3. INTRODUCTION
• A fracture of the shaft of the femur is
usually caused by a severe violence, as in
a RTA
• The force causing the fracture may be
- Indirect : twisting / bending force
- Direct : traffic accidents
4. PATHO-ANATOMY
• The fracture is almost equally
common in the upper, middle and
lower thirds of the femur
• May be transverse, oblique, spiral or
comminuted, depending on the nature
of the fracturing force
5. DISPLACEMENTS
• More marked in adults compared to children
• Proximal fragment : flexed, abducted &
externally rotated
• Distal fragment :
- Adducted (due to adductor pull)
- Sags due to gravity &
- Migrates proximally (overriding) because of
pull by muscles going across the fracture
7. DIAGNOSIS
CLINICAL FEATURES
• History of severe violence followed by
classic signs of fracture in the thigh region
(pain, swelling, deformity, abnormal
mobility, etc)
• Diagnosis is not difficult
8. RADIOLOGICAL EXAMINATION
• X-ray should include the whole of the
femur
• An X-ray of the pelvis should be done,
since an associated injury of the pelvis is
quite common
9. TREATMENT
CONSERVATIVE METHODS :
• TRACTION :
- A fracture of the femoral shaft can be treated
by traction, with or without a splint
- Usually a Thomas’ splint is used
- Skin traction is sufficient in children
- In adults, skeletal traction through the upper
tibia (Steinmann pin) is required
10. • HIP-SPICA :
- It is a plaster cast incorporating part of
the trunk and the limb
- Used for immobilising femoral fractures
in children
- In young adults, it can be used once the
fracture becomes ‘sticky’
18. TREATMENT(OPERATIVE)
• Wherever facilities are available, closed or open
reduction and internal fixation is the treatment of choice
• The internal fixation may be intra-medullary nailing or
plating
• Common methods of internal fixation :
Closed intra-medullary nailing
Interlocking nailing
Kuntscher’s cloverleaf IM nail (K-nail)
Plating
36. TREATMENT PLAN
• Treatment depends on :
- Age of the patient
- Location of the fracture
- Type of the fracture (transverse, oblique, etc)
- Presence of a wound
In general, an open facture is treated conservatively; in
some cases, an external fixator may be used
• In children :
- Treatment is mostly by non-operative methods
- The technique of traction varies in different age groups
37. a) From birth to 2 years :
By Gallow’s traction :
- The legs of the child are tied to an overhead
beam
- The hips are kept a little raised from the bed
so that the weight of the body provides
counter-traction and the fracture is reduced
- This is continued till sufficient callus forms
(3-6 weeks)
39. b) From 2 years to 16 years :
- Treatment is essentially conservative
- Different methods of traction are used to
keep fragments aligned
- Once the fracture is ‘sticky’, hip spica can be
given
- In older children, where it is more difficult to
keep the fracture reduced for the required
time, internal fixation is sometimes preferred
(child >10 yrs)
42. • In adults and the elderly :
- Treatment is by operation (if proper facilities
are available)
- It allows the patient to be up and about, out of
bed with crutches very early
- The fracture is reduced and fixed internally by
a nail or plate depending on the type of the
fracture
43. COMPLICATIONS - EARLY
1) Shock :
- Average loss of blood in a closed femoral fracture is
1000-1500 ml
- Such a loss suddenly can lead to hypovolemic shock
- Early post-injury watch on pulse and BP is necessary
- IV line with blood arranged in all cases of such a
fracture
2) Fat embolism :
- S/S seen after 24-48 hours of the fracture
- Frequent shifting of the patient without proper
splinting should be avoided
44. 3) Injury to femoral artery :
- A sharp edge of the bone may
penetrate soft-tissues and damage the
femoral artery (rare)
- Occurs most commonly in fractures at
the junction of the M/3 X L/3 of the femoral
shaft
- Immediate surgery to restore the continuity of
the vessel is required to save the limb
45. 4) Injury to sciatic nerve :
- May be damaged by a sharp bone end or by traction
- Severity of damage varies from neuropraxia to
complete severence of the nerve
5) Infection :
- In case of open fractures, contamination, with
consequent infection can lead to osteomyelitis
- The risk is maximum in fractures with extensive
wounds and those with gun-shot wounds
46. COMPLICATIONS - LATE
1) Delayed union :
- If union is still insufficient to allow unprotected
weight-bearing after 5 months, it is
considered as DU
- X-ray shows evidence of union, but not solid
enough to permit weight-bearing
- Treatment : bone-grafting
47. 2) Non-union :
- Fracture surfaces become round and
sclerotic
- In an ununited internally fixed fracture,
persistent micro-mobility at the fracture site
leads to fatigue fractures in the plate or nail
- Clinically, there may be frank mobility, pain
on stressing or tenderness at the fracture site
- Treatment : Internal fixation and bone-
grafting
48. 3) Mal-union :
- Inability to maintain a proper position or
redisplacement may lead to union in an
unacceptable, deformed position
- The deformity is generally lateral angulation
and external rotation
- Significant shortening due to overlap of
fragments may occur
49. • Treatment : depends on degree of mal-union
and age of patient
• In children, significant deformities get
corrected by remodelling; hence, surgical
correction rarely required
• In young adults, correction surgically (redoing
the fracture or osteotomy) +IF + BG required
• In elderly patients, tendency is towards
accepting the deformity. A shoe-raise may be
given to compensate for shortening
50. 4) Knee stiffness :
- Some amount of temporary knee stiffness
occurs in most cases of fractures of the
shaft of the femur
- A course of PT is enough to regain full
movements
- Causes of persistent knee stiffness :
. Intra-articular and peri-articular adhesions
. Quadriceps adhering to the fracture site
. An associated (often undetected) knee
injury
51. Treatment :
• If conscientious PT does not improve stiffness, proper
assessment of the contributing factor and its treatment is
required
• Intra-articular adhesions :
Arthrolysis (arthroscopic) or gentle manipulation under
G/A
• Quadriceps adhesion : release
• Quadriceps contracture : Quadriceps-plasty
(lengthening)
