This document discusses the management of femur shaft fractures in obese patients. It notes that obesity is a risk factor for certain types of musculoskeletal injuries and increased mortality with trauma. Immobilization with casting or traction is difficult in obese patients, forcing surgeons to consider internal fixation. Complication rates are higher for obese patients compared to those with normal BMI. Early definitive fixation is preferred for stable patients if the comorbidities can be controlled, while temporary stabilization may be best initially for unstable patients with head or chest trauma to reduce risks of respiratory complications. Retrograde nailing is often favored over antegrade nailing for femur fractures in obese individuals due to less soft tissue disruption.

1. Time of Management
Green, D.P., 2010. Rockwood and Green's fractures in adults (Vol. 1). Lippincott williams & wilkins. Page 736

2. Laboratory Examination Consideration
Green, D.P., 2010. Rockwood and Green's fractures in adults (Vol. 1). Lippincott williams & wilkins. Page 738

3. Obesity
Green, D.P., 2010. Rockwood and Green's fractures in adults (Vol. 1).
Lippincott williams & wilkins. Page 745
Streubel, P.N., Gardner, M.J. and Ricci, W.M., 2011. Management of femur
shaft fractures in obese patients. Orthopedic Clinics, 42(1), pp.21-35.

4. Obesity is a risk factor The standard recommendations
for duration of use of anticoagulants apply to Obese
patients. There is no published data or official
recommendations on the need to prescribe
anticoagulants to an obese patient for a procedure where
anticoagulants are typically not used, such as
arthroscopic meniscectomy.
However, mechanical prophylaxis is recommended.
Compression stockings and bandages are not
welltolerated by obese patients.
Obesity and fracture types. Obese patients are exposed to
select types of musculoskeletal injuries and their mortality
ratesare higher when subjected to high-energy trauma
Even with low-energy trauma, they have a tendency to
expe-rience comminuted fractures with skin and soft
tissues injuries,especially at the distal end of long bones
In obese patients, cast immobilization of the lower or upper limbs and
temporary or permanent traction are very difficult to achieve. Obesity
makes any indication for conservative treatment difficult thereby forcing the
surgeon to perform internal fixation. For example, immobilizing a humerus
fracture along the chest of an obese woman causes arm abduction, which
could be detrimental to fracture alignment
Complication rates are higher in obese patients
relative to patients with normal BMI. The complication
risk is 6.8 times higher and the need for re-operation
is 4.7 times higher in pelvic ring fracture patients
having BMI > 30 kg/m2 relative to ones with BMI < 30
kg/m2
Parratte, S., S. Pesenti, and J-N. Argenson. "Obesity in orthopedics and
trauma surgery." Orthopaedics & Traumatology: Surgery & Research 100.1
(2014): S91-S97.

5. Patients with increased body mass index (BMI) have more chances of sustaining distal extremity
injuries than are those with a normal body mass index (BMI) [6]. The risk of incidence of ankle and
upper leg fractures is also found to be significantly higher in obese than non-obese women, while
the risk of wrist fracture was found to be significantly lower.
The strong association of obesity with diabetes mellitus further complicates the picture in
patients with such conditions. Hence, with an increase in BMI there are more chances of
associated comorbid medical conditions such as diabetes mellitus, hypertension, renal failure
and GERD.
We conclude that the obese patients (BMI of ≥ 30 kg/m2) are at a significant higher risk of
adverse events for the lower limb trauma and trauma related complication with respect to the
operative intervention.
Nikose, S. S., M. Gudhe, and P. K. Singh. "Outcome Analysis of Obesity in Trauma Surgery Related to Closed Injuries of Lower Limb in
Orthopedic Surgery." J Obes Weight Loss Ther 5.287 (2015): 2.

