femoral fracture

1. FEMORAL FRACTURE
FATHIYAH BT MAZLAN
4th year MedicalStudent
Quest International University of Perak

2. Classification
• Femoral Head Fractures
• Femoral Neck Fractures
• Intertrochanteric
Fractures
* Subtrochanteric Fractures
* Femoral Shaft Fractures
* Distal Femur Fractures

3. Subtrochanteric Fractures
• Subtrochanteric typically defined as area from
lesser trochanter to 5cm distal fractures with
an associated intertrochanteric component
may be called peritrochanteric fracture

4. Fielding Classification
• Type I – At level of
lesser trochanter
• Type 2- <2.5cm below
lesser trochanter
• Type 3 – 2.5 to cm
below lesser trochanter

7. Unique Aspect
• Blood loss is greater than with femoral neck or trochanteric fractures –
covered with anastomosing branches of the medial and lateral circumflex
femoral arteries branch of profunda femoris trunk.
•Transition from cancellous bone to cortical bone
(low vascularity, small fracture area)
• Contralateral pull Varus deformity
- gluteus ms attach to greater trochanter – abduct proximal part
- Iliopsoas attach to lesser trochanter – flex and ext. rotate proximal part
- Ext. rotator + obt. Internus – ext. rotation of proximal part
- Adductor muscle - adduction of distal part

8. Clinical presentation
• Symptoms
– hip and thigh pain
– inability to bear weight
• Physical exam
– pain with motion
– typically associated with obvious deformity
(shortening and varus alignment)
– flexion of proximal fragment may threaten
overlying skin

9. Imaging
X-Ray
• views
– AP and lateral of the hip
– AP pelvis
– full length femur films including the knee
• Important feature:
- an unusually long fracture line extending proximally
towards the greater trochanter and piriform fossa
- large, displaced fragment which includes the lesser trochanter
- lytic lesions in the femur.

11. Treatment
• Non operative
Traction may help to reduce blood loss and pain. It is an interim
measure until the patient, especially if elderly and with multiple
medical problems
• Operative
Open reduction and internal fixation is the treatment of choice
a) intramedullary nail with a proximal interlocking screw
- fracture is very comminuted or unstable
- operative dissection may have compromised bone viability
b) 95 degree hip screw-and-plate device.

12. (a) a 95° screw and plate device; (b) an intramedullary nail with
proximal interlocking screw into the femoral head; and (c) a proximal femoral
plate with locking screws.

13. Femoral Shaft Fracture
• 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
• The femoral shaft is padded with large muscles.
- reduction can be difficult as muscle
contraction displaces the fracture
- potential is improved by having this well-
vascularized

14. Classification
Winquist’s classification reflects the observation that the degrees of soft-tissue damage and
fracture instability increase with increasing grades of comminution. In Type 1 there is only a tiny
cortical fragment. In Type 2 the ‘butterfly fragment’ is larger but there is still at least 50 per cent
cortical contact between the main fragments. In Type 3 the butterfly fragment involves more than
50 percent of the bone width. Type 4 is essentially a segmental fracture.

15. Age
• usually a fracture of young
adults and results from a high
energy injury
• elderly patients should be
considered ‘pathological’ until
proved otherwise
• children under 4 years the
suspected possibility of
physical abuse
Pattern
• spiral fracture
Cause by a fall which the foot is
anchored while a twisting force is
transmitted to the femur.
• Transverse and oblique
often due to angulation or direct
violence and are therefore
particularly common in road
accidents.
• Comminuted or segmental
severe violence (often a
combination of direct and indirect
forces) the fracture may

16. Clinical presentation
• Advanced Trauma Life Support (ATLS) should be initiated
• Symptoms
– pain in thigh
• Physical exam
– inspection
• tense, swollen thigh
– blood loss in closed femoral shaft fractures is 1000-1500ml
– blood loss in open fractures may be double that of closed fractures
• affected leg often shortened
• tenderness about thigh
– motion
• examination for ipsilateral femoral neck fracture often difficult secondary to
pain from fracture
– neurovascular
• must record and document distal neurovascularstatus

17. • Boundaries:
• Content:
1) Femoral artery
2) Femoral vein
3) Saphenous
nerve

18. IMAGING
Views:
• AP and lateral views of entire femur
• AP and lateral views of ipsilateral hip
– important to rule-out coexisting femoral neck
fracture
• AP and lateral views of ipsilateral knee

19. (a) The upper fragment of this femur is adducted, which should alert the surgeon to the
possibility of (b) an associated hip dislocation. With this combination of injuries the
dislocation is frequently missed; the safest plan is to x-ray the pelvis with every fracture
of the femoral shaft.

20. Treatment
1) Lock IM nail
- standard for treatment of diaphyseal femur fracture
- exception is a patient with a closed head injury
» critical to avoid hypotension andhypoxemia
» consider provisional fixation (damage control)
2) Traction, Bracing, Spica cast
- All isolated femoral shaft fracture except upper 1/3
- Long bedrest/NWB (10-14 weeks)
3) External Fixator
-alternative for multiple injury
-severe open injury

21. FRACTURES ASSOCIATED WITH
VASCULAR INJURY
• Warning signs of an
associated vascular injury
are
• (1) excessive bleeding or
haematoma formation; and
• (2) paraesthesia, pallor or
pulselessness in the leg and
foot.
*Warm ischemia in 2-3H
*If > 6H – salvage not possible
‘FLOATING KNEE’
• Ipsilateral fractures of the
femur and tibia may leave
the knee joint ‘floating’
• Both fractures will need
immediate stabilization

22. Distal Femoral Fracture
• Defined as fractures from articular surface to
5cm above metaphyseal flare
• Direct violence is the usual cause

23. AO Classification
Type A (Extra-articular) fractures do not involve the joint surface;
Type B (Partial articular) fractures involve the joint surface (one condyle) but leave the
supracondylar region intact;
Type C (Complete articular) fractures have supracondylar and condylar components

24. Extra-articular
A1 Simple
A2 Metaphyseal wedge
A3 Metaphyseal Complex
Partial articular
B1 Lateral condyle
B2 Medial condyle
B3 Coronal plane
Complete articular
CI Anterior and lateral flake
C2 Unicondyler posterior
C3 Bicondyler posterior

25. Clinical Feature
• The knee is swollen because of a
haemarthrosis – this can be severe enough to
cause blistering later
• Movement is too painful to be attempted
• The tibial pulses should always be checked to
ensure the popliteal artery was not injured in
the fracture.

26. Imaging
• The entire femur should be x-rayed so as not to
missed a proximal fracture or dislocated hip
(a) whether there is a fracture into the joint
and if it is comminuted
(b) the size of the distal segment
(c) whether the bone is osteoporotic
**These factors influence the type of internal fixation
required, if that is the chosen mode of treatment

27. Treatment
• Non-operative
a) Traction
- If the fracture is only slightly displaced and extra-articular, or
if it reduces easily with the knee in flexion
• Surgery
a) Lock IM
- Type A & simpler Type C
b) Angle blade plate/ 95 degree condyler screw plate
-Type A & simpler Type C
c) Simple lag screw
-Type B

28. (d) dynamic condylar screw and plate for a Type A fracture
(e,f,g) combination of lag screws and a lateral side plate for more complex fracture
patterns