Femoral shaft fractures

Tony Olasinde,
Senior Lecturer in Department of Surgery,
Faculty Clinical Medicine and Dentistry,
Kampala International University ( Western Campus),
Ishaka- Bushenyi.
Learning objective
• Know about.
• Epidemiology
• Relevant anatomy
• Patho-anatomy
• Etiology
• Classification
• Clinical features
• Investigation
• Treatment
• Operative
• Non operatives
• Complications
Epidemiology
• 37.1 in 10000 person annually
• Male > female
• Mechanism of injury
• High energy – most common in the young
• Often high Motor vehicle accident
• Rarely fall from heights
• Civilian assault with gunshot either velocity or low velocity missile injury
• Sport injury
• Low energy injury
• as in trivial falls in the elderly.
• Stress fractures as in military recruit
• Pathological fractures
Fracture patterns
• Transverse
• Caused by pure bending force
• Spiral
• Rotational movement
• Oblique
• Uneven bending moment
• Segmental
• 4- point bending moment
• Communited
• High speed crush or torsion mechanism
Associated conditions
• Ipsilateral femoral neck fractures
• 2-6 % incidence- basicervical, vertical and non displaced
• Missed in 19-31% of time
• Bilateral femur fractures
• Increased of pulmonary complications
• Increased mortality compared to unilateral
• Ipsilateral tibia fractures
• Ipsilateral acetabular frctures
• Thoracic injury- Pulmonary injury- ARDS
• Cerebral haemorrhage, subdural hemorrhage
Relevant anatomy
• Bone
• Strongest and longest bone in the body --- 45 ± 2.5cm cf with other structure in the body
• Tubular with anterior bowing
• Anatomically shaft is 5cm below lesser trochanter and 5cm proximal to supracondylar ridge
• Linear aspera
• Rough crest of bone middle third posteriorly
• Attachment for various muscles and fascia
• Acts as compressive strut to accommodate anterior bowing
• Muscle's
• 3 compartments
• Anterior – Quadriceps femoris, Satorius
• Posterior – Hamstring muscles
• Medial– Pectineus , gracilis, adductor longus and brevis and adductor magnus
• Obturator externus.
• Blood supply
• Nutrient artery
• Periosteal blood supply from the surrounding muscles
Bony part of the Femur
Biomechanics
• Deforming forces after a fracture
• Abducted proximal fragment …..
• Flexed …….
• Distal fragment
• Varus …..adductors
• Extension – Gastrocnemius acting on distal aspect of the posterior femur
Classification – Winquist and Hansen
classification
AO classification of femur diaphysis fracture
Presentation
• Initial evaluation
• ATLS- should be initiated
• Adequate resuscitation
• Normal vital signs
• HR<100bpm
• SBP>100
• DBP>70
• Normothermia>35degree Celsius
• Adequate urine output
• 0.5 to 1.0ml/kg /hr.
• Labs
• Lactate<2.5mmol/l
• Base deficit within -2 and +2
• IL6 levels<500pg/dl
• Gastric mucosal PH >7.3
Initial evaluation continues
• Compensated shock
• Commonly missed
Attributes – normotensive,
tachycardic without fever,
cool extremities,
Narrowing pulse pressure,
weak peripheral pulses
Delayed capillary refill
symptoms
• Pains in the thigh
• Inspection
• tense and swollen thigh( 750-1500ml per thigh)
• Closed fracture tibial (500-1000ml )
• Blood loss in open fractures may be double
• Affected leg shortened
• Tenderness
• Motion causes pain
• Neurovascular check and document
investigation
• Radiograph of the affected limbs
• Ap and Lateral view
• AP and lateral view of ipsilateral Hip
• Ap and lateral of the ipsilateral knee
• CT scan to rule out ipsilateral femoral neck fracture
• **** adequate resuscitation is defined as
• <500pg of IL6
• <2.5 mmol/l of serum lactate
• Base deficit within -2 and +2
Treatment
• Operative intervention
• Antegrade IM nailing GOLD standard
• Outcomes within 24 hours associated with
• Decreased ARDS
• Decreased thromboembolic events
• Decreased LOS and cost of hospitalization
• DCO vs ETC care
• Retrograde nailing
• Indications
• Ipsilateral femoral neck #
• Floating knee
• Ipsilateral acetabular #
• Polytrauma patient
• Bilateral femoral #s
• Morbid obesity
• Pregnancy in the first trimester
• CI….. Skeletal immature, knee sepsis, or soft tissue injury involving the knee.