6. The mechanisms accounting for the relationship between adverse outcomes and
obesity are proposed to stem from a chronic inflammatory state and biomechanical
stress
With prior evidence suggesting a multi-factorial etiology of poor outcomes, we
proposed that inferior outcomes in this population may be due, in part, to potentially
improvable clinical and surgical factors and enhanced post-operative care.
Bryant, Mary K., et al. "Inferior clinical outcomes after femur fracture in the obese are potentially
preventable." Injury 50.11 (2019): 2049-2054.
Obese patients have lower self-reported health-related quality of life as well as an increased
risk of having coronary artery disease, type 2 diabetes mellitus, and endometrial, breast,
colon cancer, hypertension, dyslipidemia, stroke, gallbladder disease, osteoarthritis, sleep
apnea, and respiratory problems. As a consequence, obese patients carry an increased risk
for systemic complications including infection, deep venous thrombosis, myocardial
infarction, and
Assessment and management of obese patients should be addressed in a similar fashion to
nonobese patients, and should follow the guidelines of the advanced trauma life support.
An important consideration in the initial physiologic stabilization of these patients is that
despite the large body mass, total blood volume in obese individuals is similar to that of
normal-sized individuals because excess body mass is mainly composed of adipose tissue. As
a consequence, the percentage of blood loss caused by femoral fracture should be
calculated in relation to lean body mass rather than total patient weight.

7. Fracture stabilization should adjust to the patient’s physiologic reserve, with early definitive
fracture fixation in the stable patient and temporary stabilization after damage-control guidelines in
unstable individuals with additional major injuries.
Given the increased rate of complications and the prolonged metabolic acidosis of obese patients,
even after adequate resuscitation, a lower threshold for a damage-control approach should exist.
Similar to nonobese patients, the presence of concomitant head and/or chest trauma may indicate
initial external fixation in order to reduce the risk of acute respiratory distress syndrome and
multiorgan failure.
External fixation is considered the method of choice for temporary fixation in unstable patients, and
can be safely followed by staged intramedullary nailing. In morbidly obese patients, however,
fixation may be challenging to achieve, given the long distance between the skin surface and the
femoral cortex. Tactile feedback as well as visual orientation using an image intensifier should lead
to adequate pin placement. Given the large loads the construct supports, additional pins may be
required as well as the use of double bars for fracture bridging. Nonreamed retrograde nailing with
or without locking has been recently proposed as an alternative to temporary external fixation.
https://musculoskeletalkey.com/management-of-femur-shaft-fractures-in-obese-patients-
2/journal

8. Fracture Fixation
Streubel, P.N., Gardner, M.J. and Ricci, W.M., 2011. Management of femur shaft fractures in obese patients. Orthopedic Clinics, 42(1), pp.21-35.

9. Green, D.P., 2010. Rockwood and Green's fractures in
adults (Vol. 1). Lippincott williams & wilkins. Page 3609
Parratte, S., Pesenti, S. and Argenson, J.N., 2014.
Obesity in orthopedics and trauma surgery.
Orthopaedics & Traumatology: Surgery & Research,
100(1), pp.S91-S97.

10. Retrograde Nailing
Given the lower amount of soft tissue present around the knee, retrograde nailing
has become the treatment of choice in morbidly obese patients(Fig. 6). Tucker
and colleagues compared the outcomes of intramedullary nailing of femoral shaft
fractures in obese (BMI 30 kg/m2) and non obese patients (BMI <30 kg/m2) using
either antegrade or retrograde nails.
Antegrade nailing was on average 30 minutes longer in obese than in non obese
patients (94 vs 62 minutes, respectively) and required significantly longer
irradiation (247 vs135 seconds, respectively). No differences were found among
groups when retrograde nailing was performed. More importantly, in the obese
group retrograde nailing was performed in a significantly shorter time with less
irradiation than antegrade nailing (94 vs 67 minutes and 242 vs 76 seconds,
respectively).
Although no significant differences in healing rate and final functional recovery
based on the lower extremity measure were observed, obese patients were found
to recover at a slower rate and to a lesser extent than patients who were not
obese

11. Positive
• Better preparation and
stabilization
• Blood product
• Multidisciplinary treatment to
control comorbidities
• Reduced risk of ARDS or SIRS that
could developed in DCO
Negative
• Increased rate of complication
• Prolonged bedridden
• DVT
• Pneumonia due to prolonged
bedridden
• Infective skin traction
• Prolonged LOS

