Shaft of femur fracture

SHAFT OF FEMUR
FRACTURE
Dr. Pramesh Prasad Shrestha
FCPS Resident (2nd year)
Department of Orthopedics

▪ Longest and strongest bone
▪ Bears weight,
transmit weight to tibia
▪ The shaft is padded by
muscles of thigh
INTRODUCTION

▪ Shaft of femur:
5cm distal to lesser trochanter to 5cm
proximal to adductor tubercle
5cm
5cm
INTRODUCTION

ETIOLOGY
• Causes of Shaft of Femur Fracture:
– Almost always result of high energy trauma
• Motor vehicles accident
• Gun shot injury
• Fall from height
– Low energy femur fracture:
• Elderly women
• Osteoporosis
• Long-term bisphosphonate therapy

TYPES
• Location of fracture
• Pattern of Fracture
• Open/Closed
Proximal
Distal
Middle

TYPES
• Location of fracture
• Pattern of Fracture
• Open/Closed

CLASSIFICATION
• Winquist & Hansen Classification

CLASSIFICATION
• AO/OTA Classification

CLINICAL EVALUATION
• History of trauma
• Symptoms
– Severe pain
– Unable to bear weight
– Deformity

CLINICAL EVALUATION
• ABC:
– Large amount of blood loss should be anticipated
– Features of hemorrhagic shock.
•

BLEEDING IN SHAFT OF FEMUR FRACTURE
• Bleeding in Closed Femur
fracture can be as high as 500-
700ml
• Even more in open fractures
• Impact hemodynamic stability

CLINICAL EVALUATION
• Look
– Deformity
– Swelling
– Bruises/ hematoma
– Skin integrity
– Cyanosis of distal parts

CLINICAL EVALUATION
• Attitude
– Proximal shaft fracture: Proximal fragment is flexed,
abducted and externally rotated; distal fragment is adducted
– Mid shaft Fracture the proximal fragment is flexed and
externally rotated but abduction is less marked
– Distal shaft fracture: proximal fragment is adducted and the
distal fragment is tilted by gastrocnemius pull

CLINICAL EVALUATION
• Feel
– Tenderness
– Increased temperature
– Distal Neurovascular status
– Tightness of skin
• Move
– Decreased movement of knee or hip joint
– Movement of toes

CLINICAL EVALUATION
• Rule out
– Ipsilateral Femur Neck fracture
– Pelvis Fracture
– Ipsilateral Tibia Fracture (Floating Knee)
– Chest Injury
– Head injury
– Abdominal injury

INVESTIGATIONS
• Imaging:
– Xrays:
• Entire Femur in AP and Lateral Views
• Ipsilateral Hip in AP and Lateral Views
• Ipsilateral Knee in Ap and Lateral Views
– CT Scan
• Trauma Series
• 3D imaging

MANAGEMENT
• 4 R’s
– Resuscitation
– Reduction
– Retention
– Rehabilitation

MANAGEMENT
• Non Surgical
– Almost all femur shaft fracture requires Surgery
– Non surgical approach mainly in children
– Preoperatively in adults
– Traction
• Skin traction
• Skeletal traction
• Splints

MANAGEMENT
– Pavlik harness
• Pediatric patients up to 3 months of age

MANAGEMENT
• Hip Spica
– Any fracture pattern in children up to 4 years of age
Single Leg Spica One and
Half Leg
Spica
Two Leg
Spica
Optional:
Bar

MANAGEMENT
• Surgical
– External Fixation
– ORIF with Plate
– Kuntscher’s Cloverleaf Nail
– Intramedullary Interlocking Nail
– Titanium Elastic Nail System

MANAGEMENT
• External fixation
– For temporary use before definitive surgery
– Contraindication
• Osteoporosis (relative contraindication)
– Advantage
• Rapidly applied provisional treatment
– Disadvantages
• Pin-track infection
• May interfere with procedures for soft-tissue reconstruction
• High risk of nonunion/malunion when used for definitive treatment

