion
> 2.5 cm shortening> 2.5 cm shortening > 10> 10° angular deformity° angular deformity >15>15° rotation deformity° rotation deformity
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Malunion Malunion
> 2.5 cm shortening> 2.5 cm shortening > 10> 10° angular deformity° angular deformity Rotation that the pt can see !Rotation that the pt can see !
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Fractures of the Femoral Fractures of the Femoral ShaftShaft (AO 3.2)(AO 3.2)
Why should I fix the #?Why should I fix the #? Damage controlDamage control Restore functionRestore function
How should I fix it ?How should I fix it ? For the fracture / for the patientFor the fracture / for the patient
What complications can I expectWhat complications can I expect Length , Rotation the pt can seeLength , Rotation the pt can see
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