Fracture shaft of femur

brief summary of # shaft of femur

1. Fracture SHAFT of femur Presented by Prakat c. A ryal Intern Orthopedics Group N 4/15/17 P.C.Aryal Intern Group N 1

2. femur largest and heaviest bone in the body transmits a person’s a person’s body weight to tibia while standing has an anterior bow Shaft of femur is mostly smoothly rounded except posteriorly, broad rough line , linea aspera exists providing aponeurotic attachment to adductors of thigh. Especially prominent at the middle third of shaft where it has medial and lateral lips. 4/15/17 P.C.Aryal Intern Group N 2

3. anatomy 4/15/17 P.C.Aryal Intern Group N 3

4. Anatomy contd.. 4/15/17 P.C.Aryal Intern Group N 4

5. Anatomy contd. 4/15/17 P.C.Aryal Intern Group N 5

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7. 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 The femoral shaft is circumferentially padded with large muscles. Advantage: improved healing potential due to good vascular tissue coverage. disadvantage: difficult reduction due to possible displacement due to muscle pull 4/15/17 P.C.Aryal Intern Group N 7

8. 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   spiral fracture is usually caused by a fall in which the foot is anchored while a twisting force is transmitted to the femur. Transverse / obligue : angulation or direct violence. communited / segmental : very high energy trauma 4/15/17 P.C.Aryal Intern Group N 8

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11. Clinical presentation Symptoms pain in thigh History of trauma, RTAs, explosives, gunshots, sports related injury(skiing, climbing)(high velocity trauma) 4/15/17 P.C.Aryal Intern Group N 11

12. Physical exam inspection tense, swollen thigh blood loss in closed femoral shaft fractures is 1000-1500ml (features of shock may be present) for closed tibial shaft fractures, 500-1000ml blood loss in open fractures may be double that of closed fractures tenderness about thigh Distal neurovascular status may be compromised 4/15/17 P.C.Aryal Intern Group N 12

13. Clinical feature contd.. Attitude In proximal shaft fractures the proximal fragment is flexed, abducted and externally rotated because of gluteus medius and iliopsoas pull; the distal fragment is frequently adducted. In mid-shaft fractures the proximal fragment is again flexed and externally rotated but abduction is less marked. In lower third fractures the proximal fragment is adducted and the distal fragment is tilted by gastrocnemius pull. 4/15/17 P.C.Aryal Intern Group N 13

14. The soft tissues are always injured and bleeding from the perforators of the profunda femoris may be severe. Beware of the fracture at the junction of the middle and distal thirds of the femoral shaft – it can be responsible for damaging the femoral artery in the adductor canal. 4/15/17 P.C.Aryal Intern Group N 14

15. Other fractures to rule out Ipsilateral Femoral neck fracture(10%) Pelvis fracture Fracture of ipsilateral tibia( floating knee) P atient should also be evaluated for: chest injury, head/abdominal injury. 4/15/17 P.C.Aryal Intern Group N 15

16. IMAGING R ecommended views AP and lateral views of entire femur AP and lateral views of ipsilateral hip   AP and lateral views of ipsilateral knee 4/15/17 P.C.Aryal Intern Group N 16

17. The 4 r’s of fracture management R – Resuscitation done at the site of trauma/ER, comprises the addressing of acute life threatening condition related to fracture/ trauma R-Reduction Definitive management of fracture done internally/externally R-Retention Stabilization of fracture segment throughout the healing process R-Rehabilitation Focusing on getting the patient back to his ADL as soon as possible 4/15/17 P.C.Aryal Intern Group N 17

18. Management Once the diagnosis of #shaft of femur is established following steps should be taken in the ER before starting the definitive treatment Resuscitation/management as per the ATLS protocol Immobilization(using splints) elevation 4/15/17 P.C.Aryal Intern Group N 18

19. management Nonoperative (used for closed fractures) Traction: treated by traction with or without splint. Usually a thomas splint(temporary) is used, skin traction sufficient in children. skeletal traction in adults given by steinmann pin( tibial traction) Uses of traction: birth to 2 years: gallows' traction is used(3-6 weeks), older child: Russell's traction 2 to 16 years: different methods of traction can be used followed by immobilization using hip spica . Hip spica : plaster cast incorporating part of trunk and limb. Long leg cast 4/15/17 P.C.Aryal Intern Group N 19

20. Thomas splint Indications Medically unfit for surgery Polytrauma , in extremis Advantage Stabilization when immediate surgery is not possible or practical Disadvantages Overlap of the fracture can occur despite traction Continuing motion at the fracture site Continuing soft-tissue compromise and bleeding 4/15/17 P.C.Aryal Intern Group N 20

21. Operative treatment Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the strongest mechanical fixation and is the best treatment for early mobilization. 4/15/17 P.C.Aryal Intern Group N 21

22. IMIL Indications All patients with femoral shaft fractures except those not fit for definitive surgery Isolated fractures Closed fractures Gustilo types I & II open fractures Polytrauma patients in stable condition 4/15/17 P.C.Aryal Intern Group N 22

23. IMIL Contraindications Polytrauma patients in unstable condition Not medically fit for surgery(avoid the second hit) Image intensifier unavailable Associated vascular injury requiring open repair Periprosthetic fractures Continuing infection Occluded intramedullary canal Gustilo type III C open fractures 4/15/17 P.C.Aryal Intern Group N 23

