REFERRALS

FEMUR FRACTURE

Creator:
Nama: Muhammad Pino Hakim
NIM: 71 2016 063

Advisor:
dr. Rizal Daulay, Sp. OT, MARS

DEPARTMENT OF SURGICAL
MUHAMMADIYAH PALEMBANG HOSPITAL
FACULTY OF MEDICINE
UNIVERSITAS MUHAMMADIYAH PALEMBANG
2019
 CHAPTER I

PREFACE

1.1. Background
Femur fractures represent a major public health challenge in developed
countries due to the increasing age of the population. In 2000, there were almost 1
million patients with an episode of femur fracture in the European Union, and it
has been predicted that this figure will increase more than twofold in the coming
50 years. The increasing trend in the incidence of femur fractures along with
associated morbidity complications, dependence, and mortality make this
condition a major public health concern. In addition, hospital resources for injury-
related admissions are one of the major causes of total health-care costs in Europe
. Distribution of this injury in the world is heterogeneous, although Europe holds
an important share of these fractures (37 %) worldwide.
Femur fracture is a bone fracture that involves the femur. They are typically
sustained in high-impact trauma, such as car crashes, due to the large amount of
force needed to break the bone. Fractures of the diaphysis, or middle of the femur,
are managed differently from those at the head, neck, and trochanter.2
Estimated worldwide annual femur fracture incidence between 1.0 and 2.9
million. Most femur fractures occurred between ages 5 and 14 years (29%), 15 and
1
44 years (34%), and in those older than 60 (21%).
Femoral shaft fractures occur in 10–37 / 100.000 patients per year (1, 37), and
mainly male young patients are affected (median age 27 years) compared to the
fracture of the elderly in female patients (median age 80 years). In multiple injured
patients femoral fractures account for up to 30%, with open femoral fractures
found in 11,5 in 100,000 injured persons.
 CHAPTER 2

THEORETICS REVIEW

2.1. Introduction
Femur fracture is a bone fracture that involves the femur. They are typically
sustained in high-impact trauma, such as car crashes, due to the large amount of
force needed to break the bone. Fractures of the diaphysis, or middle of the femur,
are managed differently from those at the head, neck, and trochanter.2
2.2. Epidemiology
Estimated worldwide annual femur fracture incidence between 1.0 and 2.9
million. Most femur fractures occurred between ages 5 and 14 years (29%), 15 and
44 years (34%), and in those older than 60 (21%). estimated worldwide annual
femur fracture incidence between 1.0 and 2.9 million. Most femur fractures
occurred between ages 5 and 14 years (29%), 15 and 44 years (34%), and in those
older than 60 (21%).1
2.3. Anatomy
Femur The head of the femur is hemispheric in shape and fits into the
acetabulum to form the hip joint. The fovea capitis is a small depression in the
center of the head for the attachment of the ligament of the head. Part of the blood
supply to the head of the femur from the obturator artery is conveyed along this
ligament and enters the bone at the fovea. The neck connects the head to the shaft
(Fig. 5-2). The greater and the lesser trochanters are large eminences at the junction
of the neck and the shaft. Connecting the two trochanters are the intertrochanteric
line anteriorly (where the iliofemoral ligament is attached) and a prominent
intertrochanteric crest posteriorly (on which is the quadrate tubercle). The shaft is
smooth on its anterior surface but has a ridge posteriorly (the linea aspera) to which
are attached muscles and intermuscular septa. The medial margin of the linea
aspera continues below (as the medial supracondylar ridge) to the adductor
tubercle (Fig. 5-2) on the medial condyle. The lateral margin becomes continuous
below with the lateral supracondylar ridge. On the posterior surface of the shaft
below the greater trochanter is the gluteal tuberosity for the insertion of the gluteus
maximus muscle. A flat, triangular area on the posterior surface of the lower end
of the shaft is called the popliteal surface. The lower end of the femur has a lateral
and a medial condyle, which are separated posteriorly by the intercondylar notch.
The anterior surfaces of the condyles are joined by an articular surface for the
patella. The two condyles take part in the formation of the knee joint. Above the
condyles are the medial and the lateral epicondyles. The adductor tubercle is
continuous with the medial epicondyle.
2.4. Patterns of Fracture 4

Neck Femur Fractures

 Fractures of the femoral neck are intracapsular injuries and therefore entail the
risks of posttraumatic arthrosis, avascular necrosis of the head of femur and eventually
the loss of the joint due to implantation of an alloarthroplasty.
The fracture of the femoral neck is a common event that usually affects the older
patient with accompanying osteoporosis after a trivial trauma. The increased number
of fractures of the femoral neck is essentially due to the demographic progress with
increasing life expectancy in industrial countries. These injuries demand conclusive
concepts of treatment by the attending surgeon depending on whether the aim is to
preserve the hip joint with good results and pleasant function or whether preference
must be given to hip joint replacement. The presentation at hand intends to help to get
a differentiated point of view of fractures of the femoral neck as well as to provide
stringent therapy for fractures of the hip joint.

