femoralfracturepresentation-130220092741-phpapp02

8/12/2019 femoralfracturepresentation-130220092741-phpapp02

1/38

ACCIDENTAL FEMORAL SHAFT FRACTURES:ITS

MANAGEMENT

Orthopaedic unit

presentation

PRESENTER :

DR MUKORO D GEORGE

B.sc,MBBS

DR AGBIKI DOYE

MD


2/38

CASE PRESENTATIONS

Femoral fracture has

been a common

presentation in thisfacility , shaft fractures

is the commonest part

involved in recent

months ,common

implicated causes are

RTA and fall from

heights. They usuallyassociate and present

with other injuries,

morbidity, and

mortality.


3/38

CASE PRESENTATION 1

Miss I.I. ,24 yr old waiteress, Admitted viaA/E 27/1/2012, with history of inability to

move Left Lower Limb 19 hrs durationfollowing an RTA on a motorcycle).

Sustained wound to left knee, thighswelling .

On general exam- , conscious ,not pale,afebrile. PR 126 b/min, Bp 110/70mmhg

RR 24c/min.

Sutured laceration Lt knee, medial sideof Lt leg, swelling of the knee,

Marked abduction of the leg at rest

X-RAY:Displaced Spiral fracture of distalshaft of the Rt femur with medialcondylar and patella fractures.

ASS:Rt femoral fracture with intra-

articular involvement following a RTA


4/38

MANAGEMENT .

HAD resuscitative measures at A/E

Along With anti tetanus prophylaxis,IV fluids

ORIF with condylar plate for spiral

fracture ,cancellous screw forcondylar fragment fixation andfixation of the avulsed posteriorcruciate ligament , on 26thday afterpresentation

Analgesics, blood transfusion,antibiotics, hematinics,antithrombotic

Currently on the ward ,immobilizedwith Above knee synthetic cast


5/38

OPERATION SECTION

Distal bonefragment with

spiral edge withgood exposure .

Stay close to the bone as much as

possible


6/38

CASE PRESENTATION TWOMr O.J ,43 year old Architect Admitted via A/E

(22/12/11)with history of multiple injuries

following a RTA (motorcycle) ,4 hrs to

presentation.Sustained facial swelling ,open injury to left thigh

.loss of consciousness which improved within 4

hrs

Generally , Conscious but drowsy. GCS 13/15 ,not

pale, febrile 37.2 C, receiving oxygen viaintranasal prongs ,PR 100 b/min,BP 120/80mmhg,

RR 32c/min

Hemifacial swelling (left side),enclosing

mandibular region ,left thigh swelling and

deformity,wound 6cm in dimensionX-RAY result:communited segmental fracture of

left femur with associated fracture of the

mandible

Mild head injury with left femoral fracture 2 to

RTA


7/38

MANAGEMENTHAD resuscitative measures at A/E

Along with cervical collar, antitetanus prophylaxis ,IV fluids

ORIF with condylar plate on 14thday after presentation

Blood transfusion, Analgesics,,antibiotics,,hemtinics

Discharged 15th DAY post -op With

clutches

Follow upVIA clinic with POST-OP

X-ray film.


8/38

IN SUMMARY

In the last 2 months we had several cases of

femoral fractures , with a few bilateral. Some

opt-for surgical intervention .

Surgical option should be seen as the best

option for management of femoral fracture

following RTA ,to allow for early mobilization

,knowing well that:

life is movement and movement is life .

THANK YOU


9/38

PRESENTATION CONTINUE

Introduction

Anatomy of thefemur

Epidemiology offemoral fractures

Aetiology

mechanism Classification of

shaft fractures

Clinical features

Investigations

Treatment complications


10/38

INTRODUCTION

A fracture by definition, is a break in the

continuity of a bone. It occurs when an

external force overcomes the modules of

elasticity of the bone.

Strongest and largest bone.

Femoral shaft fractures ,may be associated

with multisystem trauma.


11/38

ANATOMY OF THE FEMUR


12/38

BLOOD SUPPLY


13/38

ANATOMICAL RELATIONS


14/38

EPIDEMIOLOGY

Common injury : major violent trauma

1 femur fracture/ 10,000 people

More common : < 25 y or >65 yRTA , waterway motorcycle, fall from height

and gunshot wound accidents are most

frequent causes.


15/38

AETIOLOGY

. Trauma.

RTA (motorcycle races, auto/pedestranaccident, auto crash, plane crash, vehicle,).

Sports(skiing, football, hockey).

Falls(mountain, pole).

