Fractures of the femurFractures of the femur

FrequencyFrequency

Fractures of the femoral shaft are Fractures of the femoral shaft are the most common fractures that the most common fractures that orthopedist see. orthopedist see.

incidence - 1.33 fractures per incidence - 1.33 fractures per 10,000 people. 10,000 people.

In The United States

The incidence of hip fractures exceeds 250,000 per year, with an estimated cost of nearly $10 billion.

Proximal femoral part fractures Proximal femoral part fractures (medial and lateral fractures)(medial and lateral fractures)

Classification of fractures

1.Subcapital2.Trancervical3.Basal 4. Intertrochanteric

(=basal)5.Separation of the lesser

trochanter6.Subtrochanteric7.Separation of the greater

trochanter

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3

5

4

6

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Blood to the femoral head is primarily supplied by the medial circumflex femoral artery through its subsynovial retinacular vessels. The lateral circumflex and ligamentum teres arteries provide minor contributions to the femoral head.

Anterior view

Retinaculararteries(subsynovial)

Retinaculararteries(subsynovial)

Acetabular branch ofobturator artery(often minute)

Posterior viewMedial circumflexfemoral artery

Femoral neck fractures are at risk due to the limited Femoral neck fractures are at risk due to the limited blood supplyblood supply

Femoral neck Femoral neck fracturefracture

Femoral Neck FracturesFemoral Neck Fractures

A B

A - adducted, neck-shaft angle at such cases reduces up to the direct one, as the result of the hip displacement upwards. These fractures are never impacted. They unite very bad in view of insufficient blood supply of the central fragment, absence of the periosteum in the area of the femoral neck, and also difficulties of the fragments compa-rison and their strong holding together.

B B - - abductedabducted,, with the formation of coxa with the formation of coxa valga (neck-shaft angle at this fracture valga (neck-shaft angle at this fracture remains normal or even increases). remains normal or even increases). These fractures are more often impacted These fractures are more often impacted

Femoral Neck FractureFemoral Neck Fracture

Tenderness will be found over the femoral neck anteriorly (1) and in extra-capsular fractures over the greater trochanter. Pain is produced by rotation of the hip (2). Swelling localizes in groin region or at the greater trochanter area. Rarely, with an undisplaced fracture, the patient may be able to bear weight.

Femoral Neck FractureFemoral Neck Fracture Mechanism of injuryMechanism of injury : :

A fall on the side is A fall on the side is the commonest cause.the commonest cause.

DiagnosisDiagnosisThe leg is rotated The leg is rotated

outwardsoutwards , especially at , especially at subtrochanteric subtrochanteric fractures; fractures;

- the external edge of the - the external edge of the heel touches the bed or heel touches the bed or the table on which the the table on which the patient lays.patient lays.

- He cannot l i f t the leg - He cannot l i f t the leg actively; there is a sign actively; there is a sign of the of the "stuck heel”. "stuck heel”.

Patient with a displaced femoral neck Patient with a displaced femoral neck fracture on the right. fracture on the right. Note that the leg is shortened and Note that the leg is shortened and externally rotatedexternally rotated

Femoral Neck FracturesFemoral Neck Fractures

subcapital subcapital transcervical transcervical basicbasic

A non displaced A non displaced femoral neck femoral neck

fracturefracture

A displaced A displaced femoral neck femoral neck

fracturefracture

Emergency manipulationsEmergency manipulations

Transport splints f ixationTransport splints f ixation AnalgesicsAnalgesics Local anesthesiaLocal anesthesia Tourniquet in cases with external Tourniquet in cases with external

bleedingbleeding I/v f luid infusionI/v f luid infusion - Traumatic shock therapy - Traumatic shock therapy

Skin traction and splinting are used in the field in emergent situations to provide comfort for the patient and to prevent any further soft tissues, vessels and nerves damage.

DUAL ARM TRACTION SPLINT

Conservative TreatmentConservative Treatment

Skeletal tractionSkeletal traction Skeletal traction Skeletal traction

with further with further external f ixationexternal f ixation

External f ixation External f ixation onlyonly

Symptomatic Symptomatic treatmenttreatment

Unilat HipSpica Cast

One and One-half Hip Sp. Cast

Bilat. Long-leg Hip Spica Cast

Surgical treatmentSurgical treatment

internal f ixation is sti l l the treatment of internal f ixation is sti l l the treatment of choice for most closed injuries because choice for most closed injuries because of the higher union rate, lower rate of of the higher union rate, lower rate of complications, lower morbidity, earlier complications, lower morbidity, earlier weight bearing, shorter hospital stay weight bearing, shorter hospital stay and better control of al ignment. and better control of al ignment. However, in some situations in which However, in some situations in which the hardware is not available or the the hardware is not available or the patient cannot undergo surgery patient cannot undergo surgery relatively soon, temporary skeletal relatively soon, temporary skeletal traction may be a viable choice.traction may be a viable choice.

