fracture shaft of femur.pptx

Dr. Saurabh Agrawal
Assistant Professor
Dept. of Orthopedics
AIIMS bedwas
FRACTURE SHAFT OF FEMUR
2/3/2018
P.C.Aryal Intern Group N
1

FEMUR
2/3/2018
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• Largest and heaviest bone.
• Transmits body weight to tibia while standing it has
an anterior bow.
• Shaft of femur is mostly smoothly rounded except
posteriorly, broad rough line ,linea aspera exists
providing aponeurotic attachment to adductors of thigh.

ANATOMY
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ANATOMY CONTD..
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BLOOD SUPPLY
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• fracture of diaphysis:
• occurring between 5 cm distal to the lesser trochanter and
5 cm proximal to the adductor tubercle.
• High energy injuries associated with life-threatening
conditions
• femoral shaft is circumferentially padded with large muscles.
improved healing potential due to good vascular tissue
coverage.
difficult reduction due to possible displacement due to
muscle pull

MECHANISM
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• Traumatic
• high-energy
• most common in younger population
• result of high-speed motor vehicle accidents
• low-energy
• more common in elderly
• result of a fall from standing
spiral fracture is usually caused by a fall in which the foot is anchored
while a twisting force is transmitted to the femur.
Transverse /obligue: angulation or direct violence.
communited/ segmental: very high energy trauma

2/3/2018
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2/3/2018
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• Physical examination
• inspection
• tense, swollen thigh
• blood loss in closed femoral shaft fractures is 1000-
1500ml (features of shock may be present
• blood loss in open fractures may be double that of
closed fractures
• tenderness
• Distal neurovascular status may be compromised
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• The soft tissues are always injured and bleeding from
the perforators of the profunda femoris may be severe.
• fracture at the junction of the middle and distal thirds
can be responsible for damaging the femoral artery in
the adductor canal.
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OTHER FRACTURES TO RULE OUT
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• Ipsilateral Femoral neck fracture(10%)
• Pelvis fracture
• Fracture of ipsilateral tibia( floating knee)
Patient should also be evaluated for: chest injury,
head/abdominal injury.

RADIO IMAGING
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• Recommended views
• AP and lateral views of entire femur
• AP and lateral views of ipsilateral hip
• AP and lateral views of ipsilateral knee

4 R’S OF FRACTURE MANAGEMENT
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• R – Resuscitation
done at the site of trauma/ER
comprises addressing acute life threatening condition related to
fracture/ trauma
• R-Reduction
Definitive management of fracture
• R-Retention
Stabilization of fracture segment throughout the healing process
• R-Rehabilitation

MANAGEMENT
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• Once the diagnosis of #shaft of femur is established
following steps should be taken in the ER before starting
the definitive treatment
1. Resuscitation/management as per the ATLS protocol
2. Immobilization(using splints)
3. Elevation

MANAGEMENT
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• Nonoperative (used for closed fractures)
Traction: traction with or without splint.
Usually a thomas splint (temporary) is used
skin traction sufficient in children.
skeletal traction in adults given by steinmann pin (tibial traction)
traction: birth to 2 years: gallows' traction is used(3-6 weeks),
older child: Russell's traction
2 to 16 years: different methods of traction can be used
followed by immobilization using hip spica.
Hip spica: plaster cast incorporating part of trunk and limb.
Long leg cast

THOMAS SPLINT
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• Indications
• Medically unfit for surgery
• Polytrauma, in extremis
• Advantage
• Stabilization when immediate surgery is not possible or
practical
• Disadvantages
• Overlap of the fracture can occur despite traction
• Continuing motion at the fracture site
• Continuing soft-tissue compromise and bleeding

OPERATIVE TREATMENT
2/3/2018
• Most femoral shaft fractures are treated with
intramedullary nailing
• strongest mechanical fixation
• treatment for early mobilization.