24. IMIL Advantages Less invasive procedure / indirect reduction Minimizes soft-tissue damage Fracture can be reduced (length, angular and rotational control are obtained) Better biomechanical properties Definitive procedure Rapid mobilization of patients postoperatively Minimal blood loss Good cosmetic results 4/15/17 P.C.Aryal Intern Group N 24

25. IMIL Disadvantages Risk of iatrogenic femoral neck fracture Risk of fat embolization Closed reduction may be more challenging than open reduction Frequent use of image intensifier – risk of increased radiation exposure 4/15/17 P.C.Aryal Intern Group N 25

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27. In places without facilities of image intensifier open K( kuntscher’s clover leaf intra- medullary ) nailing gives good results Most suited for a transverse or a short oblique fractures. Not preferred for communited fracture as these cannot provide adequate stability 4/15/17 P.C.Aryal Intern Group N 27

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29. ORIF with plate Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in which ORIF with a plate may be indicated. Indications All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but the patient is fit for surgery Indirect reduction impossible No image intensifier available Early pregnancy (up to 12 weeks gestation) due to the risks from radiation exposure 4/15/17 P.C.Aryal Intern Group N 29

30. ORIF with plate Polytrauma patient with associated chest injury Communited fractures Contraindications Patient not medically fit for surgery Osteomyelitis Compromised local soft tissues 4/15/17 P.C.Aryal Intern Group N 30

31. ORIF with plate Advantages Less demanding procedure Less exposure to ionizing radiation Direct reduction Fracture can be reduced (length, angular and rotational control are obtained) Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM nailing Fracture stabilization allows for early patient mobilization 4/15/17 P.C.Aryal Intern Group N 31

32. ORIF with plate Disadvantages Greater blood loss Exposure of fracture zone / risk of interference with healing process Larger operative soft-tissue trauma Less appealing cosmetic result There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking screws. 4/15/17 P.C.Aryal Intern Group N 32

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35. External fixation Unstable fracture, patient or soft tissues, unsuitable for definitive internal fixation. Further indications for external fixation Subtotal amputation or prolonged vascular deficit Salvage after major complications following internal fixation Unavailability of other treatment options Bone loss Gustillo anderson type III B and C 4/15/17 P.C.Aryal Intern Group N 35

36. External fixation Contraindication Osteoporosis (relative contraindication) Advantage Rapidly applied provisional treatment, early mobilization Disadvantages Possible loss of fixation Pin-track infection Cumbersome fixation interferes with lower limb function May interfere with procedures for soft-tissue reconstruction High risk of nonunion/ malunion when used for definitive treatment 4/15/17 P.C.Aryal Intern Group N 36

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39. Conversion of temporary external fixation to an intramedullary nail within the first 2 weeks after a femoral shaft fracture is standard practice. However, due to financial constraints, in large parts of the world external fixation of femoral shaft fractures is often the definitive treatment. 4/15/17 P.C.Aryal Intern Group N 39

40. M. Zlowodzki , 1   J. S. Prakash , 2  and  N. K. Aggarwal 3 Fifty-eight patients with 60 femoral fractures seen between July 1989 and July 1994 were treated at the Christian Medical College and Hospital in Ludhiana, India, with an external fixation device as definitive treatment . Only six patients regained full range of motion. The average flexion was 72° (knee-5/0 to 135) . Pin tract infections occurred in 26 patients, leading to loosening of four pins. Satisfactory results can be obtained with definitive external fixation of femoral shaft fractures. Pin tract infections, although a common occurrence, are not a major problem and can be treated by local wound care and antibiotic therapy. The most common problem is significant decrease in the range of motion of the knee. 4/15/17 P.C.Aryal Intern Group N 40

41. rehabilitation Important to start early mobilization as soon as possible Decreased hospital stay Decreased chances of joint stiffness, preserve normal range of motion Return to activities of daily life as soon as practicable 4/15/17 P.C.Aryal Intern Group N 41

42. Early complications SHOCK(1000-1500ml in closed # double in open) Fat embolism: symptoms occur with in 24-48 hrs proper splinting required to prevent this from occurring. Injury to femoral artery: most commonly in fractures at the junction of middle and distal third of femoral shaft Injury to sciatic nerve. I nfection 4/15/17 P.C.Aryal Intern Group N 42

43. Late complications Delayed union(union still insufficient to allow unprotected weight bearing after 5 months, bone grafting) Non union(internal fixation and bone grafting) Malunion ( lateral angulation and external rotation, shoe raise, internal fixation ,bone grafting ) Knee stiffness( intraarticular periarticular adhesions, quadriceps adhering to fracture site , undetected knee injury, physiotherapy , athrolysis quadricepsplasty ) 4/15/17 P.C.Aryal Intern Group N 43

44. Thankyou References Apley's System of Orthopaedics and Fractures 9th ed. Essential ortho paedics 5 th edition Clinically oriented antomy 6 th edition www.aofoundation.org www.ncbi.nlm.nih.gov / pmc /articles/PMC2267585 4/15/17 P.C.Aryal Intern Group N 44

45. Happy new year 4/15/17 P.C.Aryal Intern Group N 45