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Accidental Femoral fractures

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the slide describes femoral fracture with case presentations as well as rediological diagnosis ,when opened and closed .the management from emergency period and through to stabilization

the slide describes femoral fracture with case presentations as well as rediological diagnosis ,when opened and closed .the management from emergency period and through to stabilization

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  • 1. ACCIDENTAL FEMORAL SHAFT FRACTURES:ITSMANAGEMENT Orthopaedic unit presentation PRESENTER :DR MUKORO D GEORGE B.sc,MBBSDR AGBIKI DOYE MD
  • 2. CASE PRESENTATIONS Femoral fracture has been a common presentation in this facility , shaft fractures is the commonest part involved in recent months ,common implicated causes are RTA and fall from heights. They usually associate and present with other injuries, morbidity, and mortality.
  • 3. CASE PRESENTATION 1Miss I.I. ,24 yr old waiteress, Admitted via A/E 27/1/2012, with history of inability to move Left Lower Limb 19 hrs duration following an RTA on a motorcycle). Sustained wound to left knee, thigh swelling . On general exam- , conscious ,not pale, afebrile. PR 126 b/min, Bp 110/70mmhg RR 24c/min. Sutured laceration Lt knee, medial side of Lt leg, swelling of the knee, Marked abduction of the leg at rest X-RAY:Displaced Spiral fracture of distal shaft of the Rt femur with medial condylar and patella fractures. ASS:Rt femoral fracture with intra- articular involvement following a RTA
  • 4. MANAGEMENT . HAD resuscitative measures at A/E Along With anti tetanus prophylaxis ,IV fluids ORIF with condylar plate for spiral fracture ,cancellous screw for condylar fragment fixation and fixation of the avulsed posterior cruciate ligament , on 26th day after presentation Analgesics, blood transfusion ,antibiotics, hematinics, antithrombotic Currently on the ward ,immobilized with Above knee synthetic cast
  • 5. Distal bonefragment withspiral edge withgood exposure .Stay close to the bone as much aspossibleOPERATION SECTION
  • 6. CASE PRESENTATION :TWO Mr 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 via intranasal 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 dimension X-RAY result:communited segmental fracture of left femur with associated fracture of the mandible Mild head injury with left femoral fracture 2º to RTA
  • 7. MANAGEMENTHAD resuscitative measures at A/EAlong 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 WithclutchesFollow up –VIA clinic with POST-OPX-ray film.
  • 8. IN SUMMARYIn 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. PRESENTATION CONTINUE • Anatomy of the femur • Epidemiology of femoral fractures • Aetiology • mechanism • Classification ofIntroduction shaft fractures • Clinical features • Investigations • Treatment • complications
  • 10. 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. ANATOMY OF THE FEMUR
  • 12. BLOOD SUPPLY
  • 13. ANATOMICAL RELATIONS
  • 14. EPIDEMIOLOGY Common injury : major violent trauma 1 femur fracture/ 10,000 people More common : < 25 y or >65 y RTA , waterway motorcycle, fall from height and gunshot wound accidents are most frequent causes.
  • 15. AETIOLOGY. Trauma. RTA (motorcycle races, auto/pedestran accident, auto crash, plane crash, vehicle,). Sports(skiing, football, hockey). Falls(mountain, pole). Gunshot. Pathologic Stress
  • 16. 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. AETIOLOGY /MECHANISM CONTD
  • 18. CLASSIFICATIONS:0TA/A0
  • 19. 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 comminutionWinquist and Hansen 66A, 1984
  • 20. ACCORDING TO THE PRESENCE/ABSENCE OF WOUND. 1. OPEN FRACTURES 2. CLOSE FRACTURES
  • 21. SYNTOMS Age/sex/occupation Duration Severe pain Swelling Inability to move the limb Deformity shortening
  • 22. SIGNS tenderness visible deformity shortening crepitus Swollen thigh Signs of vascular compromise should be looked out for to rule out vascular injury. - absent or diminished pulses - expanding haematoma - tachycardia - hypotension
  • 23. INVESTIGATIONS Done after the initial resuscitation of the patient. PCV/Hb Radiograph of the affected femur, adjacent joints and hip.(rule of 2s) Wound swab for m/c/s in open fractures. E/U/Cr Depends on the patient’s presentation.
  • 24. 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. TREATMENT Initial resuscitation. Definitive treatment. - non operative / conservative - operative Physiotherapy.
  • 26. INITIAL RESUSCITATION ABCD of resuscitation. IV Fluid IV antibiotics Oxygen Anti-tetanus prophylaxis Blood transfusion Analgesics Wound care (wound debridement ). Splinting
  • 27. DEFINITIVE TREATMENT Non operative /Conservative mgt split traction casting (for children < 8 years)
  • 28. HARE TRACTION
  • 29. GALLOW SKIN TRACTION THOMAS SPLIT
  • 30. OPERATIVE METHODS Operative treatment.1) ORIF2) External fixation3) Minimally invasive method.
  • 31. 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.  ORIF :1. Intramedullary nails are used e.g. Kuntcher interlocking nail{Grosse’s and Kempf } This could be done either by antegrade or retrograde ;reamed and non reamed method.2. Plate and screws.
  • 33. ANTEGRADE IM NAILING RETROGRADE IM NAILING
  • 34. Externalfixation isusuallyused foropenfractures ofthe femoralshaft withsevere softtissueinjury.
  • 35. Minimallyinvasivemethodinvolvesclosedmethod of IMnailing underimageintensification.eg :ESIN
  • 36. REHABILITATION /PHYSIOTHERAPYThis should be started early as soon as the pain begins to settle. Exercises for quadriceps, 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 patient should not bear weight. Physiotherapy continues after discharge from the hospital.
  • 37. COMPLICATIONS EARLY Infection Hypovolaemic shock. Fat embolism (1st 72 hrs ). DVT. Pulmonary embolism. LATE Delayed union Malunion Non – union Atrophy of the thigh and gluteal muscles Limb shortening
  • 38. A femoral shaft fracture is aserious injury that takes a longtime ( 3 to 6 months ) Averageof 12 weeks to heal, hencemost femoral shaft fracturesare treated surgically. Thegoal of treatment is reliableanatomic stabilization,allowing mobilization as earlyas possible.