INTRAMEDULLARY INTERLOCKING NAIL
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• Indications
• All patients with femoral shaft fractures except those not
fit for definitive surgery
• Isolated fractures
• Closed fractures
• Gustilo types I & II open fractures
• Polytrauma patients in stable condition

IMIL
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• Contraindications
• Polytrauma patients in unstable condition
• Not medically fit for surgery (avoid the second
hit)
• Associated vascular injury requiring open repair
• Continuing infection
• Occluded intramedullary canal
• Gustilo type III C open fractures

IMIL
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• Advantages
• Less invasive procedure / indirect reduction
• Minimizes soft-tissue damage
• Better biomechanical properties
• Definitive procedure
• Rapid mobilization of patients postoperatively
• Minimal blood loss
• Good cosmetic results

IMIL
2/3/2018
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• Disadvantages
• Risk of iatrogenic femoral neck fracture
• Risk of fat embolization
• Closed reduction may be more challenging than open
reduction
• Frequent use of image intensifier – risk of increased
radiation exposure

2/3/2018
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OPEN REDUCTION INTERNAL
FIXATION
• circumstances in which ORIF with a plate may be
indicated.
Indications
• Indirect reduction impossible
• No image intensifier available
• Early pregnancy (up to 12 weeks gestation) due to the risks
2/3/20f1r8omradiation exposuP
.rCe.AryalIntern Group N 29

ORIF WITH PLATE
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• Polytrauma patient with associated chest injury
• Communited fractures
Contraindications
• Patient not medically fit for surgery
• Osteomyelitis
• Compromised local soft tissues

ORIF WITH PLATE
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• Advantages
• Less demanding procedure
• Less exposure to ionizing radiation
• Direct reduction
• Fracture stabilization with a plate reduces the incidence
of fat embolization compared to IM nailing
• Fracture stabilization allows for early patient mobilization

ORIF WITH PLATE
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• Disadvantages
• Greater blood loss
• Exposure of fracture zone / risk of interference with
healing process
• Larger operative soft-tissue trauma
• Less appealing cosmetic result
• There is a risk of screws pulling out in osteoporotic bone.
This risk is reduced with locking screws.

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EXTERNAL FIXATION
2/3/2018
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• Unstable fracture, patient or soft tissues, unsuitable
for definitive internal fixation.
• Further indications for external fixation
• Subtotal amputation or prolonged vascular deficit
• Salvage after major complications following internal
fixation
• Unavailability of other treatment options
• Bone loss

EXTERNAL FIXATION
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• Contraindication
• Osteoporosis (relative contraindication)
• Advantage
• Rapidly applied provisional treatment, early mobilization
• Disadvantages
• Possible loss of fixation
• Pin-track infection
• Cumbersome fixation interferes with lower limb function
• May interfere with procedures for soft-tissue reconstruction
• High risk of nonunion/malunion when used for definitive
treatment

2/3/2018
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EARLY COMPLICATIONS
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• SHOCK(1000-1500ml in closed # double in
open)
• Fat embolism: symptoms occur with in 24-48 hrs
proper splinting required to prevent this from
occurring.
• Injury to femoral artery: most commonly in
fractures at the junction of middle and distal third
of femoral shaft
• Injury to sciatic nerve.
• Infection

LATE COMPLICATIONS
 Delayed union(union still insufficient to allow unprotected
 weight bearing after 5 months, bone grafting)
 Non union(internal fixation and bone grafting)
 Malunion( lateral angulation and external rotation, shoe raise,
internal fixation ,bone grafting)
 Knee stiffness(intraarticular periarticular adhesions, quadriceps
adhering to fracture site , undetected knee injury,
physiotherapy ,athrolysis quadricepsplasty)
2/3/2018
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•Distal femur becomes trapezoidal in cross
section towards knee
•Medial condyle extends more distal than
lateral
•Posterior halves of both condyles are
posterior to posterior cortex of femoral
shaft

•Strong muscles in the front of your
thigh (quadriceps) and back of your
thigh (hamstrings) support your knee
joint and allow you to bend and
straighten your knee.

