Fracture of shaft of Fracture of shaft of femurfemur

Introduction.-Introduction.-

• It is a fracture of femoral diaphysis occurring between 5cm distal to lesser trochanter and 5cm proximal to adductor tubercle.

• Usually occur in young men after high energy trauma and elderly women (even after a low energy fall).

Fig : -

Anatomy

Fig :

Fig

AnatomyAnatomy

• Femur is the largest tubular bone. • Surrounded by large muscle mass.• Major deforming muscle forces-

– Abductors: Gluteus medius and minimus.– Iliopsoas ;- flexion and external rotation.– Adductors -pectineus, adductor brevis ,adductor

longus , gracilis and adductor magnus .

Thigh musclesThigh muscles

• Anterior compartment: quadriceps femoris, iliopsoas, sartorius.

• Medial compartment: gracilis, adductor longus, brevis, magnus, obturator externus.

• Posterior compartment: biceps femoris, semitendinosus, semimembranosus.

• Because of the large volume, compartment syndrome is much less common.

Vascular supplyVascular supply• Mainly from profunda

femoris.

Mechanism of injury Mechanism of injury • Almost always due to high energy trauma: RTA, gunshot injury, fall from height.

• Pathologic fractures occur at the metaphyseal/diaphyseal junction.

• If degree of trauma inconsistent with fracture, rule out pathological #.

Classification:Winquist and Hansen’s

comminution

Clinical featuresClinical features -Pain, - swelling, - deformity, - shortening of the lower limb and complete external

rotation deformity. - severe blood loss ( up to 1500 mL )

- shock features : - unconsciousness , pallor , cold nose , tachycardia ,

cold and clammy skin , hypotension etc.

Associated injuriesAssociated injuries

• Ligament and meniscus injuries of ipsilateral knee.

• Spinal injuries.• Injury to the Pelvis.

Radiographic evaluationRadiographic evaluation

• AP and lateral views of the femur, hip and knee.

• AP view of the pelvis.• Fracture pattern, comminution, shortening

should be evaluated.

Treatment (Non operative)Treatment (Non operative)

• Skeletal traction:• Hip spica

• Skin traction: Gallow’s traction

– For children upto 2yrs.– Legs of the child are tied to an overhead beam.– Hips are raised about 2 inches from the bed so that

weight of the body provides counter traction.– For 4 to 6 weeks.

Operative methodsOperative methods

• Standard treatment for most femoral shaft fractures.

• Early surgery is recommended.

Closed Intramedullary nailingClosed Intramedullary nailing

Advantages-• Inside the medullary cavity, so more stable

than plate, less exposure required.• Fracture hematoma is maintained.• Early use of limb, restoration of length and

alignment, rapid union and low re-fracture rates are the advantages.

Interlocking nailingInterlocking nailing

• Nail is introduced in the medullary cavity.

• The screws are passed from the cortex through the holes in the nail.

Kuntscher’s cloverleaf Intramedullary Kuntscher’s cloverleaf Intramedullary nail.nail.

• Open reduction required.• For # at the junction of

upper and middle 1/3.• Not suitable for

comminuted fractures, fractures in the distal shaft and in open fractures.

Plate fixationPlate fixation

• Advantage: no additional trauma .• Disadvantage:

– more risk of infection, more bleeding, soft tissue injury.

– Higher rate of implant failure as it is load bearing.– Decreased vascularization beneath the plate.

• Indications of plating– Extremely narrow medullary canal where IM

nailing is difficult.– Fractures that occur through previously malunited

fracture.– Fractures that have extended to the trochanters

or condyles.– For comminuted fractures.

ComplicationsComplications

– Shock.– Fat embolism.– Femoral artery injury.– Sciatic nerve injury.– Infection.

• Late– Delayed union.– Non union.– Malunion.– Knee stiffness.