For unstable patients
• Early external fixation and conversion to IMN within 2-3 weeks
• Indications
• Unstable poly trauma patients
• Those with vascular injuries
• Severe open fractures
• ORIF with plate and screws
• INDICATION
• Ipsilateral femoral neck # requiring plate fixation
• # at distal diaphyseal- metaphyseal junction
• Narrow medullary cavity with difficult access
• Has increased infection. Non union, hardware failure
Complication of treatment
• Heterotrophic ossification
• Incidence 25%
• Pudendal nerve injury
• If traction table is used 10% incidence
• Femoral artery or nerve injury
• In retrograde nailing when placing the proximal screw above the lesser trochanter
• Malunion or rotational malalignment
• 30% in proximal # and 10% in distal #...... Risk factors use of # table fracture
comminution, night time surgery
• Delayed union
• Non union – incomplete within 9month of treatment
Complication continue
• Risk factors
• use of NSAID, smoking
• Broken distal interlock screws
• Infection
• Incidence <1%
• Quadriceps and abductors muscles weaker on the affected limb
• Iatrogenic fractures
• Mechanical axis deviation
• Anterior cortical penetration
External fixation, and IMN
Femoral fracture plating
references
• Femoral shaft fractures available online at www.orthobullet.com
accessed 16th August, 2022.
• Case presentation on Femoral shaft fractures available online at
www.slideshares.com
• Accessed 16th August, 2022.
• Gansslen A, Gosling T, Hilderbrand F, Pape HC, Oestern HJ. Femoral
shaft fractures in Adults: Treatment options and controversies. Acta
Chirurgiae orthpaedicae Et Traumatologiae Cehosl, 81, 2014: p.108-
117
Distal Femoral fractures
• Learning objectives :Know the;
• Epidemiology
• Relevant anatomy
• Patho-anatomy
• Etiology
• Classification
• Clinical features
• Investigation
• Treatment
• Operative
• Non operatives
• Complications
epidemiology
• Common fracture
• 3-6 % of all fracture femur
• 1% of the all fractures
• Bimodal pattern of occurrence
• Elderly – low energy injury- trivial fall, domestic fall lesser degree of
displacement preponderance for occurrence in females.
• Young – High energy mostly Motor vehicle accident, sport injury
Relevant anatomy
• Bone .
