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fracture shaft of femur.pptx
- 1. Dr. Saurabh Agrawal AssistantProfessor Dept. of Orthopedics AIIMS bedwas FRACTURE SHAFT OF FEMUR 2/3/2018 P.C.Aryal Intern Group N 1
- 2. FEMUR 2/3/2018 P.C.Aryal Intern GroupN 2 • Largest and heaviest bone. • Transmits body weight to tibia while standing it has an anterior bow. • Shaft of femur is mostly smoothly rounded except posteriorly, broad rough line ,linea aspera exists providing aponeurotic attachment to adductors of thigh.
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- 7. 2/3/2018 P.C.Aryal Intern GroupN 7 • fracture of diaphysis: • occurring between 5 cm distal to the lesser trochanter and 5 cm proximal to the adductor tubercle. • High energy injuries associated with life-threatening conditions • femoral shaft is circumferentially padded with large muscles. improved healing potential due to good vascular tissue coverage. difficult reduction due to possible displacement due to muscle pull
- 8. MECHANISM 2/3/2018 P.C.Aryal Intern GroupN 8 • Traumatic • high-energy • most common in younger population • result of high-speed motor vehicle accidents • low-energy • more common in elderly • result of a fall from standing spiral fracture is usually caused by a fall in which the foot is anchored while a twisting force is transmitted to the femur. Transverse /obligue: angulation or direct violence. communited/ segmental: very high energy trauma
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- 11. • Physical examination •inspection • tense, swollen thigh • blood loss in closed femoral shaft fractures is 1000- 1500ml (features of shock may be present • blood loss in open fractures may be double that of closed fractures • tenderness • Distal neurovascular status may be compromised 2/3/2018 P.C.Aryal Intern Group N 11
- 12. • The softtissues are always injured and bleeding from the perforators of the profunda femoris may be severe. • fracture at the junction of the middle and distal thirds can be responsible for damaging the femoral artery in the adductor canal. 2/3/2018 P.C.Aryal Intern Group N 12
- 13. OTHER FRACTURES TORULE OUT 2/3/2018 P.C.Aryal Intern Group N 13 • Ipsilateral Femoral neck fracture(10%) • Pelvis fracture • Fracture of ipsilateral tibia( floating knee) Patient should also be evaluated for: chest injury, head/abdominal injury.
- 14. RADIO IMAGING 2/3/2018 P.C.Aryal InternGroup N 14 • Recommended views • AP and lateral views of entire femur • AP and lateral views of ipsilateral hip • AP and lateral views of ipsilateral knee
- 15. 4 R’S OFFRACTURE MANAGEMENT 2/3/2018 P.C.Aryal Intern Group N 15 • R – Resuscitation done at the site of trauma/ER comprises addressing acute life threatening condition related to fracture/ trauma • R-Reduction Definitive management of fracture • R-Retention Stabilization of fracture segment throughout the healing process • R-Rehabilitation
- 16. MANAGEMENT 2/3/2018 P.C.Aryal Intern GroupN 16 • Once the diagnosis of #shaft of femur is established following steps should be taken in the ER before starting the definitive treatment 1. Resuscitation/management as per the ATLS protocol 2. Immobilization(using splints) 3. Elevation
- 17. MANAGEMENT 2/3/2018 P.C.Aryal Intern GroupN 17 • Nonoperative (used for closed fractures) Traction: traction with or without splint. Usually a thomas splint (temporary) is used skin traction sufficient in children. skeletal traction in adults given by steinmann pin (tibial traction) traction: birth to 2 years: gallows' traction is used(3-6 weeks), older child: Russell's traction 2 to 16 years: different methods of traction can be used followed by immobilization using hip spica. Hip spica: plaster cast incorporating part of trunk and limb. Long leg cast
- 18. THOMAS SPLINT 2/3/2018 P.C.Aryal InternGroup N 18 • Indications • Medically unfit for surgery • Polytrauma, in extremis • Advantage • Stabilization when immediate surgery is not possible or practical • Disadvantages • Overlap of the fracture can occur despite traction • Continuing motion at the fracture site • Continuing soft-tissue compromise and bleeding
- 19. OPERATIVE TREATMENT 2/3/2018 • Mostfemoral shaft fractures are treated with intramedullary nailing • strongest mechanical fixation • treatment for early mobilization.
