Fracture Femur

Presented by:
Erin Triana
Ronald Tejoprayitno

Anatomy

Anatomy
The Head (caput femoris)
The head which is globular and forms rather
more than a hemisphere, is directed upward,
medialward, and a little forward, the greater
part of its convexity being above and in
front. Its surface is smooth, coated with
cartilage in the fresh state, except over an
ovoid depression, the fovea capitis
femoris, which is situated a little below and
behind the center of the head, and gives
attachment to the ligamentum teres.

Anatomy
The Neck (collum femoris).
The neck is a flattened pyramidal process of bone,
connecting the head with the body, and forming with
the latter a wide angle opening medialward. The angle
is widest in infancy, and becomes lessened during
growth, so that at puberty it forms a gentle curve from
the axis of the body of the bone. In the adult, the neck
forms an angle of about 125 with the body, but this
varies in inverse proportion to the development of the
pelvis and the stature. In addition to projecting
upward and medialward from the body of the femur,
the neck also projects somewhat forward; the amount
of this forward projection is extremely variable, but on
an average is from 12 to 14.

Anatomy
The Trochanters
The trochanters are prominent
processes which afford leverage to
the muscles that rotate the thigh on
its axis. They are two in number, the
greater and the lesser.

Picture right femur anterior surface

Anatomy
The Greater Trochanter (trochanter major; great trochanter) is a
large, irregular, quadrilateral eminence, situated at the junction
of the neck with the upper part of the body
The lateral surface, quadrilateral in form, is broad, rough, convex,
and marked by a diagonal impression, which extends from the
postero-superior to the antero-inferior angle, and serves for the
insertion of the tendon of the Glutus medius. Below and behind
the diagonal impression is a smooth, triangular surface, over
which the tendon of the Glutus maximus plays, a bursa being
interposed.
The medial surface, of much less extent than the lateral, presents
at its base a deep depression, the trochanteric fossa (digital
fossa), for the insertion of the tendon of the Obturator externus,
and above and in front of this an impression for the insertion of
the Obsturator internus and Gemelli.
The superior border is free; it is thick and irregular, and marked
near the center by an impression for the insertion of the
Piriformis.
The inferior border corresponds to the line of junction of the base
of the trochanter with the lateral surface of the body; it is marked
by a rough, prominent, slightly curved ridge, which gives origin to
the upper part of the Vastus lateralis.
The anterior border is prominent and somewhat irregular; it
affords insertion at its lateral part to the Glutus minimus. The
posterior border is very prominent and appears as a free,
rounded edge, which bounds the back part of the trochanteric
fossa.
Picture of right femur posterior surface

Anatomy
The Lesser Trochanter (trochanter minor;
small trochanter) is a conical eminence, which
varies in size in different subjects; it projects
from the lower and back part of the base of
the neck. From its apex three well-marked
borders extend; two of these are abovea
medial continuous with the lower border of
the neck, a lateral with the intertrochanteric
crest; the inferior border is continuous with
the middle division of the linea aspera. The
summit of the trochanter is rough, and gives
insertion to the tendon of the Psoas major.

Anatomy
The Body or Shaft (corpus femoris)
The body, almost cylindrical in form, is a little
broader above than in the center, broadest and
somewhat flattened from before backward
below. It is slightly arched, so as to be convex
in front, and concave behind, where it is
strengthened by a prominent longitudinal
ridge, the linea aspera. It presents for
examination three borders, separating three
surfaces. Of the borders, one, the linea aspera,
is posterior, one is medial, and the other,
lateral.

Anatomy
The anterior surface includes that portion of the shaft
which is situated between the lateral and medial
borders. It is smooth, convex, broader above and below
than in the center. From the upper three-fourths of this
surface the Vastus intermedius arises; the lower fourth
is separated from the muscle by the intervention of the
synovial membrane of the knee-joint and a bursa; from
the upper part of it the Articularis genu takes origin.
The lateral surface includes the portion between the
lateral border and the linea aspera; it is continuous
above with the corresponding surface of the greater
trochanter, below with that of the lateral condyle: from
its upper three-fourths the Vastus intermedius takes
origin.
The medial surface includes the portion between the
medial border and the linea aspera; it is continuous
above with the lower border of the neck, below with the
medial side of the medial condyle: it is covered by the
Vastus medialis.

Anatomy
The medial epicondyle is a large convex eminence to which
the tibial collateral ligament of the knee-joint is attached.
At its upper part is the adductor tubercle, already referred
to, and behind it is a rough impression which gives origin to
the medial head of the Gastrocnemius.
The lateral epicondyle, smaller and less prominent than
the medial, gives attachment to the fibular collateral
ligament of the knee-joint. Directly below it is a small
depression from which a smooth well-marked groove
curves obliquely upward and backward to the posterior
extremity of the condyle. This groove is separated from the
articular surface of the condyle by a prominent lip across
which a second, shallower groove runs vertically downward
from the depression. In the fresh state these grooves are
covered with cartilage. Above and behind the lateral
epicondyle is an area for the origin of the lateral head of
the Gastrocnemius, above and to the medial side of which
the Plantaris arises.

