2. FrequencyFrequency
Fractures of the femoral shaft areFractures of the femoral shaft are
the most common fractures thatthe most common fractures that
orthopedist see.orthopedist see.
incidence - 1.33 fractures perincidence - 1.33 fractures per
10,000 people.10,000 people.
3. In The United States
The incidence of hip fractures exceeds
250,000 per year, with an estimated
cost of nearly $10 billion.
4. Proximal femoral part fracturesProximal femoral part fractures
(medial and lateral fractures)(medial and lateral fractures)
Classification of
fractures
1.Subcapital
2.Trancervical
3.Basal
4.Intertrochanteric
(=basal)
5.Separation of the lesser
trochanter
6.Subtrochanteric
7.Separation of the greater
12
3
5
4
6
7
6. Blood to the femoral head is primarily supplied by the
medial circumflex femoral artery through its subsynovial
retinacular vessels. The lateral circumflex and ligamentum
teres arteries provide minor contributions to the femoral
head.
Anterior view
Retinacular
arteries
(subsynovial)
Retinacular
arteries
(subsynovial)
Acetabular
branch of
obturator artery
(often minute)
Posterior viewMedial
circumflex
femoral artery
Femoral neck fractures are at risk due to the limitedFemoral neck fractures are at risk due to the limited
blood supplyblood supply
8. Femoral Neck FracturesFemoral Neck Fractures
A B
A - adducted, neck-shaft angle at such cases reduces
up to the direct one, as the result of the hip displacement
upwards. These fractures are never impacted.
They unite very bad in view of insufficient blood supply of the
central fragment, absence of the periosteum in the area of the
femoral neck, and also difficulties of the fragments compa-
rison and their strong holding together.
9. BB -- abductedabducted,, with the formation of coxawith the formation of coxa
valga (neck-shaft angle at this fracturevalga (neck-shaft angle at this fracture
remains normal or even increases).remains normal or even increases).
These fractures are more often impactedThese fractures are more often impacted
10. Femoral Neck FractureFemoral Neck Fracture
Tenderness will be found
over the femoral neck
anteriorly (1) and in extra-
capsular fractures over the
greater trochanter. Pain is
produced by rotation of the
hip (2). Swelling localizes in
groin region or at the greater
trochanter area. Rarely, with
an undisplaced fracture, the
patient may be able to bear
weight.
11. Femoral Neck FractureFemoral Neck Fracture
Mechanism of injuryMechanism of injury ::
A fall on the side isA fall on the side is
the commonest cause.the commonest cause.
DiagnosisDiagnosis
The leg is rotatedThe leg is rotated
outwardsoutwards, especially at, especially at
subtrochantericsubtrochanteric
fractures;fractures;
- the external edge of the- the external edge of the
heel touches the bed orheel touches the bed or
the table on which thethe table on which the
patient lays.patient lays.
- He cannot lift the leg- He cannot lift the leg
actively; there is a signactively; there is a sign
of theof the "stuck heel”."stuck heel”.
12. Patient with a displaced femoral neckPatient with a displaced femoral neck
fracture on the right.fracture on the right.
Note that the leg is shortened andNote that the leg is shortened and
externally rotatedexternally rotated
14. A non displacedA non displaced
femoral neckfemoral neck
fracturefracture
A displacedA displaced
femoral neckfemoral neck
fracturefracture
15. Emergency manipulationsEmergency manipulations
Transport splints fixationTransport splints fixation
AnalgesicsAnalgesics
Local anesthesiaLocal anesthesia
Tourniquet in cases with externalTourniquet in cases with external
bleedingbleeding
I/v fluid infusionI/v fluid infusion
- Traumatic shock therapy- Traumatic shock therapy
16. Skin traction and splinting are used in the
field in emergent situations to provide
comfort for the patient and to prevent any
further soft tissues, vessels and nerves
damage.
18. Conservative TreatmentConservative Treatment
Skeletal tractionSkeletal traction
Skeletal tractionSkeletal traction
with furtherwith further
external fixationexternal fixation
External fixationExternal fixation
onlyonly
SymptomaticSymptomatic
treatmenttreatment
Unilat Hip
Spica Cast
One and One-
half Hip Sp.
Cast
Bilat. Long-
leg Hip
Spica Cast
19. Surgical treatmentSurgical treatment
internal fixation is still the treatment ofinternal fixation is still the treatment of
choice for most closed injuries becausechoice for most closed injuries because
of the higher union rate, lower rate ofof the higher union rate, lower rate of
complications, lower morbidity, earliercomplications, lower morbidity, earlier
weight bearing, shorter hospital stayweight bearing, shorter hospital stay
and better control of alignment.and better control of alignment.
However, in some situations in whichHowever, in some situations in which
the hardware is not available or thethe hardware is not available or the
patient cannot undergo surgerypatient cannot undergo surgery
relatively soon, temporary skeletalrelatively soon, temporary skeletal
traction may be a viable choice.traction may be a viable choice.
20. Open reduction and internalOpen reduction and internal
fixation of neck fracturesfixation of neck fractures
must be performed withinmust be performed within
hours after the injury.hours after the injury.
22. 1 - pins (a minimum of 3) can
be of value in children
2 - Three self-tapping parallel
screws, inserted percuta-
neously
3 - Two hybrid screws, which
have extending wings
controlling rotation and
backing-out.
