brief and basic information about femoral shoft fracture :mechanism,diagnosis,treatment(conservative and non conservative) with appropriate pictures

1. Fracture of shaft and distal part
of femoral bone
prepared by : AMIT KUMAR
BPT 2ND year
CPRS,JMI

2. Femoral Shaft fracture
 A fracture of the shaft of the femur is usually sustained by a
severe violence,as may occur in a road accident. The force
causing the fracture may be indirect(twistingor bending
force) or direct(traffic accidents).
 The fracture may occur at any site and is most equally
common in the upper,middle and lower thirds of the shaft. It
may be a transverse ,oblique ,spiral or comminuted fracture
depending upon the nature of the fracturing force.

4. Mechanism of Femoral shaft fracture :
This is usually a
fracture of young
adults and results
from a high energy
injury.
 Like road
accidents,falls from
height,gun shots etc.

5. Special features of femoral shaft fracture :
 Essentially fracture of young
adult .
 Result from high energy injury
 If occur in eldery should be
considered pathological until
proved otherwise .
 In children under 4 years of age
the possibility of physical abuse
may be kept in mind .

6. Classification (Winquist’s classification):
Type 1 Type 2 Type 3 Type 4
Type 1 there is only a tiny cortical
fragment.
Type 2 the ‘butterfly fragment is larger
but there is still at least 50 per cent
cortical contact between the main
fragments.
Type 3 the butterfly fragment involves
more than 50 per cent of the bone
width.
Type 4 is essentially a comminuted
fracture .

7. Cont…...
 Reflects the observation that the degree of soft tissue
damage .
 Fracture instability increase when increasing the grades of
comminution .

8. Diagnosis :
Radiological examination
1- History and physical exam .
2-X-ray done for a femoral shaft
fracture must include whole femur .
3-An X-ray of the pelvis should be
done because it is common that a
patient with fracture of the femur
has an associated injury in the
pelvis.

9. CT scan :

10. Clinical picture :
 Pain
 Swelling
 Deformity
 Tenderness
 Loss of function

11. Treatment :
Conservative method
 Traction and bracing(Thomas splint, perkins traction)
 Hip spica
 Gallow’s traction(in children from birth to 2 years)
Operative method
 Open reduction and plating .
 Closed interlock nailing
 Kuntscher”s clover leaf Intramedullary nailing (k-nail)
 External fixation
 Titanium elastic nail system(TENS)

12. Traction and bracing :
 Traction with a splint is first aid for a patient with a femoral shaft
fracture.
Indication :
1-fracture of children .
2- contraindication to anesthesia .
3- lack of suitable skills for internal fixation .
 Length of time spent in bed is about 10 – 14 weeks .
 Method : 1- Thoma’s splint . 2- Perkin’s traction .

13. Thoma’s splint
 This method
rarely used
because it
lead to knee
stiffness.

16.  Skletal traction without splints.
 The traction is applied directly
on the bone by inserting a k-
wire or stienmen’s pin through
the bone.
perkin’s traction

17. Hip spica
 This is a plaster cast incorporating part
of trunk and the limb.
 It may be a single spica or one-and-half.
 It can be safely used for immobilising these
fractures in children.
 It may also be used for treating fractures in
young adults,once the fracture becomes”sticky”.

18. Gallow’s traction
 Fracture of children from birth to 2 years are treated.
 In this,the legs of the child are tied to the overhead beam.
The hips are kept a little raised from the bed so that the weight of the body
provide counter traction and fracture is reduced.
 This is continued till sufficient callus forms(3-6weeks).

19. Open reduction and plating :
 Internal fixation with
plate and screws .
 Indications :
1- combination of shaft
and femoral neck
fracture .
2- fracture associated with
vascular injury .

