Fracture of Femur

Fracture of Femur

1. Fractures of the femurFractures of the femur

2. FrequencyFrequency

Fractures of the femoral shaft are Fractures of the femoral shaft are
the most common fractures that the most common fractures that
orthopedist see. orthopedist see.

incidence - 1.33 fractures per incidence - 1.33 fractures per
10,000 people. 10,000 people.

3. In The United States
The incidence of hip fractures exceeds
250,000 per year, with an estimated
cost of nearly $10 billion.

4. Proximal femoral part fractures Proximal femoral part fractures
(medial and lateral fractures)(medial and lateral fractures)
Classification of
fractures
1.Subcapital
2.Trancervical
3.Basal
4.Intertrochanteric
(=basal)
5.Separation of the lesser
trochanter
6.Subtrochanteric
7.Separation of the greater
trochanter
12
3
5
4
6
7

5. Blood to the femoral head is primarily supplied by the
medial circumflex femoral artery through its subsynovial
retinacular vessels. The lateral circumflex and ligamentum
teres arteries provide minor contributions to the femoral
head.
Anterior view
Retinacular
arteries
(subsynovial)
Retinacular
arteries
(subsynovial)
Acetabular
branch of
obturator artery
(often minute)
Posterior view
Medial
circumflex
femoral artery
Femoral neck fractures are at risk due to the limited Femoral neck fractures are at risk due to the limited
blood supplyblood supply

6. Femoral neck Femoral neck
fracturefracture

7. Femoral Neck FracturesFemoral Neck Fractures
A B
A - adducted, neck-shaft angle at such cases reduces
up to the direct one, as the result of the hip displacement
upwards. These fractures are never impacted.
They unite very bad in view of insufficient blood supply of the
central fragment, absence of the periosteum in the area of the
femoral neck, and also difficulties of the fragments compa-
rison and their strong holding together.

8. B B - - abductedabducted,, with the formation of coxa with the formation of coxa
valga (neck-shaft angle at this fracture valga (neck-shaft angle at this fracture
remains normal or even increases). remains normal or even increases).

These fractures are more often impacted These fractures are more often impacted

9. Femoral Neck FractureFemoral Neck Fracture
Tenderness will be found
over the femoral neck
anteriorly (1) and in extra-
capsular fractures over the
greater trochanter. Pain is
produced by rotation of the
hip (2). Swelling localizes in
groin region or at the greater
trochanter area. Rarely, with
an undisplaced fracture, the
patient may be able to bear
weight.

10. Femoral Neck FractureFemoral Neck Fracture

Mechanism of injuryMechanism of injury: :
A fall on the side is A fall on the side is
the commonest cause.the commonest cause.
DiagnosisDiagnosis
The leg is rotated The leg is rotated
outwardsoutwards, especially at , especially at
subtrochanteric subtrochanteric
fractures; fractures;
- the external edge of the - the external edge of the
heel touches the bed or heel touches the bed or
the table on which the the table on which the
patient lays.patient lays.
- He cannot lift the leg - He cannot lift the leg
actively; there is a sign actively; there is a sign
of the of the "stuck heel”. "stuck heel”.

11. Patient with a displaced femoral neck Patient with a displaced femoral neck
fracture on the right. fracture on the right.
Note that the leg is shortened and Note that the leg is shortened and
externally rotatedexternally rotated

12. Femoral Neck FracturesFemoral Neck Fractures
subcapital subcapital transcervical transcervical basicbasic

13. A non displaced A non displaced
femoral neck femoral neck
fracturefracture
A displaced A displaced
femoral neck femoral neck
fracturefracture

14. Emergency manipulationsEmergency manipulations

Transport splints fixationTransport splints fixation

AnalgesicsAnalgesics

Local anesthesiaLocal anesthesia

Tourniquet in cases with external Tourniquet in cases with external
bleedingbleeding

I/v fluid infusionI/v fluid infusion
- Traumatic shock therapy - Traumatic shock therapy

15. Skin traction and splinting are used in the
field in emergent situations to provide
comfort for the patient and to prevent any
further soft tissues, vessels and nerves
damage.

16. DUAL ARM
TRACTION SPLINT

17. Conservative TreatmentConservative Treatment

Skeletal tractionSkeletal traction

Skeletal traction Skeletal traction
with further with further
external fixationexternal fixation

External fixation External fixation
onlyonly

Symptomatic Symptomatic
treatmenttreatment
Unilat Hip
Spica Cast
One and One-
half Hip Sp.
Cast
Bilat. Long-
leg Hip
Spica Cast

18. Surgical treatmentSurgical treatment

internal fixation is still the treatment of internal fixation is still the treatment of
choice for most closed injuries because choice for most closed injuries because
of the higher union rate, lower rate of of the higher union rate, lower rate of
complications, lower morbidity, earlier complications, lower morbidity, earlier
weight bearing, shorter hospital stay weight bearing, shorter hospital stay
and better control of alignment. and better control of alignment.
However, in some situations in which However, in some situations in which
the hardware is not available or the the hardware is not available or the
patient cannot undergo surgery patient cannot undergo surgery
relatively soon, temporary skeletal relatively soon, temporary skeletal
traction may be a viable choice.traction may be a viable choice.

