the slide describes femoral fracture with case presentations as well as rediological diagnosis ,when opened and closed .the management from emergency period and through to stabilization

1. ACCIDENTAL FEMORAL SHAFT FRACTURES:ITS
MANAGEMENT
Orthopaedic unit
presentation
PRESENTER :
DR MUKORO D GEORGE
B.sc,MBBS
DR AGBIKI DOYE
MD

2. CASE PRESENTATIONS
Femoral fracture has
been a common
presentation in this
facility , shaft fractures
is the commonest part
involved in recent
months ,common
implicated causes are
RTA and fall from
heights. They usually
associate and present
with other injuries,
morbidity, and
mortality.

3. CASE PRESENTATION 1
Miss I.I. ,24 yr old waiteress, Admitted via
A/E 27/1/2012, with history of inability to
move Left Lower Limb 19 hrs duration
following an RTA on a motorcycle).
 Sustained wound to left knee, thigh
swelling .
 On general exam- , conscious ,not pale,
afebrile. PR 126 b/min, Bp 110/70mmhg
RR 24c/min.
 Sutured laceration Lt knee, medial side
of Lt leg, swelling of the knee,
 Marked abduction of the leg at rest
 X-RAY:Displaced Spiral fracture of distal
shaft of the Rt femur with medial
condylar and patella fractures.
 ASS:Rt femoral fracture with intra-
articular involvement following a RTA

4. MANAGEMENT .
 HAD resuscitative measures at A/E
 Along With anti tetanus prophylaxis
,IV fluids
 ORIF with condylar plate for spiral
fracture ,cancellous screw for
condylar fragment fixation and
fixation of the avulsed posterior
cruciate ligament , on 26th day after
presentation
 Analgesics, blood transfusion
,antibiotics, hematinics,
antithrombotic
 Currently on the ward ,immobilized
with Above knee synthetic cast

5. OPERATION SECTION
Distal bone
fragment with
spiral edge with
good exposure .
Stay close to the bone as much as
possible

6. CASE PRESENTATION :TWO
Mr O.J ,43 year old Architect Admitted via A/E
(22/12/11)with history of multiple injuries
following a RTA (motorcycle) ,4 hrs to
presentation.
Sustained facial swelling ,open injury to left thigh
.loss of consciousness which improved within 4
hrs
Generally , Conscious but drowsy. GCS 13/15 ,not
pale, febrile 37.2 C, receiving oxygen via
intranasal prongs ,PR 100 b/min,BP 120/80mmhg,
RR 32c/min
Hemifacial swelling (left side),enclosing
mandibular region ,left thigh swelling and
deformity,wound 6cm in dimension
X-RAY result:communited segmental fracture of
left femur with associated fracture of the
mandible
Mild head injury with left femoral fracture 2º to
RTA

7. MANAGEMENT
HAD resuscitative measures at A/E
Along with cervical collar, anti
tetanus prophylaxis ,IV fluids
ORIF with condylar plate on 14th
day after presentation
 Blood transfusion, Analgesics,
,antibiotics,,hemtinics
Discharged 15th DAY post -op With
clutches
Follow up –VIA clinic with POST-OP
X-ray film.

8. IN SUMMARY
In the last 2 months we had several cases of
femoral fractures , with a few bilateral. Some
opt-for surgical intervention .
Surgical option should be seen as the best
option for management of femoral fracture
following RTA ,to allow for early mobilization
,knowing well that:
life is movement and movement is life .
THANK YOU

9. PRESENTATION CONTINUE
Introduction
• Anatomy of the
femur
• Epidemiology of
femoral fractures
• Aetiology
• mechanism
• Classification of
shaft fractures
• Clinical features
• Investigations
• Treatment
• complications

10. INTRODUCTION
 A fracture by definition, is a break in the
continuity of a bone. It occurs when an
external force overcomes the modules of
elasticity of the bone.
 Strongest and largest bone.
 Femoral shaft fractures ,may be associated
with multisystem trauma.

11. ANATOMY OF THE FEMUR

12. BLOOD SUPPLY

13. ANATOMICAL RELATIONS

14. EPIDEMIOLOGY
 Common injury : major violent trauma
 1 femur fracture/ 10,000 people
 More common : < 25 y or >65 y
 RTA , waterway motorcycle, fall from height
and gunshot wound accidents are most
frequent causes.

