Femoral fracture

1) Subtrochanteric Fracture
Subtrochanteric typically defined as area from lesser trochanter to 5cm distal fractures with an associated intertrochanteric component may be called peritrochanteric fracture.

*Unique Aspect
Blood loss is greater than with femoral neck or trochanteric fractures – covered with anastomosing branches of the medial and lateral circumflex femoral arteries branch of profunda femoris trunk.

2) Femoral Shaft Fracture
Femoral shaft fracture is defined as a fracture of the diaphysis occurring between 5 cm distal to the lesser trochanter and 5 cm proximal to the adductor tubercle

The femoral shaft is padded with large muscles.
- reduction can be difficult as muscle contraction displaces the fracture
- healing potential is improved by having this well-vascularized
*Age
-usually a fracture of young adults and results from a high energy injury
-elderly patients should be considered ‘pathological’ until proved otherwise
-children under 4 years the suspected possibility of physical abuse
*FRACTURES ASSOCIATED WITH VASCULAR INJURY
Warning signs of an associated vascular injury are
(1) excessive bleeding or haematoma formation; and
(2) paraesthesia, pallor or pulselessness in the leg and foot.
~Warm ischemia in 2-3H
~If > 6H – salvage not possible
*‘FLOATING KNEE’
Ipsilateral fractures of the femur and tibia may leave the knee joint ‘floating’

3) Distal Femoral Fracture
Defined as fractures from articular surface to 5cm above metaphyseal flare

*clinical feature
The knee is swollen because of a haemarthrosis – this can be severe enough to cause blistering later
Movement is too painful to be attempted
The tibial pulses should always be checked to ensure the popliteal artery was not injured in the fracture.

Reference: Apley's System of Orthopaedic and Fracture (9th edition)

1. FEMORAL FRACTURE FATHIYAH BT MAZLAN 4 th year Medical Student Quest International University of Perak

2. Classification Femoral Head Fractures Femoral Neck Fractures Intertrochanteric Fractures * Subtrochanteric Fractures * Femoral Shaft Fractures * Distal Femur Fractures

3. Subtrochanteric Fractures Subtrochanteric typically defined as area from lesser trochanter to 5cm distal fractures with an associated intertrochanteric component may be called peritrochanteric fracture

4. Fielding Classification Type I – At level of lesser trochanter Type 2- <2.5cm below lesser trochanter Type 3 – 2.5 to cm below lesser trochanter

5. Unique Aspect Blood loss is greater than with femoral neck or trochanteric fractures – covered with anastomosing branches of the medial and lateral circumflex femoral arteries branch of profunda femoris trunk . Transition from cancellous bone to cortical bone (low vascularity, small fracture area) Contralateral pull Varus deformity - gluteus ms attach to greater trochanter – abduct proximal part Iliopsoas attach to lesser trochanter – flex and ext. rotate proximal part Ext. rotator + obt . Internus – ext. rotation of proximal part Adductor muscle - adduction of distal part

6. Clinical presentation Symptoms hip and thigh pain inability to bear weight Physical exam pain with motion typically associated with obvious deformity (shortening and varus alignment) flexion of proximal fragment may threaten overlying skin

7. Imaging X-Ray views AP and lateral of the hip AP pelvis full length femur films including the knee Important feature: - an unusually long fracture line extending proximally towards the greater trochanter and piriform fossa large , displaced fragment which includes the lesser trochanter lytic lesions in the femur.

8. Treatment Non operative Traction may help to reduce blood loss and pain. It is an interim measure until the patient, especially if elderly and with multiple medical problems Operative Open reduction and internal fixation is the treatment of choice intramedullary nail with a proximal interlocking screw - fracture is very comminuted or unstable - operative dissection may have compromised bone viability b ) 95 degree hip screw-and-plate device .

9. (a) a 95° screw and plate device; (b) an intramedullary nail with proximal interlocking screw into the femoral head ; and (c) a proximal femoral plate with locking screws.

