Fractures of the femur

AO Principles Course

Leeds2005

Module : Principles of operative management of common fractures

David L ShawDavid L Shaw

Fractures of the Femoral Fractures of the Femoral ShaftShaft (AO 3.2)(AO 3.2)

Why should I fix the #?Why should I fix the #? How should I fix it ?How should I fix it ? What complications can I expect ?What complications can I expect ?

Paediatric fracturesPaediatric fractures

See articleSee article GallowsGallows Hip SpicaHip Spica TractionTraction

Why fix the #Why fix the #

Save life Save life Poly traumaPoly trauma

Save limbSave limb

Preserve functionPreserve function Stabilisation with immediate rehabilitationStabilisation with immediate rehabilitation

Choose a method ?Choose a method ?

PlatingPlating Rigid fixation Abs stability Rigid fixation Abs stability LISSLISS LCPLCP

Ext fixnExt fixn

IM NailIM Nail

•Consider absolute vs relative stabilityConsider absolute vs relative stability•Consider soft tissues and scarsConsider soft tissues and scars•Consider facilities and equipmentConsider facilities and equipment

Choose a method 2Choose a method 2

Patient factorsPatient factors Facilities, time and polytraumaFacilities, time and polytrauma Damage control orthopaedicsDamage control orthopaedics

““Get me a nail!”Get me a nail!”

Rods & NailsRods & Nails

When is a nail not a nailWhen is a nail not a nail Hollow – Slotted – SolidHollow – Slotted – Solid

Why nails failWhy nails fail

Effects of ReamingEffects of Reaming

Bones & NailsBones & NailsHollow structuresHollow structures

Hollow bones for strengthHollow bones for strength

Early nails were hollow & needed 3 point Early nails were hollow & needed 3 point fixationfixation

Kuntcher - Clover leaf Kuntcher - Clover leaf nailnail

3 point fixation3 point fixation

Inserted open so no Inserted open so no guide wire requiredguide wire required

GK & AOGK & AO – Slotted hollow nail – Slotted hollow nail

Allowed guide wire insertion Allowed guide wire insertion

Flat sheet manufactureFlat sheet manufacture

Reaming to increase the Reaming to increase the contact areacontact area

Lets talk about stiffnessLets talk about stiffness

Bending StiffnessBending StiffnessSecond Moment of Inertia Second Moment of Inertia (I)(I)

TubeTube I=(RoI=(Ro44 – Ri – Ri44) * ) * ¶/4¶/4

Radius Radius cubedcubed

Hollow structures are relatively strong for the volume of Hollow structures are relatively strong for the volume of materialmaterial

For a given increase in radius torsional and bending For a given increase in radius torsional and bending stiffness go up to the fourth powerstiffness go up to the fourth power

Torsional stiffness roughly 2x inc vs bending as radius Torsional stiffness roughly 2x inc vs bending as radius

At physiological loads torsional deformation more At physiological loads torsional deformation more clinically evidentclinically evident

Slotted nails especially Slotted nails especially are weak in torsionare weak in torsion

The advantage of The advantage of “Unreamed”“Unreamed”

Solid Ti nails are strong enough at Solid Ti nails are strong enough at diameters small enough to be inserted diameters small enough to be inserted without reaming without reaming

Not possible with SS nailsNot possible with SS nails

ExpensiveExpensive

The advantage of The advantage of SolidSolid

““You be the Judge”You be the Judge”

For For unreamedunreamed

Healing Healing 170 #170 # Equivalent healing time (19/52)Equivalent healing time (19/52) 55mins quicker55mins quicker = delayed unions= delayed unions Reynders Injury 2000Reynders Injury 2000

General ResultsGeneral Results 164# retrospective series164# retrospective series 93% union rate with UFN93% union rate with UFN AO type C healed at 6.2mo (ave)AO type C healed at 6.2mo (ave) UFN “healing rates comparable with UFN “healing rates comparable with

historical standards”historical standards” Herscovici JOT 2000Herscovici JOT 2000

For For unreamedunreamed

For For unreamedunreamed

Intramedullary pressureIntramedullary pressure Clinical trial 38 ptsClinical trial 38 pts 5x increased pressure in reamed group5x increased pressure in reamed group Pressure correlated with fat extravasationPressure correlated with fat extravasation Berger JOT 1997Berger JOT 1997

Poly TraumaPoly Trauma Femur # in polytrauma pts managed by;Femur # in polytrauma pts managed by;

Early Total CareEarly Total Care Intermediate Stabilisation Intermediate Stabilisation ““Damage Control Surgery”Damage Control Surgery” ““A significant reduction in the incidence of A significant reduction in the incidence of

complications was found ..regardless of the type complications was found ..regardless of the type of fixation”of fixation”

