PRESENTATION ON FRACTURE SHAFT OF FEMUR. BY SAJAL TWANABASU INTERN – GMCTH
INTRODUCTION• FEMUR IS THE ANATOMICAL NAME GIVEN TO THIGH BONE.• IT IS THE LARGEST AND THE STRONGEST BONE OF THE
BODY.• THE LONG, STRAIGHT PART OF FEMUR IS CALLED
FEMORAL SHAFT.• BREAK ANYWHERE IN THE LENGTH OF SHAFT OF THE
BONE IS CALLED FEMORAL SHAFT FRACTURE.
ANATOMY• THE FEMUR CONSISTS OF A SHAFT (BODY) AND TWO
ENDS SUPERIOR OR PROXIMAL AND INFERIOR OR DISTAL
• THE SUPERIOR END OF FEMUR CONSISTS OF HEAD, NECK, TWO TROCHANTERS(GREATER AND LESSER).
• THE SITE WHERE NECK AND SHAFT JOIN IS INDICATED BY INTERTROCHANTERIC LINE.
• THE SHAFT OF FEMUR IS SLIGHTLY CONVEX ANTERIORLY• MOST OF THE SHAFT IS SMOOTH EXCEPT POSTERIORLY
WHERE THERE IS A BROAD, ROUGH LINE: LINEA ASPERA
• THE INFERIOR END CONSISTS OF TWO LARGE CONDYLE: MEDIAL AND LATERAL:
ANTERIORLY THEY ARE UNITED BUT POSTERIORLY SEPARATED BY DEEP GAP INTERCONDYLAR FOSSA
ANATOMY (CONTD…)
• BLOOD SUPPLY OF SHAFT OF FEMURMETAPHYSEAL VESSELS SINGLE NUTRIENT ARTERY IN DIAPHYSIS ENTERS
LINEA ASPRAMEDULLARY ARTERIES SUPPLY 2/3RD OF ENDOSTEAL
BLOOD SUPPLYNUTRIENT ARTERY COMMUNICATES WITH
MEDULLARY ARTERIES IN INTERMEDULLARY CANAL
MECHANISM OF INJURY• USUALLY IT IS A FRACTURE OF YOUNG ADULT• RESULTS FROM HIGH ENERGY INJURY AS IN ROAD TRAFFIC
ACCIDENT.• FORCE CAUSING FRACTURE MAY BE INDIRECT (TWISTING OR
BENDING FORCE) OR DIRECT (ROAD TRAFFIC ACCIDENTS)• DIAPHYSIAL FRACTURE IN ELDERLY SHOULD BE CONSIDERED
PATHOLOGICAL UNLESS PROVED OTHERWISE• PATHOLOGICAL FRACTURE MAY OCCUR WITH RELATIVELY LESS
FORCE AND MAY BE THE RESULT OF BONE WEAKNESS FROM OSTEOPOROSIS OR LYTIC LESIONS
• CONSIDER PHYSICAL ABUSE IN FRACTURE SHAFT OF FEMUR IN CHILDREN BELOW 4 YRS OF AGE
TYPES OF FRACTURE:
SPIRAL FRACTURETRANSVERSE FRACTUREOBLIQUE FRACTURECOMMINUTED FRACTUREOPEN FRACTURE
CLASSIFICATION OF FRACTURE SHAFT OF FEMURTYPE 0: NO COMMINUATIONTYPE 1: ONLY TINY CORTICAL FRAGMENTTYPE 2: BUTTERFLY FRAGMENT IS LARGER BUT ATLEAST 50% CORTICAL CONTACT BETWEEN MAIN FRAGMENTTYPE 3: BUTTERFLY FRAGMENT INVOLVES MORE
THAN 50% OF BONE WIDTHTYPE 4: SEGMENTAL FRACTUREWINQUIST AND HANSEN 66A, 1984
CLINICAL PRESENTATIONHISTORY OF TRAUMATIC FRACTURE:• SIGNIFICANT PAIN AND INABILITY TO BEAR WEIGHT• PATIENT NOTED TO HAVE SHORTENING OF ONE LEG,
SWELLING AND GROSS DEFORMITY• DIAPHYSIAL FRACTURE MAY BE ASSOCIATED WITH
SIGNIFICANT BLOOD LOSS (1L OR MORE) RESULTING IN TACHYCARDIA AND HYPOTENSION
• LARGE FORCE NEEDED TO BREAK FEMURE; SO USUALLY ASSOCIATED WITH ACCOMPANYING INJURIES.
• TIBIAL SHAFT #, IPSILATERAL FEMORAL NECK # ETC SHOULD BE LOOKED FOR.
CLINICAL PRESENTATION (CONTD…)HISTORY OF PATHOLOGICAL FRACTURE• INSIDIOUS ONSET OF PAIN AND/OR
DEFORMITY IN THE AFFECTED EXTREMITY• FREQUENT COMPLAINS OF NIGHT PAIN• COMPLETE REVISION OF SYSTEMIC
EXAMINATION TO RULE OUT METABOLIC AND METASTATIC DISEASE AS A CAUSE OF PATHOLOGICAL BONE DISEASE SHOULD BE SOUGHT.
