Anatomy

Long tubular bone, anterior bow, flair at femoral condyles.The longest and strongest bone.Blood supplyMetaphyseal vesselsnutrient artery medullary arteries in intramedullary canal

Femur Fracture

Common injury due to major violent traumaMore common in people < 25 yo or >65 yoMechanism traumatic high-energy most common in younger populationresult of high-speed RTAlow-energy more common in elderly often a result of a fall

Femur Fracture
Classification

AO/OTA Femur Diaphysis - Bone segment 32

Femur Fracture
Classification

Winquist and Hansen Classification

Type 0 - No comminutionType 1 - Insignificant butterfly fragment with transverse or short oblique fractureType 2 - Large butterfly of less than 50% of the bony width, > 50% of cortex intactType 3 - Larger butterfly leaving less than 50% of the cortex in contactType 4 - Segmental comminution-

Clinicaly

Symptoms pain in thigh,NWBPhysical exam inspection tense, swollen ,deformated thighaffected leg often shortenedExternal rotated,abductedmust record and document distal neurovascular status

Femur Fracture Management

Initial traction with portable traction splint or transosseous pin and balanced suspensionTiming of surgery is dependent on:Resuscitation of patientOther injuries - abdomen, chest, brainIsolated femur fracture

Femur Fracture Management

Diaphyseal fractures are managed by intramedullary nailing through an antegrade or retrograde insertion siteProximal or distal 1/3 fractures may be managed best with a plate or an intramedullary nail depending on the location and morphology of the fracture

Femur Fracture Antegrade Nailing

Antegrade nailing gold standardHighest union rates with reamed nailsExtraarticular starting pointimproved rehabilitationAntegrade nailing problems:Varus alignment of proximal fracturesCan be difficult with obese or multiply injured patientsnot indicated for use with ipsilateral femoral neck fracture

Femur Fracture Antegrade Nailing

Antegrade nailingapproach 3 cm incision proximal to the greater trochanter in line with the femoral canal

Femur Fracture Antegrade Nailing

Femur Fracture Antegrade Nailing

Femur Fracture Retrograde Nailing

Retrograde nailing advantagesEasier in large patients to find starting pointBetter for combined fracture patterns (ipsilateral femoral neck, tibia,acetabulum)Union approaching antegrade nails when reamedRetrograde nailing problems:Union rates are slightly lower, more dynamizing with small diameter nailsIntra-articular starting point

Femur Fracture Retrograde Nailing

Approach2 cm incision starting at distal pole of patellamedial parapatellartranstendinous approaches

Femur Fracture Retrograde Nailing

Entry point:

center of intercondylar notch on AP viewextension of Blumensaat's line on lateral

Femur Fracture Retrograde Nailing

Prostechnically easierunion rates comparableto those of antegrade nailingno increased rate of septic knee with retrograde nailing of open femur fracturesConsknee painincreased rate of interlocking screw irritationcartilage injurycruciate ligament injury with improper starting point

Antegrade v Retrograde Comparisons

Equal union rates

Tornetta, JBJS (B), 2000
Ricci, JOT, 2001
Ostrum, JOT, 2000

5.unknown6.unknown

Tucker M. JOT 2007

ObeseBMI >30Non-ObeseBMI

ORIF With Plate

Indicationsipsilateral neck fracture requiring screw fixationfracture at distal metaphyseal-diaphyseal junctioninability to access medullary canalOutcomesinferior when compared to IM nailing due to increased rates of:infectionnonunionhardware failure

External Fixator for Femoral Shaft Fracture

Multiply injured patientComplex distal femur fractureDirty open fracture Vascular injury

Femur Fracture
Complications Non union

Incidence

Femur Fracture
Complications

Hardware failureMalunion - shortening, malrotation, angulationInfection < 1%Neurologic, vascular injury,Heterotopic ossification

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