fracture shaft femur
TRANSCRIPT
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Dr. A. PathakDr. A. PathakAssistant Professor Assistant Professor
OrthopaedicsOrthopaedicsGandhi Medical college, BhopalGandhi Medical college, Bhopal
Fractures of the Femoral Fractures of the Femoral Shaft Shaft
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Femur FracturesFemur Fractures Common injury due to major violent traumaCommon injury due to major violent trauma 1 femur fracture/ 10,000 people1 femur fracture/ 10,000 people More common in people < 25 yo or >65 yoMore common in people < 25 yo or >65 yo Femur fracture leads to reduced activity for Femur fracture leads to reduced activity for
107 days, the average length of hospital 107 days, the average length of hospital stay is 25 daysstay is 25 days
Motor vehicle, motorcycle, auto-pedestrian, Motor vehicle, motorcycle, auto-pedestrian, aircraft, and gunshot wound accidents are aircraft, and gunshot wound accidents are most frequent causesmost frequent causes
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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
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MECHANISM OF INJURYMECHANISM OF INJURY
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MECHANISM OF INJURYMECHANISM OF INJURY
High velocity trauma in young
adults
Pathological fracture in elderly
should be suspected
In children (<4) child abuse is a possibility.
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Femur Fractures- Associated Femur Fractures- Associated InjuriesInjuries
Struck by car- triad of femur fracture, Struck by car- triad of femur fracture, torso injuries, head injurytorso injuries, head injury
Potential damage to physes of femur Potential damage to physes of femur and proximal tibia in childrenand proximal tibia in children
Head Injury – spasticity can make Head Injury – spasticity can make traction and cast treatment difficulttraction and cast treatment difficult
Abdominal injury – spica cast can Abdominal injury – spica cast can constrict abdomen and limit ability to constrict abdomen and limit ability to examineexamine
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Physical ExamPhysical Exam
Complete exam: head, chest, Complete exam: head, chest, abdomen, and other skeletal abdomen, and other skeletal segments segments
Document distal neurologic and Document distal neurologic and vascular functionvascular function
Palpate all bonesPalpate all bones First Aid principles - Splint or First Aid principles - Splint or
traction, especially prior to transfer traction, especially prior to transfer to another institutionto another institution
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Radiographic Evaluation Radiographic Evaluation
AP PelvisAP Pelvis AP/Lat femurAP/Lat femur Visualize hip & knee jointsVisualize hip & knee joints
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ClassificationClassification
Open or closedOpen or closed Location of fracture- subtrochanteric, Location of fracture- subtrochanteric,
diaphyseal (proximal, mid, distal diaphyseal (proximal, mid, distal third), supracondylarthird), supracondylar
Fracture pattern- transverse, spiral, Fracture pattern- transverse, spiral, oblique, comminuted, greenstickoblique, comminuted, greenstick
Amount of shorteningAmount of shortening Angular deformityAngular deformity
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Decision MakingDecision Making
AgeAge Mechanism of injuryMechanism of injury Fracture pattern & locationFracture pattern & location Associated InjuriesAssociated Injuries Surgeon preferenceSurgeon preference
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Fracture patternFracture pattern
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Spiral fractures are seen where fall on a fixed foot transmits an oblique twisting
force
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Transverse or short oblique fractures are due to high velocity direct trauma and are commonest in RTA
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Segmntal or Communited fractures are due to a combination of direct and twisting force
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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
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DISTAL THIRD FEMORAL FRACTURES
The proximal fragment may abduct or adduct while the distal fragment is flexed by gastrocnemius
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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 blood in the thigh
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Traction TechniquesTraction Techniques
Skin or skeletalSkin or skeletal Avoid physes if place skeletal traction Avoid physes if place skeletal traction
pins in childrenpins in children Place pin perpendicular to shaft to Place pin perpendicular to shaft to
avoid varus/valgus angulationavoid varus/valgus angulation Longitudinal in line traction for Longitudinal in line traction for
comfort prior to definitive treatmentcomfort prior to definitive treatment Split Russells traction (90-90) if Split Russells traction (90-90) if
awaiting early healing prior to castingawaiting early healing prior to casting
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ClassificationClassification
Most femoral shaft fractures have Most femoral shaft fractures have some degree of communition, some degree of communition, although it may not be readily although it may not be readily apparent on x-ray.apparent on x-ray.
In closed communited fractures, the In closed communited fractures, the small fagemnts are live bony pieces small fagemnts are live bony pieces with intact soft tissue attachments with intact soft tissue attachments and blood supply and blood supply
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This forms the basis of the Winquist This forms the basis of the Winquist classification.classification.
