Femur fracture

femur fracture and surgical management.

1. Femur fracture By : DR. SAEED AHMED ASSITANT PROFESSOR PIMS ORTHO AND TRAUMA DEPARTEMENT

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

3. Blood supply of femur head F emoral head has 3 sources of arterial supply    extracapsular arterial ring medial circumflex femoral artery (main supply to the head) from profunda femoris lateral circumflex femoral artery ascending cervical branches artery to the ligamentum teres from the obturator artery or MCFA supplies perifoveal area

4. Femur head fracture A ssociated with hip dislocations -- Anterior hip dislocation. -- Posterior hip dislocation. location and size of the fracture fragment and degree of comminution depend on the position of the hip at the time of dislocation .

5. Mechanism I mpaction , avulsion or shear forces involved unrestrained passenger MVA (knee against dashboard) falls from height sports injury industrial accidents 5-15% of posterior hip dislocations are associated with a femoral head fracture because of contact between femoral head and posterior rim of acetabulum anterior hip dislocations usually associated with impaction/indentation fractures of the femoral head

6. Classification of femur head fracture

7. Pipkin Classification Type I Fx below fovea/ ligamentum (small) Does  not involve the weightbearing portion  of the femoral head     Type II Fx above fovea/ ligamentum (larger) Involves the   weightbearing portion  of the femoral head        Type III Type I or II with  associated femoral neck   fx High incidence of AVN   Type IV Type I or II with associated  acetabular fx ( usually  posterior wall fracture )  

8. Presentation History frontal impact MVA with knee striking dashboard fall from height  Symptoms localized hip pain unable to bear weight other symptoms associated with impact Physical exam inspection shortened lower limb with large acetabular wall fractures, little to no rotational asymmetry is seen posterior dislocation limb is flexed, adducted, internally rotated anterior dislocation limb is flexed, abducted, externally rotated neurovascular may have signs of sciatic nerve injury

9. IMAGING STUDIES Radiographs recommended views AP pelvis, lateral hip and Judet views both pre-reduction and post-reduction inlet and outlet views if acetabular or pelvic ring injury suspected CT scan indications after reduction to evaluate: concentric reduction loose bodies in the joint acetabular fracture femoral head or neck fracture

10. TREATMENT Nonoperative hip reduction indications acute dislocations reduce hip dislocation within 6 hours technique obtain post reduction CT TDWB x 4-6 weeks, restrict adduction and internal rotation indications Pipkin I undisplaced Pipkin II with < 1mm step off no interposed fragments stable hip joint technique perform serial radiographs to document maintained reduction

11. Operative --ORIF indications Pipkin II with > 1mm step off if performing removal of loose bodies in the joint associated neck or acetabular fx  ( Pipkin type III and IV) polytrauma irreducible fracture-dislocation Pipkin IV treatment dictated by characteristics of acetabular fracture small posterior wall fragments can be treated nonsurgically and suprafoveal fractures can then be treated through an anterior approach

12. Arthroplasty indicationsPipkin I, II (displaced), III, and IV in older patients F ractures that are significantly displaced, osteoporotic or comminuted

13. Femoral Neck Fractures Mechanism high energy in young patients low energy falls in older patients

14. Osteology normal neck shaft-angle 130 +/- 7 degrees normal anteversion  10 +/- 7 degrees Blood supply to femoral head    major contributor is medial femoral circumflex (lateral epiphyseal artery) some contribution to anterior and inferior head from lateral femoral circumflex some contribution from inferior gluteal artery small and insignificant supply from artery of ligamentum teres displacement of femoral neck fracture will disrupt the blood supply and cause an intracapsular hematoma (effect is controversial)  

15. Garden Classification

16. GARDEN CLASSIfication

17. Presentation Symptoms impacted and stress fractures slight pain in the groin or pain referred along the medial side of the thigh and knee displaced fractures pain in the entire hip region Physical exam impacted and stress fractures no obvious clinical deformity minor discomfort with active or passive hip range of motion, muscle spasms at extremes of motion pain with percussion over greater trochanter displaced fractures leg in external rotation and abduction, with shortening

18. Radiographs recommended views obtain AP pelvis and cross-table lateral, and full length femur film of ipsilateral side consider obtaining dedicated imaging of uninjured hip to use as template intraop traction-internal rotation AP hip is best for defining fracture type  Garden classification is based on AP pelvis CT helpful in determining displacement and degree of comminution in some patients

19. Nonoperative observation alone indications may be considered in some patients who are non- ambulators , have minimal pain, and who are at high risk for surgical intervention

20. cannulated screw fixation  indications nondisplaced transcervical fx Garden I and II fracture patterns in the physiologically elderly displaced transcervical fx in young patient considered a surgical emergency achieve reduction to limit vascular insult reduction must be anatomic, so open if necessary

21. sliding hip screw  or   cephalomedullary nail indications basicervical fracture vertical fracture pattern in a young patient biomechanically superior to cannulated screws consider placement of additional cannulated screw above sliding hip screw to prevent rotation hemiarthroplasty     indications debilitated elderly patients metabolic bone disease total hip arthoplasty        indications older active patients patients with preexisting hip osteoarthritis more predictable pain relief and better functional outcome than hemiarthroplasty arthroplasty for Garden III and IV in patient < 85 years

22. Intertrochanteric Fractures Extracapsular  fractures of the proximal femur between the greater and lesser trochanters.

