Fracture of shaft of femur

Introduction.- It is a fracture of femoral diaphysis occurring between 5cm distal to lesser trochanter and 5cm proximal to adductor tubercle. Usually occur in young men after high energy trauma and elderly women (even after a low energy fall).

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Anatomy

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Fig

Anatomy Femur is the largest tubular bone. Surrounded by large muscle mass. Major deforming muscle forces- Abductors: Gluteus medius and minimus. Iliopsoas ;- flexion and external rotation. Adductors -pectineus, adductor brevis ,adductor longus , gracilis and adductor magnus .

Thigh muscles Anterior compartment: quadriceps femoris, iliopsoas, sartorius. Medial compartment: gracilis, adductor longus, brevis, magnus, obturator externus. Posterior compartment: biceps femoris, semitendinosus, semimembranosus. Because of the large volume, compartment syndrome is much less common.

Vascular supply Mainly from profunda femoris.

Mechanism of injury Almost always due to high energy trauma: RTA, gunshot injury, fall from height. Pathologic fractures occur at the metaphyseal/diaphyseal junction. If degree of trauma inconsistent with fracture, rule out pathological #.

Classification: Winquist and Hansen’s comminution

Clinical features - shock features : -Pain, - swelling, - deformity, - shortening of the lower limb and complete external rotation deformity. - severe blood loss ( up to 1500 mL ) - shock features : - unconsciousness , pallor , cold nose , tachycardia , cold and clammy skin , hypotension etc.

Associated injuries Ligament and meniscus injuries of ipsilateral knee. Spinal injuries. Injury to the Pelvis.

Radiographic evaluation AP and lateral views of the femur, hip and knee. AP view of the pelvis. Fracture pattern, comminution, shortening should be evaluated.

Treatment (Non operative) Skeletal traction: Hip spica 

Skin traction: Gallow’s traction For children upto 2yrs. Legs of the child are tied to an overhead beam. Hips are raised about 2 inches from the bed so that weight of the body provides counter traction. For 4 to 6 weeks.

Operative methods Standard treatment for most femoral shaft fractures. Early surgery is recommended.

Closed Intramedullary nailing Advantages- Inside the medullary cavity, so more stable than plate, less exposure required. Fracture hematoma is maintained. Early use of limb, restoration of length and alignment, rapid union and low re-fracture rates are the advantages.

Interlocking nailing Nail is introduced in the medullary cavity. The screws are passed from the cortex through the holes in the nail.

Kuntscher’s cloverleaf Intramedullary nail. Open reduction required. For # at the junction of upper and middle 1/3. Not suitable for comminuted fractures, fractures in the distal shaft and in open fractures.

Plate fixation Advantage: no additional trauma . Disadvantage: more risk of infection, more bleeding, soft tissue injury. Higher rate of implant failure as it is load bearing. Decreased vascularization beneath the plate.

Indications of plating Extremely narrow medullary canal where IM nailing is difficult. Fractures that occur through previously malunited fracture. Fractures that have extended to the trochanters or condyles. For comminuted fractures.

Complications Shock. Fat embolism. Femoral artery injury. Sciatic nerve injury. Infection.

Late Delayed union. Non union. Malunion. Knee stiffness.