Fracture shaft of femur by Dr Bipul Borthakur

1. By: Dr.Bipul Borthakur
Professor,
Dept. of Orthopaedics, SMCH

2.  Largest tubular bone in the body.
 Surrounded by the largest mass of
muscle.
 ‘Antero-lateral’ bow – important
feature.
 Isthmus – it is the region of femur
with smallest intra-medullary
diameter, it’s at the junction of
upper 1/3rd and lower 2/3rd .

3. ▪ rough crest of bone running down
middle third of posterior femur
▪ attachment site for various
muscles and fascia
▪ acts as a compressive strut to
accommodate anterior bow to
femur

4.  ABDUCTORS :- They abducts hip joint and
are mainly gluteus medius and minimus.They
insert on greater trochenter , abduct proximal
femur following fracture.
 ILIOPSOAS :- flex and external rotates the
proximal fragment by its attachment in lesser
trochenter.
 ADDUCTOR :- Mainly Adductor longus,
Adductor magnus and Adductor brevis. Exerts
a strong axial and varus load to bone by
traction on distal part
 FASCIA LATA :- acts as a tension band by
resisting the medial angulating forces of
abductor.It’s a continuation of Ilio-tibial tract
of thigh and is also known as DEEP FASCIA OF
Thigh.

5.  Three compartments.
 ANTERIORCOMPARTMENT - Quadriceps femoris,
iliopsoas, sartorius and pectineus. Femoral artery, vein,
nerve, lat femoral cutaneous nerve.
 MEDIAL COMPARTMENT – gracilis, adductor longus,
brevis, magnus and obturator externus muscles.
Obturator artery,vein,nerve and profunda femoris
artery.
 POSTERIORCOMPARTMENT –biceps femoris,
semitendinosus and semimembranosus, a portion of
the adductor magnus ( Hamstring muscles) branches
of profunda femoris artery, sciatic nerve, post femoral
cutaneous nerve.

6.  Mainly from the profunda femoris,
branch of Femoral artery
 One to two nutrient vessels usually
enter the bone proximally and
posteriorly along the linea aspera.
 This artery then arborizes proximally
and distally to provide endosteal
circulation.
 Periosteal vessels also entres along
the linea aspera.

7.  Outer 1/3rd of cortex supply – periosteal vessels.
 Inner 2/3rd of cortex supply – endosteal vessels.
 After most of the femoral shaft fracture
- endosteal supply disrupted
- periosteal vessels proliferate to heal
- medullary vessels restored late in healing process.

8.  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

9.  Pathological fracture – elderly, inconsistent with
degree of trauma, at the weak metaphyseal-diaphyseal
junction.

10.  Transverse
 pure bending movement
 Spiral
 Rotational/twisting movement
 Oblique
 uneven bending movement
 Segmental
 More than 1 fracture line
 Comminuted
 Single fracture line with multiple fragments

11.  Ipsilateral femoral neck fracture
▪ often basicervical, vertical, and nondisplaced
▪ missed 19-31% of time
 Bilateral femur fractures
▪ significant risk of pulmonary complications
▪ increased rate of mortality as compared to unilateral fractures
 Ipsilateral tibial shaft fractures
 Ipsilateral acetabular fracture

12. Symptoms
▪ H/O trauma followed by inability to walk
Physical examination
Diagnostic features of fracture are
1.Bony crepitus
2.Abnormal mobility .
3. Loss of transmitted mobility

13. Type 0 • No comminution
Type I • Insignificant amount of comminution
Type II • More than 50% cortical contact
Type III • Less than 50% cortical contact
Type IV • Segmental fracture with no contact
between proximal and distal fragment

15.  Radiographs
 AP and lateral views of femur with hip and knee
 AP view of Pelvis
▪ important to rule-out coexisting femoral neck fracture
 CT indications
 may be considered in midshaft femur fractures to
rule-out associated femoral neck fracture

17.  Resuscitation of patient as per ATLS guidelines.
 Airway
 Breathing
 Circulation
 Disability
 Normally 500ml -2000 ml blood loss occurs so patient
may present with shock.
 Volume replenishment by IV fluids or blood
transfusion if required.
 Catheterization to be done.

18.  Application of below knee-skin traction with
Thomas splint should be done as early as
possible.
 Stabilization should be done at the
emergency room.

19.  Nonoperative
 Long leg cast or hip spica cast in Paediatric age group upto 5 Years
 Operative
 Done after stabilization of patient usually after 5-7 days.
1. Adolescent age groups- Tension Elastic nail application,
done under IOTP without opening fracture site
2. After skeletal maturity -Antegrade intra-medullary
nail done under IOTP without opening the fracture site.

20. Titanium Elastic Nailing Intramedullary nailing

21.  Retrograde intramedullary nailing-
Practiced in difficult situations, in which
opening of fracture site is necessary.

22.  External fixation with conversion to
intramedullary nail within 2-3 weeks
Indications
 In compound fractures

23.  Open reduction internal fixation with plate
Indications
 ipsilateral neck fracture requiring screw fixation
 fracture at distal metaphyseal-diaphyseal junction
 inability to access medullary canal