12. 1.Why this patient we plan to Closed Reduction Internal Fixation?
• Answer :
Due to there is no emergency orthopaedic condition in this patien and we want to make sure the
comorbid condition in this patien with obesity, we suspected the patien has Diabetes melittus and
hiperlipidemia.
To make a clear condition about haemodinamic functional of cardio pulmonal in this patient , is it
the patient necessary need an antikoagulan medicine that become a contraindication for the
patient to surgery.
Fracture stabilization should adjust to the patient’s physiologic reserve, with early definitive
fracture fixation in the stable patient and temporary stabilization after damage-control guidelines in
unstable individuals with additional major injuries.
Given the increased rate of complications and the prolonged metabolic acidosis of obese patients,
even after adequate resuscitation, a lower threshold for a damage-control approach should exist.
Similar to nonobese patients, the presence of concomitant head and/or chest trauma may indicate
initial external fixation in order to reduce the risk of acute respiratory distress syndrome and
multiorgan failure.

13. Discussion
2. What the advantages if definitive treatment was perform in within 24
hours?
• Answer :
According to journal, the obesity patient with closed fractur femur have
risk condition
Complication rates are higher in obese patients
relative to patients with normal BMI. The complication
risk is 6.8 timeshigher and the need for re-operation is
4.7 times higher in pelvic ring fracture patients having
BMI > 30 kg/m2relative to ones withBMI < 30 kg/m2

14. Discussion
3. Is the immobilization with skin traction still effective In this case?
Answer:
The skin traction provide a traction for distal fragment,so the displaced can reduced ,pain will
decrease and soft tissue sweeling will reduce. For the operative the skin traction can reduce the
displacement,so easier when due the reduction when perform fixation with intramedullary nail.
In obese patients, cast immobilization of the lower or upper limbs and
temporary or per-manent traction are very difficult to achieve. Obesity
makes any indication for conservative treatment difficult thereby forcing the
surgeon to perform internal fixation. For example, immobilizing ahumerus
fracture along the chest of an obese woman causes arm abduction, which
could be detrimental to fracture alignment
Assessment and management of obese patients should be addressed in a similar
fashion to nonobese patients, and should follow the guidelines of the advanced
trauma life support. An important consideration in the initial physiologic
stabilization of these patients is that despite the large body mass, total blood
volume in obese individuals is similar to that of normal-sized individuals because
excess body mass is mainly composed of adipose tissue. As a consequence, the
percentage of blood loss caused by femoral fracture should be calculated in
relation to lean body mass rather than total patient weight.

15. Skin Traction
AO Surgery Reference

16. Choudhry, B., Leung, B., Filips, E. and Dhaliwal, K., 2020. Keeping the traction on in orthopaedics. Cureus, 12(8).

17. Fat Embolism Syndrome

20. Obesity is a risk factor The standard recommendations
forduration of use of anticoagulants apply to Obese
patients .There is no published data or official
recommendations on the needto prescribe
anticoagulants to an obese patient for a procedure where
anticoagulants are typically not used, such as
arthroscopicmeniscectomy.
However, mechanical prophylaxis is recom-mended.
Compression stockings and bandages are not
welltolerated by obese patients.
Obesity and fracture types. Obese patients are exposed
toselect types of musculoskeletal injuries and their
mortality ratesare higher when subjected to high-energy
trauma
Even with low-energy trauma, they have a tendency to
expe-rience comminuted fractures with skin and soft
tissues injuries,especially at the distal end of long bones
In obese patients, cast immobilization of the lower or upper limbs and
temporary or per-manent traction are very difficult to achieve. Obesity
makes any indication for conservative treatment difficult thereby forcing the
surgeon to perform internal fixation. For example, immobilizing ahumerus
fracture along the chest of an obese woman causes arm abduction, which
could be detrimental to fracture alignment
Complication rates are higher in obese patients
relative topatients with normal BMI. The complication
risk is 6.8 timeshigher and the need for re-operation is
4.7 times higher in pelvicring fracture patients having
BMI > 30 kg/m2relative to ones withBMI < 30 kg/m2
Parratte, S., S. Pesenti, and J-N. Argenson. "Obesity in orthopedics and trauma
surgery." Orthopaedics & Traumatology: Surgery & Research 100.1 (2014): S91-S97

54. Indikasi Tibial nailing

55. Approach tibial nailing

56. Gustilo anderson

57. Perjalanan ulnar nerve

60. Triceps anatomy

61. Lefort I

62. Winquist hansen

63. Tscherne

64. Femur deforming force