- 20. INTRAMEDULLARY INTERLOCKING NAIL 2/3/2018 P.C.AryalIntern Group N 20 • Indications • All patients with femoral shaft fractures except those not fit for definitive surgery • Isolated fractures • Closed fractures • Gustilo types I & II open fractures • Polytrauma patients in stable condition
- 21. IMIL 2/3/2018 P.C.Aryal Intern GroupN 21 • Contraindications • Polytrauma patients in unstable condition • Not medically fit for surgery (avoid the second hit) • Associated vascular injury requiring open repair • Continuing infection • Occluded intramedullary canal • Gustilo type III C open fractures
- 22. IMIL 2/3/2018 P.C.Aryal Intern GroupN 22 • Advantages • Less invasive procedure / indirect reduction • Minimizes soft-tissue damage • Better biomechanical properties • Definitive procedure • Rapid mobilization of patients postoperatively • Minimal blood loss • Good cosmetic results
- 23. IMIL 2/3/2018 P.C.Aryal Intern GroupN 23 • Disadvantages • Risk of iatrogenic femoral neck fracture • Risk of fat embolization • Closed reduction may be more challenging than open reduction • Frequent use of image intensifier – risk of increased radiation exposure
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- 25. OPEN REDUCTION INTERNAL FIXATION •circumstances in which ORIF with a plate may be indicated. Indications • Indirect reduction impossible • No image intensifier available • Early pregnancy (up to 12 weeks gestation) due to the risks 2/3/20f1r8omradiation exposuP .rCe.AryalIntern Group N 29
- 26. ORIF WITH PLATE 2/3/2018 P.C.AryalIntern Group N 26 • Polytrauma patient with associated chest injury • Communited fractures Contraindications • Patient not medically fit for surgery • Osteomyelitis • Compromised local soft tissues
- 27. ORIF WITH PLATE 2/3/2018 P.C.AryalIntern Group N 27 • Advantages • Less demanding procedure • Less exposure to ionizing radiation • Direct reduction • Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM nailing • Fracture stabilization allows for early patient mobilization
- 28. ORIF WITH PLATE 2/3/2018 P.C.AryalIntern Group N 28 • Disadvantages • Greater blood loss • Exposure of fracture zone / risk of interference with healing process • Larger operative soft-tissue trauma • Less appealing cosmetic result • There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking screws.
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- 30. EXTERNAL FIXATION 2/3/2018 P.C.Aryal InternGroup N 30 • Unstable fracture, patient or soft tissues, unsuitable for definitive internal fixation. • Further indications for external fixation • Subtotal amputation or prolonged vascular deficit • Salvage after major complications following internal fixation • Unavailability of other treatment options • Bone loss
- 31. EXTERNAL FIXATION 2/3/2018 P.C.Aryal InternGroup N 31 • Contraindication • Osteoporosis (relative contraindication) • Advantage • Rapidly applied provisional treatment, early mobilization • Disadvantages • Possible loss of fixation • Pin-track infection • Cumbersome fixation interferes with lower limb function • May interfere with procedures for soft-tissue reconstruction • High risk of nonunion/malunion when used for definitive treatment
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- 33. EARLY COMPLICATIONS 2/3/2018 P.C.Aryal InternGroup N 33 • SHOCK(1000-1500ml in closed # double in open) • Fat embolism: symptoms occur with in 24-48 hrs proper splinting required to prevent this from occurring. • Injury to femoral artery: most commonly in fractures at the junction of middle and distal third of femoral shaft • Injury to sciatic nerve. • Infection
- 34. LATE COMPLICATIONS Delayedunion(union still insufficient to allow unprotected weight bearing after 5 months, bone grafting) Non union(internal fixation and bone grafting) Malunion( lateral angulation and external rotation, shoe raise, internal fixation ,bone grafting) Knee stiffness(intraarticular periarticular adhesions, quadriceps adhering to fracture site , undetected knee injury, physiotherapy ,athrolysis quadricepsplasty) 2/3/2018 P.C.Aryal Intern Group N 34
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- 37. •Distal femur becomestrapezoidal in cross section towards knee •Medial condyle extends more distal than lateral •Posterior halves of both condyles are posterior to posterior cortex of femoral shaft
- 39. •Strong muscles inthe front of your thigh (quadriceps) and back of your thigh (hamstrings) support your knee joint and allow you to bend and straighten your knee.
