Fx femur diaphysis

1. CASE CONFERENCE
มูฮำหมัดอัฟนัน แวดอเล๊าะ

2. PATIENT PROFILE
➤ ชายไทยโสด อายุ 22 ปี อาชีพเกษตรกร
(นาข้าว)
➤ภูมิลำเนา ตำบลหินดาด อำเภอด่านขุนทด
➤ นับถือศาสนาพุทธ
➤ สิทธิการรักษาประกันสุขภาพถ้วน

3. CHIEF COMPLAINT : MCA 4 HR
Present illness:
4 ชม.ก่อนมาโรงพยาบาล ประสบอุบัติเหตุ
ขับจักรยานยนต์ชนกับรถยนต์โดยสาร ศีรษะ
กระแทกรถ สลบ จำเหตุการณ์ไม่ได้ แขนซ้าย
และขาขวาผิดรูป ดื่มแอลกอฮอล์ก่อนขี่
จักรยานยนต์

4. PRIMARY SURVEY
A: spontaneous response in conversation. No neck pain nor
deformity
B: No dyspnea, equal breathing sound on both lung
C: Full pulse in all extremities rate 106 bpm
BP at scene: 116/65 mmHg
D: E4V5M6 Pupil 3 mm RTLBE,
E: Laceration wound 15 and 5 cm. at forehead and mandible
Lt forearm and Rt thigh deformities with ecchymosis at
anterior Rt. thigh

9. SECONDARY SURVEY
➤ A: No drug nor food allergies
➤ M: No on going medication
➤ P: No underlying disease
➤ L: NPO time; 8.00 a.m.
➤ E: As in present illness

10. PHYSICAL EXAMINATION
➤GA: A Thai man, Drunk, Alert, Good conscious
➤HEENT: Laceration wounds at face,no active bleeding, No per ear or nose, No pale
conjunctivae. Anichteric sclerae
➤Heart: full pulse in all extremities, Normal S1, S2 No Murmur
➤Lungs: Normal chest expansion. Clear breathing sound.
➤Abdomen:No distension, Positive bowel sound, Soft, not tender, No rebound
tenderness, No guarding, No ascites
➤Extremities: Lt forearm and Rt thigh deformities with ecchymosis at anterior Rt.
thigh. Capillary refill < 2 sec. No numbness.
➤Genitalia : No bleeding per urethra nor rectum
➤Neurological findings:
➤E4V5M6 Pupil 2 mm RTLBE
➤Reflex Gr.2 all extreme

15. DIAGNOSIS
➤Close fracture diaphysis of femur
➤Close fracture both bone of Lt. forearm

16. INITIAL MANAGEMENT AT SCENE
➤ On Philadelphia hard collar
➤ Access of IV fluid
➤ Posterior long leg slab

17. INITIAL MANAGEMENT AT ER (ORTHOPEDIC)
➤MO 4 mg IV pro q 4 hr with stat
➤Plasil 1 amp pro for N/V
➤Cefazolin 1 g IV q 6 hr with stat
➤dT 0.5 ml IM
➤Skeletal traction 5kg Rt.Leg
➤Posterior long arm slab Lt.Arm

18. FRACTURE FEMUR DIAPHYSIS
or Fx shaft of femur

19. EPIDEMIOLOGY AND RISK FACTORS
➤The annual incidence of midshaft femur fractures
is approximately 10 per 100,000 person-years
➤The incidence peaks among the young, decreasing
after age 20, and then again in the elderly
➤Patients younger than 40 are more likely to sustain
high energy trauma (eg, motor vehicle crash)
➤while those over 40 are more likely to sustain low
energy trauma (eg, fall) and fracture the proximal
third of the femur

21. MUSCLES OF THIGH
➤ The muscles that surround the femoral
shaft are divided into three compartments:
➤anterior (sartorius, pectineus, quadriceps,
and iliopsoas) (figure 2 and figure 3),
➤medial (gracilis and adductors longus,
brevis, and magnus) (figure 4), and
➤posterior (biceps femoris,
semitendinosus, and semimembranosus)

24. MECHANISM OF INJURY
➤Midshaft femur fractures in younger adults
are most commonly caused by high energy
trauma, but low energy trauma is becoming
an increasingly important cause among older
adults
➤Pathologic midshaft femur fractures are
uncommon but can occur from metastases
(breast, lung, and prostate are most
common)

25. CLINICAL PRESENTATION
➤The clinical diagnosis is usually obvious based
upon the mechanism and the presence of pain,
swelling, and deformity, including shortening
of the thigh.
➤Extensive soft tissue injury and bleeding are
common and shock may develop.
➤the patient must be carefully assessed
following the basic guidelines of advanced
trauma life support (ATLS)

26. ➤ There is a well-documented correlation between femur
fractures and soft tissue injuries of the ipsilateral knee
➤Partial or complete anterior or posterior cruciate ligament
tears, or meniscal injuries, occur in approximately 20 to 50
percent of cases.
➤ Therefore, the ipsilateral knee should be carefully examined
➤Neurologic injury is rare
➤Nevertheless, a careful neurovascular assessment of the
affected limb should be performed.
➤Distal pulses should be palpated, and sensation and motor
function assessed.
➤Useful to compare findings to the contralateral limb, assuming
it is uninjured.

