1) A female patient was brought to the hospital after a motorcycle accident where she collided with a car 1 hour prior and lost consciousness. On examination, she had an abrasion on her right thigh and was unable to walk but could move her toes. 2) X-rays showed a fracture of the right femur. She was given pain medication and placed in skeletal traction awaiting surgery. 3) Surgical fixation with a plate and screws was planned to treat the femoral shaft fracture.

1. Case Discussion
BY EXT.JIRAWATH ASSAWADARACHAI

2. Patient profile


3. Chief Complaint
 ขับรถจักรยานยนต์ชนรถยนต์1 ชั่วโมงก่อนมารพ.

4. Initial management
 Primary survey
A : spontaneous speech,no cervical tenderness
B : clear both lung,CCT negative
C : BP 115/68 mmHg , P 94 /min,PCT negative
D : E4V5M6,pupil 3 mm RTLBE

5. Secondary survey
 History
A : ไม่มีประวัติแพ้ยา แพ้อาหาร
M : ไม่มียาประจา
P : no underlying disease
L : ทานข้าวล่าสุดตอน 12.00 น.
E : 1 ชั่วโมง ก่อนมารพ. ผู้ป่วยขี่รถจักรยานยนต์ผ่านสี่แยกไปชนกับ
รถยนต์สลบ หลังมีสติไม่มีคลื่นไส้ อาเจียน ไม่ปวดศีรษะ ไม่ปวด
คอ ไม่เจ็บหน้าอก ไม่ปวดท้อง ไม่มีเลือดไหลออกจากจมูก/หู มี
อาการเจ็บที่ต้นขาขวา ลุกขึ้นเดินไม่ได้ ยังสามารถขยับข้อเท้าได้

6. Physical examination
 V/S : T 37 C,BP 115/68 mmHg,P 94/min,RR 20/min,BW 45
kg
 GA : A Thai girl,good consciousness,look fatigue
 HEENT : not pale conjunctiva,anicteric sclera
 Chest : normal breath sound,no adventitious sound
 Heart : normal s1,s2,no murmur
 Abdomen : soft,not tender
 Neuro : E4V5M6,pupil 3 mm RTLBE,motor power grade V
all extremities,sensory grossly intact

7.  Extremities : Rt.leg > ext.rotation,tender at
rt.thigh,abrasion wound at rt.thigh 2*3 cm,shortening
rt.leg,popliteal & post.tibial a. & dorsalis pedis 2+,sensory
intact

9. Investigation
 Film Rt.femur AP/Lat
 Film pelvis AP
 Film Rt.knee AP/Lat

10. Femur AP

11. Femur Lat

12. Pelvis AP

13. Knee AP

14. Knee Lat

15. Femur AP(After skeletal traction)

16. Femur Lat(After skeletal traction)

17. Management
 Tramol 50 mg IV stat
 On skeletal traction 5 kg at rt.leg
 Wating for surgery > ORIF with plate & screw

18. Femoral Shaft
Fractures

19. Anatomy
 It is the largest and the strongest bone of
the body
 The femur consists of a shaft (body) and
two ends superior and inferior
 The superior end of femur consists of head,
neck, two trochanters(greater and lesser).
 The inferior end consists of two large
condyle: medial and lateral

20. Blood supply of shaft of femur
 Metaphyseal vessels
 Single nutrient artery in diaphysis
enters linea aspra
 Medullary arteries supply 2/3rd of
endosteal blood supply
 Nutrient artery communicates
with medullary arteries in
intermedullary canal

22. Nerve

23. Muscle
Muscle of the thigh are arranged in three
Compartments
1-anterior compartment of thigh
-sartorius
-quadriceps(rectus femoris,vastus
medialis/lateralis/intermedius)
2-medial compartment of thigh
-gracilis
-adductor longus/brevis/magnus

24. 3-posterior compartment of thigh
-hamstring(biceps femoris,semitendinosus,semimembranosus)

26. Femoral Shaft Fractures
 Common injury due to major violent trauma
-1 femur fracture/ 10,000 people
-More common in people < 25 yo or >65 yo
-Motor vehicle, motorcycle and gunshot wound accidents
are most frequent causes

27. Mechanism of injury
 High energy trauma
-Motor vehicle accident
-Gun shot injury
-Fall from height
 Pathologic fractures
-especially in elderly ,commonly occur following a trivial fall

28. Classification of Femoral shaft
Fracture
Type 0 - No commination
*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 commination

30. Clinical
 Non weight-bearing
 Pain
 Deformity
 Leg position
-Ext.rotation,shortening

31. Associated injuries
 Hemodynamic instability
 Ipsilateral Fx neck of femur
 Hip dislocation
 Tibial shaft fx
 Vascular injury
 Nerve injury

32. X-ray
well confirm the diagnosis and establish the sites ,line ,extent and
displacement

34. Immediate management
 ATLS resuscitation
 Analgesia
 X-ray
 Skeletal traction

35. Skeletal traction
-Keep length,immobilize
-Wating for surgery

36. Operative management
 IM nail
 Plate fixation
 External fixation

37. IM nail
Advatage
-small wound
-less damage soft tissue
-rapid recovery
-decrease rate of infection
Weak point
-Fx site not complete closed
IM nail is gold standard

39. Plate fixation
Indication
-Ipsilateral fx neck of femur
Advantage
-Rigid internal fixation
Weak point
-Higher infection and implant failure rates

41. External fixation
 Use temporarily before change to IM nail or
plate
 Indication
-Dirty open fracture
-Vascular injury

43. COMPLICATION
 Nerve injuries
 Malunion
 Nonunion
 Heterotropic ossification
 Vascular injuries

44. Thank you