Femoral shaft fractures Important notes: Femur is well padded in muscles. Great force is needed to fracture the bone in a young adult. Fragments are displaced by muscle pull which makes closed reduction difficult.

In elderly it is a pathological fracture until proved otherwise. In children think of physical abuse.

X-ray: Usually there is some comminution. X-ray of the pelvis and the knee to avoid missing injuries.

Treatment Remember the risk of systemic complications: Bleeding and shock. DVT and pulmonary embolism. Fat embolism. Etc….

Early stabilization Splintage or tracion to reduce and hold the fracture in a reasonable alignment to reduce further tissue damage and bleeding, e.g. Thomas splint.

Traction Indications: 1- Children. 2-Contraindication to anesthesia. 3-Lack if skills and facility for surgical therapy.

Contraindications to traction: 1- Elderly. 2- Pathological fracture. 3- Multiple injuries.

Drawbacks of traction Prolonged bed rest (10-14 wks) with its attendant problems: DVT, UTI, Bed sores, Pneumonia…. Joint stiffness. Malunion. Skin problems (irritation, blistering, necrosis,…) Neurovascular complications.

Open reduction and plating Out of favor because of high rate of complications e.g. implant failure, infection… Indications: Shaft and neck fractures. Vascular injury.

Implant failure

Intramedullary nail with interlocking screws Is the method of choice

External fixation Indications: Open injuries. Multiple injuries to reduce operating time. Bone transport for bone loss. In adolescents.

Femoral fractures in children Infants: 1-2 wks traction then hip spica for 3-4 wks. (Gallows traction) Children <10 years: traction 2-4 wks then spica for 6 wks. Teenagers: traction then spica or plate and screws.

Supracondylar fractures of femur In young adults after high energy injury. In elderly osteoporotic after trivial injury. Intercondylar extension may occur.

Supracondylar fracture with intercondylar extension

Tibial plateau fractures Fractures of the superior articular surface of the tibia Mechanism: medial or lateral bending force with axial loads, e.g. bumper fracture. Doughy swelling of hemarthrosis. Diffuse tenderness. May be associated with knee ligament injury (collateral ligament, cruciate ligament).

X-ray: One or both condyles may fracture with varying degrees of comminution. C-T: scan in complex fractures.

Patella fractures 3 types Undisplaced crack. Stellate comminuted fracture- direct blow on front of knee. Transverse fracture with a gap- indirect traction force. Quadriceps mechanism usually lost.

Undisplaces crack

congenital Bipartate patella

Clinical assessment Degree of hemarthrosis. Ability to extend the knee (integrity of quadriceps mechanism). Differential diagnosis: congenital bipartate patella.

Treatment Undisplaced or minimally displaced crack: Aspirate hemarthrosis. POP cylinder for 4-6 wks. Quadirceps exercise.

Comminuted (stellate) fractures: Extensor expansion is intact. Undersurface of patella irregular- may damage patellofemoral joint. Patellectomy.

Displaced transverse fractures: Knee extension is impossible. Initial fixation by tension wire with backslab.

Dislocation of patella Knee is normally in valgus- quadriceps tend to pull the patella laterally. Sudden severe quadriceps contraction with the knee stretched in valgus lead to lateral dislocation of the patella.

Clinical features First time dislocation; tearing sensation, patient collapse on the ground. Patella may remain dislocated or springs back into position spontaneuously.

Treatment Reduction with or without anesthesia Backslab for 3 weeks Recurrent dislocation occur in patients with small high patella and excessive genu valgum and joint laxity