23. Mechanism elderly low energy falls in osteoporotic patients young high energy trauma

24. Osteology intertrochanteric area exists between greater and lesser trochanters  made of dense trabecular bone calcar femorale vertical wall of dense bone that extends from posteromedial aspect of femoral shaft to posterior portion of femoral neck  Determines stability

25. Clinical Presentation Physical Exampainful , shortened, externally rotated lower extremity

26. IMAGING Radiographs recommended views AP pelvis AP of hip, cross table lateral full length femur radiographs CT or MRI useful if radiographs are negative but physical exam consistent with fracture

27. Treatment sliding hip compression screw indications stable intertrochanteric fractures outcomes equal outcomes when compared to intramedullary hip screws for stable fracture patterns intramedullary hip screw ( cephalomedullary nail)  indications stable fracture patterns unstable fracture patterns  reverse obliquity fractures    56% failure when treated with sliding hip screw subtrochanteric extension lack of integrity of femoral wall  associated with increased displacement and collapse when treated with sliding hip screw

28. Treatment Arthroplasty indications severely comminuted fractures preexisting symptomatic degenerative arthritis osteoporotic bone that is unlikely to hold internal fixation salvage for failed internal fixation

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

30. 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

31. Radiographs views AP and lateral of the hip AP pelvis full length femur films including the knee additional views traction views may assist with defining fragments in comminuted patterns but is not required findings bisphosphonate-related fractures have  lateral cortical thickening transverse fracture orientation medial spike lack of comminution

32. Treatment Nonoperative observation with pain management indications non-ambulatory patients with medical co-morbidities that would not allow them to tolerate surgery limited role due to strong muscular forces displacing fracture and inability to mobilize patients without surgical intervention Operative intramedullary nailing  (usually cephalomedullary )  indications historically Russel -Taylor type I fractures newer design of intramedullary nails has expanded indications most subtrochanteric fractures treated with IM nail  fixed angle plate  indications surgeon preference associated femoral neck fracture narrow medullary canal pre-existing femoral shaft deformity

33. Proximal femur fracture in paediatrics

34. ANAtomy of femur Growth centers of the proximal femurproximal femoral epiphysis accounts for 13-15% of leg length accounts for 30% length of femur proximal femoral physis grows 3 mm/ yr entire lower limb grows 23 mm/ yr trochanteric apophysis traction apophysis contributes to femoral neck growth disordered growth injury to the GT apophysis leads to shortening of the GT and  coxa valga overgrowth of the GT apophysis leads to  coxa vara

35. treament Nonoperative -- spica cast in abduction, weekly radiographs for 3wks indications Type IA, II, III, IV, nondisplaced , <4yrs

36. treament Operative  emergent ORIF,  capsulotomy , or joint aspiration   indications open hip fracture vessel injury where large vessel repair is required concomitant hip dislocation or significant displacement, especially type I may decrease the rate of AVN (supporting data equivocal) closed reduction internal fixation (CRIF)/ percutaneous pinning (CRPP) indications Type II, displaced postop spica (abduction and internal rotation) x 6-12wk Type III and IV, displaced and older children open reduction and internal fixation (ORIF) indications Type IB pediatric hip screw / DHS indications Type IV

37. Femoral Shaft Fractures Definition . 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 High energy injuries frequently associated with life-threatening conditions

38. Mechanism of sof fracture T raumatic high-energy most common in younger population often a result of high-speed motor vehicle accidents low-energy more common in elderly often a result of a fall from standing gunshot 

39. OSTEOLOGY OF FEMUR DIAPHYSIS largest and strongest bone in the body femur has an anterior bow  linea aspera   rough crest of bone running down middle third of posterior femur attachment site for various muscles and fascia acts as a compressive strut to accommodate anterior bow to femur

40. Femur Fracture Classification AO/OTA Femur Diaphysis - Bone segment 32

41. 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  for closed tibial shaft fractures, 500-1000ml 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

42. IMAGING recommended views 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

43. treatment Nonoperative long leg cast indications nondisplaced femoral shaft fractures in patients with multiple medical comorbidities Operative antegrade intramedullary nail with reamed technique  indications gold standard for treatment of diaphyseal femur fractures outcomes stabilization within 24 hours is associated with decreased pulmonary complications (ARDS) decreased thromboembolic events improved rehabilitation decreased length of stay and cost of hospitalization exception is a patient with a closed head injury critical to avoid hypotension and hypoxemia   consider provisional fixation (damage control) 

