Femoral Shaft FracturesDr. Ajay Alex

CMC, Ludhiana

Anatomy

Long tubular bone, anterior bowed forward and has oblique course from the neck to distal end.

Compartments of thigh Muscle of the thigh are arranged in three Compartments1-anterior compartment of thighContains the sartorius and the four large quadriceps2-medial compartment of thigh(gracilis ,pectineus, adductor longus, adductor brevis, adductor magnus, and obturator externus)

3-posterior compartment of thigh contain three large muscle termed the ‘”hamstring”Femur is surrounded by massive musculature ,which provide the blood supply to femur

Fracture Shaft Of Femur• A femoral shaft

fracture is a fracture of the femoral diaphysis occurring between 5 cm distal to the lesser trochanter and 5 cm proximal to the adductor tubercle

Epidemiology

-Common injury due to major violent trauma

-1 femur fracture/ 10,000 peoplemore common in people < 25 yr or >65 yr

-Motor vehicle, motorcycle, auto-pedestrian, fall from height, and gunshot wound

Mechanism Of Injury• In Young Adults, almost always the result of

high-energy trauma,– Motor vehicle accident– Gunshot injury, or– Fall from a height

• Pathologic fractures, especially in the elderly, commonly occur following a trivial fall• Stress fractures occur mainly in military

recruits or runners

Symptoms Diffuse pain or ache, and tenderness and swelling in the thigh or groin.

Bleeding and bruising in the thigh (uncommon).

Weakness and inability to bear weight on the injured leg.Paleness and deformity

Clinical Evaluation• A full trauma survey is indicated (ABC)• The patient is–Non ambulatory with pain–Variable gross deformity of thigh – Swelling,– Shortening of the affected extremity.

• A careful neurovascular examination is essential

• A careful assessment of hemodynamic stability is essential,Average expected Blood loss of 750-1500ml• Thorough examination of the ipsilateral hip

and knee should be performed• Knee ligament injuries are common,

however, and need to be assessed after fracture fixation

Associated Injuries

• Ipsilateral femur neck, intertroch, distal femur #s

• Patella, tibia, acetabular, pelvic ring #s• Soft tissue injuries of knee• Thoracic & abdominal injuries(5-15%)

X-ray Will confirm the diagnosis and establish the sites ,line ,extent and

displacement

• AP and Lateral views of the femur, hip, and knee

• AP view of the pelvis should be obtained

• Look for evidence of an associated femoral neck or intertrochanteric fracture, knee injuries

Winquist and Hansen , 1984

* Type 0 - No commination

* Type 1 - Insignificant butterfly fragment with transverse or short oblique fracture,

* Type 2 - Large butterfly of less than 50% of the bony width, > 50% of cortical contact

* Type 3 - Larger butterfly leaving less than 50% of the cortex in contact

* Type 4 - Segmental commination

AO classification

Management-paediatrics

Pavlik Harness for Age<6months

Hip Spica Castfor Age upto 5 years

Gallows Traction

PaediatricThomas Splint

Flexible Intramedullary Nail Fixation

Adults-Non operative

• Traction- Skeletal, thomas splint• Cast braces- uncommonly used

For patients in whom surgery needs to be delayed, temporary stabilisation with

Skeletal traction is required

Operative Fixation Options

• Intramedullary Fixation• Open Reduction and Plate Fixation• External Fixation

(For Open/ Infected Fractures)

Intramedullary Fixation

Plate Fixation

Indications for plating

• Patients wit extremely narrow medullary canal

• Fractures around or adjacent previous malunion

• Fractures extending proximally or distally into the pertrochanteric or metaphyseal region

• Ipsilateral neck fractures

External Fixation• Severe soft tissue

injuries• Contamination• Associated vascular

injuries• Polytrauma-temporary

method

COMPLICATION

1-GENERALBlood loss, shock ,fat embolism, and acut respiratory distress are common in high-energy injuries

COMPLICATION

2-Vascular injury3-Nerve injury-iatrogenic(femoral, sciatic, pudendal, peroneal)4-Thromboembolism5-Compartment syndrome(1-2%)6-Infection 7-Delayed union and non-union8-Joint stiffness, knee & hip pain9-Heterotrophic ossification