Vascularisation of Femur

The Femoral artery is one of the major arteries in the human body that
extends from the iliac artery near the abdomen, down to the legs. The
primary function of this artery is to supply blood to the lower portion of the
body. This artery is anatomically sub-divided into a superficial artery, a
deep artery and a common artery. Each of these sub-arteries supplies
blood to different parts of the body. The largest branch of the Femoral
artery is the profunda femoris, which supplies blood to the buttocks and
thigh area. The femoral vein runs along this artery to bring the
deoxygenated blood from these areas back to the heart.

Vascularisation of Femur
The deep femoral artery is a branch of the common femoral
artery of the human body. The common femoral artery is
one of the largest arteries in the human body, with multiple
branches.
The deep femoral artery is a major blood vessel supplying the
leg. The deep femoral artery supplies the thigh with blood.
As an artery, it carries oxygenated (oxygen-rich) blood to
the muscles of the thigh and upper leg in general; a vein will
remove deoxygenated (oxygen-depleted) blood from the
thigh.
The deep femoral artery branches off from the common
femoral artery at a point known as the femoral triangle.
After leaving the femoral triangle, the deep femoral artery
develops further branches to supply blood to the back of the
thigh.
Two such branches are the medial and lateral circumflex
femoral arteries. Both of these branches, as well as the
deep femoral artery itself, are important suppliers of blood
to the entire thigh and underlying bones.
The medial circumflex is also particularly important as it
supplies the femur with blood.

Fracture
Definition

A structural brake in continuity

Classification of femoral
fracture
Proximal femoral Fracture

Femoral Neck Fracture

Femoral Intertrochanteric Fracture

Femoral Shaft Fracture

Proximal Femoral Shaft Fracture
Middle Femoral Shaft Fracture
Distal Femoral Shaft Fracture

Distal Femoral Fracture

Femoral Supracondylar Fracture
Femoral Intercondylar Fracture

Femoral Shaft Fracture

Need high energy trauma to break Femur

because Femur is the largest, the longest,

and the strongest bone in the body
Exception : Pathological fracture
Estimated bleeding : 1-2 litre of blood

Clinical Manifestation
History & Physical Examination
Swelling/Hematoma
Pain/Tenderness
Deformity
Shortened lower extremity

Always look for vascular & neurologic

compromise :
- Expanding hematoma
- Diminished pulse
- Progressive neurologic deficit

Workup
Blood test : cross match for transfusion,

serial CBC
X-ray : AP & lateral, including hip & knee
CT-Scan

Treatment of fracture femur

Emergency treatment:

Fluid Resuscitation / Blood Transfusion!!!

Reduction using Traction & Splint: Thomas
splint (require IV anesthesia)
Pain Control
Infection Control

Definitive Treatment
Non operative (Traction)

Children
Contraindicated for anesthesia
Lack of facility for ORIF

4R:
- Recognition
- Reduction
- Retention
- Rehabilitation
Disadvantage: Require longer time in bed (10-14
weeks)
Advantage : there are no operative risk

Operative
Intramedullary nailling
Plate & Screw
External Fixation

Complication
Early
Shock Hemorrhagic
Fat Embolism
Compartment Syndrome
Neurovascular Injury
Infection

Late
DVT
Delayed union/non union
Malunion
Joint stiffness

Bone Fracture Healing

Illustration Case
Identity
Name: Jaroh
Age : 48 years old
Address: Bulak Cabe
Patient comes to the emergency installation with
main complain broken of her leg from 2 weeks ago.
Before that, patient feel intermittent pain in her leg
within 5 months ago. There was absent of trauma
before. Patient feel loosening weight about 10 kg
within 2 months. Menstrual period cycle patient
stopped 8 years ago. Patient had child with leg
deformity and her father had that leg appearance.

Illustration Case
Physical examination
The primary survey during physical
examination was clear airway, spontaneous
breathing, vital signs was within normal
limits, with GCS 15 (E4M6V5), and on
secondary survey there was found
deformity of both leg, and right arm (see
local status). Other physical examinations
were within normal limits except blood
pressure 150/90 mmHg

Illustration Case
Laboratory findings
Laboratory

Findings

Normal

Hemoglobin

10,5

12-16

Hematokrit

32

36-45

Leukosit

5200

4100-10900

Trombosit

251.000

140000-440000

Eritrosit

3,57

4-5

MCV

89

80-100

MCH

29

26-34

MCHC

33

31-36

Illustration Case
Laboratory findings
Laboratory

Findings

Normal

LED

67

<15

Masa
perdarahan

1-6

APTT

33,4

31-47

PT

10,1

9,9-10,6

SGOT

16

10-31

SGPT

17

9-36

Ureum

39

20-40

Kreatinin

0,5

0,7-1,5

GDS

95

<180

Na

145

135-147

2,8

3,5-5,0

Cl

107

96-126

Illustration Case
Right leg

Left leg

Illustration Case

Illustration Case
The diagnosis for this patient was fracture
(R) shaft femur.
Patient was treated with ketorolac and pro
ORIF