Open reduction and internal Open reduction and internal f ixation of neck fractures f ixation of neck fractures must be performed within must be performed within hours after the injury.hours after the injury.

Surgical Surgical TreatmentTreatment

A similar fracture treated with three large cancellousbone screws.

Use of three-flanged nail

1 - pins (a minimum of 3) can be of value in children

2 - Three self-tapping parallel screws, inserted percuta- neously 3 - Two hybrid screws, which have extending wings controlling rotation and backing-out.

Surgical TreatmentSurgical Treatment

Femoral neck basic fracture fixed Femoral neck basic fracture fixed with Gama-nailwith Gama-nail

ComplicationsComplications General complications. Particularly in elderly General complications. Particularly in elderly

patients: deep vein thrombosis, pulmonary patients: deep vein thrombosis, pulmonary embolism, pneumonia, bed sores;embolism, pneumonia, bed sores;

Avascular necrosis. Occurs in about 30% of Avascular necrosis. Occurs in about 30% of patients with displaced fractures and in 10% patients with displaced fractures and in 10% with undisplaced fractures);with undisplaced fractures);

Non-union. More than 30% of al l femoral neck Non-union. More than 30% of al l femoral neck fractures fai l to unite, and the risk is fractures fai l to unite, and the risk is particularly high in those that are severely particularly high in those that are severely displaced;displaced;

Osteoarthrit is. Avascular necrosis of femoral Osteoarthrit is. Avascular necrosis of femoral head collapse may lead to secondary head collapse may lead to secondary osteoarthrit is of the hip.osteoarthrit is of the hip.

Avascular Necrosis Avascular Necrosis of the Femoral Headof the Femoral Head

The patient with avulsion fracture of the greater tro-chanter. The injury was immobilized in a one-and-a-half hip spica for five weeks.

After six months, the radio-graphs showed beginning avascular necrosis of the femoral head, which later developed into complete necrosis with subluxation.

Subcapital displaced fracture treated Subcapital displaced fracture treated with Austin Moor endoprothesiswith Austin Moor endoprothesis

Total Hip Total Hip replacementreplacement

Total hip replacement may be preferable in a old patient with severely dis- placed fracture. Prosthetic replacement may be quicker and less traumatic than fixation and may also permit earlier rehabilitation.

Trochanteric Trochanteric FracturesFractures

Proximal femoral part fractures Proximal femoral part fractures (lateral fractures)(lateral fractures)

Classification of fractures

4. Transtrochanteric - intertrochanteric

5. Separation of the lesser trochanter

6. Subtrochanteric7. Separation of the

greater trochanter

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Where trochanteric region is involved, a blade plate (1), DHS or 95° Dynamic Condylar Screw, Gama nail may be used.

Surgical TreatmentSurgical Treatment

Trochanteric region fracture (lateral Trochanteric region fracture (lateral fracture) fixed with DHSfracture) fixed with DHS

DHS (Dynamic Hip Screw)DHS (Dynamic Hip Screw) with long blade with long blade

With further involvement of the shaft, a With further involvement of the shaft, a Russell-Taylor reconstruction (locking) nail, Russell-Taylor reconstruction (locking) nail,

Gama-nail or DHS with long blade offer Gama-nail or DHS with long blade offer considerable versatility. considerable versatility.

Gama-nailGama-nail

Surgery for Subtrochanteric Femoral Surgery for Subtrochanteric Femoral FractureFracture

for childrenfor children

Femoral Shaft Femoral Shaft FracturesFractures

Mechanism of injuryThis is essentially a fracture of young adults and usually results from a high-energy injury.

Femoral Shaft FracturesFemoral Shaft Fractures

The femoral shaft is well padded with powerful muscles - an advantage in protecting the bone from all but the most powerful forces, but a disadvantage in that fractures are often severely displaced by muscle pull, making reduction difficult.

Emergency treatmentEmergency treatment

Thomas Thomas splintsplint

Nonsurgical treatmentNonsurgical treatment

The most common use of traction is in the treatment of young children (usually 5-10 y/o) with 2-3 weeks duration in the face of soft-tissue injury.

