FRACTURE FEMUR

Lec.- 2

Sadeq Al-Mukhtar
Consultant orthopaedic
surgeon

. Fracture neck femur- 1

Intertrochanteric fracture- 2

.Diaphyseal fracture-3

Diaphyseal fractures are

common in young adult and if
occurred in elderly, think of
pathological fracture,. Due to
thick muscles in the thigh this
makes the shaft fractured only by
severe trauma and causing
severe bleeding that may reach
.about two liters of blood

:- Types
.Transverse fractures- 1
.Spiral fractures- 2
Oblique fracture with or without- 3
.butterfly
.Comminuted fractures- 4

Clinical findings
.History of traumaOn examination:- there is shock , deformity, externally rotated limb,
swelling, tenderness with loss of
.function
x-ray revels the fractures& its -
type.do AP and lateral view

:Treatment
Urgent: this includes treatment of shock and
dealing with other injuries of vital organs
regarding the fracture immobilized by Thomas
splint
: Conservative
Skeletal traction for 6 to 8 weeks followed by cast
bracing for other 6 to 8 weeks then
physiotherapy. Sometimes continueous traction
without cast bracing. regarding quadriceps and
hamstring during traction better to use lower
.femoral skeletal traction

Surgical treatment
Indications
failure of conservative treatment due to- 1
muscle(soft tissue)interposition or mal
.alignment
.transverse fracture- 2
.multiple fractures- 3
.pathological fractures- 4
presence of any contraindication to- 5
conservative treatment especially in elderly
.patients
vascular injuries associated with the- 6
.fracture

:Notes
in regions of the world where
intramedullary technique are not
available or where risks of surgery
are unacceptable, non-operative
treatment remain the treatment of
.choice

:Types of surgical treatment

open intramedullary nailing used in patients in whom closed reduction -1
and internal fixation are not possible as in arthrodesis or stiffness of
hip joint.its also used in patients whom the guide pin cant pass in the
canal as in presence of bony fragments in th canal ,also used in open
.fractures where the ends of the bones aare exposed
flexible nail :antgrade or retrograde flexible nailing of Enders nail -2
;single or multiple under fluoroscopic control (unreamed)
closed antigrade interlocked reamed nailing ,it has good results-3
.especially if undreamed(less blood loss and decrease operation time)
.closed retrograde nailing through lateral epicondyl area-4
;plate fixation- 5

Indications of plate fixation

Inadequate experience with above techniques or if fluoroscopy was not available or if
instruments and implants are not available or
if associated with vascular injury and plating
.can be done through the same approach
In non-union and mal-union in which the
canal is obstructed and sometimes
.osteotomy or bone graft is needed
In the presence of arthrodesis of hip and
.here nailing is difficult or impossible

Extenal fixation
Compound fractures ,temporary or- 1
.definitive treatment

Multiply injured patient for rapid- 2

'mobilization

Fractures associated with vascular - 3

injury need to be repaired

Complications
Early:- shock, fat embolism ,DVT that causes
.pulmonary , vascular injury, infection

:-Late
Delayed union: If healing not occurs in within 3-4 - 1
.months. It is treated by bone graft and IF

Malunion: Up to 2 cm shortening and 10-15 -2

degrees angulation is accepted but never rotation.
.
Treatment is corrective osteotomy and IF
Joint stiffness; prevented by early mobilization - 3

Supracondylar fracture
This is common in young adults
.usually caused by direct violence
Types; Simple and comminuted. It
may be associated with intraarticular extension T or Y
.fracture

Fracture femur in children

This is usually caused by direct trauma. Treatment is
almost always by conservative methods i.e skin
traction then if the fracture becomes stable, apply
pop for 4-6 weeks. Children less than 4 years; use
Gallows traction. Two cm shorting and up to 20
degrees angulation is accepted in children but again
. no rotation

Complications
MalunionLeg length discrepancy usually shortening but
may be increase in length due to 1- Active healing
process( hyperaemia and hypervascularity).2.Increased growth hormone secretion

;Treatment
Young adults are usually treated- 1
conservatively by high tibial skeletal traction
in 90 degree flexed knee to cancel the action
.of gastrocnemus muscle for 4-6 weeks

In elderly by IF; the types of fixation 2

;are
Blade plate
-
Dynamic condylar screws
-
.Other plates
-

;Complications
Early; Vascular injury, skin
.damage
Late; Non-union,Knee
.stiffness

Condylar fractures
These are the same as supracondylar
fractures but always check distal
neurovascular function. It is usually caused
by direct injury to the knee. It takes T
or
.Y shaped fracture
On examination; Swelling, tender knee ,
doughy consistency due to hemoarthrosis
(rapid onset, to differentiate it from simple
.knee effusion). Check x-ray to prove it

Treatment
.Conservative by skeletal traction 4-6 weeks - 1
;Surgical treatment by internal fixation- 2
.DCP, Compression screws with washers
With posterior above knee slab followed by full
cast for 4-6 weeks followed by
.physiothrerapy and gradual weight bearing

Displacement of femoral
epiphysis
This occurs in children. It is type-2 salterHarris fracture. Caused by lateral or
.hyperextension force
Complications; Malunion leading to
deformity and growth disturbance (like any
.epiphyseal injury)

Treatment
succeed or unstable, reduction under
screen and percutaneous k-wire
followed by posterior above knee
.slab

Conservative
by manipulation under anaesthesia
and pop. If not succeed or unstable,
reduction under screen and
percutaneous k-wire followed by
.posterior above knee slab

Thank you