Garapati & Krettek J of T 2002Garapati & Krettek J of T 2002

For For unreamedunreamed

Against unreamed Against unreamed methodmethod

Healing Healing 147#147# 6 weeks longer to heal 6 weeks longer to heal Giannoudis Injury 1997Giannoudis Injury 1997

172#172# 4 weeks longer to heal4 weeks longer to heal More “technical complications”More “technical complications” Tornetta JOT 2000Tornetta JOT 2000

Against unreamed Against unreamed methodmethod

Stimulation of the inflammatory systemStimulation of the inflammatory system IL6, CD11b, s-ICAM-1, E-selectin & elastaseIL6, CD11b, s-ICAM-1, E-selectin & elastase Reamed vs Unreamed Reamed vs Unreamed Evidence of a “second hit” to the immune Evidence of a “second hit” to the immune

systemsystem No difference reamed vs unreamed No difference reamed vs unreamed

Giannoudis JBJS(B) 1999Giannoudis JBJS(B) 1999

• If you don’t ream you still get a second If you don’t ream you still get a second hit to the immune systemhit to the immune system

Against unreamed Against unreamed methodmethod

ComplicationsComplications 100 randomised pts 100 randomised pts

2x iatrogenic comminution in unreamed2x iatrogenic comminution in unreamed Reaming was “required” in the unreamed Reaming was “required” in the unreamed

group in 3group in 3 Shepherd J Orthop Trauma 2001Shepherd J Orthop Trauma 2001

For unreamedFor unreamed QuickerQuicker SimplerSimpler Less equipmentLess equipment Equivalent healing rateEquivalent healing rate Less fat embolusLess fat embolus Less H-OLess H-O Lower immune “hit”Lower immune “hit”

For reamedFor reamed

Faster unionFaster union Fewer implant Fewer implant

related complicationsrelated complications Lung injury not Lung injury not

directly & only directly & only caused by reamingcaused by reaming

““Second hit” not Second hit” not specifically caused specifically caused by reamingby reaming

It’s all about techniqueIt’s all about technique

Reaming is a Reaming is a techniquetechnique

Solid nails are implantsSolid nails are implants

Solid nail ?Solid nail ?

Who would put a Who would put a 9mm nail in this pt!9mm nail in this pt!

Summary & “Verdict”Summary & “Verdict”

Reaming is a technique Reaming is a technique

Solid vs Slotted vs Cannulated Solid vs Slotted vs Cannulated is a design / manufacturing processis a design / manufacturing process

““I always do reamed I always do reamed nails”nails”

SummarySummary

Chose the smallest nail which is strong Chose the smallest nail which is strong enough for the patient and his/her injuryenough for the patient and his/her injury

Ream if necessary to put the appropriate Ream if necessary to put the appropriate size of nail in for the patient & injurysize of nail in for the patient & injury

Don’t confuse implants with techniqueDon’t confuse implants with technique

Other peoples’ Other peoples’ complicationscomplications

•General complicationsGeneral complications

•Specific # related comlpicationsSpecific # related comlpications

•MalunionMalunion

Cambell’s Operative Cambell’s Operative OrthopaedicsOrthopaedics

““Malunions after closed treatment are the Malunions after closed treatment are the rule”rule”

MalrotationMalrotation

> 10 degrees in 8-19% of fractures> 10 degrees in 8-19% of fractures

JBJS 75 (B) 799-803JBJS 75 (B) 799-803 JBJS 66 (A) 529-39JBJS 66 (A) 529-39

Cambell’s Operative Cambell’s Operative OrthopaedicsOrthopaedics

““..become significant only if they result in..become significant only if they result in shortening of more than 2.5 cmshortening of more than 2.5 cm angulated more than 10 degreesangulated more than 10 degrees internally or externally rotated to the point internally or externally rotated to the point

that the knee cannot be aligned with that the knee cannot be aligned with forward motion during gait.”forward motion during gait.”

? How much rotation ?? How much rotation ?

External rotation less well compensated External rotation less well compensated

than internalthan internal 15 degree limit15 degree limit Based on functional assessments and Based on functional assessments and

FPAFPA Nijmegen group: Injury 35 1270-1278 2004Nijmegen group: Injury 35 1270-1278 2004

Malunion Malunion

> 2.5 cm shortening> 2.5 cm shortening > 10> 10° angular deformity° angular deformity >15>15° rotation deformity° rotation deformity

Malunion Malunion

> 2.5 cm shortening> 2.5 cm shortening > 10> 10° angular deformity° angular deformity Rotation that the pt can see !Rotation that the pt can see !

Fractures of the Femoral Fractures of the Femoral ShaftShaft (AO 3.2)(AO 3.2)

Why should I fix the #?Why should I fix the #? Damage controlDamage control Restore functionRestore function

How should I fix it ?How should I fix it ? For the fracture / for the patientFor the fracture / for the patient

What complications can I expectWhat complications can I expect Length , Rotation the pt can seeLength , Rotation the pt can see