Fracture shaft of the femurFracture shaft of the femur

While the powerful muscles surrounding the femur protect it from all but the While the powerful muscles surrounding the femur protect it from all but the powerful forces it cause sever displacement of the # fragments making powerful forces it cause sever displacement of the # fragments making reduction difficult. reduction difficult.

Mechanism of Injury:Mechanism of Injury:The # usually occur in adult as a result of high energy injury, in elderly The # usually occur in adult as a result of high energy injury, in elderly diaphysial # should be considered pathological. In children under 4 years of age diaphysial # should be considered pathological. In children under 4 years of age it is possibly due to child abuseit is possibly due to child abuse

•Spiral # caused by twisting force, transverse or oblique # caused by direct Spiral # caused by twisting force, transverse or oblique # caused by direct violence, comminuted # caused by a combination of direct & indirect force violence, comminuted # caused by a combination of direct & indirect force which may also cause the bone to be broken in more than one place i.e. which may also cause the bone to be broken in more than one place i.e. segmental #. segmental #.

Clinical Features:Clinical Features:There is swelling, deformity of the limb & movement is painful, bleeding is sever, more than 1 liter may be lost in theThere is swelling, deformity of the limb & movement is painful, bleeding is sever, more than 1 liter may be lost in thesoft tissue, one must exclude neurovascular injury & other lower limb or pelvic #. # of the femoral shaft & tibial shaftsoft tissue, one must exclude neurovascular injury & other lower limb or pelvic #. # of the femoral shaft & tibial shafton the same side produce floating knee.on the same side produce floating knee.

X ray:X ray:Determine # pattern, one must x ray the hip & knee as well as base line chest x ray because of the risk of ARDS in Determine # pattern, one must x ray the hip & knee as well as base line chest x ray because of the risk of ARDS in those with multiple injuries. those with multiple injuries.

Treatment:Treatment:* Emergency treatment: 1- treat the shock. 2- splint the #either by tying the limb to the other leg. Or by the use of* Emergency treatment: 1- treat the shock. 2- splint the #either by tying the limb to the other leg. Or by the use ofThomas splint, this will control pain, reduce bleeding & make transfer easier.Thomas splint, this will control pain, reduce bleeding & make transfer easier.* Definitive treatment: to reduce the systemic complications the # must be stabilized either by: * Definitive treatment: to reduce the systemic complications the # must be stabilized either by: (1)- Traction& bracing:(1)- Traction& bracing:Traction can reduce & hold most #s. in reasonable alignment except those in the upper 1/3 of the femur.Traction can reduce & hold most #s. in reasonable alignment except those in the upper 1/3 of the femur.The main indications for traction: 1- # in children. 2- contraindication to anesthesia. Lack of suitable skills & facilitiesThe main indications for traction: 1- # in children. 2- contraindication to anesthesia. Lack of suitable skills & facilitiesfor internal fixation.for internal fixation.Relative contraindications to traction: 1- elderly patient. 2- pathological #. 3- multiple injuries.Relative contraindications to traction: 1- elderly patient. 2- pathological #. 3- multiple injuries.Types of traction:Types of traction:1- for infant less than 12 KG. the lower limb suspended from un overhead pullies “Gallows traction” but no more 2 KG. 1- for infant less than 12 KG. the lower limb suspended from un overhead pullies “Gallows traction” but no more 2 KG. used to avoid circulatory embarrassment. used to avoid circulatory embarrassment. 2- for older children use Russell’s traction for 4 wk. then spica cast for 6-12 wk.2- for older children use Russell’s traction for 4 wk. then spica cast for 6-12 wk.3- for adult or older adolescents use skeletal traction with 8-10 KG. for 8 wk. then pop cast for another 16-24 wk.3- for adult or older adolescents use skeletal traction with 8-10 KG. for 8 wk. then pop cast for another 16-24 wk.

((22 -) -)open reduction & plating: indicated inopen reduction & plating: indicated in

11 - -combination of femoral shaft & neck #. 2- shaft # associated with vascular injurycombination of femoral shaft & neck #. 2- shaft # associated with vascular injury . .

((33 -) -)intramedullary nailingintramedullary nailing : :

Is the method of choice for most femora shaft #, if locking screw used it will control even subtrocanteric & Is the method of choice for most femora shaft #, if locking screw used it will control even subtrocanteric & distal 1/3distal 1/3# #

((44 -) -)external fixation: indicated forexternal fixation: indicated for::

11 - -sever open injury. 2- multiple injury. 3- deal with bone losssever open injury. 2- multiple injury. 3- deal with bone loss . .

Advantages: 1- not expose # site. 2- provide small amount of axial movement. 3- reduce operative time. 4- Advantages: 1- not expose # site. 2- provide small amount of axial movement. 3- reduce operative time. 4- allow early movement & exercises. Reduce blood lossallow early movement & exercises. Reduce blood loss . .

Complications of femoral shaftComplications of femoral shaft:# :#

EarlyEarly::

11 - -shock: 1-2 liter of blood can be lost even in closedshock: 1-2 liter of blood can be lost even in closed .# .#

22 - -fat embolism & ARDS: because # through large marrow filled cavity result in small shower of fat emboli fat embolism & ARDS: because # through large marrow filled cavity result in small shower of fat emboli being swept to the lungbeing swept to the lung . .

33 - -thromboembolism: prolong traction in bed predispose to thrombosisthromboembolism: prolong traction in bed predispose to thrombosis..

44 - -infection: risk occur in open injury & follow internal fixation & should be treated as for acute osteomyelitisinfection: risk occur in open injury & follow internal fixation & should be treated as for acute osteomyelitis..