• The musculature of the thigh can be split into three
sections; anterior, medial and posterior.
• There are three major muscles in the anterior thigh –
the pectineus, sartorius and quadriceps femoris. In
addition to these, the end of the iliopsoas muscle
passes into the anterior compartment.
• Anterior compartment , innervated by the femoral nerve
(L2-L4), and extend the leg at the knee joint.

• The muscles in the posterior compartment of the thigh
are collectively known as the hamstrings.
• As group, these muscles act to extend at the hip, and flex at the
knee. They are innervated by the sciatic nerve (L4-S3).

• The muscles in the medial compartment of the thigh are
collectively known as the hip adductors. There are five
muscles in this group; gracilis, obturator externus, adductor
brevis, adductor longus and adductor magnus.
• All the medial thigh muscles are innervated by the obturator
nerve, which arises from the lumbar plexus. Arterial supply is
via the obturator artery.

INTRODU
CTION
Epidemiology :
• Traditionally young patients but increasing in geriatric
population
• Bimodal distribution: young, healthy males, elderly
osteopenic females
• Periprosthetic fractures becoming more common

MECHANISM
Axial loading with varus / valgus or rotational forces.
• young patients :
high energy with significant displacement such as from a car crash.
• older patients:
low energy, often fall from standing, in osteoporotic bone, usually
with less displacement
In both the elderly and the young, the breaks may extend into the
knee joint and may shatter the bone into many pieces.

• When the distal femur breaks, both the hamstrings and
quadriceps muscles tend to contract and shorten. When this
happens the bone fragments change position and become
difficult to line up with a cast.
• gastrocnemius: extends distal fragment (apex posterior)
• adductor Magnus: leads to distal femoral Varus

TYPESOF
FRACTURES
Descriptive :
• Supracondylar
• Intercondylar
OTA :
A: Extra articular
B: Partial articular
:
Portion of articular surface remains in continuity with
shaft C: Complete articular
Articular fragment separated from shaft

CLINICAL
FEATURES
SYMPTOMS
• H/O TRAUMA
• PAIN
•Swelling and
bruising SIGNS
• Tenderness to
touch
• Deformity

INVESTIGAT
IONS
X-ray :
- obtain standard
AP and Lateral
view

CT :
•obtain with frontal and
sagittal
reconstructions

ANGIOGRAPHY
• Indicated when diminished distal pulses after gross
alignment restored
• Consider if associated with knee dislocation

TREATMENT
Non - Operative :
• Skeletal traction
• Casting and bracing for 6
weeks

INDICATION
- Non displaced fractures
- Non ambulatory patient
- Patient with significant comorbidities presenting unacceptably
high degree of surgical/anesthetic risk

OPERATIVE:
GOALS OF OPERATIVE TREATMENT
Anatomic reduction of the articular surface,
Restoration of limb alignment and length,
Stable internal fixation,
Rapid mobilisation and early functional rehabilitation of the knee.

COMPLICATIONS
1) Malunions:
• Most commonly
associated with
plating, usually
valgus
• Functional results
satisfactory if
malalignment is within
5 degrees in any
plane

• In many cases, the
devices used to fix a
fracture break or loosen
when the fracture fails to
heal.

3) nonunions :
• Up to 19%, most commonly in metaphyseal area, with
articular portion healed (comminution, bone loss and open
fractures more likely in metaphysis)
• Decreasing with less invasive techniques
• Treatment with revision ORIF and autograft indicated
• Consider changing fixation technique to improve
biomechanics

4) infection :
• Treat with debridement, culture-specific antibiotics,
hardware removal if fracture stability permits
5) implant failure :
• Up to 9%
• Titanium plates may be superior to stainless steel

fracture shaft of femur.pptx

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