Surgical TreatmentSurgical Treatment
24. ComplicationsComplications
General complications. Particularly in elderlyGeneral complications. Particularly in elderly
patients: deep vein thrombosis, pulmonarypatients: deep vein thrombosis, pulmonary
embolism, pneumonia, bed sores;embolism, pneumonia, bed sores;
Avascular necrosis. Occurs in about 30% ofAvascular necrosis. Occurs in about 30% of
patients with displaced fractures and in 10%patients with displaced fractures and in 10%
with undisplaced fractures);with undisplaced fractures);
Non-union. More than 30% of all femoral neckNon-union. More than 30% of all femoral neck
fractures fail to unite, and the risk isfractures fail to unite, and the risk is
particularly high in those that are severelyparticularly high in those that are severely
displaced;displaced;
Osteoarthritis. Avascular necrosis of femoralOsteoarthritis. Avascular necrosis of femoral
head collapse may lead to secondaryhead collapse may lead to secondary
osteoarthritis of the hip.osteoarthritis of the hip.
25. Avascular NecrosisAvascular Necrosis
of the Femoral Headof the Femoral Head
The patient with avulsion
fracture of the greater tro-
chanter. The injury was
immobilized in a one-and-a-
half hip spica for five
weeks.
After six months, the radio-
graphs showed beginning
avascular necrosis of the
femoral head, which later
developed into complete
necrosis with subluxation.
27. Total HipTotal Hip
replacementreplacement
Total hip replacement may
be preferable in a old
patient with severely dis-
placed fracture.
Prosthetic replacement may be quicker
and less traumatic than fixation and may
also permit earlier rehabilitation.
29. Proximal femoral part fracturesProximal femoral part fractures
(lateral fractures)(lateral fractures)
Classification of
fractures
4. Transtrochanteric -
intertrochanteric
5. Separation of the lesser
trochanter
6. Subtrochanteric
7. Separation of the
greater trochanter
12
3
5
4
6
7
30. Where trochanteric
region is involved, a
blade plate (1), DHS or
95° Dynamic Condylar
Screw, Gama nail may
be used.
Surgical TreatmentSurgical Treatment
31.
32. Trochanteric region fracture (lateralTrochanteric region fracture (lateral
fracture) fixed with DHSfracture) fixed with DHS
33. DHS (Dynamic Hip Screw)DHS (Dynamic Hip Screw)
with long bladewith long blade
34. With further involvement of the shaft, aWith further involvement of the shaft, a
Russell-Taylor reconstruction (locking) nail,Russell-Taylor reconstruction (locking) nail,
Gama-nail or DHS with long blade offerGama-nail or DHS with long blade offer
considerable versatility.considerable versatility.
38. Femoral Shaft FracturesFemoral Shaft Fractures
The femoral shaft is well padded with powerful
muscles - an advantage in protecting the bone from
all but the most powerful forces, but a disadvantage
in that fractures are often severely displaced by
muscle pull, making reduction difficult.
41. Nonsurgical treatmentNonsurgical treatment
The most common
use of traction is in
the treatment of
young children
(usually 5-10 y/o)
with 2-3 weeks
duration in the face
of soft-tissue
injury.
42. Nonsurgical treatmentNonsurgical treatment
Adult nonsurgical treatment optionsAdult nonsurgical treatment options
include skin traction, skeletalinclude skin traction, skeletal
traction, cast brace, casting.traction, cast brace, casting.
Children have the same options.Children have the same options.
Nonsurgical options are usedNonsurgical options are used
infrequently outside of the youngerinfrequently outside of the younger
pediatric population.pediatric population.
44. Nonsurgical treatmentNonsurgical treatment
Complications of tractionComplications of traction
OverdistractionOverdistraction
Pin track infectionPin track infection
Loss of positionLoss of position
Pressure soresPressure sores
47. Surgical treatmentSurgical treatment
internal fixation is still the treatment ofinternal fixation is still the treatment of
choice for most closed injuries andchoice for most closed injuries and
some open because of the higher unionsome open because of the higher union
rate, lower rate of complications, lowerrate, lower rate of complications, lower
morbidity, earlier weight bearing,morbidity, earlier weight bearing,
shorter hospital stay, and better controlshorter hospital stay, and better control
of alignment.of alignment.
56. Injuries of the lower end of
the femur:
(a)the mechanism of flexi-
on of the distal fragment in
a supracondylar fracture
(b)slipped lower femoral
epiphysis.
68. Frequency: Patella fractures account for
approximately 1% of all skeletal injuries.
Fractures occur as a result of a
compressive force such as a direct blow, a
sudden tensile force as occurs with
hyperflexion of the knee, or from a
combination of these.
70. Clinical:Clinical:
- The patient usually presents with pain in- The patient usually presents with pain in
the affected knee.the affected knee.
- Overlying abrasions, any lacerations- Overlying abrasions, any lacerations
must be assumed to communicate with themust be assumed to communicate with the
jointjoint
- An accompanying intra-articular effusion- An accompanying intra-articular effusion
may be present, which, if aspirated, willmay be present, which, if aspirated, will
reveal fat globules.reveal fat globules.
- If the fracture is displaced, a defect is- If the fracture is displaced, a defect is
palpable at the fracture site.palpable at the fracture site.
- The extensor mechanism must always be- The extensor mechanism must always be
evaluated.evaluated.
- Disruption of the extensor mechanism- Disruption of the extensor mechanism
results in the inability to extend the kneeresults in the inability to extend the knee
against gravityagainst gravity
75. If the fracture is not displaced the fractureIf the fracture is not displaced the fracture
may be treated with immobilization,may be treated with immobilization, placingplacing
the affected extremity in a cylinder cast for 4-the affected extremity in a cylinder cast for 4-
6 weeks6 weeks. The patient is allowed to bear weight. The patient is allowed to bear weight
in the cast.in the cast.
With proper patient selection, good resultsWith proper patient selection, good results
can be expected in approximately 90% ofcan be expected in approximately 90% of
patients with nondisplaced fractures.patients with nondisplaced fractures.
Closed treatment
