–Diaphyseal fractures are common in young adult and if occurred in elderly, think of pathological fracture,. Due to thick muscles in the thigh this makes the shaft fractured only by severe trauma and causing severe bleeding that may reach about two liters of blood.
Types:- 1- Transverse fractures. 2- Spiral fractures. 3- Oblique fracture with or without butterfly. 4- Comminuted fractures.
Clinical findings - History of trauma. - On examination:- there is shock, deformity, externally rotated limb, swelling, tenderness with loss of function. - x-ray revels the fractures& its type.do AP and lateral view
Treatment : Urgent: this includes treatment of shock and dealing with other injuries of vital organs regarding the fracture immobilized by Thomas splint Conservative : Skeletal traction for 6 to 8 weeks followed by cast bracing for other 6 to 8 weeks then physiotherapy. Sometimes continueous traction without cast bracing. regarding quadriceps and hamstring during traction better to use lower femoral skeletal traction.
Surgical treatment Indications 1- failure of conservative treatment due to muscle(soft tissue)interposition or mal alignment. 2- transverse fracture. 3- multiple fractures. 4- pathological fractures. 5- presence of any contraindication to conservative treatment especially in elderly patients. 6- vascular injuries associated with the fracture.
Notes: in regions of the world where intramedullary technique are not available or where risks of surgery are unacceptable, non-operative treatment remain the treatment of choice.
Types of surgical treatment : 1-open intramedullary nailing used in patients in whom closed reduction and internal fixation are not possible as in arthrodesis or stiffness of hip joint.its also used in patients whom the guide pin cant pass in the canal as in presence of bony fragments in th canal,also used in open fractures where the ends of the bones aare exposed. 2-flexible nail :antgrade or retrograde flexible nailing of Enders nail ;single or multiple under fluoroscopic control (unreamed) 3-closed antigrade interlocked reamed nailing,it has good results especially if undreamed(less blood loss and decrease operation time). 4-closed retrograde nailing through lateral epicondyl area. 5- plate fixation;
Indications of plate fixation - Inadequate experience with above techniques or if fluoroscopy was not available or if instruments and implants are not available or if associated with vascular injury and plating can be done through the same approach. - In non-union and mal-union in which the canal is obstructed and sometimes osteotomy or bone graft is needed. - In the presence of arthrodesis of hip and here nailing is difficult or impossible.
Extenal fixation 1- Compound fractures,temporary or definitive treatment. 2- Multiply injured patient for rapid mobilization' 3- Fractures associated with vascular injury need to be repaired
Complications Early:- shock, fat embolism,DVT that causes pulmonary, vascular injury, infection. Late:- 1- Delayed union: If healing not occurs in within 3-4 months. It is treated by bone graft and IF. 2-Malunion: Up to 2 cm shortening and 10-15 degrees angulation is accepted but never rotation. Treatment is corrective osteotomy and IF. 3- Joint stiffness; prevented by early mobilization
Supracondylar fracture This is common in young adults usually caused by direct violence. Types; Simple and comminuted. It may be associated with intra- articular extension T or Y fracture.
Fracture femur in children This is usually caused by direct trauma. Treatment is almost always by conservative methods i.e skin traction then if the fracture becomes stable, apply pop for 4-6 weeks. Children less than 4 years; use Gallows traction. Two cm shorting and up to 20 degrees angulation is accepted in children but again no rotation. Complications - Malunion - Leg length discrepancy usually shortening but may be increase in length due to 1- Active healing process( hyperaemia and hypervascularity).2- Increased growth hormone secretion.
Treatment; 1- Young adults are usually treated conservatively by high tibial skeletal traction in 90 degree flexed knee to cancel the action of gastrocnemus muscle for 4-6 weeks. 2 –In elderly by IF; the types of fixation are ; - Blade plate - Dynamic condylar screws - Other plates.
Condylar fractures These are the same as supracondylar fractures but always check distal neurovascular function. It is usually caused by direct injury to the knee. It takes T or Y shaped fracture. On examination; Swelling, tender knee, doughy consistency due to hemoarthrosis (rapid onset, to differentiate it from simple knee effusion). Check x-ray to prove it.
Treatment 1- Conservative by skeletal traction 4-6 weeks. 2- Surgical treatment by internal fixation; DCP, Compression screws with washers. With posterior above knee slab followed by full cast for 4-6 weeks followed by physiothrerapy and gradual weight bearing.
Displacement of femoral epiphysis This occurs in children. It is type-2 salter- Harris fracture. Caused by lateral or hyperextension force. Complications; Malunion leading to deformity and growth disturbance (like any epiphyseal injury).
Treatment –succeed or unstable, reduction under screen and percutaneous k-wire followed by posterior above knee slab. – Conservative by manipulation under anaesthesia and pop. If not succeed or unstable, reduction under screen and percutaneous k-wire followed by posterior above knee slab.