Gunshot.

Pathologic

Stress


16/38

MECHANISM

High Energy

Often high-speed impact or rapid deceleration

But may take surprisingly little energy in children

Direct blow

Proximal - distal compression Twisting/torsion Injury

Shear

Compression with angulation

Fall from height

High speed collisions

Often seen in combination with other significant injuries


17/38

AETIOLOGY /MECHANISM CONTD


18/38

CLASSIFICATIONS:0TA/A0


19/38

Winquist and Hansen 66A, 1984

CLASSIFICATION

Type 0 - No comminution

Type 1 - Insignificant butterfly

fragment with transverse or

short oblique fracture

Type 2 - Large butterfly of less

than 50% of the bony width, >

50% of cortex intact

Type 3 - Larger butterfly

leaving less than 50% of the

cortex in contact

Type 4 - Segmental

comminution


20/38

ACCORDING TO THE PRESENCE/ABSENCE OF WOUND.

1. OPEN FRACTURES

2. CLOSE FRACTURES


21/38

SYNTOMS

Age/sex/occupation

Duration

Severe pain Swelling

Inability to move the limb

Deformity shortening


22/38

SIGNS

tenderness

visible deformity

shortening

crepitus

Swollen thigh

Signs of vascular compromise should be lookedout for to rule out vascular injury.

- absent or diminished pulses- expanding haematoma

- tachycardia

- hypotension


23/38

INVESTIGATIONS

Done after the initial resuscitation of the

patient.

PCV/Hb

Radiograph of the affected femur, adjacentjoints and hip.(rule of 2s)

Wound swab for m/c/s in open fractures.

E/U/CrDepends on the patients presentation.


24/38

FIELD MANAGEMENT

Control bleeding, treat shock Dress wounds Distal CMS :FACT Manual stabilization

Traction splint for mid-shaft fracture Backboard without traction for hip injury

Re-check CMS Address other injuries as needed Early coordination with EMS agencies

ALS transport criteria per local protocol Frequent vital sign checks and documentation

Expedited transport to definitive care


25/38

TREATMENT

Initial resuscitation.

Definitive treatment.

- non operative / conservative

- operative

Physiotherapy.


26/38

INITIAL RESUSCITATION

ABCD of resuscitation. IV Fluid

IV antibiotics

Oxygen

Anti-tetanus prophylaxis

Blood transfusion

Analgesics

Wound care (wound debridement ).

Splinting


27/38

DEFINITIVE TREATMENT

Non operative /Conservative mgt

split

traction

casting (for children < 8 years)


28/38

HARE TRACTION


29/38

GALLOW SKIN TRACTION THOMAS SPLIT


30/38

OPERATIVE METHODS

Operative treatment.

1) ORIF

2) External fixation3) Minimally invasive method.


31/38

INDICATIONS FOR FEMORAL SHAFT ORIF

Inability to secure and maintain reduction by

manipulation.

Old and frail px.

Px with multiple injuries.

Pathological fractures.

Fractures suitable for nailing.

Early ambulation is needed.


32/38

ORIF :1. Intramedullary nails are used e.g.

Kuntcher

interlocking nail{Grosses and Kempf }

This could be done either by antegrade or

retrograde ;reamed and non reamed method.

2. Plate and screws.


33/38

ANTEGRADE IM NAILING RETROGRADE IM NAILING


34/38

External

fixation is

usually

used for

open

fractures ofthe femoral

shaft with

severe softtissue

injury.


35/38

Minimally

invasive

method

involves

closed

method of IMnailing under

image

intensification.eg :ESIN


36/38

REHABILITATION /PHYSIOTHERAPY

This should be started early as soon as thepain begins to settle. Exercises forquadriceps, leg and foot are necessary to

preserve muscle tone and prevent deformity.For post surgical patients, it can be started

two weeks after surgery but the patientshould not bear weight.

Physiotherapy continues after dischargefrom the hospital.


37/38

COMPLICATIONS

EARLY Infection

Hypovolaemic shock.

Fat embolism (1st72 hrs ).

DVT.

Pulmonary embolism.

LATE

Delayed union

Malunion

Non union

Atrophy of the thigh and gluteal muscles

Limb shortening


38/38

A femoral shaft fracture is a

serious injury that takes a long

time ( 3 to 6 months ) Averageof 12 weeks to heal, hence

most femoral shaft fractures

are treated surgically. The

goal of treatment is reliable

anatomic stabilization,

allowing mobilization as early

as possible.

femoralfracturepresentation-130220092741-phpapp02

Documents