FRACTURE

OF
FEMORAL SHAFT

By : Ivan Rinaldi

COUNSELOR
dr. Rieva Ermawan, Sp.OT(K)
 Fracture of Femoral Shaft
• Definition
A femoral shaft fracture is a diaphyseal
fracture of the femur that does not extend
into the articular or metaphyseal region

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 Fracture of Femoral Shaft
Major cause of morbidity and mortality
Sustain from high-energy trauma
Morbidity arise from shortening, malalignment, knee
contracture / stiffness, and complication of fracture
care
Mortality can result from an open wound, fat
embolism, ARDS, crush syndrome, SIRS until MOF

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 MECHANISM OF INJURY
• High-energy trauma such as motor vehicle
accident is the cause of most femur fractures.
These fracture are often associated with
significant soft tissue trauma.
• Low-energy trauma and indirect forces may
cause fractures in elderly adults. Usually result
from rotational or spiral forces and have less
associated soft tissue injury.

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 CLASSIFICATION
• Winquist & Hansen classification:

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BIMBINGAN FEMUR
 ANATOMY

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Deforming Muscle Forces
The femoral shaft is subjected to major
muscular forces that deform the thigh
after a fracture:
A. Abductors mm : abduct the
proximal femur
B. Iliopsoas : flexes & externally
rotates the prox fragment
C. Adductors mm: medial angulated
the distal fragment
D. Gastrocnemius : flexes the distal
fragment
E. Fascia lata : as tension band vs
adductors

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Three Compartement

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 Three Compartment
• Anterior compartment
-M.quadriceps femoris, m.iliopsoas, m.sartorius, m.pectineus,
AVN femoralis & n.lateral femoral cutaneous
• Medial compartment
-M.gracilis, m.adductor longus, brevis & magnus, m.obturator
ext, AVN obturator , & a.profunda femoris
• Posterior compartment
-M.bicep femoris, m.semitendinosus, m.semimembranosus,
portion of adductor magnus, branches of a.profunda femoris ,
n.sciatic , n.posterior femoral cutaneous

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 BIOMECHANICS
• Femur is the largest bone  load several times the body’s weight in
normal activity
• To fracturing this bone requiring a significant amount of force
• The most common mechanism of injury is a bending force  transverse
fracture
• The most femoral fracture in young adults are due to high-energy injuries
• Fatigue fracture can occur in in femur (usually in proximal and mid-shaft
femur), associated with a prolonged increased in physical activity
• During aging  significant changes
- cortex become thinner
- less force required to produce fracture
(trivial trauma)
- have a spiral pattern
- not associated with significant soft tissue damage
 Treatment
• Femoral shaft fractures are normally treated
operatively, using intramedullary nailing.
• They should only be considered for
nonoperative fracture treatment if there are
neither facilities, nor skills, for surgical
treatment.

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 Treatment
• Nonoperative treatment means that the
patient will be in a form of traction for at least
6-8 weeks, often 10-12 weeks.
• The initial treatment is usually skin traction,
later converted to skeletal traction.

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 TREATMENT GOALS
• Restore the alignment and length of the femur
• Restore cortical contact for axial stability
• Preservation of the blood supply to aid union and
prevent infection
• Restore and maintain full range of motion of the
knee and hip
• Improve the strength of the muscles that are
affected by fracture
• Restore normal gait pattern

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 Absolute stability
• There is no movement at fracture site
• It is achieved by interfragmentary
compression, eg. lag screws, compression
plate.
• There is no callus formation. Direct bone
healing is achieved.

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 Relative stability
• Movement at fracture site.
• There is no interfragmentary compression at
fracture site. It is achieved by splinting or
bridging, eg. elastic nails.
• There is callus formation. Indirect bone
healing is achieved.

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 Operative treatment

A. Intramedullary nail

B. Plating

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INTRAMEDULLARY NAILING OF THE
FEMUR

Intramedullary nail for femur

The cloverleaf profile

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Patient positioning
- Position the patients on his side with
the injured limbs upwards.
- Flex the hip and the knee

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The guide pin
• Drill it proximally through the upper end of the
femur until its point resides in a subcutaneous
position.
• Adduct and slightly flex the hip as this is done so
that the guide pin will emerge subcutaneously
just proximal to the trochanter
• The guide pin should exit from the superior neck
at the base of trochanter

Details of insertion of
medullary nail. Guide
pin emerges through
small incision
in upper outer
quadrant of buttock.