15. AETIOLOGY
. Trauma.
 RTA (motorcycle races, auto/pedestran
accident, auto crash, plane crash, vehicle,).
 Sports(skiing, football, hockey).
 Falls(mountain, pole).
 Gunshot.
Pathologic
Stress

16. MECHANISM
 High Energy
 Often high-speed impact or rapid deceleration
 But may take surprisingly little energy in children
 Direct blow
 Proximal - distal compression
 Twisting/torsion Injury
 Shear
 Compression with angulation
 Fall from height
 High speed collisions
 Often seen in combination with other significant injuries

17. AETIOLOGY /MECHANISM CONTD

18. CLASSIFICATIONS:0TA/A0

19. Winquist and Hansen 66A, 1984
CLASSIFICATION
 Type 0 - No comminution
 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
comminution

20. ACCORDING TO THE PRESENCE/ABSENCE OF WOUND.
1. OPEN FRACTURES
2. CLOSE FRACTURES

21. SYNTOMS
 Age/sex/occupation
 Duration
 Severe pain
 Swelling
 Inability to move the limb
 Deformity
 shortening

22. SIGNS
 tenderness
 visible deformity
 shortening
 crepitus
 Swollen thigh
 Signs of vascular compromise should be looked
out for to rule out vascular injury.
- absent or diminished pulses
- expanding haematoma
- tachycardia
- hypotension

23. INVESTIGATIONS
 Done after the initial resuscitation of the
patient.
 PCV/Hb
 Radiograph of the affected femur, adjacent
joints and hip.(rule of 2s)
 Wound swab for m/c/s in open fractures.
 E/U/Cr
 Depends on the patient’s presentation.

24. FIELD MANAGEMENT
 Control bleeding, treat shock
 Dress wounds
 Distal CMS :FACT
 Manual stabilization
 Traction splint for mid-shaft fracture
 Backboard without traction for hip injury
 Re-check CMS
 Address other injuries as needed
 Early coordination with EMS agencies
 ALS transport criteria per local protocol
 Frequent vital sign checks and documentation
 Expedited transport to definitive care

25. TREATMENT
 Initial resuscitation.
 Definitive treatment.
- non operative / conservative
- operative
 Physiotherapy.

26. INITIAL RESUSCITATION
 ABCD of resuscitation.
 IV Fluid
 IV antibiotics
 Oxygen
 Anti-tetanus prophylaxis
 Blood transfusion
 Analgesics
 Wound care (wound debridement ).
 Splinting

27. DEFINITIVE TREATMENT
 Non operative /Conservative mgt
split
traction
casting (for children < 8 years)

28. HARE TRACTION

29. GALLOW SKIN TRACTION THOMAS SPLIT

30. OPERATIVE METHODS
Operative treatment.
1) ORIF
2) External fixation
3) Minimally invasive method.

31. INDICATIONS FOR FEMORAL SHAFT ORIF
 Inability to secure and maintain reduction by
manipulation.
 Old and frail px.
 Px with multiple injuries.
 Pathological fractures.
 Fractures suitable for nailing.
 Early ambulation is needed.

32.  ORIF :
1. Intramedullary nails are used e.g.
 Kuntcher
 interlocking nail{Grosse’s and Kempf }
This could be done either by antegrade or
retrograde ;reamed and non reamed method.
2. Plate and screws.

33. ANTEGRADE IM NAILING RETROGRADE IM NAILING

34. External
fixation is
usually
used for
open
fractures of
the femoral
shaft with
severe soft
tissue
injury.

35. Minimally
invasive
method
involves
closed
method of IM
nailing under
image
intensification
.eg :ESIN

36. REHABILITATION /PHYSIOTHERAPY
This should be started early as soon as the
pain begins to settle. Exercises for
quadriceps, leg and foot are necessary to
preserve muscle tone and prevent deformity.
For post surgical patients, it can be started
two weeks after surgery but the patient
should not bear weight.
Physiotherapy continues after discharge
from the hospital.

37. COMPLICATIONS
 EARLY
 Infection
 Hypovolaemic shock.
 Fat embolism (1st 72 hrs ).
 DVT.
 Pulmonary embolism.
 LATE
 Delayed union
 Malunion
 Non – union
 Atrophy of the thigh and gluteal muscles
 Limb shortening

38. A femoral shaft fracture is a
serious injury that takes a long
time ( 3 to 6 months ) Average
of 12 weeks to heal, hence
most femoral shaft fractures
are treated surgically. The
goal of treatment is reliable
anatomic stabilization,
allowing mobilization as early
as possible.