20. Intramedullary nailing :
 Is the method of choice and mostly used .
 Implantation of intramedullary nail and fixed by screws which inserted
transversely at proximal and distal ends .
 The implantation of intramedullary nail may be antegrade or retrograde .
 Antegrade nailing :- insertion of the nail through pyriform fossa and transverse
locking screws proximally and distally .
 Retrograde nailing :- insertion of the nail through intercondylar notch at the knee
.
 This operation control the rotatory movement and ensures stability .

22. Nail or… Plate

23. External fixation :
Main indication are :
1- Treatment of severe open injuries .
2- Patient with multiple injuries .
3- Severe bone loss which need to bone transport.
4- Femoral fracture in adolescence .

26. Advantage & disadvantage of intramedullary nailing
and external fixation :
Advantage :
 Not exposing the fracture site .
 Callus increase in the volume and quality .
 Promoting quicker consolidation by increase stress transfer to the
fracture site .
Disadvantage :
 Pins-site infection .
 Most femoral shaft fracture will unite in under 5 month but some take
longer if the fracture is badly comminuted or contact between fracture
end is poor .

27. Titanium Elastic Nail System(TENS)
 In recent times there has been an increasing trend
towards surgical intervention in paediatric femoral
shaft fractures with widening indications. Titanium
elastic nails and external fixation are two widely
practiced procedures for such fractures.
 TENS is preffered to internally fix the fracture in
older children(more than 10 years of age).

29. Open fracture :
In open fracture
should be carefully
assessed for :
 1- neurovascular
injury .
 2- muscle ischemia .
 3- skin loss .
 4- wound
contamination .

30. Warning sign in the fracture with vascular injury :
 Excessive bleeding or hematoma formation .
 Parasthesia , pallor , pulselessness and other
6P in the leg and foot .

31. Treatment of open fractures :
The immediate treatment is similar to that of closed
fractures; in addition:
1- the patient is started on intravenous line to prevent shock .
2- I.V antibiotics.
3- The wound will need cleaning .
4- contaminated areas and dead tissue must be excised and
the entire area should be washed thoroughly and the wound should be left
open .

32. Complications of femoral shaft fractures :
 Early :
 Fat embolism .
 Shock (hypovolaemic shock)
 Infection .
 Thromboembolism .
 :LATE:
 Delayed union and non-union .
 Malunion .
 Joint stiffness .
 Refracture and implant failure .
 Shortening of limb .

33. CONDYLAR(distal end)FRACTURE
Condylar fracture of femur are of 3 types :
 Supracondylar fracture……………………..(a)
 Intercondylar fracture(T or Y-type)………..(b)
 Unicondylar(medial or lateral)fracture……(c)

34. Mechanism
Mechanism :
Direct violence is the usual cause.
 This fracture are seen in :
 1- young adult usually as a result of
high energy truma .
 2- in eldery due to osteoporosis .
The fracture is line just above the
condyle .

35. AO group classification :
 Type A : fractures have no articular splits and are truly ‘supracondylar’; .
 Type B : fracture are simply shear fracture of one of the condyle .
 Type C : fracture have supracondylar and intracondylar fissure .
Type A Type B Type C

36. Diagnosis :
Radiological
examination
 History and physical
exam .
 By X-Ray .
 By CT scan .

37. Clinical features :
 The knee is swollen and deformed because of a
haemarthrosis .
 Movement is too painful .
 Important note : The tibial pulses should always be checked
to ensure the popliteal artery was not injured in the fracture.

38. Treatment :
Non operative :
 Traction by
thoma’s splint :
skeletal traction
through the
proximal tibia .
 This method used if
the fracture only
slightly displaced
and extra-articular .

39. Treatment :
 Operative treatment :
 1- locked intramedullary nail which are introduce retrograde
through the intercondylar notch .It is suitable for the type A .
 2- Plates that are applied to the lateral surface of the femur
.It is suitable for the type A and type C .
 3- Simple lag screws . suitable for the type B .

41. Complications :
 Early :
 Arterial damage
 Infection
 Osteoarthritis
 Late :
 Joint stiffness
 Malunion
 Non-nunion