19. 
Open reduction and internal Open reduction and internal
fixation of neck fractures fixation of neck fractures
must be performed within must be performed within
hours after the injury.hours after the injury.

20. Surgical Surgical
TreatmentTreatment
A similar fracture treated
with three large cancellous
bone screws.
Use of three-
flanged nail

21. 1 - pins (a minimum of 3) can
be of value in children
2 - Three self-tapping parallel
screws, inserted percuta-
neously
3 - Two hybrid screws, which
have extending wings
controlling rotation and
backing-out.
Surgical TreatmentSurgical Treatment

22. Femoral neck basic fracture fixed Femoral neck basic fracture fixed
with Gama-nailwith Gama-nail

23. ComplicationsComplications

General complications. Particularly in elderly General complications. Particularly in elderly
patients: deep vein thrombosis, pulmonary patients: deep vein thrombosis, pulmonary
embolism, pneumonia, bed sores;embolism, pneumonia, bed sores;

Avascular necrosis. Occurs in about 30% of Avascular necrosis. Occurs in about 30% of
patients with displaced fractures and in 10% patients with displaced fractures and in 10%
with undisplaced fractures);with undisplaced fractures);

Non-union. More than 30% of all femoral neck Non-union. More than 30% of all femoral neck
fractures fail to unite, and the risk is fractures fail to unite, and the risk is
particularly high in those that are severely particularly high in those that are severely
displaced;displaced;

Osteoarthritis. Avascular necrosis of femoral Osteoarthritis. Avascular necrosis of femoral
head collapse may lead to secondary head collapse may lead to secondary
osteoarthritis of the hip.osteoarthritis of the hip.

24. Avascular Necrosis Avascular Necrosis
of the Femoral Headof the Femoral Head
The patient with avulsion
fracture of the greater tro-
chanter. The injury was
immobilized in a one-and-a-
half hip spica for five
weeks.
After six months, the radio-
graphs showed beginning
avascular necrosis of the
femoral head, which later
developed into complete
necrosis with subluxation.

25. Subcapital displaced fracture treated Subcapital displaced fracture treated
with Austin Moor endoprothesiswith Austin Moor endoprothesis

26. Total Hip Total Hip
replacementreplacement
Total hip replacement may
be preferable in a old
patient with severely dis-
placed fracture.
Prosthetic replacement may be quicker
and less traumatic than fixation and may
also permit earlier rehabilitation.

27. Trochanteric Trochanteric
FracturesFractures

28. Proximal femoral part fractures Proximal femoral part fractures
(lateral fractures)(lateral fractures)
Classification of
fractures
4. Transtrochanteric -
intertrochanteric
5. Separation of the lesser
trochanter
6. Subtrochanteric
7. Separation of the
greater trochanter
12
3
5
4
6
7

29. Where trochanteric
region is involved, a
blade plate (1), DHS or
95° Dynamic Condylar
Screw, Gama nail may
be used.
Surgical TreatmentSurgical Treatment

31. Trochanteric region fracture (lateral Trochanteric region fracture (lateral
fracture) fixed with DHSfracture) fixed with DHS

32. DHS (Dynamic Hip Screw)DHS (Dynamic Hip Screw)
with long blade with long blade

33. With further involvement of the shaft, a With further involvement of the shaft, a
Russell-Taylor reconstruction (locking) nail, Russell-Taylor reconstruction (locking) nail,
Gama-nail or DHS with long blade offer Gama-nail or DHS with long blade offer
considerable versatility. considerable versatility.

34. Gama-nailGama-nail

35. Surgery for Subtrochanteric Femoral Surgery for Subtrochanteric Femoral
FractureFracture
for childrenfor children

36. Femoral Shaft Femoral Shaft
FracturesFractures
Mechanism of injury
This is essentially a
fracture of young adults
and usually results from
a high-energy injury.

37. Femoral Shaft FracturesFemoral Shaft Fractures
The femoral shaft is well padded with powerful
muscles - an advantage in protecting the bone from
all but the most powerful forces, but a disadvantage
in that fractures are often severely displaced by
muscle pull, making reduction difficult.

38. Emergency treatmentEmergency treatment

39. Thomas Thomas
splintsplint

40. Nonsurgical treatmentNonsurgical treatment
The most common
use of traction is in
the treatment of
young children
(usually 5-10 y/o)
with 2-3 weeks
duration in the face
of soft-tissue
injury.

