FRACTURE SHAFT OF FEMUR

Presented by
Prakat c. Aryal
Intern Orthopedics
Group N

05/13/2024 P.C.Aryal Intern Group N 1

 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.

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 ANATOMY

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 ANATOMY CONTD..

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 ANATOMY CONTD.

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 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

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 MECHANISM OF SOF FRACTURE
• 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
• 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
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 CLINICAL PRESENTATION

• Symptoms
• pain in thigh
• History of trauma, RTAs, explosives, gunshots, sports related
injury(skiing, climbing)(high velocity trauma)

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 • 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

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 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.

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 • 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.

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 OTHER FRACTURES TO RULE OUT

• Ipsilateral Femoral neck fracture(10%)

• Pelvis fracture
• Fracture of ipsilateral tibia( floating knee)
Patient should also be evaluated for: chest injury,
head/abdominal injury.

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 IMAGING

• Recommended views
• AP and lateral views of entire femur
• AP and lateral views of ipsilateral hip
• AP and lateral views of ipsilateral knee

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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

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 MANAGEMENT

• Once the diagnosis of #shaft of femur is established

following steps should be taken in the ER before starting the
definitive treatment
1. Resuscitation/management as per the ATLS protocol
2. Immobilization(using splints)
3. elevation

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 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
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 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

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 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.

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 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

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 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

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 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

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 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

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 • 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

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 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
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 ORIF WITH PLATE

• Polytrauma patient with associated chest injury

• Communited fractures

Contraindications
• Patient not medically fit for surgery
• Osteomyelitis
• Compromised local soft tissues

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 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

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 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.

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 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

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 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
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 • 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.

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 • M. Zlowodzki,1 J. S. Prakash,2 and N. K. Aggarwal3
• 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.

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 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

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 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.
• Infection

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 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)

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 THANKYOU

References
• Apley's System of Orthopaedics and Fractures 9th ed.
• Essential ortho paedics 5th edition
• Clinically oriented antomy 6th edition
• www.aofoundation.org
• www.ncbi.nlm.nih.gov/pmc/articles/PMC2267585

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 HAPPY NEW YEAR

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