• Distal femur is in 6-11 degrees of valgus in its anatomical axis
• Medial condyle extend more than lateral
• Distal femur is trapezoidal in axial plane with medial having a slope of 20-25degrees and lateral 10 degrees
• Posterior halves of both condyles are posterior to the posterior part of the femur
• Deforming forces
• Muscles
• Quadricep femoris
• Hamstring
• Adductor magnus
• Gastrocnemius
• Ligaments
• ACL
• PCL
• MCL
• LCL
Classification
• Descriptive
• Supracondylar
• Intercondylar
• OTA classification
• A.- Extraarticular
• B- partial articular
• Portion of the articular surface remains in continuity with shaft
• 33B3 is in the coronal plane ( Hoffa fragment)
• C- Complete articular
• Articular fragments completely separated from the shaft
AO Classification of distal femoral fractures
Detail of AO Classification
Clinical features
• History of fall of other traumatic events
• Symptoms
• pain in the distal femur worse on movement
• Inability to bear weight
• Signs
• Tenderness swelling, ecchymosis around the knee
• Deformity – varus or valgus
• Knee effusion especially in those with articular involvement
• Evaluate for wound in open # SPC region -5-10%
• Neurovascular exam
• Popliteal artery injury in significant displacement
• ABI-
• <0.9 – angiography…….97% specific and 99%sensitive for major arterial injury
• If ABI is > 0.9 – 99% negative predictive value for major arterial injury
investigation
• Radiographs in two orthogonal planes
• AP and lateral views
• Imaging to entire femur to rule out associated injuries
• Consider contralateral femur imaging for preop and postoperative templating
• Watch out for Hoffa fracture
• Missed in up to 31% of cases difficult to visualize
• A fractures in coronal plane with intraarticular extension
• Lateral condyles in 80% of cases
• Evaluate the knee joint for Degenerative joint disease in the elderly
• CT scan
• Preop planning
• Intraarticular extension
• Coronal planes fracture as in Hoffa Fractures
Angiography
• Indication
• ABI <0.9
• Obvious signs of vascular injury as expansile hematoma, pulselessness,
massive bleeding
• Findings
• Identifies vascular segment with diminished flow
• Especially for displace distal fracture fragment
Treatment
• Operative always…..
• External fixation
• As stop gap or temporizing measures to restore length, alignment and stability
• Indication
• Polytrauma patient, hemodynamically unstable patient
• Poor or compromise soft tissue for incision
• Contamination requiring debridement
• Definitive treatment
• Those with severe open and/ or comminuted fractures
• Patients unstable for surgery
• Outcomes- variables – patient characteristic, fracture pattern, degree of soft tissue injury
• 92-100% union rates on mean 4-6 months has been reported.
• Non operative- rarely indicated except non ambulators, severe poor controlled comorbid
factors
ORIF with Plate and screws
• Fixed angle blade plate – in metaphyseal comminution no fixed angle
plates are prone to Varus collapse
• Indication
• Displaced #s
• Intraarticular fractures
• CI
• In Hoffa fractures
• Sometime Dual plating i.e. lateral and medial plating done
• adv. Increased stiffness, prevent torsional deformity
• Non- union rate up to 18% due extensive periosteal stripping
Retrograde nailing
• Indications
• Extraarticular fractures
• Simple Fractures with intraarticular extension
• Periprosthetic fractures
• Requirement – minimum 4cm distal fracture fragment- newer
implants have overcome this
• Adv
• High union rates, more symmetrical callus compared to plating
• Reduced rate of mal-union and higher patient satisfaction compared to ORIF
Arthroplasty and distal femoral replacement
• Indications
• Elderly patient with advance OA,
• Low demand patient
• Disad.
• Reduced longevity compared to Plating
• Adv.
• Permit immediate weight bearing.
Complications
• Knee pain and stiffness
• Treatment – early ROM and physical therapy
• Symptomatic hardware
• Lateral plate
• Pain with knee flexion/extension due to IT band contact with the plate
• Medial screw placement- excessively long screws irritate medial soft tissues
• Treatment is determine appropriate screw length
• Removal of hard ware
• Malunion common deformities are Rotation hyperextension( recurvatum) and
coronal plane malalignment
• More common with IM nails
Complications continues
• Non-union
• Incidence up to 19%
• Metaphyseal area most commonly affected.
• Infection
• Risk factors
• Diabetics with foot ulcers
• Treatment
• Debride, give culture specific antibiotics
• Hardware removal if # stability permits

• Implant failure
• Incidence up to 9%
• Risk factors
• Improper bridge plating technique
• Stainless steel implant inferior to titanium.
Complication continues
• Loss of fixation
• Varus collapse( most common cause)
• Due to toggling of distal non fixed angle screws used for comminuted metaphyseal
segment
• IM nail fixation.
• Proximal ( diaphyseal ) screw failure
• Associated with non- locked plate and short plates.