X-RAY• X-RAY SHOULD INCLUDE WHOLE
FEMUR• AP AND LATERAL VIEWS SHOULD BE
DONE• X-RAY OF PELVIS AND KNEE SHOULD
ALSO BE DONE• CHEST X-RAY SHOULD ALSO BE DONE
AS THERE IS A RISK OF ARDS IN THE PT WITH MULTIPLE INJURIES
MANAGEMENT:EMERGENCY TREATMENT:• TRACTION WITH SPLINT IS FIRST AID FOR PATIENT WITH
FRACTURE SHAFT OF FEMUR• THOMAS SPLINT OR ITS MODERN DEVIATIONS CAN BE USED • TEMPORARY STABILIZATION HELPS CONTROL PAIN,
DECREASE BLEEDING AND MAKES THE TRANSPORT EASIER• SHOCK SHOULD BE TREATED; BLOOD VOLUME SHOULD BE
RESTORED AND MAINTAINED• WET STERILE DRESSING OVER AN OPEN FRACTURE SHOULD
BE APPLIED • IF WOUND GROSSLY CONTAMINATED, STERILE SUCTION
IRRIGATION MAY BE USED.
DEFINITIVE TREATMENT:
1. TRACTION:• HOLDS MOST FRACTURE IN REASONABLE ALIGNMENT
EXCEPT THOSE IN UPPER 1/3RD
INDICATIONS:a) FRACTURE IN CHILDRENb) CONTRADICTIONS TO ANAESTHESIAc) LACK OF SUITABLE SKILL/FACILITIESDRAWBACK• INCREASED LENGTH OF TIME SPENT IN BED
DEFINITIVE TREATMENT (CONTD…)
METHODS OF TRACTION:• SKIN TRACTION: YOUNG CHILDREN• GALLOW’S TRACTION: INFANTS LESS THAN 12
KG OF WT• RUSSELS’S TRACTION: OLDER CHILDRENHIP SPICA ONCE FRACTURE UNION PROGRESSES
SUFFICIENTLY• SKELETAL TRACTION : ADULTS• ONCE FRACTURE STICKY (8 WEEKS IN ADULTS),
TRACTION DISCONTINUED AND PARTIAL WEIGHT BEARING IN CAST/BRACE
DEFINITIVE TREATMENT (CONTD…)2.PLATE AND SCREW FIXATION• PLATING COMPARATIVELY EASY WAY OF OBTAINING REDUCTION AND
FIRM FIXATION• PLATE APPLIED THROUGH WIDE OPEN EXPOSURE OF FRACTURE SITE
AND PERFECT ANATOMICAL REDUCTION OF ALL BONE PIECES DONE INDICATIONS:• FRACTURE AT THE EITHER END OF FEMUR SHAFT ESP. THOSE WITH EXTENSION INTO SUPRACONDYLAR AND INTERTROCHANTERIC AREAS• FRACTURE IN GROWING CHILD• FRACTURE WITH VASCULAR INJURY REQUIRING REPAIR
DEFINITIVE TREATMENT (CONTD…)3. CLOSED INTRAMEDULLARY NAILING• TREATMENT OF CHOICE FOR MOST OF THE FRACTURE SHAFT
OF FEMUR• METHODS OF INSERTION:a) ANTEGRADE: INSERTION THROUGH EITHER PIRIFORMIS FOSSA OR TIP OF
GREATER TROCHANTERB) RETROGRADE:INSERTION THROUGH INTERCONDYLAR NOTCH DISTALLY• STABILITY IMPROVED BY USING INTERLOCKING SCREWS
DEFINITIVE TREATMENT (CONTD…)4. OPEN MEDULLARY NAILING• FEASIBLE AT THE PLACE WHERE FACILITIES OF CLOSED
NAILING IS LACKING.5. EXTERNAL FIXATION:• INDICATIONS:a) IN CASE OF SEVERE OPEN INJURIESb) PATIENTS WITH MULTIPLE INJURIES WHERE THERE IS A
NEED TO REDUCE OPERATING TIME AND PREVENT THE ‘SECOND HIT’
c) TREATING FEMORAL FRACTURES IN ADOLESCENTS
DECIDING TREATMENT PLAN1. CHILDREN: USUALLY CONSERVATIVEa) BIRTH TO 2 YEAR: • GALLOW’S TRACTION; CONTINUED TILL SUFFICIENT
CALLUS FORMATION OCCURSb) 2 TO 10 YEARS: • BALANCED TRACTION FOR 2-3 WEEKS FOLLOWED
BY HIP SPICA FOR ANOTHER 4 WEEKSC) TEENAGER• BALANCED TRACTION FOR LARGE PERIOD (4-6
WEEKS)D) >15 YRS: SKELETAL TRACTION; ONCE FRACTURE FEELS FIRM, TRACTION EXCHANGED FOR SPICA CAST (UPPER AND MIDDLE 1/3RD) AND CAST BRACE (LOWER 1/3RD)
DECIDING TREATMENT PLAN: (CONTD…)• OPERATIVE TREATMENT: OLDER THE CHILD, MORE DIFFICULT IT BECOMES TO KEEP THE FRACTURE REDUCED FOR REQUIRED PERIOD IN OLDER CHILDREN SOMETIMES IT IS PREFERRED TO INTERNALLY FIX THE FRACTURE.TENS (TITANIUM ELASTIC NAIL SYSTEM) IS USED FOR THISGROWING POPULARITY AS IT REDUCES THE DURATION OF HOSPITAL STAY2) IN ADULTS AND ELDERLY• TREATMENT IS USUALLY BY OPERATION AS FAR AS FACILITIES AVAILABLE
COMPLICATIONS:1. EARLY COMPLICATIONS:a) SHOCKb) FAT EMBOLISMc) INJURY TO FEMORAL
ARTERYd) INJURY TO SCIATIC
NERVE
e) INFECTION2. LATE COMPLICATIONS:f) DELAYED UNIONg) NON UNIONh) MALUNIONi) KNEE STIFFNESS