The document discusses fractures of the femoral shaft. It begins by describing the anatomy of the femur bone. It then discusses clinical presentation of femoral shaft fractures, including symptoms of pain in the thigh and history of trauma. Imaging recommended includes AP and lateral views of the femur, hip, and knee. Surgical treatment options are then outlined, with intramedullary nailing being the preferred method. Other options discussed include plating or external fixation. Early and late complications are also summarized.
2. FEMUR
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• largest and heaviest bone in the body
• transmits a person’s a person’s body weight to tibia
while standing 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.
Especially prominent at the middle third of shaft where it
has medial and lateral lips.
7. FEMORAL SHAFT FRACTURES
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• Definition. femoral shaft fracture is defined as a fracture of
the diaphysis occurring between 5 cm distal to the lesser
trochanter and 5 cm proximal to the adductor tubercle
• High energy injuries frequently associated with life-threatening
conditions
• The femoral shaft is circumferentially padded with large
muscles. Advantage: improved healing potential due to good
vascular tissue coverage. disadvantage: difficult reduction due
to possible displacement due to muscle pull
8. MECHANISM OF SOF FRACTURE
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• Traumatic
• high-energy
• most common in younger population
• often a result of high-speed motor vehicle accidents
• low-energy
• more common in elderly
• often a result of a fall from standing
• Gunshot
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
11. CLINICAL PRESENTATION
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• Symptoms
• pain in thigh
• History of trauma, RTAs, explosives, gunshots, sports related
injury(skiing, climbing)(high velocity trauma)
12. • Physical exam
• inspection
• tense, swollen thigh
• blood loss in closed femoral shaft fractures is 1000-
1500ml (features of shock may be present)
• for closed tibial shaft fractures, 500-1000ml
• blood loss in open fractures may be double that of
closed fractures
• tenderness about thigh
• Distal neurovascular status may be compromised
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13. CLINICAL FEATURE CONTD..
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• Attitude
• In proximal shaft fractures the proximal fragment is flexed, abducted
and externally rotated because of gluteus medius and iliopsoas pull;
the distal fragment is frequently adducted.
• In mid-shaft fractures the proximal fragment is again flexed and
externally rotated but abduction is less marked.
• In lower third fractures the proximal fragment is adducted and the
distal fragment is tilted by gastrocnemius pull.
14. • The soft tissues are always injured and bleeding from
the perforators of the profunda femoris may be severe.
• Beware of the fracture at the junction of the middle and
distal thirds of the femoral shaft – it can be responsible
for damaging the femoral artery in the adductor canal.
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15. 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.
16. 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
17. THE 4 R’S OF FRACTURE MANAGEMENT
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• R – Resuscitation
done at the site of trauma/ER, comprises the addressing of
acute life threatening condition related to fracture/ trauma
• R-Reduction
Definitive management of fracture done internally/externally
• R-Retention
Stabilization of fracture segment throughout the healing process
• R-Rehabilitation
Focusing on getting the patient back to his ADL as soon as
possible
18. 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
19. MANAGEMENT
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• Nonoperative(used for closed fractures)
Traction: treated by 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)
Uses of 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
20. 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
21. OPERATIVE TREATMENT
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• Most femoral shaft fractures are treated with
intramedullary nailing where practical.
• This gives the strongest mechanical fixation and is the
best treatment for early mobilization.
22. IMIL
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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
23. IMIL
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• Contraindications
• Polytrauma patients in unstable condition
• Not medically fit for surgery(avoid the second hit)
• Image intensifier unavailable
• Associated vascular injury requiring open repair
• Periprosthetic fractures
• Continuing infection
• Occluded intramedullary canal
• Gustilo type III C open fractures
24. IMIL
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• Advantages
• Less invasive procedure / indirect reduction
• Minimizes soft-tissue damage
• Fracture can be reduced (length, angular and rotational
control are obtained)
• Better biomechanical properties
• Definitive procedure
• Rapid mobilization of patients postoperatively
• Minimal blood loss
• Good cosmetic results
25. IMIL
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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
27. • In places without facilities of image intensifier open K(
kuntscher’s clover leaf intra-medullary ) nailing gives
good results
• Most suited for a transverse or a short oblique fractures.
• Not preferred for communited fracture as these cannot
provide adequate stability
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29. ORIF WITH PLATE
• Although the majority of femoral shaft fractures are fixed
with IM nails, there are circumstances in which ORIF with a
plate may be indicated.
Indications
• All patients with femoral shaft fractures where
intramedullary nailing is contraindicated, but the patient is
fit for surgery
• Indirect reduction impossible
• No image intensifier available
• Early pregnancy (up to 12 weeks gestation) due to the risks
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30. 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
31. ORIF WITH PLATE
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• Advantages
• Less demanding procedure
• Less exposure to ionizing radiation
• Direct reduction
• Fracture can be reduced (length, angular and rotational
control are obtained)
• Fracture stabilization with a plate reduces the incidence
of fat embolization compared to IM nailing
• Fracture stabilization allows for early patient mobilization
32. 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.
35. EXTERNAL FIXATION
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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
• Gustillo anderson type III B and C
36. 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
39. • Conversion of temporary external fixation to an
intramedullary nail within the first 2 weeks after a femoral
shaft fracture is standard practice.
• However, due to financial constraints, in large parts of
the world external fixation of femoral shaft fractures is
often the definitive treatment.
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40. • M. Zlowodzki,1 J. S. Prakash,2 and N. K. Aggarwal3
• Fifty-eight patients with 60 femoral fractures seen between July
1989 and July 1994 were treated at the Christian Medical College
and Hospital in Ludhiana, India, with an external fixation device as
definitive treatment
• . Only six patients regained full range of motion. The averageflexion
was 72°(knee-5/0 to 135). Pin tract infections occurred in 26
patients, leading to loosening of four pins.
• Satisfactory results can be obtained with definitive external fixation
of femoral shaft fractures. Pin tract infections, although a common
occurrence, are not a major problem and can be treated by local
wound care and antibiotic therapy.
• The most common problem is significant decrease in the range of
motion of the knee.
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41. REHABILITATION
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• Important to start early mobilization as soon as possible
• Decreased hospital stay
• Decreased chances of joint stiffness, preserve normal
range of motion
• Return to activities of daily life as soon as practicable
42. 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
43. LATE COMPLICATIONS
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• 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)
44. THANKYOU
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References
• Apley's System of Orthopaedics and Fractures 9th ed.
• Essential ortho paedics 5th edition
• Clinically oriented antomy 6th edition
• www.aofoundation.org
• www.ncbi.nlm.nih.gov/pmc/articles/PMC2267585