44. treament R etrograde intramedullary nail with reamed technique indications ipsilateral femoral neck fracture  floating knee ( ipsilateral tibial shaft fracture)  use same incision for tibial nail ipsilateral acetabular fracture does not compromise surgical approach to acetabulum multiple system trauma bilateral femur fractures avoids repositioning morbid obesity

45. ORIF with plate indications ipsilateral neck fracture requiring screw fixation fracture at distal metaphyseal-diaphyseal junction inability to access medullary canal

46. Distal Femur Fractures Defined as fxs from articular surface to 5cm above  metaphyseal flare Mechanism young patients high energy with significant displacement older patients low energy in osteoporotic bone with less displacement

47. Osteology anatomical axis of distal femur is 6-7 degrees of valgus lateral cortex of femur slopes ~10 degrees, medial cortex slopes ~25 degrees

48. Classification of distal femur S upracondylar I ntercondylar

49. imaging Radiographs obtain standard AP and Lat traction views AP, Lat , and oblique traction views can help characterize injury CT obtain with frontal and sagittal reconstructions useful for establish intra-articular involvement identify separate osteochondral fragments in the area of the intercondylar notch identify coronal plane  fx (Hoffa fx )    38% incidence of Hoffa fx's in Type C fractures  preoperative planning Angiography indicated when diminished distal pulses after gross alignment restored

50. Treatment of supracondylar femur fracture open reduction internal fixation indications displaced fracture intra-articular fracture nonunion goals need anatomic reduction of joint stable fixation of articular component to shaft preserve vascularity technique (see below) postoperative early ROM of knee important non-weight bearing or touch toe weight-bearing for 6-8 weeks quadriceps and hamstring strength exercises 

51. ORIF in distal femur fracture Blade Plate Fixation Dynamic Condylar Screw Placement Locked Plate Fixation

52. Distal femur plates

53. Distal femur plating

54. retrograde IM nail  indications good for  supracondylar fx without significant comminution preferred implant in  osteoporotic bone distal femoral replacement indications unreconstructable fracture fracture around prior total knee arthroplasty with loose component

55. Shaft of femur fracture in children

56. mechanism correlated with age due to the increasing thickness of the cortical shaft during skeletal growth and maturity falls most common cause in toddlers high energy trauma is responsible for second peak in adolescents MVC or ped vs vehicle fractures after minor trauma can be the result of a pathologic process bone tumors, OI, osteopenia, etc.

57. Classification Descriptive classification characteristics of the fracture transverse comminuted spiral etc. integrity of soft-tissue envelope open closed fracture Stability length stable fractures are typically transverse or short oblique length unstable fractures are spiral or comminuted fractures

58. Treatment of diaphysis femur fracture Based on age and size of patient and fracture pattern Guidelines provided by AAOS 

59. Distal Femoral Physeal Fractures Physeal considerations of the knee general assumptions leg growth continues until  16 yrs in boys 14 yrs in girls growth contribution leg grows 23 mm/year, with most of that coming from the knee (15 mm/ yr ) proximal femur - 3 mm / yr (1/8 in) distal femur - 9 mm / yr (3/8 in) proximal tibia - 6 mm / yr (1/4 in) distal tibia - 5 mm / yr (3/16 in)

60. Clinical presentation Symptoms unable to bear weight Physical exam pain and swelling tenderness along the physis in the presence of a knee effusion may see varus or valgus knee instability on exam

61. imaging MRI or ultrasound is now the diagnositic modality of choice when confirmation of a physeal fracture is needed follow up radiographs after 2-3 weeks of casting can be used as treatment if physeal injury is likely but not identifiable on injury films  stress radiographs to look for opening of the physis were indicated in the past if there was suspicion of physeal injury 

62. Salter- harris classification

63. Treatment of distal femur fracture Nonoperative long leg casting    indications stable  nondisplaced fractures close clinical followup is mandatory 

64. Treatment of distal femur Operative closed reduction and percutaneous pinning followed by casting    indications displaced Salter-Harris I or II fractures displaced fractures successfully reduced with closed methods should still be pinned (undulating physis makes unstable following reduction) technique  avoid multiple attempts at reduction avoid physis with hardware if possible if physis must be crossed (SH I and SH II with small Thurston-Holland fragments), use smooth k-wires SH II fracture, if possible, should be fixed with lag screws across the metaphyseal segment avoiding the physis   postoperatively follow closely to monitor for deformity

65. Orif in dstal femur fracture indications Salter-Harris III and IV in order to anatomically reduce articular surface irreducible SHI and SHII fractures reduction often blocked by periosteum infolding into fracture site techniques If anatomic reduction cannot be obtained via closed techniques, incision over the displaced physis to remove interposed periosteum is necessary.