FRACTURE SHAFT FEMUR PPT by dr.bharti pawar.pptx

includes fracture shaft femur and its ortho management

1. FRACTURE SHAFT OF FEMUR BY DR.BHARTI PAWA (PT)

2. Anatomy Largest tubular bone in the body. Surrounded by the largest mass of muscle. ‘Antero-lateral’ bow – important feature. Isthmus – it is the region of femur with smallest intra-medullary diameter, it’s at the junction of upper 1/3 rd and lower 2/3 rd .

3. 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

4. Muscular deforming force/ Biomechanics ABDUCTORS :- They abducts hip joint and are mainly gluteus medius and minimus . They insert on greater trochenter , abduct proximal femur following fracture. ILIOPSOAS :- flex and external rotates the proximal fragment by its attachment in lesser trochenter . ADDUCTOR :- Mainly Adductor longus , Adductor magnus and Adductor brevis . Exerts a strong axial and varus load to bone by traction on distal part FASCIA LATA :- acts as a tension band by resisting the medial angulating forces of abductor.It’s a continuation of Ilio-tibial tract of thigh and is also known as DEEP FASCIA OF Thigh.

5. Compartments of thigh Three compartments. ANTERIOR COMPARTMENT - Quadriceps femoris , iliopsoas , sartorius and pectineus . Femoral artery, vein, nerve, lat femoral cutaneous nerve. MEDIAL COMPARTMENT – gracilis , adductor longus , brevis , magnus and obturator externus muscles. Obturator artery,vein,nerve and profunda femoris artery. POSTERIOR COMPARTMENT –biceps femoris , semitendinosus and semimembranosus, a portion of the adductor magnus ( Hamstring muscles ) branches of profunda femoris artery, sciatic nerve, post femoral cutaneous nerve.

6. Blood supply Mainly from the profunda femoris , branch of Femoral artery One to two nutrient vessels usually enter the bone proximally and posteriorly along the linea aspera . This artery then arborizes proximally and distally to provide endosteal circulation. Periosteal vessels also entres along the linea aspera .

7. Outer 1/3 rd of cortex supply – periosteal vessels. Inner 2/3 rd of cortex supply – endosteal vessels. After most of the femoral shaft fracture - endosteal supply disrupted - periosteal vessels proliferate to heal - medullary vessels restored late in healing process.

8. Mechanism TRAUMATIC 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

9. Pathological fracture – elderly, inconsistent with degree of trauma, at the weak metaphyseal-diaphyseal junction.

10. Fracture patterns Transverse  pure bending movement  Spiral  Rotational/twisting movement Oblique uneven bending movement Segmental  More than 1 fracture line Comminuted Single fracture line with multiple fragments

11. Associated orthopaedic conditions Ipsilateral femoral neck fracture  often basicervical , vertical, and nondisplaced   missed 19-31% of time  Bilateral femur fractures   significant risk of pulmonary complications increased rate of mortality as compared to unilateral fractures Ipsilateral tibial shaft fractures Ipsilateral acetabular fracture

12. Clinical features Symptoms H/O trauma followed by inability to walk Physical examination Diagnostic features of fracture are 1.Bony crepitus 2.Abnormal mobility . 3. Loss of transmitted mobility

13. Winquist and Hansen classification Type 0 • No comminution Type I • Insignificant amount of comminution Type II • More than 50% cortical contact Type III • Less than 50% cortical contact  Type IV • Segmental fracture with no contact between proximal and distal fragment

14. Winquist and Hansen classification

15. Imaging Radiographs AP and lateral views of femur with hip and knee AP view of Pelvis important to rule-out coexisting femoral neck fracture      CT indications may be considered in midshaft femur fractures to rule-out associated femoral neck fracture

16. INITIAL MANAGEMENT Resuscitation of patient as per ATLS guidelines. Airway Breathing Circulation Disability Normally 500ml -2000 ml blood loss occurs so patient may present with shock. Volume replenishment by IV fluids or blood transfusion if required. Catheterization to be done.

17. Application of below knee-skin traction with Thomas splint should be done as early as possible. Stabilization should be done at the emergency room.

18. Treatment Nonoperative Long leg cast or hip spica cast in Paediatric age group upto 5 Years Operative Done after stabilization of patient usually after 5-7 days. 1. Adolescent age groups- Tension Elastic nail application, done under IOTP without opening fracture site 2 . After skeletal maturity - Antegrade intra-medullary nail  done under IOTP without opening the fracture site.

19. Titanium Elastic Nailing Intramedullary nailing

20. Treatment Retrograde intramedullary nailing- Practiced in difficult situations, in which opening of fracture site is necessary.

21. Treatment External fixation with conversion to intramedullary nail within 2-3 weeks Indications In compound fractures

22. Treatment Open reduction internal fixation with plate  Indications ipsilateral neck fracture requiring screw fixation fracture at distal metaphyseal-diaphyseal junction inability to access medullary canal