LateLate : :

11 - -delayed & nonunion: when union delayed > 3-4 months & this should be treated by rigid fixation & bone delayed & nonunion: when union delayed > 3-4 months & this should be treated by rigid fixation & bone graftgraft..

22 - -malunion: no more than 15 degree angulation should be accepted & if shortening occur can be malunion: no more than 15 degree angulation should be accepted & if shortening occur can be accommodated by building up the shoeaccommodated by building up the shoe . .

33 - -joint stiffness: may be caused by soft tissue adhesion or the joint injured at the same time of initial joint stiffness: may be caused by soft tissue adhesion or the joint injured at the same time of initial traumatrauma..

44 - -re# & implant failurere# & implant failure..

Supracondylar # of the femurSupracondylar # of the femurMechanism of injuryMechanism of injury::

Seen in adult usually caused by high energy trauma & in elderly osteoporotic individual the usual cause Seen in adult usually caused by high energy trauma & in elderly osteoporotic individual the usual cause is direct violence, the # line is just above the condyl but may extend between them & in worst case is direct violence, the # line is just above the condyl but may extend between them & in worst case it is severely comminuted, if the lower fragment is intact it may be markedly displaced by the pull it is severely comminuted, if the lower fragment is intact it may be markedly displaced by the pull of the gastrocnemius thus risk injury the popliteal arteryof the gastrocnemius thus risk injury the popliteal artery..

Clinical featureClinical feature::Swelling of the knee, deformity, painful movement, the tibial artery should be palpatedSwelling of the knee, deformity, painful movement, the tibial artery should be palpated..

X rayX ray: of the entire femur to exclude proximal or dislocation of the hip joint: of the entire femur to exclude proximal or dislocation of the hip joint..

TreatmentTreatment::A)- if the # is undisplaced or reduced easily with knee flexion, the # treated by traction by pin through A)- if the # is undisplaced or reduced easily with knee flexion, the # treated by traction by pin through proximal tibia 4-6 wk. then replaced by cast-brace & patient allowed partial weight bearingproximal tibia 4-6 wk. then replaced by cast-brace & patient allowed partial weight bearing..B)- operative: when closed reduction fail then open reduction & internal fixation done either with angled B)- operative: when closed reduction fail then open reduction & internal fixation done either with angled compression device or a retrograde locked intramedullary nail. Unprotected weight bearing not compression device or a retrograde locked intramedullary nail. Unprotected weight bearing not allowed until the # consolidated after 12 wkallowed until the # consolidated after 12 wk..

ComplicationsComplications:: Early: arterial damageEarly: arterial damage..Late: 1- joint stiffness. 2- non unionLate: 1- joint stiffness. 2- non union..

Femoral condylFemoral condyl# # Mechanism of injuryMechanism of injury::

Usually occur in association with supracondylar # or in isolation, the cause is direct trauma or fall from a Usually occur in association with supracondylar # or in isolation, the cause is direct trauma or fall from a height with the tibia driven upward into the intercondylar notchheight with the tibia driven upward into the intercondylar notch..

Clinical feature: Clinical feature: as for supracondylaras for supracondylar.# .#

X ray:X ray: show three type of show three type of # #

Type A: extra articular supracondylarType A: extra articular supracondylar.# .# Type B: intra articular unicodylarType B: intra articular unicodylar.# .# Type C: intra articular bicondylarType C: intra articular bicondylar.# .#

Treatment: (1)- Treatment: (1)- closed if the # not displaced by skeletal traction through the proximal tibia & closed if the # not displaced by skeletal traction through the proximal tibia & manual compression of the # to improve the position. Traction is maintained for 4-6 wk. then manual compression of the # to improve the position. Traction is maintained for 4-6 wk. then changed to cast-brace until the # firmly unitedchanged to cast-brace until the # firmly united . .

((22 -) -)operative: if closed reduction fail by OR&IF exercises begin early but weight bearing not permitted operative: if closed reduction fail by OR&IF exercises begin early but weight bearing not permitted until the # consolidateduntil the # consolidated..

Fracture separation of distal femoral epiphysisFracture separation of distal femoral epiphysisUsually occur in children or adolescent, the lower femoral epiphysis may be displaced laterally by forced Usually occur in children or adolescent, the lower femoral epiphysis may be displaced laterally by forced

angulation of straight knee or forward by hyperextension injuryangulation of straight knee or forward by hyperextension injury . .

The # separation is usually Salter-Harris type II & all type of # especially S-H type III & IV may result in The # separation is usually Salter-Harris type II & all type of # especially S-H type III & IV may result in femoral shortening as 70% of femoral length come from the distal physisfemoral shortening as 70% of femoral length come from the distal physis..

C/F: C/F: as with supracondylaras with supracondylar.# .#

Treatment: Treatment: for S-H type I & II closed by manual manipulation & pop cast, if the # is instable, can be for S-H type I & II closed by manual manipulation & pop cast, if the # is instable, can be stabilized with percutaneous K wirestabilized with percutaneous K wire . .

For S-H type III & IV should be accurately reduced & fixed & immobilized in plaster for 6-8 wkFor S-H type III & IV should be accurately reduced & fixed & immobilized in plaster for 6-8 wk..

ComplicationsComplications::

Early: Early: vascular injuryvascular injury

Late:Late: physeal arrest may result in angular deformity; treated by osteotomy. Or shortening treated by physeal arrest may result in angular deformity; treated by osteotomy. Or shortening treated by

femoral lengtheningfemoral lengthening . .