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

THANK YOU!

• HAVE A WONDERFUL AFTERNOON!