10. Femoral Shaft Fracture Femoral shaft fracture is defined as a fracture of the diaphysis occurring between 5 cm distal to the lesser trochanter and 5 cm proximal to the adductor tubercle The femoral shaft is padded with large muscles. - reduction can be difficult as muscle contraction displaces the fracture - potential is improved by having this well- vascularized

11. Classification Winquist’s classification reflects the observation that the degrees of soft-tissue damage and fracture instability increase with increasing grades of comminution . In Type 1 there is only a tiny cortical fragment. In Type 2 the ‘butterfly fragment’ is larger but there is still at least 50 per cent cortical contact between the main fragments. In Type 3 the butterfly fragment involves more than 50 percent of the bone width. Type 4 is essentially a segmental fracture.

12. Age usually a fracture of young adults and results from a high energy injury elderly patients should be considered ‘ pathological’ until proved otherwise children under 4 years the suspected possibility of physical abuse Pattern spiral fracture Cause by a fall which the foot is anchored while a twisting force is transmitted to the femur . Transverse and oblique often due to angulation or direct violence and are therefore particularly common in road accidents. Comminuted or segmental severe violence (often a combination of direct and indirect forces) the fracture may

13. Clinical presentation Advanced Trauma Life Support (ATLS) should be initiated Symptoms pain in thigh Physical exam inspection tense, swollen thigh blood loss in closed femoral shaft fractures is 1000-1500ml  blood loss in open fractures may be double that of closed fractures affected leg often shortened tenderness about thigh motion examination for ipsilateral femoral neck fracture often difficult secondary to pain from fracture neurovascular must record and document distal neurovascular status

14. Boundaries: Content: Femoral artery Femoral vein Saphenous nerve

15. IMAGING V iews: AP and lateral views of entire femur AP and lateral views of ipsilateral hip important to rule-out coexisting femoral neck fracture    AP and lateral views of ipsilateral knee

16. (a) The upper fragment of this femur is adducted, which should alert the surgeon to the possibility of (b) an associated hip dislocation . With this combination of injuries the dislocation is frequently missed; the safest plan is to x-ray the pelvis with every fracture of the femoral shaft .

17. Treatment Lock IM nail standard for treatment of diaphyseal femur fracture exception is a patient with a closed head injury critical to avoid hypotension and hypoxemia   consider provisional fixation (damage control)  2) Traction, Bracing, Spica cast All isolated femoral shaft fracture except upper 1/3 Long bedrest /NWB (10-14 weeks) 3) External Fixator - alternative for multiple injury -severe open injury

18. FRACTURES ASSOCIATED WITH VASCULAR INJURY Warning signs of an associated vascular injury are (1) excessive bleeding or haematoma formation; and (2) paraesthesia , pallor or pulselessness in the leg and foot. *Warm ischemia in 2-3H *If > 6H – salvage not possible ‘FLOATING KNEE’ Ipsilateral fractures of the femur and tibia may leave the knee joint ‘floating ’ Both fractures will need immediate stabilization

19. Distal Femoral Fracture Defined as fractures from articular surface to 5cm above  metaphyseal flare Direct violence is the usual cause

20. AO Classification Type A (Extra-articular) fractures do not involve the joint surface; Type B (Partial articular ) fractures involve the joint surface (one condyle) but leave the supracondylar region intact; T ype C (Complete articular) fractures have supracondylar and condylar components

21. Extra-articular A1 Simple A2 Metaphyseal wedge A3 Metaphyseal Complex Partial articular B1 Lateral condyle B2 Medial condyle B3 Coronal plane Complete articular CI Anterior and lateral flake C2 Unicondyler posterior C3 Bicondyler posterior

22. Clinical Feature The knee is swollen because of a haemarthrosis – this can be severe enough to cause blistering later Movement is too painful to be attempted The tibial pulses should always be checked to ensure the popliteal artery was not injured in the fracture.

23. Imaging The entire femur should be x-rayed so as not to missed a proximal fracture or dislocated hip (a) whether there is a fracture into the joint and if it is comminuted (b ) the size of the distal segment (c ) whether the bone is osteoporotic **These factors influence the type of internal fixation required, if that is the chosen mode of treatment

24. Treatment Non-operative Traction - If the fracture is only slightly displaced and extra-articular, or if it reduces easily with the knee in flexion Surgery Lock IM - Type A & simpler Type C b) Angle blade plate/ 95 degree condyler screw plate -Type A & simpler Type C c) Simple lag screw -Type B

25. (d ) dynamic condylar screw and plate for a Type A fracture ( e,f,g ) combination of lag screws and a lateral side plate for more complex fracture patterns