41. Nonsurgical treatmentNonsurgical treatment

Adult nonsurgical treatment options Adult nonsurgical treatment options
include skin traction, skeletal include skin traction, skeletal
traction, cast brace, casting. traction, cast brace, casting.
Children have the same options. Children have the same options.

Nonsurgical options are used Nonsurgical options are used
infrequently outside of the younger infrequently outside of the younger
pediatric population. pediatric population.

42. Nonsurgical treatment – skeletal
traction

43. Nonsurgical treatmentNonsurgical treatment

Complications of tractionComplications of traction

OverdistractionOverdistraction

Pin track infectionPin track infection

Loss of positionLoss of position

Pressure soresPressure sores

44. CastsCasts
Complications of
casts:
- Circulatory
embarrassment
- Pressure sores
- Undiagnosed
wound infection
- Joint stiffness
Unilat Hip
Spica Cast
One and One-
half Hip Sp.
Cast
Bilat. Long-
leg Hip
Spica Cast

45. Surgical treatmentSurgical treatment

46. Surgical treatmentSurgical treatment

internal fixation is still the treatment of internal fixation is still the treatment of
choice for most closed injuries and choice for most closed injuries and
some open because of the higher union some open because of the higher union
rate, lower rate of complications, lower rate, lower rate of complications, lower
morbidity, earlier weight bearing, morbidity, earlier weight bearing,
shorter hospital stay, and better control shorter hospital stay, and better control
of alignment. of alignment.

47. Intramedullary Nailing of the Intramedullary Nailing of the
FemurFemur

48. Russell-Taylor standart (locking) nailRussell-Taylor standart (locking) nail

49. Russell-Taylor reconstruction Russell-Taylor reconstruction
(locking) nail for duble fracture(locking) nail for duble fracture

50. Russell-Taylor standart (locking) nail Russell-Taylor standart (locking) nail
for triple fracturefor triple fracture

51. AO-system plateAO-system plate

52. Buttress long plate (cobra plate)Buttress long plate (cobra plate)

53. External fixation
has two great
advantages:
- It can be used in
patients with skin
loss or infection.
- It can be used
for temporary
fixation
.

54. Distal Femoral Fractures

55. Injuries of the lower end of
the femur:
(a)the mechanism of flexi-
on of the distal fragment in
a supracondylar fracture
(b)slipped lower femoral
epiphysis.

56. Types of Types of
infraarticular infraarticular
fracturesfractures

PartialPartial

Complete Complete
infraarticular infraarticular

Comminuted Comminuted
infraarticularinfraarticular

Extraarticular Extraarticular
metadiaphysal metadiaphysal
fracturesfractures

62. 95º CONDYLAR PLATE (DCP)95º CONDYLAR PLATE (DCP)

66. Patella Fractures

67. Frequency: Patella fractures account for
approximately 1% of all skeletal injuries.
Fractures occur as a result of a
compressive force such as a direct blow, a
sudden tensile force as occurs with
hyperflexion of the knee, or from a
combination of these.

68. Patient examinationPatient examination

69. Clinical:Clinical:

- The patient usually presents with pain in - The patient usually presents with pain in
the affected knee. the affected knee.

- Overlying abrasions, any lacerations - Overlying abrasions, any lacerations
must be assumed to communicate with the must be assumed to communicate with the
joint joint

- An accompanying intra-articular effusion - An accompanying intra-articular effusion
may be present, which, if aspirated, will may be present, which, if aspirated, will
reveal fat globules. reveal fat globules.

- If the fracture is displaced, a defect is - If the fracture is displaced, a defect is
palpable at the fracture site. palpable at the fracture site.

- The extensor mechanism must always be - The extensor mechanism must always be
evaluated. evaluated.

- Disruption of the extensor mechanism - Disruption of the extensor mechanism
results in the inability to extend the knee results in the inability to extend the knee
against gravityagainst gravity

70. Classification of
patella fractures

72. Tangential patellar radiograph

73. Transverse
fracture of the
patella after a
direct blow to the
knee.

74. If the fracture is not displaced the fracture If the fracture is not displaced the fracture
may be treated with immobilization, may be treated with immobilization, placing placing
the affected extremity in a cylinder cast for 4-the affected extremity in a cylinder cast for 4-
6 weeks6 weeks. The patient is allowed to bear weight . The patient is allowed to bear weight
in the cast. in the cast.
With proper patient selection, good results With proper patient selection, good results
can be expected in approximately 90% of can be expected in approximately 90% of
patients with nondisplaced fractures.patients with nondisplaced fractures.
Closed treatment

75. Surgical treatmentSurgical treatment

76. Surgical treatmentSurgical treatment

77. Menisci injuriesMenisci injuries

78. Collateral ligaments injuryCollateral ligaments injury

79. Clinical investigationClinical investigation