• ORIF with Compression Plate
– Indication:
• Polytrauma associated with chest injury
• All patients with femoral shaft fractures where intramedullary
nailing is contraindicated, but the patient is fit for surgery
– Contraindications:
• Not medically fit for surgery
• Compromised local soft tissues
MANAGEMENT

MANAGEMENT
– Advantages:
• Direct Reduction
• Reduction achieved with length, angular and directional control
• Reduced chance of fat embolization
– Disadvantages:
• Grater blood loss
• Exposure of fracture site, may interfere healing
• Large operative soft tissue trauma
• Less appealing cosmetic result

MANAGEMENT
• ORIF with Compression Plate with DCS and
• ORIF with Locking Compression Plate
– Can be used in all type of femur Proximal and Distal
shaft fractures

MANAGEMENT
• ORIF with Compression Plate
– For Simple mid shaft transverse fracture
• ORIF with Lag Screw and Protection Plate
– For Oblique, Spiral and Intact Wedge midshaft fracture

MANAGEMENT
• Bridge Plating
– All type of Fragmented Wedge and Segmental femur
Fracture

MANAGEMENT
• Intramedullary Interlocking Nail (IMIL Nail)
– Indications:
• All patients with femoral shaft fractures except those not fit for
definitive surgery
• Closed fractures
• Gustilo types I & II open, and clean IIIA fractures
• Polytrauma patients in stable condition
• Isolated fractures in case of Proximal Shaft Fractures

MANAGEMENT
– Contraindications
• Polytrauma patients in unstable condition
• Occluded intramedullary canal
• Gustilo type III B and C open fractures

MANAGEMENT
• Reduction (Before IMIL Nail)

MANAGEMENT
• Antegrade Nailing
– Extremely successful
– Minimally Invasive
– Entry Points
• Piriformis (For Straight Nails)
• Trochanteric (For Curved Nails)

MANAGEMENT
– Advantages
• Less invasive procedure / indirect reduction
• Fracture can be reduced (length, angular and rotational control
are obtained)
• Better biomechanical properties
• Rapid mobilization of patients postoperatively
• Minimal blood loss

MANAGEMENT
– Disadvantages
• Risk of iatrogenic femoral neck fracture
• Risk of fat embolization
• Risk of malrotation

MANAGEMENT
• Retrograde Nail
– Minimally Invasive
– Entry Points

MANAGEMENT
• Retrograde Nailing
• Advantages over other techniques
– Less invasive procedure / indirect reduction
– Minimizes soft-tissue damage
– Fracture can be reduced (length, angular and rotational
control are obtained)
– Better biomechanical properties
– Rapid mobilization of patients postoperatively
– Minimal blood loss

• Disadvantages
– Risk of iatrogenic intraarticular damage to the knee joint
– Risk of fat embolization
– Difficult control of proximal fracture fragment in more
proximal fractures
– Risk of damage to the anterior cruciate ligament
– Risk of malrotation – angular deformity
– Risk of damage to the patellar tendon
– Risk of chronic knee pain

MANAGEMENT
• Titanium Elastic Nailing System (TENS)
– Indications:
• Shaft fractures in children from 4 up to 12–13
years of age (depending on body size/weight)
• In highly length unstable or comminuted
fractures sometimes this technique may not be
suitable.
• To provide stability in these unstable fractures
end caps are strongly recommended.

MANAGEMENT
• Advantages
– Short stay
– Minimally invasive
– Relatively inexpensive implant
• Disadvantages
– Increased risk of malunion with increasing age and weight of
patient
– Risk of pain at insertion site
– Risk of iatrogenic stress fracture at entry points

• Entry points:
• 2–3 cm proximal to the growth plate

MANAGEMENT
• 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

COMPLICATIONS
• Early Complications
– Shock
– Fat Embolism
– Neurovascular Injury
• Sciatic Nerve
• Femoral Artery
– Infection

• Late Complications
– Delayed Union
– Mal Union
– Non Union
– Knee Stiffness
– Implant Failure
– Limb Shortening

Shaft of femur fracture

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