Fracture of shaft and distal part of Femoral bone by Dr. Ammar Alsabae

Fracture of shaft and distal

part of femural bone

prepared by : Ammar Fuad Alsabae

Anatomy

Mechanism

Classification

Clinical picture

Diagnosis

Treatment

Complicatoin

Anatomy

Femoral shaft is well

padded with muscle

Advantage : protection

the bone .

Disadvantage : in that

fracture are severly

displaced by muscle pull ,

macking difficulty in

reduction .

Special features of femoral shaft fracture :

Essentially fracture of young

adult .

Result from hiegh energy injury .

If occur in eldery should be

considered pathological until

proved otherwise .

In children under 4 years of age

the possibility of physical abuse

may be kept in mind .

Mechanism of Femoral shaft fracture :

This is usually a

fracture of young

adults and results

from a high energy injury.

Classification (Winquist’s classification ) :

Reflects the observation that the degree of soft tissue

damage .

Fracture instability increase when increasing the grades

of comminution .

Type 1 Type 2 Type 3 Type 4

Type 1 there is only a tiny cortical fragment.Type 2 the ‘butterfly fragment is larger but there is still at least 50 per cent cortical contact between the main fragments. Type 3 the butterfly fragment involves more than 50 per cent of the bone width.Type 4 is essentially a segmental fracture .

Clinical picture :

Pain

Swelling

Deformity

Tenderness

Loss of function

Diagnosis :

1- history and physical exam .

2- clinical picture .

3- X-Ray for femur but never

forget to x-ray the hip and knee .

CT scan :

Treatment :

Traction and bracing …conservative.

Open reduction and plating .

Intramedullary nailing .

External fixation .

Traction and bracing :

Traction and bracing :

Traction with a splint is first aid for a patient with a femoral shaft fracture.

Indication :

1-fracture of children .

2- contraindication to anesthesia .

3- lack of suitable skills for internal fixation .

Length of time spent in bed is about 10 – 14 weeks .

Method : 1- thoma’s splint . 2- perkin’s traction .

Thoma’s splint

This

method

rarely used

because it

lead to

knee

stiffness

Skletal traction

without splints .

perkin’s traction

Open reduction and plating :

Internal fixation with plate

and screws .

Indications :

1- combination of shaft and

femoral neck fracture .

2- fracture associated with

vascular injury .

Intramedullary nailing :

Is the method of choice and mostly used .

Implantation of intramedullary nail and fixed by screws which inserted

transversely at proximal and distal ends .

The implantation of intramedullary nail may be antegrade or retrograde .

Antegrade nailing >> insertion of the nail through pyriform fossa and

transverse locking screws proximally and distally .

Retrograde nailing >> insertion of the nail through intercondylar notch at

the knee .

This operation control the rotatory movement and ensures stability .

Nail or… Plate

External fixation :

Main indication are :

1- treatment of severe open injuries .

2- patient with multiple injuries .

3- severe bone loss wich need to bone transport .

4- femoral fracture in adolescence .

Advantage & disadvantage of intramedullary

nailing and external fixation :

Advantage :

Not exposing the fracture site .

Callus increase in the volume and quality .

Promoting quicker consildation by increase stress transfre to the fracture

site .

Disadvantage :

Pins-site infection .

Most femoral shaft fracture will unite in under 5 month but some take

longer if the fracture is badly comminuted or contact between fracture

end is poor .

Open fracture :

In open fracture

should be carefully

assessed for :

1- neurovascular

injury .

2- muscle ischemia .

3- skin loss .

4- wound

contamination .

Warning sign in the fracture with vascular injury :

Excessive bleeding or hematoma

formation .

Parasthesia , pallor , pulselessness and

other 6P in the leg and foot .

Treatment of open fractures :

The immediate treatment is similar to that of closed

fractures; in addition:

1- the patient is started on intravenous line to prevent shock .

2- I.V antibiotics.

3- The wound will need cleaning .

4- contaminated areas and dead tissue must be excised and

the entire area should be washed thoroughly and the wound should

be left open .

Complications of femoral shaft fractures :

Early :

Fat embolism .

Shock .

Infection .

Thromboembolism .

:LATE

Delayed union and non-union .

Malunion .

Joint stiffness .

Refracture and implant failure .

Shortening of limb .

Supracondylar and condylar fracture of femur :

Mechanism

Mechanism :

Direct violence is the usual cause.

This fracture are seen in :

1- young adult usually as a result of

high energy truma .

2- in eldery due to osteoporosis .

The fracture is line just above the

condyle .

AO group classification :

Type A : fractures have no articular splits and are truly ‘supracondylar’; .

Type B : fracture are simply shear fracture of one of the condyle .

Type C : fracture have supracondylar and intracondylar fissure .

Type A Type B Type C

Clinical features :

The knee is swollen and deformed because of a haemarthrosis .

Movement is too painful .

Important note : The tibial pulses should always be checked to ensure the

popliteal artery was not injured in the fracture.

Diagnosis :

History and physical

exam .

Clinical picture .

By X-Ray .

By CT scan .

Treatment :

Non operative :

Traction by

thoma’s splint :

skeletal traction

through the

proximal tibia .

This method used

if the fracture only

slightly displaced

and extra-

articular .

Treatment :

Operative treatment :

1- locked intramedullary nail which are introduce retrograde through the

intercondylar notch >> suitable for the type A .

2- Plates that are applied to the lateral surface of the femur >> suitable for

the type A and type C .

3- Simple lag screws >> suitable for the type B .

Complications :

Early :

Arterial damage

Infection

Osteoarthritis

Late :

Joint stiffness

Malunion

Ununion

Prepared by : Ammar Fuad Alsabae .