A 14 year old female presented with right thigh pain and inability to bear weight after falling from a height. On examination, she had an abrasion on her right thigh and shortening of the right leg. X-rays showed a femoral shaft fracture of the right femur. She was given pain medication and placed in skeletal traction of the right leg while waiting for surgery to undergo an open reduction internal fixation with plate and screws.

1. Case Discussion
BY EXT.JIRAWATH ASSAWADARACHAI

2. Patient profile
ผผผผผผผผผผผผผผ ผผผผ 14 ผผ
ผผผผผผผผผผ ผ.ผผผผผผผผผผ
ผผผผผผผผผผผผผผผ

3. Chief Complaint
ผผผผผผผผผผผผผผผผผผผผผผผผ 1
ผผผผผผผผผผผผผผผ.

4. Initial management
 Primary survey
A : spontaneous speech,no cervical tenderness
B : clear both lung,CCT negative
C : BP 115/68 mmHg , P 94 /min,PCT negative
D : E4V5M6,pupil 3 mm RTLBE

5. Secondary survey
 History
A : ผผผผผผผผผผผผผผผผผ ผผผผผผผผ
M : ผผผผผผผผผผผผผ
P : no underlying disease
L : ผผผผผผผผผผผผผผผผ 12.00 ผ.
E : 1 ผผผผผผผ ผผผผผผผผ. ผผผผผผผผผผผผ
ผผผผผผผผผผผผผผผผผผผผผผผผผผผผ
ผผผผผผ ผผผ ผผผผผผผผผผผผผผ
ผผผผผผผผ ผผผผผผผ ผผผผผผผผผผผ ผผผ

6. Physical examination
V/S : T 37 C,BP 115/68 mmHg,P 94/min,RR 20/min,BW 45
kg
GA : A Thai girl,good consciousness,look fatigue
HEENT : not pale conjunctiva,anicteric sclera
Chest : normal breath sound,no adventitious sound
Heart : normal s1,s2,no murmur
Abdomen : soft,not tender
Neuro : E4V5M6,pupil 3 mm RTLBE,motor power grade V
all extremities,sensory grossly intact

7.  Extremities : Rt.leg > ext.rotation,tender at
rt.thigh,abrasion wound at rt.thigh 2*3 cm,shortening
rt.leg,popliteal & post.tibial a. & dorsalis pedis 2+,sensory
intact

9. Investigation
 Film Rt.femur AP/Lat
 Film pelvis AP
 Film Rt.knee AP/Lat

10. Femur AP

11. Femur Lat

12. Pelvis AP

13. Knee AP

14. Knee Lat

15. Femur AP(After skeletal traction)

16. Femur Lat(After skeletal traction)

17. Management
 Tramol 50 mg IV stat
 On skeletal traction 5 kg at rt.leg
 Wating for surgery > ORIF with plate & screw

18. Femoral Shaft
Fractures

19. Anatomy
 It is the largest and the strongest bone of
the body
 The femur consists of a shaft (body) and
two ends superior and inferior
 The superior end of femur consists of head,
neck, two trochanters(greater and lesser).
 The inferior end consists of two large
condyle: medial and lateral

20. Blood supply of shaft of femur
 Metaphyseal vessels
 Single nutrient artery in diaphysis
enters linea aspra
 Medullary arteries supply 2/3rd
of
endosteal blood supply
 Nutrient artery communicates
with medullary arteries in
intermedullary canal

22. Nerve

23. Muscle
Muscle of the thigh are arranged in three
Compartments
1-anterior compartment of thigh
-sartorius
-quadriceps(rectus femoris,vastus
medialis/lateralis/intermedius)
2-medial compartment of thigh
-gracilis
-adductor longus/brevis/magnus

24. 3-posterior compartment of thigh
-hamstring(biceps femoris,semitendinosus,semimembranosus)

26. Femoral Shaft Fractures
 Common injury due to major violent trauma
-1 femur fracture/ 10,000 people
-More common in people < 25 yo or >65 yo
-Motor vehicle, motorcycle and gunshot wound accidents
are most frequent causes

27. Mechanism of injury
 High energy trauma
-Motor vehicle accident
-Gun shot injury
-Fall from height
 Pathologic fractures
-especially in elderly ,commonly occur following a trivial fall

28. Classification of Femoral shaft
Fracture
Type 0 - No commination
*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 commination

30. Clinical
 Non weight-bearing
 Pain
 Deformity
 Leg position
-Ext.rotation,shortening

31. Associated injuries
 Hemodynamic instability
 Ipsilateral Fx neck of femur
 Hip dislocation
 Tibial shaft fx
 Vascular injury
 Nerve injury

32. X-ray
well confirm the diagnosis and establish the sites ,line ,extent and
displacement

34. Immediate management
 ATLS resuscitation
 Analgesia
 X-ray
 Skeletal traction

35. Skeletal traction
-Keep length,immobilize
-Wating for surgery

36. Operative management
 IM nail
 Plate fixation
 External fixation

37. IM nail
Advatage
-small wound
-less damage soft tissue
-rapid recovery
-decrease rate of infection
Weak point
-Fx site not complete closed
IM nail is gold standard

39. Plate fixation
Indication
-Ipsilateral fx neck of femur
Advantage
-Rigid internal fixation
Weak point
-Higher infection and implant failure rates

41. External fixation
 Use temporarily before change to IM nail or
plate
 Indication
-Dirty open fracture
-Vascular injury

43. COMPLICATION
 Nerve injuries
 Malunion
 Nonunion
 Heterotropic ossification
 Vascular injuries

44. Thank you