Fracture of shaft and distal part

of femoral bone

prepared by : AMIT KUMAR

BPT 2ND year

CPRS,JMI

Femoral Shaft fracture

A fracture of the shaft of the femur is usually sustained by a

severe violence,as may occur in a road accident. The force

causing the fracture may be indirect(twistingor bending

force) or direct(traffic accidents).

The fracture may occur at any site and is most equally

common in the upper,middle and lower thirds of the shaft. It

may be a transverse ,oblique ,spiral or comminuted fracture

depending upon the nature of the fracturing force.

Mechanism of Femoral shaft fracture :

This is usually a

fracture of young

adults and results

from a high energy

injury.

Like road

accidents,falls from

height,gun shots etc.

Special features of femoral shaft fracture :

Essentially fracture of young

adult .

Result from high energy injury

If occur in eldery should be

considered pathological until

proved otherwise .

In children under 4 years of age

the possibility of physical abuse

may be kept in mind .

Classification (Winquist’s classification): Type 1 Type 2 Type 3 Type 4

Type 1 there is only a tiny cortical fragment.Type 2 the ‘butterfly fragment is larger but there is still at least 50 per cent cortical contact between the main fragments. Type 3 the butterfly fragment involves more than 50 per cent of the bone width.Type 4 is essentially a comminuted fracture .

Cont…...

Reflects the observation that the degree of soft tissue

damage .

Fracture instability increase when increasing the grades of

comminution .

Diagnosis :

Radiological examination 1- History and physical exam .

2-X-ray done for a femoral shaft fracture must include whole femur .

3-An X-ray of the pelvis should be done because it is common that a patient with fracture of the femur has an associated injury in the pelvis.

CT scan :

Clinical picture :

Pain

Swelling

Deformity

Tenderness

Loss of function

Treatment :

Conservative method

Traction and bracing(Thomas splint, perkins traction)

Hip spica

Gallow’s traction(in children from birth to 2 years)

Operative method

Open reduction and plating .

Closed interlock nailing

Kuntscher”s clover leaf Intramedullary nailing (k-nail)

External fixation

Titanium elastic nail system(TENS)

Traction and bracing :

Traction with a splint is first aid for a patient with a femoral shaft fracture.

Indication :

1-fracture of children .

2- contraindication to anesthesia .

3- lack of suitable skills for internal fixation .

Length of time spent in bed is about 10 – 14 weeks .

Method : 1- Thoma’s splint . 2- Perkin’s traction .

Thoma’s splint

This method

rarely used

because it

lead to knee

stiffness.

Skletal traction without splints.

The traction is applied directly

on the bone by inserting a k-

wire or stienmen’s pin through

the bone.

perkin’s traction

Hip spica

This is a plaster cast incorporating part

of trunk and the limb.

It may be a single spica or one-and-half.

It can be safely used for immobilising these

fractures in children.

It may also be used for treating fractures in

young adults,once the fracture becomes”sticky”.

Gallow’s traction

Fracture of children from birth to 2 years are treated.

In this,the legs of the child are tied to the overhead beam.

The hips are kept a little raised from the bed so that the weight of the body

provide counter traction and fracture is reduced.

This is continued till sufficient callus forms(3-6weeks).

Open reduction and plating :

Internal fixation with

plate and screws .

Indications :

1- combination of shaft

and femoral neck

fracture .

2- fracture associated with

vascular injury .

Intramedullary nailing :

Is the method of choice and mostly used .

Implantation of intramedullary nail and fixed by screws which inserted

transversely at proximal and distal ends .

The implantation of intramedullary nail may be antegrade or retrograde .

Antegrade nailing :- insertion of the nail through pyriform fossa and transverse

locking screws proximally and distally .

Retrograde nailing :- insertion of the nail through intercondylar notch at the knee

.

This operation control the rotatory movement and ensures stability .

Nail or… Plate

External fixation :

Main indication are :

1- Treatment of severe open injuries .

2- Patient with multiple injuries .

3- Severe bone loss which need to bone transport.

4- Femoral fracture in adolescence .

Advantage & disadvantage of intramedullary nailing

and external fixation :

Advantage :

Not exposing the fracture site .

Callus increase in the volume and quality .

Promoting quicker consolidation by increase stress transfer to the

fracture site .

Disadvantage :

Pins-site infection .

Most femoral shaft fracture will unite in under 5 month but some take

longer if the fracture is badly comminuted or contact between fracture

end is poor .

Titanium Elastic Nail System(TENS)

In recent times there has been an increasing trend

towards surgical intervention in paediatric femoral

shaft fractures with widening indications. Titanium

elastic nails and external fixation are two widely

practiced procedures for such fractures.

TENS is preffered to internally fix the fracture in

older children(more than 10 years of age).

Open fracture :

In open fracture

should be carefully

assessed for :

1- neurovascular

injury .

2- muscle ischemia .

3- skin loss .

4- wound

contamination .

Warning sign in the fracture with vascular injury :

Excessive bleeding or hematoma formation .

Parasthesia , pallor , pulselessness and other

6P in the leg and foot .

Treatment of open fractures :

The immediate treatment is similar to that of closed

fractures; in addition:

1- the patient is started on intravenous line to prevent shock .

2- I.V antibiotics.

3- The wound will need cleaning .

4- contaminated areas and dead tissue must be excised and

the entire area should be washed thoroughly and the wound should be left

open .

Complications of femoral shaft fractures :

Early :

Fat embolism .

Shock (hypovolaemic shock)

Infection .

Thromboembolism .

:LATE:

Delayed union and non-union .

Malunion .

Joint stiffness .

Refracture and implant failure .

Shortening of limb .

CONDYLAR(distal end)FRACTURE

Condylar fracture of femur are of 3 types :

Supracondylar fracture……………………..(a)

Intercondylar fracture(T or Y-type)………..(b)

Unicondylar(medial or lateral)fracture……(c)

Mechanism

Mechanism :

Direct violence is the usual cause.

This fracture are seen in :

1- young adult usually as a result of

high energy truma .

2- in eldery due to osteoporosis .

The fracture is line just above the

condyle .

AO group classification :

Type A : fractures have no articular splits and are truly ‘supracondylar’; .

Type B : fracture are simply shear fracture of one of the condyle .

Type C : fracture have supracondylar and intracondylar fissure .

Type A Type B Type C

Diagnosis :

Radiological

examination

History and physical

exam .

By X-Ray .

By CT scan .

Clinical features :

The knee is swollen and deformed because of a

haemarthrosis .

Movement is too painful .

Important note : The tibial pulses should always be checked

to ensure the popliteal artery was not injured in the fracture.

Treatment :

Non operative :

Traction by

thoma’s splint :

skeletal traction

through the

proximal tibia .

This method used if

the fracture only

slightly displaced

and extra-articular .

Treatment :

Operative treatment :

1- locked intramedullary nail which are introduce retrograde

through the intercondylar notch .It is suitable for the type A .

2- Plates that are applied to the lateral surface of the femur

.It is suitable for the type A and type C .

3- Simple lag screws . suitable for the type B .

Complications :

Early :

Arterial damage

Infection

Osteoarthritis

Late :

Joint stiffness

Malunion

Non-nunion