عادل الهنداوي . دOrthopedicsFemoral shaft fractures
This is a fracture of young adults following high energy
injury; in elderly, it is pathological until proved otherwise.
MOI: Spiral # is caused by→ a twisting force;
Transverse &ob lique #→ direct or angulation force;
Comminuted &Segmental #→ direct &indirect severe violence.
Winquist's classification: depend on degree
of # comminution which reflects # stability:
CF: short &externally rotated limb wi th deformed ,bruised &swollen thigh due to soft tissue bleeding
(1liter). Look for other limb or pelvic injury or
associated life - threatening injury. Exclude
X -ray: always x -ray the hip(to exclude another
# or ≠ ) &the knee (float ing knee). Those with
multiple injury, also need pelvic &CXR.
Emergency treatment: at the site of accident, thelimb should be splinted by tying to other limb or any available splint but
the ideal is Thomas' splint to: control pain, ↓ bleeding &make tran sfer easier.
Operative treatment:Plating: lateral plate with 4-5screws in both fragments.
Intramedullary nailing: open or closed reduction with
ante - or retro -grade nailing→ for mid &upper 1/3 stable #.
Locked IM nailing: closed reduction with IM nail lockedby interlocking proximal &distal screws for unstable
comminuted # & for subtrochanteric &lower 1/3 #.
External fixation: closed reduction &percutaneous fixation for:
1-severe open #; 2 -multiply injured patients; 4 -severly comminuted #;
5-# with bone loss; and 5 -# with vascular injury.
Fracture with vascular injury: warning signs are: 1 -severe bleeding orhematoma; and 2 -distal ischemia. Investigations: 1 -doppler; and 2 -arterio
graphy. Ŗ→ quick # fixation &arterial repair or bypass(no >6 hrs delay).
Complications: Early: 1 -Shock: 1-2liters lost, Ŗ→ transfusion.2-Fa t embolism &ARDS : risk factors are multiple injury, chest
injury & shock. CF: ↑pulse rate, ↑temp, dyspnea, restless &petechial
hemorrhage. Investigation: blood gases. Ŗ→ supportive.
3-Thromboembolism; 4 -Infection: in open # &after IF of closed #; Ŗ→
AB, de bridement, external fixation.
Late: 1 -Delayed union &nonunion: Ŗ→ rigid fixation &bone graft.
2-Malunion: angulation(<15°is accepted), shortening &malrotation.
3-Knee stiffness: due to soft tissue adhesion, Ŗ→ early physiotherapy.
4-Implant failure: due to early weight bearing before # healing.
Femoral shaft fracture in children:are common; MOI: FFH or RTA.
Treatment: usually conservative, according to the age:
Infant(<2yr): 1-2weeks traction→ 4weeks spica cast(30°angulation is accepted).
Childre n(2 -10yr): 2-3weeks traction → 4weeks spica cast(20°
angulation & 1cm shortening are accepted); or early CR &spica cast.
Teenager: 4-6weeks traction→ 6weeks spica cast.
Operative treatment: if traction fails to reduce the #→ internal or external fixation.
An gulation &shortening may be corrected to some extent with growth but rotation will not. *
Supracondylar fractures of the femur: seen in youngas a result of high energy injury or in old osteoporotic patients.
MOI: direct force ; the dis tal fragment may be flexed by gastro -
cnemius pressing on popletial artery.
CF: swollen deformed knee; always palpate the distal pulse.
X -ray: transverse # line just above the condyles or comminuted #.
Conservative: for young with undisplaced or easily reduced #:
skeletal traction through upper tibia with knee in flexion for
6weeks→ cast -brace &partial weight bearing(PWB).
Operative: if closed reduction fails→ ORIF using angled device like L -plate
or bet ter dynamic condylar screw(DCS) or locked IM nail. The advantages of
ORIF: easy nursing for elderly &knee movements can be started early
Complications: Early: arter ial injury.
Late: knee stiffness &nonunion
Fracture -separation of the distal femoral epiphysis: is the adolescent equiv alentof supracondylar #. MOI: either hyperextension force→ forward displacement of
distal epiphysis or angulation force→ lateral shift of epiphysis.
CF: swollen deformed knee; the popliteal artery may be obstructed
by lower femur. X -ray: usually Salter -H arris type П.
Treatment: closed reduction &cast splint or ORPP or screw fixation.
Complications: 1-Vascular injury in hyperextension deformity→ urgent reduction.
2-Physeal arrest causing varus or valgus deformity or shortening.
Femoral condyle fractures :MOI: either direct force or FFH; or in association with supracondylar #.
CF: swollen deformed knee with 'doughy' feeling of the haemarthrosis.
X -ray : one condyle is # &pushed up or both condyles are # in T - or Y -shape.
Conservative : 6weeks sk eletal traction→ cas t brace. If reduction fails :
Operative : ORIF using: cannulated screws, blade -plate or DCS.