27. RADIOGRAPHIC
➤AP and lateral x-ray of the thigh should be
obtained when a femur fracture is suspected
➤The hip and knee should also be examined
with radiographs to rule out associated injury
➤ A femoral neck fracture may occur in
association with a midshaft femur fracture
and, if overlooked, can result in significant
morbidity and even mortality

28. INITIAL MANAGEMENT
➤ evaluating the patient for major injuries and treating them as
appropriate
➤placing an intravenous catheter and
➤providing analgesia, and
➤immobilizing the injured extremity.
➤Patients with open fractures receive antibiotics and tetanus
prophylaxis.
➤Prehospital personnel should splint the extremity in the
position it was found.
➤If signs of neurovascular compromise are observed, the limb
should be reduced after administering analgesia.

29. SPLINTING AND TRACTION
➤ skin traction or skeletal traction reduces
patient discomfort, improves fracture alignment,
and may resolve problems with arterial flow
➤A splint without traction can be used to support
injuries around the knee
➤ A femoral neck fracture may occur in
association with a midshaft femur fracture and,
if overlooked, can result in significant morbidity
and even mortality

30. WINQUIST AND HANSEN CLASSIFICATION
➤ Type 0 : No comminution
➤ Type I : Insignificant of comminution
➤ Type II : >50% Cortical bone contact
➤ Type III : <50% Cortical bone contact
➤ Type IV : Segmental fracture without cortical contact between
proximal and distal fragment

34. DEFINITIVE TREATMENT
➤ Definitive treatment for mid-shaft femur fractures must
take into consideration as following
➤patient's age
➤concomitant injuries
➤underlying comorbidities
➤resource availability and clinician experience
➤Standard treatment of a femoral shaft fracture is an
antegrade reamed intramedullary nail
➤Antegrade intramedullary nailing is associated with a 98
to 99 percent union rate and low risk of infection

35. ➤Randomized and observational studies suggest that
performing operative fracture repair within the first 24
hours decreases mortality, respiratory complications,
multisystem organ failure, and length of hospitalization
➤Orthopedic consultation should be obtained in all cases
of midshaft femur fractures. Surgery is indicated for the
large majority of such fractures because of the high rate
of union, low rate of complications, and the advantage
of early fracture stabilization, which decreases
morbidity and mortality.f

36. CHOICES OF TREATMENT
➤ Nonoperative
➤long leg cast
indications : nondisplaced femoral shaft
fractures in patients with multiple
medical comorbidities

37. CHOICES OF TREATMENT
➤ Operative
antegrade intramedullary nail
➤ Indications
Gold standard for treatment of diaphyseal femur fractures
➤ Outcomes
Stabilization within 24 hours is associated
Decreased thromboembolic events
Improved rehabilitation
Decreased length of stay and cost of hospitalization

38. CHOICES OF TREATMENT
➤ Retrograde intramedullary nail
Indications
➤Ipsilateral femoral neck fracture
➤Floating knee (ipsilateral tibial shaft fracture)
➤Ipsilateral acetabular fracture
➤Multiple system trauma
➤Bilateral femur fractures
➤Avoids repositioning
➤Morbid obesity

39. CHOICES OF TREATMENT
➤ External fixation with conversion to
intramedullary nail within 2-3 weeks
Indications
➤unstable polytrauma victim
➤vascular injury
➤severe open fracture

40. CHOICES OF TREATMENT
➤ ORIF with plate
Indications
➤ipsilateral neck fracture requiring
screw fixation
➤fracture at distal metaphyseal-
diaphyseal junction
➤inability to access medullary canal

41. COMPLICATIONS
➤Overall, complication rates are low for femoral shaft
fractures managed with intramedullary rods
➤The most common complications following femur
fracture include
➤Infection
➤Malunion (femur heals at an abnormal angle)
➤Delayed union (no sign of healing at three months)
➤Nonunion (no sign of healing at six months)
➤Pain associated with orthopedic hardware.

42. COMPLICATIONS
➤The most commonly injured nerve is the
pudendal nerve, followed by the sciatic
nerve
➤Nerve injury associated with a femoral
shaft fracture is rare.
➤The sciatic and femoral nerves are well
protected by the muscles surrounding the
femur