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ACCIDENTAL FEMORAL SHAFT FRACTURES:ITS

MANAGEMENT
Orthopaedic unit
presentation

PRESENTER :

DR MUKORO D GEORGE

B.sc,MBBS

DR AGBIKI DOYE
MD


CASE PRESENTATIONS
Femoral fracture has
been a common
presentation in this
facility , shaft fractures
is the commonest part
involved in recent
months ,common
implicated causes are
RTA and fall from
heights. They usually
associate and present
with other injuries,
morbidity, and
mortality.
CASE PRESENTATION 1
Miss I.I. ,24 yr old waiteress, Admitted via
A/E 27/1/2012, with history of inability to
move Left Lower Limb 19 hrs duration
following an RTA on a motorcycle).
Sustained wound to left knee, thigh
swelling .
On general exam- , conscious ,not pale,
afebrile. PR 126 b/min, Bp 110/70mmhg
RR 24c/min.

Sutured laceration Lt knee, medial side
of Lt leg, swelling of the knee,
Marked abduction of the leg at rest

X-RAY:Displaced Spiral fracture of distal
shaft of the Rt femur with medial
condylar and patella fractures.
ASS:Rt femoral fracture with intra-
articular involvement following a RTA

MANAGEMENT .
HAD resuscitative measures at A/E
Along With anti tetanus prophylaxis
,IV fluids

ORIF with condylar plate for spiral
fracture ,cancellous screw for
condylar fragment fixation and
fixation of the avulsed posterior
cruciate ligament , on 26
th
day after
presentation

Analgesics, blood transfusion
,antibiotics, hematinics,
antithrombotic

Currently on the ward ,immobilized
with Above knee synthetic cast



OPERATION SECTION
Distal bone
fragment with
spiral edge with
good exposure .





Stay close to the bone as much as
possible
CASE PRESENTATION :TWO
Mr O.J ,43 year old Architect Admitted via A/E
(22/12/11)with history of multiple injuries
following a RTA (motorcycle) ,4 hrs to
presentation.
Sustained facial swelling ,open injury to left thigh
.loss of consciousness which improved within 4
hrs
Generally , Conscious but drowsy. GCS 13/15 ,not
pale, febrile 37.2 C, receiving oxygen via
intranasal prongs ,PR 100 b/min,BP 120/80mmhg,
RR 32c/min
Hemifacial swelling (left side),enclosing
mandibular region ,left thigh swelling and
deformity,wound 6cm in dimension
X-RAY result:communited segmental fracture of
left femur with associated fracture of the
mandible
Mild head injury with left femoral fracture 2 to
RTA

MANAGEMENT
HAD resuscitative measures at A/E
Along with cervical collar, anti
tetanus prophylaxis ,IV fluids

ORIF with condylar plate on 14
th

day after presentation

Blood transfusion, Analgesics,
,antibiotics,,hemtinics

Discharged 15
th
DAY post -op With
clutches

Follow up VIA clinic with POST-OP
X-ray film.
IN SUMMARY
In the last 2 months we had several cases of
femoral fractures , with a few bilateral. Some
opt-for surgical intervention .
Surgical option should be seen as the best
option for management of femoral fracture
following RTA ,to allow for early mobilization
,knowing well that:
life is movement and movement is life .

THANK YOU
PRESENTATION CONTINUE
Introduction
Anatomy of the
femur
Epidemiology of
femoral fractures
Aetiology
mechanism
Classification of
shaft fractures
Clinical features
Investigations
Treatment
complications

INTRODUCTION
A fracture by definition, is a break in the
continuity of a bone. It occurs when an
external force overcomes the modules of
elasticity of the bone.
Strongest and largest bone.

Femoral shaft fractures ,may be associated
with multisystem trauma.

ANATOMY OF THE FEMUR
BLOOD SUPPLY
ANATOMICAL RELATIONS
EPIDEMIOLOGY
Common injury : major violent trauma
1 femur fracture/ 10,000 people
More common : < 25 y or >65 y
RTA , waterway motorcycle, fall from height
and gunshot wound accidents are most
frequent causes.