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Introduce the intramedullary nail
• After drilling this hole , introduce intramedullary nail
over the guide pin with the extraction eye of the nail
facing posteromedially and drive the nail into
trochanteric region of femur
• Positioning of the slot nail in relation to the femur is
critical to its strength of fixation

Küntscher nail inserted into

proximal femoral fragment
over guide pin. When nail
has been driven down to
level of fracture guide pin is
removed and fracture
reduced. Nail is then driven
correct distance into distal
fragment

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 Surgical approach
• Lateral
• Posterolateral
• Anteromedial
• Posterior

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 Lateral Approach
• Open reduction and internal fixation of intertrochanteric
fractures (this is by far the most common use of the
approach)
• Insertion of internal fixation in the treatment of subcapital
fractures or slipped upper femoral epiphysis
• Subtrochanteric or intertrochanteric osteotomy
• Open reduction and internal fixation of femoral shaft
fractures and supracondylar fractures of the femur
• Extraarticular arthrodesis of the hip joint
• Treatment of chronic osteomyelitis of the femur
• Biopsy and treatment of bone tumors

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Skin Incision of lateral approach

An incision is made along an imaginary line between the

lateral femoral epicondyle and the greater trochanter,
along the length of the femur required by the specific
fracture pattern.

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 Lateral Approach

The major vessels and nerves are located medially / posteromedially to the
femoral shaft and are not exposed using this approach.

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Danger
Perforating branches of profunda femoris

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 Opening Facia lata

The fascia lata is incised with a scalpel and split with scissors parallel to the
skin incision, along its fibers. The muscle fascia over the vastus lateralis is
exposed.
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The vastus lateralis is now retracted anteromedially.
The muscle fascia investing the vastus lateralis is incised about 1
cm anterior to the intermuscular septum.

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The muscle is detached from the lateral intermuscular septum and the
linea aspera with a periosteal elevator.

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Larger vessel bundles must be ligated, smaller ones can be alternatively
cauterized with the diathermy.

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Exposure of the proximal femoral shaft
If exposure of the proximal femoral shaft is necessary, mostly only for
subtrochanteric fractures, the origin of the vastus lateralis must be identified.

The muscle is retracted anteriorly and an L-shaped incision is made down to

the bone. The muscle origin is then dissected off with the periosteal elevator.

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Plating
• Choice of implant
- Broad plate DCP 4.5 or LC-DCP 4.5
- at least 7 cortices on either sides of
fracture
- tension site

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 Compression Plating

Compression plating provides fixation with absolute stability for

two-part fracture patterns, where the bone fragments can be
compressed.
The objective of compression plating is to produce absolute
stability, eliminating all interfragmentary motion.

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COMPRESSION

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Dynamic compression principle
Compression of the fracture is usually produced by eccentric screw
placement at one or more of the dynamic compression plate holes.

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The screw head slides down the inclined plate hole as it is tightened,
with the head forcing the plate to move along the bone, thereby
compressing the fracture

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• The plate should be positioned on the lateral aspect of the femur.
• A plate acts as a dynamic tension band when applied to the tension side of the
bone and when stable cortical contact is present on the opposite side to the
plate.
• The plate is positioned over the fracture so that at least four holes are
available in each proximal and distal fragment.

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Posterolateral
The posterolateral approach can
expose the entire length of the
femur.

supine on the operating table with a

sandbag beneath the buttock on
the affected side to

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 Posterolateral
• Open reduction and plating of femoral fractures, especially
supracondylar fractures
• Open intramedullary rod placement for femoral shaft
fractures
• Treatment of nonunion of femoral fractures
• Femoral osteotomy (which is performed rarely in the region of
the femoral shaft)
• Treatment of chronic or acute osteomyelitis
• Biopsy and treatment of bone tumors

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 Anteromedial approach
• The anteromedial approach provides an
excellent view of the lower two thirds of the
femur and the knee joint.

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Anteromedial approach

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 Posterior approach
• The posterior approach is useful in patients
who cannot undergo more anterior
approaches because of local skin problems

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Posterior approach

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 COMPLICATION
• Nerve injury: uncommon
• Vascular injury: due to tethering of the femoral artery to
the hiatus adductorius
• Infection
• Refracture: vulnerable during early callus formation &
after hardware removal
• Nonunion, delayed union: unusual healing > 6 months
• Malunion: usually varus deformity, internal rotation, &
shortening
• Fixation failure: due to nonunion or “cycling” of the
device

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 Rehabilitation
• Quadriceps- and hamstring-setting exercises should be
practiced faithfully as soon as the reaction after surgery
permits.
• These exercises are important to maintain muscle tone and
strength that compress the fracture, prevent distraction, and
probably stimulate local vascularity, callus, and subsequent
union.
• First six weeks, if the fracture has bone to bone contact and a
stable construct with nail diameter of 12 mm or more, allow
weight bearing to tolerance, with progression to full weight
bearing as tolerated
• Patient with unstable fracture or stabilized with smaller
diameter nail, begin with partial weight bearing begin with 25
kg with crutches or walker

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