Fracture of the femoral shaft

Simplifying fracture of the femoral shaft. All information are collected from authentic sources.

1. Fracture of the femoral shaft Dr. Ashiqur Rahman Resident Orthopedics Dhaka Medical College & Hospital

2. Winquist -Hansen classification Type I: Comminuted fracture with a tiny cortical fragment, not affecting fracture stability. Type II : Butterfly fragment larger but at least 50% cortical contact (<50% comminution ). Type III: Butterfly fragment involves > 50% bone width, less than 50% cortical contact, allowing shortening, rotation and translation. Type IV: Essentially a segmental fracture, no contact between fractures fragments.

3. AO classification of femoral shaft #

4. Q. What is the significance of third fragment in femoral shaft fracture? 3 rd fragment determines: Stability of the fracture Necessity of interlocking fixation. Q. What is the anatomical and mechanical axis of femur? Anatomical axis: Tip of the greater trochanter to the centre of the knee.( patella) Mechanical axis: Centre of head of the femur (ASIS) to centre of the knee.

5. Q. What are the various approaches to femoral shaft? Antero- lateral – Thompson, Henry Lateral Posterolateral Posterior – Bosworth Medial and lateral approaches of Henry to posterior surface of femur in popliteal fossa Lateral- proximal shaft and trochanteric region

6. Lateral approach: Advantage : Easy approach Wide exposure Fracture site is opened quickly Disadvantage: More bleeding due to muscle splinting Knee stiffness due to fibrosis and contracture

7. Posterolateral approach: Advantage : Goes through muscle plane , So no disturbance to vastus lateralis Less fibrosis Less contracture Less knee stiffness Less bleeding ( in perforators are handle with care) Disadvantages: Difficult approach ( especially in obese) Take more time ( to reach the fracture site) More bleeding

8. What are the preconditions of closed nailing? Timing of the surgery: within 7-10 days Image intensifier ( c – arm) Comminuted fractures are preferable Flexible reamer

9. What are the advantages of interlocking nail over K nail ( Kuntschen nail) ? Prevents both rotational and shearing forces better than K –nail Can be used in proximal and distal shaft fractures , including comminuted segmental fractures and fracture with bone loss Can be used for treatment of non-union Early mobilization possible in interlocking nail

10. Antegrade : Tip of the greater trochanter. Retrograde: In the intercondylar area of femur just anterior to the attachment of posterior cruciate ligament.

11. What are the problems of introducing nail through piriformis fossa ? May damage the blood supply of the neck and head of the femur Severe bleeding Fracture neck of the femur

12. What are the indications of retrograde nailing of femoral fractures ? Fractures of the distal femoral shaft Floating knee Ipsilateral femoral neck fracture in obese person

13. Q. How far tip of the IM nail should have passed? Tip reached up the epiphyseal scar (Upper pole of the patella), beyond that then chance of perforation of intercondylar notch. In case of transverse # of the shaft of the femur it has to fixed in dynamic mode, not static mode as it will cause non-union. If fixed at static mode then review the x-ray after 06 weeks & look for bone margin necrosis & take decision of dynamization .

14. Benefit of dynamic mode: Early partial weight can be given. So micro-movement will be there which in turn will increase callus formation. In dynamic mode only one screw in the upper pole is inserted. (Second screw from the top) through oblong hole.

15. Nail: A. Solid nail: Advantage : Dead space is less , so less chance of organism proliferation Strength is more Disadvantage : Guide wire cannot be inserted Close technique is not applicable

16. Hollow nail: Disadvantages: Dead space is more so more chance of organism proliferation Strength is less Advantage: Guide wire can be inserted Closed technique is applicable

17. Reaming Advantages : To enlarge the medullary cavity so that larger & stronger nail can be inserted Reaming products are distributed at the fracture site & act as internal bone graft. Disadvantages: Disturbs medullary blood supply Increase risk of fat embolism

18. K-nail Russel-Taylor nail

19. K-nail & V-nail

20. Biological osteosynthesis To leave the fracture zone untouched in extensive bony & soft tissue injury. The exact axis, rotation & length is maintained by meticulous dissection, indirect reduction, fixation of proximal & distal fragment.

21. Advantages of open method:(Camp.) 1. Less expensive equipment is required than is needed for closed nailing. 2. No special fracture table or operating table is required. 3. No image intensifier is required. 4. No period of preliminary traction is required to distract the fracture. 5. Absolute anatomic reduction is easier to obtain than with closed techniques . 6. Direct observation of the bone may identify undisplaced and undetected comminution not noted radiographically .

22. 7. Precise interdigitation of the fracture fragments improves rotational stability. 8. In segmental fractures, the middle segment can be stabilized, preventing the torquing and twisting associated with closed reduction and medullary reaming. 9. In nonunions , opening of the medullary canals of the sclerotic bone is easier. 10. Rotational malalignment is rare after open reduction.

23. Disadvantages of open method: 1. Skin scars must be considered. 2. Fracture hematoma, which is important in fracture healing , is evacuated. 3. Bone shavings created by reaming the medullary canal often are lost. 4. Infection rate is increased. 5. Rate of union is decreased. 6. If a locking nail is used, locking is difficult without image intensification .

24. Closed ante-grade nailing Patient positioning & preparation: Patient is placed in a fracture table. Lateral & supine position are used extensively. The supine position is more universal. Gaining the correct entry portal to the proximal femur is somewhat more difficult in supine position. Adduct & flex the affected hip 15 to 30 degrees. Apply traction through a skeletal pin or to the foot.

25. The leg is positioned in a scissor configuration. Failure to obtain a close reduction prior to obtain a surgery risks intra-operative difficulties in obtaining a reduction & passing guidewires. C-arm verifies that the length, angulation & fracture site translation have been corrected by manipulations of the fracture table. Estimate correct rotational alignment with respect to the normal anteversion of the hip as determined with the image intensifier. Therefore, comparable AP fluoroscopic views of the injured limb, both knee & hip, can then allow for rotational correction based on the profile of the lesser trochanter.

26. Preparation of femur Make a short oblique skin incision starting 2 to 3cm from the proximal tip of the GT & continue proximally & medially. Incise the fascia of the gluteus maximus in line with the fibres . The gluteus maximus muscle is gently divided in line with their direction to gain access into the posterior border of the gluteus medius . A retractor is placed distal to the gluteus medius to palpate the tip of the GT with the fingertip. Then, piriformis tendon is palpated & followed to its insertion site. This allows identification of the piriformis fossa, which is above the medullary canal of femur.

27. A T-handle reamer or a kuntscher awl in the piriform fossa & aim the instrument in line with the femoral shaft. The position of the starting point can be checked with the fluoroscope. Next, T-handle reamer is exchanged with a ball tipped guide wire. Flexible reamer are used to expand the medullary canal, beginning with the end cutting reamer, usually this is 8 to 9mm in size. Reaming usually progresses in 1mm increments until cortical ‘Chatter’ is felt or heard, at this point reaming continues in 0.5mm increments.

28. When reaming across the fracture site, the fracture must be appropriately reduced so that eccentric reaming does not weaken one side of the bone & cause fracture site comminution. To be certain, an appropriate size nail is used to compare the size of the last reamer with the selected nail.