1. Intertrochanteric fracture neck of femur

2. It is an extra capsular fracture neck of femur, it is common in elderly , osteoporotic people .
In compare to intra capsular fracture neck of femur , extra capsular fracture seldom cause avascular necrosis .
This fracture is divided into stable and unstable varieties .
Clinically : usually the patient is old (osteoporotic) , following a fall , he is unable to stand , the lower limb is short and externally rotated usually has bruises.

3. X-ray: fracture runs from greater to lesser trochanter, may be comminuted and displaced ,sometimes the fracture is undisplaced or even the crack can hardly be seen .

4. Intertrochanteric fracture neck of femur

5. Extra capsular fracture neck of femur

6. Treatment : inter trochanteric fracture is treated always by early internal fixation not because it fail to unite with the conservative treatment ( it unite quite readily ) but to :
1- to obtain the best possible reduction .
2- to get the patient up as soon as possible .
The fixation is by compression screws , Gamma nail and dynamic hip screw .

7. Dynamic hip screw
Gamma nail

8. Complication : early complication : the same as fracture neck of femur .
Late :
1- failed fixation .
2- malunion .
3- non union(rare) .

9. Sub trochanteric fracture neck of femur
This Fractures occur below lesser trochanter , result from severe trauma in young , trivial injury(old osteoporotic) or pathological. Leg externally rotated and short with marked swelling of the thigh, bruises and swelling . Blood loss like femoral shaft fractures, may need urgent treatment of shock and blood transfusion. X ray: shows fracture below lesser trochanter.
Treatment : open reduction and internal fixation is
the treatment of choice .

10. Subtrochanteric fracture

11. Femoral shaft fracture
This fracture occurs at any age, it is common especially in young adults, and usually results from a high energy injury, such as ( car accident , fall from height), In elderly , it may be pathological fracture, in children think of child abuse. Fracture may be spiral,transverse, comminuted, pathological, or compound. Most fractures have some degrees of comminuation (small fragment, single large butter fly, extensive comminuation).

12. Femoral shaft fracture

13. Types of fracture shaft of femur

14. Clinically:
The patient has pain and swelling, the leg externally rotated, short, deformed, swollen, bruises. Always try to exclude neurovascular injury, and look for possible serious life threatening injuries.
The fracture result in a significant blood loss of liter , shock and fat embolism are common early complications.
X-ray : Shows the type of fractures, and displacement. The x-ray should include the hip and knee and x-ray of pelvis to avoid missing segmental fractures, knee injuries, fractures of neck of femur, dislocation of hip, fractures of acetabulum and pelvis. .

15. Emergency treatment :
Traction with a splint (Thomas’ splint) is first aid for a patient with a femoral shaft fracture, Shock treatment, and early transport to hospital.
Open fractures treated by debridement and external fixation.
Definitive treatment for closed fractures: by Open reduction and internal fixation, this will decrease the systemic complications.
Exercises for the lower leg and foot are important in preserving muscle tone and in preventing deformity and they should be begin immediately.

16. Fixation of femoral shaft fracture

17. Conservative treatment: Reduction and holding by traction, ( fixed traction, balanced traction with or without splint followed by exercise) rarely applied.
COMPLICATIONS:
Early complications:
1- Shock & blood loss (1-2 litres lost even in closed fractures)
2- Fat embolism and acute respiratory distress syndrome ( formation of fat globules in blood or showering of fatty emboli from the marrow to the lungs)
3- Deep vein thrombosis and pulmonary embolism ( specially with prolonged traction in bed)
4- Infection (in open fractures) and skin damage.

18. Late complications:
1- Delayed union and non-union need rigid fixation and bone graft .
2- Malunion (Fractures treated by traction and bracing often develop some deformity; no more than 15 degrees of angulations or rotation should be accepted)
3- Joint stiffness (specially knee joint, may be injured at the same time or adhesions during treatment)

19. Supracondylar fractures of the femur
Typically the fracture occurs just proximally to the point where the medial and lateral cortices of the femur flare out to form condyles. In young it follow sever trauma and in old follow osteoporosis. A vertical extension of the fracture may split the two condyles apart in a T – shaped fracture line, and sometime there is more extensive comminuation.

20. Suprachondylar fracture with its fixation by L – plate and screws

21. Clinically : Treatment :
pain and deformity in lower thigh after trauma. Knee is swollen and distal pulses should be palpated. It may injured the popliteal artery and nerves.
Treatment :
These fractures can sometimes be treated successfully by traction through the upper tibia in young, followed by cast brace.
In old internal fixation is often preferable and the patient can get out of bed sooner (dynamic condylar screw and plate) .

22. Complicaions : popliteal vessels injuries, nerve injury ( common peroneal nerve), malunion, delayed union , and stiffness of knee.