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CLINICAL FEATURESCLINICAL FEATURES
PAINPAIN SWELLINGSWELLING DEFORMITYDEFORMITY INABILITY TO BEAR WEIGHTINABILITY TO BEAR WEIGHT SHOCK AND ITS SYMPTOMSSHOCK AND ITS SYMPTOMS BEWARE!BEWARE! MULTISYSTEM INURY MULTISYSTEM INURY
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X RAYSX RAYS X rays can be postponed until shock is X rays can be postponed until shock is
taken care of.taken care of.
Remember to immobilize the facture first, Remember to immobilize the facture first, the attempt to take the radiographsthe attempt to take the radiographs
Never forget to X ray the pelvis.Never forget to X ray the pelvis.- hip fractures and dislocation- hip fractures and dislocation- pelvic fractures and disruption- pelvic fractures and disruption
get a baseline chest X-ray done – ARDS and get a baseline chest X-ray done – ARDS and Fat embolism may superveneFat embolism may supervene
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EMERGENCY CAREEMERGENCY CARE
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Hare traction splint for initial Hare traction splint for initial reduction of femur fractures prior to reduction of femur fractures prior to
OR or skeletal tractionOR or skeletal traction
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COMPLICATIONS EXPECTED AT COMPLICATIONS EXPECTED AT THIS STAGETHIS STAGE
FAT EMBOLISM AND ARDS
SHOCK NOT RESONDING TO RESUSCITATION
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FIXATION ?FIXATION ?
Best done at this stage with Best done at this stage with interlocking intramedullary nailinginterlocking intramedullary nailing
Not always possible due to lack of Not always possible due to lack of expertise, image intensifier, fracture expertise, image intensifier, fracture table, or instrumentation. table, or instrumentation.
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Treatment in tractionTreatment 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
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Gallows and Russel’s tractions need a spica apllication after 4-5 weeks
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Hip spicaHip spica
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Surgical OptionsSurgical Options
Plate & screw fixationPlate & screw fixation External fixationExternal fixation Flexible nailingFlexible nailing Rigid nailingRigid nailing
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Gerhard KuntscherGerhard KuntscherTechnik der Marknagelung, 1945Technik der Marknagelung, 1945
First IM First IM nailing but nailing but not lockingnot locking
Straight nail with 3 point fixation
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Klemm K, Schellman WD:Klemm K, Schellman WD:Veriegelung des marnagels, Veriegelung des marnagels,
19721972
Kempf I, Grosse A: Closed Interlocking Intramedullary Nailing. Its Application to Comminuted fractures of the femur, 1985
Locking IM nails in the 1980’s
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Methods of internal fixationMethods of internal fixation
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Methods of internal fixationMethods of internal fixation
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Flexible NailingFlexible Nailing
Advantages – allows early Advantages – allows early mobilization without cast, cosmetic mobilization without cast, cosmetic scars, avoids physes and blood scars, avoids physes and blood supply to femoral headsupply to femoral head
Disadvantages – later nail removal, Disadvantages – later nail removal, ends may irritate soft tissues, may ends may irritate soft tissues, may not be amenable to some fracture not be amenable to some fracture patterns (very proximal or distal, patterns (very proximal or distal, comminution)comminution)
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ORIF with Plates/ScrewsORIF with Plates/Screws
Advantages – rigid, technique Advantages – rigid, technique familiar to most surgeons, allows familiar to most surgeons, allows early motion, favorable results early motion, favorable results reported in children with associated reported in children with associated head injuries head injuries
Disadvantages- large scar, possible Disadvantages- large scar, possible refracture after plate removed, refracture after plate removed, higher infection rate in some earlier higher infection rate in some earlier seriesseries
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ORIF Plate FixationORIF Plate Fixation
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Methods of internal fixationMethods of internal fixation
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Percutaneous Bridge Percutaneous Bridge PlatingPlating
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Open Femur FractureOpen Femur FracturePrinciplesPrinciples
IV antibiotics, tetanus IV antibiotics, tetanus prophylaxisprophylaxis
emergent irrigation & emergent irrigation & debridementdebridement
skeletal stabilizationskeletal stabilization External fixation best External fixation best
option with severe option with severe soft tissue injurysoft tissue injury
soft tissue coveragesoft tissue coverage
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External fixationExternal fixation
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ComplicationsComplications
Early :Early :• ShockShock
• Fat embolism and ARDSFat embolism and ARDS
• ThromboembolismThromboembolism
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ComplicationsComplications
Late :Late :• Delyed or non unionDelyed or non union
• MalunionMalunion
• Joint stiffnessJoint stiffness
• Refracture and implant failureRefracture and implant failure