- 41. • The musculatureof the thigh can be split into three sections; anterior, medial and posterior. • There are three major muscles in the anterior thigh – the pectineus, sartorius and quadriceps femoris. In addition to these, the end of the iliopsoas muscle passes into the anterior compartment. • Anterior compartment , innervated by the femoral nerve (L2-L4), and extend the leg at the knee joint.
- 42. • The musclesin the posterior compartment of the thigh are collectively known as the hamstrings. • As group, these muscles act to extend at the hip, and flex at the knee. They are innervated by the sciatic nerve (L4-S3).
- 44. • The musclesin the medial compartment of the thigh are collectively known as the hip adductors. There are five muscles in this group; gracilis, obturator externus, adductor brevis, adductor longus and adductor magnus. • All the medial thigh muscles are innervated by the obturator nerve, which arises from the lumbar plexus. Arterial supply is via the obturator artery.
- 46. INTRODU CTION Epidemiology : • Traditionallyyoung patients but increasing in geriatric population • Bimodal distribution: young, healthy males, elderly osteopenic females • Periprosthetic fractures becoming more common
- 47. MECHANISM Axial loading withvarus / valgus or rotational forces. • young patients : high energy with significant displacement such as from a car crash. • older patients: low energy, often fall from standing, in osteoporotic bone, usually with less displacement In both the elderly and the young, the breaks may extend into the knee joint and may shatter the bone into many pieces.
- 48. • When thedistal femur breaks, both the hamstrings and quadriceps muscles tend to contract and shorten. When this happens the bone fragments change position and become difficult to line up with a cast. • gastrocnemius: extends distal fragment (apex posterior) • adductor Magnus: leads to distal femoral Varus
- 50. TYPESOF FRACTURES Descriptive : • Supracondylar •Intercondylar OTA : A: Extra articular B: Partial articular : Portion of articular surface remains in continuity with shaft C: Complete articular Articular fragment separated from shaft
- 52. CLINICAL FEATURES SYMPTOMS • H/O TRAUMA •PAIN •Swelling and bruising SIGNS • Tenderness to touch • Deformity
- 53. INVESTIGAT IONS X-ray : - obtainstandard AP and Lateral view
- 54. CT : •obtain withfrontal and sagittal reconstructions
- 55. ANGIOGRAPHY • Indicated whendiminished distal pulses after gross alignment restored • Consider if associated with knee dislocation
- 57. TREATMENT Non - Operative: • Skeletal traction • Casting and bracing for 6 weeks
- 58. INDICATION - Non displacedfractures - Non ambulatory patient - Patient with significant comorbidities presenting unacceptably high degree of surgical/anesthetic risk
- 59. OPERATIVE: GOALS OF OPERATIVETREATMENT Anatomic reduction of the articular surface, Restoration of limb alignment and length, Stable internal fixation, Rapid mobilisation and early functional rehabilitation of the knee.
- 63. COMPLICATIONS 1) Malunions: • Mostcommonly associated with plating, usually valgus • Functional results satisfactory if malalignment is within 5 degrees in any plane
- 64. • In manycases, the devices used to fix a fracture break or loosen when the fracture fails to heal.
- 65. 3) nonunions : •Up to 19%, most commonly in metaphyseal area, with articular portion healed (comminution, bone loss and open fractures more likely in metaphysis) • Decreasing with less invasive techniques • Treatment with revision ORIF and autograft indicated • Consider changing fixation technique to improve biomechanics
- 67. 4) infection : •Treat with debridement, culture-specific antibiotics, hardware removal if fracture stability permits 5) implant failure : • Up to 9% • Titanium plates may be superior to stainless steel
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