Nonsurgical treatmentNonsurgical treatment

Adult nonsurgical treatment options Adult nonsurgical treatment options include skin traction, skeletal include skin traction, skeletal traction, cast brace, casting. traction, cast brace, casting. Children have the same options. Children have the same options.

Nonsurgical options are used Nonsurgical options are used infrequently outside of the younger infrequently outside of the younger pediatric population. pediatric population.

Nonsurgical treatment – skeletal traction

Nonsurgical treatmentNonsurgical treatment Complications of tractionComplications of traction

OverdistractionOverdistraction Pin track infectionPin track infection Loss of posit ionLoss of posit ion Pressure soresPressure sores

CastsCasts

Complications of casts:

- Circulatory embarrassment- Pressure sores- Undiagnosed wound infection- Joint stiffness Unilat Hip

Spica CastOne and One-half Hip Sp. Cast

Bilat. Long-leg Hip Spica Cast

Surgical treatmentSurgical treatment

Surgical treatmentSurgical treatment

internal f ixation is sti l l the treatment of internal f ixation is sti l l the treatment of choice for most closed injuries and choice for most closed injuries and some open because of the higher union some open because of the higher union rate, lower rate of complications, lower rate, lower rate of complications, lower morbidity, earl ier weight bearing, morbidity, earl ier weight bearing, shorter hospital stay, and better control shorter hospital stay, and better control of alignment. of alignment.

Intramedullary Nailing of the Intramedullary Nailing of the FemurFemur

Russell-Taylor standart (locking) nailRussell-Taylor standart (locking) nail

Russell-Taylor reconstruction Russell-Taylor reconstruction (locking) nail for duble fracture(locking) nail for duble fracture

Russell-Taylor standart (locking) nail Russell-Taylor standart (locking) nail for triple fracturefor triple fracture

AO-system plateAO-system plate

Buttress long plate (cobra plate)Buttress long plate (cobra plate)

External fixation has two great advantages:

- It can be used in patients with skin loss or infection.- It can be used for temporary fixation.

Distal Femoral Fractures

Injuries of the lower end of the femur:

(a)the mechanism of flexi-on of the distal fragment in a supracondylar fracture (b)slipped lower femoral

epiphysis.

Types of Types of infraarticular infraarticular fracturesfractures

PartialPartial Complete Complete

infraarticular infraarticular Comminuted Comminuted

infraarticularinfraarticular Extraarticular Extraarticular

metadiaphysal metadiaphysal fracturesfractures

95º CONDYLAR PLATE (DCP)95º CONDYLAR PLATE (DCP)

Patella Fractures

Frequency: Patella fractures account for approximately 1% of all skeletal injuries.

Fractures occur as a result of a compressive force such as a direct blow, a sudden tensile force as occurs with hyperflexion of the knee, or from a combination of these.

Patient examinationPatient examination

Clinical:Clinical: - The patient usually presents with pain in - The patient usually presents with pain in

the affected knee. the affected knee. - Overlying abrasions, any lacerations - Overlying abrasions, any lacerations

must be assumed to communicate with the must be assumed to communicate with the joint joint

- An accompanying intra-articular effusion - An accompanying intra-articular effusion may be present, which, if aspirated, wil l may be present, which, if aspirated, wil l reveal fat globules. reveal fat globules.

- If the fracture is displaced, a defect is - If the fracture is displaced, a defect is palpable at the fracture site. palpable at the fracture site.

- The extensor mechanism must always be - The extensor mechanism must always be evaluated. evaluated.

- Disruption of the extensor mechanism - Disruption of the extensor mechanism results in the inabil i ty to extend the knee results in the inabil i ty to extend the knee against gravityagainst gravity

Classification of patella fractures

Tangential patellar radiograph

Transverse fracture of the patella after a direct blow to the knee.

If the fracture is not displaced the fracture If the fracture is not displaced the fracture may be treated with immobilization, may be treated with immobilization, placing placing the affected extremity in a cylinder cast for 4-the affected extremity in a cylinder cast for 4-6 weeks6 weeks. The patient is allowed to bear weight . The patient is allowed to bear weight in the cast. in the cast. With proper patient selection, good results With proper patient selection, good results can be expected in approximately 90% of can be expected in approximately 90% of patients with nondisplaced fractures.patients with nondisplaced fractures.

Closed treatment

Surgical treatmentSurgical treatment

Surgical treatmentSurgical treatment

Menisci injuriesMenisci injuries

Collateral ligaments injuryCollateral ligaments injury

Clinical investigationClinical investigation