AETIOLOGY
. Trauma.
RTA (motorcycle races, auto/pedestran
accident, auto crash, plane crash, vehicle,).
Sports(skiing, football, hockey).
Falls(mountain, pole).
Gunshot.
Pathologic
Stress

MECHANISM
High Energy
Often high-speed impact or rapid deceleration
But may take surprisingly little energy in children
Direct blow
Proximal - distal compression
Twisting/torsion Injury
Shear
Compression with angulation
Fall from height
High speed collisions
Often seen in combination with other significant injuries

AETIOLOGY /MECHANISM CONTD

CLASSIFICATIONS:0TA/A0
Winquist and Hansen 66A, 1984

CLASSIFICATION
Type 0 - No comminution
Type 1 - Insignificant butterfly
fragment with transverse or
short oblique fracture
Type 2 - Large butterfly of less
than 50% of the bony width, >
50% of cortex intact
Type 3 - Larger butterfly
leaving less than 50% of the
cortex in contact
Type 4 - Segmental
comminution

ACCORDING TO THE PRESENCE/ABSENCE OF WOUND.
1. OPEN FRACTURES
2. CLOSE FRACTURES

SYNTOMS
Age/sex/occupation
Duration
Severe pain
Swelling
Inability to move the limb
Deformity
shortening

SIGNS
tenderness
visible deformity
shortening
crepitus
Swollen thigh
Signs of vascular compromise should be looked
out for to rule out vascular injury.
- absent or diminished pulses
- expanding haematoma
- tachycardia
- hypotension

INVESTIGATIONS
Done after the initial resuscitation of the
patient.
PCV/Hb
Radiograph of the affected femur, adjacent
joints and hip.(rule of 2s)
Wound swab for m/c/s in open fractures.
E/U/Cr
Depends on the patients presentation.

FIELD MANAGEMENT
Control bleeding, treat shock
Dress wounds
Distal CMS :FACT
Manual stabilization
Traction splint for mid-shaft fracture
Backboard without traction for hip injury
Re-check CMS
Address other injuries as needed
Early coordination with EMS agencies
ALS transport criteria per local protocol
Frequent vital sign checks and documentation
Expedited transport to definitive care

TREATMENT
Initial resuscitation.

Definitive treatment.
- non operative / conservative
- operative

Physiotherapy.

INITIAL RESUSCITATION

ABCD of resuscitation.
IV Fluid
IV antibiotics
Oxygen
Anti-tetanus prophylaxis
Blood transfusion
Analgesics
Wound care (wound debridement ).
Splinting


DEFINITIVE TREATMENT
Non operative /Conservative mgt
split
traction
casting (for children < 8 years)

HARE TRACTION
GALLOW SKIN TRACTION THOMAS SPLIT
OPERATIVE METHODS
Operative treatment.
1) ORIF
2) External fixation
3) Minimally invasive method.

INDICATIONS FOR FEMORAL SHAFT ORIF

Inability to secure and maintain reduction by
manipulation.
Old and frail px.
Px with multiple injuries.
Pathological fractures.
Fractures suitable for nailing.
Early ambulation is needed.

ORIF :
1. Intramedullary nails are used e.g.
Kuntcher
interlocking nail{Grosses and Kempf }
This could be done either by antegrade or
retrograde ;reamed and non reamed method.

2. Plate and screws.
ANTEGRADE IM NAILING RETROGRADE IM NAILING
External
fixation is
usually
used for
open
fractures of
the femoral
shaft with
severe soft
tissue
injury.

Minimally
invasive
method
involves
closed
method of IM
nailing under
image
intensification
.eg :ESIN

REHABILITATION /PHYSIOTHERAPY

This should be started early as soon as the
pain begins to settle. Exercises for
quadriceps, leg and foot are necessary to
preserve muscle tone and prevent deformity.
For post surgical patients, it can be started
two weeks after surgery but the patient
should not bear weight.
Physiotherapy continues after discharge
from the hospital.

COMPLICATIONS
EARLY
Infection
Hypovolaemic shock.
Fat embolism (1
st
72 hrs ).
DVT.
Pulmonary embolism.

LATE
Delayed union
Malunion
Non union
Atrophy of the thigh and gluteal muscles
Limb shortening

A femoral shaft fracture is a
serious injury that takes a long
time ( 3 to 6 months ) Average
of 12 weeks to heal, hence
most femoral shaft fractures
are treated surgically. The
goal of treatment is reliable
anatomic stabilization,
allowing mobilization as early
as possible.

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