Femoral shaft fractures

Femoral shaft fractures
This is a fracture of young adults following high energy
injury; in elderly, it is pathological until proved otherwise.
MOI: Spiral # is caused by? a twisting force;
Transverse &oblique #? direct or angulation force;
Comminuted &Segmental #? direct &indirect severe violence.
Winquist s classification: depend on degree
of # comminution which reflects # stability:
CF: short &externally rotated limb with deformed,
bruised &swollen thigh due to soft tissue bleeding
(1liter). Look for other limb or pelvic injury or
associated life-threatening injury. Exclude
neurovascular problem.
X-ray: always x-ray the hip(to exclude another
# or ?) &the knee (floating knee). Those with
multiple injury, also need pelvic &CXR.
Emergency ?: at the site of accident, the limb should be
splinted by tying to other limb or any available splint but the ideal
is Thomas splint to: control pain, ? bleeding &make transfer easier.
Definitive ?: (in the hospital):
Conservative ?: (Traction &bracing): Indication:
1-children, 2-contraindication to anesthesia,3-lack of facility
for internal fixation & 4-for lower 1/3 femur # than for proximal #.
Method: skeletal traction through pin in upper tibia with hanged
weight(10% of body weight) for 8 wks? when # become sticky
? use functional brace for total of 16-24wks.
Operative ?:
Plating: conventional method may delay # healing with high
rate of implant failure. Now a new technique of minimally
invasive plate osteosynthesis (MIPO) have better results
especially with # near upper or lower end of femur.
Intramedullary nailing: the classical unlocked
Kuntscher nail require OR and retrograde insertion.
It is useful for mid &upper 1/3 stable #.
Locked IM nailing: CR with antegrade IM nailing
locked by interlocking proximal &distal screws for
unstable comminuted # & for subtroch. &lower 1/3 #.
External fixation: CR &percutaneous fixation for:
1-severe open #; 2-multiple injury; 3-severely commin. #;
4- # with bone loss; and 5- # with vascular injury.
Open femoral fractures: 1-IV AB; 2-wound debridement;
3-fixation: no obvious contamination, Gustilo ?&??
same ? as closed #. Gustilo ?A, B &C? external fixation.
Fracture with vascular injury: warning signs: 1-severe
bleeding or expanding hematoma; and 2-distal ischemia.
Investig.:1-doppler & CT angiography. ?? quick external
fixation & arterial repair or bypass(no >6hrs delay).
Comp.: Early: 1-Shock: 1-2liters lost, ?? transfusion.
2-Fat embolism &ARDS: risk factors are multiple injury,
chest injury & shock. CF: ?pulse rate, ?temp, dyspnea, restless &
petechial hemorrhage. Investigation: blood gases. ?? supportive.
3-Thromboembolism; 4-Infection: occur in open # &in closed #
? by IF; ?? AB, debridement, external fixation.
Late: 1-Delayed union &nonunion: ?? rigid fixation &bone graft.
2-Malunion: angulation(<15°is accepted), shortening &malrotation.
3-Knee stiffness: due to soft tissue adhesion, ?? early physiotherapy.
4-Implant failure: due to early weight bearing before # healing.
Femoral shaft fracture in children: common; MOI: FFH or RTA.
Conservative ? (traction? spica cast or immediate spica cast ) is ?
successful for younger than older children:
Infants(<2yr): 1-2wks traction? 4wks spica cast(30°angulation is accepted).
Children(2-10yr): 2-3wks traction? 4wks spica cast(20° angulation&2cm
shortening are accepted).
Teenager: 4-6wks traction? 6wks spica cast or better operative ? like adults.
Operative ?: if traction cannot reduce the #? internal or external fixation.
Angulation &shortening will be corrected to some extent with growth but rotation will not. *
Supracondylar fractures of the femur: seen in young
following high energy injury or in old osteoporotic patients.
MOI: direct force; distal frag. may be flexed
by gastrocnemius pressing on popliteal art.
CF: deformed swollen knee (haemarthrosis);
always palpate the distal pulse.
X-ray: AO classification: A: extra articular;
B: unicondylar; C: bicondylar.
Conservative ?: Undisplaced #? hinged knee brace &NWB for 6wks.
Displaced #( if facility for ORIF is absent)? skeletal traction through upper tibia with knee in flexion for 6wks? brace &PWB.
Operative ? is the ? of choice? ORIF using traditional 95? blade plate, dynamic condylar screw(DCS), locked distal IM nail or better locked plate. The advantages of ORIF: easy nursing for elderly &knee movements
can be started early.
Comp.: Early: arterial injury. Late: knee stiffness &nonunion.
Fracture-separation of the distal femoral epiphysis:
is the adolescent equivalent of supracondylar #.
MOI: hyperextension force? forward shift of epiphysis.
or angulation force? lateral shift of epiphysis.
CF: swollen deformed knee; the popliteal artery may be
obstructed by lower femur. X-ray: usually Salter-Harris type ??.
?: CR &cast or CR or OR + PP or screw fixation.
Comp.: 1-Vascular injury in hyperextension deformity.
2-Physeal arrest ? varus or valgus deformity or shortening