Classification of the fractures of the femoral neck Any sensible classification of

the fractures of the femoral neck must include criteria that are crucial to determining
the treatment of these fractures. The classification by Garden has proven helpful when
deciding on osteosynthesis versus endoprosthesis (image 1a, b). This classification
differentiates the valgus impacted types (type I), the undisplaced, nonimpacted types
(type II) from the dislocated fractures, where the x-ray shows contact between the
trabecular and the cortical structures at the Adam’s arc (type III). In this type, the axial
x-ray depicts a perfectly continuous cortical bone line from the dorsal part of the head
of femur to the convex arc at the dorsal femoral neck. This implies that the so-called
Weitbrecht ligament which conjoins the dorsal structures as part of the capsule is not
yet torn.
A successful reduction of these fractures is considerably more promising as
opposed to those fractures with complete displacement of the fragment which is
always combined with a torn Weitbrecht ligament. With the latter fractures not only
the reduction is more difficult, but also the risk for a necrosis of the head of femur and
for a mechanical complication such as secondary redislocation or forming of
pseudoarthrosis increases. Another common classification is the one by Pauwels
originating from 1951. The Pauwels classification is primarily based on the stability
of the fracture. Type I describes a valgus impaction of the head of femur, an in itself
stable fracture. Yet, biological processes of absorption of the bone structure can turn
a stable into an unstable situation and consequently lead to secondary dislocation of
the head of femur. A Type II fracture by Pauwels describes an oblique fracture line in
the ante - rior posterior plane with angulation of the plane of the fracture between 30°
to 50°. These fractures are instable, at the same time the oblique fracture line provides
more stability with osteosynthesis than Pauwels III fractures. Pauwels III fractures
show an angulation of the fractured planes up to 90° to the horizontal in the anterior
posterior plane. In these fractures, the cranial fracture line always ends in the transition
zone between the cartilage part of the femoral head and the cranial onset of the femoral
neck. They often lead to impairment of the epiphyseal vessels, that enter the femoral
head at the same spot, are highly instable and very difficult to reduce. The
disadvantage of Pauwels classification is the disregard of the angulation of the fracture
in the axial plane.
Quite often the fracture line runs oblique in the axial plane as well, hence an exact
assessment is impossible. In addition to the already named criteria of the displacement
of the fracture and the course of the fracture line, the AO classification differentiates
the so-called subcapital fractures. These are shearing fractures with high instability
and bad prognosis regarding the vitality of the head of femur. Eventually all the aspects
of the three types of classification named above serve as decision guidance for
choosing either osteosynthesis or prosthetical treatment. Influence of the time to
treatment on the preservation of the head of femur Fractures of the femoral neck in the
young patient should be considered as absolute priority for a rapid operative
intervention with the aim of preserving the head of femur. But even with an all in all
greater risk of mortality, older patients may also benefit from imme - diate surgery if
preservation of the hip joint is considered. A workgroup in Hungary intensively dealt
with the problem of the fractures of the femoral neck and their surgical treatment.
Manninger et al. studied the course of 740 patients that underwent surgical treatment
in the Central Research Institute of Budapest between 1972 and 1977.
They arrived at the conclusion that avascular necrosis of the head of femur can be
significantly reduced (p < 0,001) when surgical treatment with reduction and fixation
of the displaced fracture is performed within six hours after the accident. An obvious
correlation and an increase of the complication rates as results of a belated procedure
(time to surgery > 6 h) could be proved. These complications include a remarkable
increase of both early and late necrosis of the head of femur even after three to six
years after the accident (31). Meanwhile other studies also confirm the advantages of
an early surgical intervention with head preserving surgery of the hip joint.

Subtrochanter Femur Fracture

The subtrochanteric segment of the femur extends from the lesser trochanter to the
junction of the proximal and middle thirds of the diaphysis. This segment of the femur
is subjected not only to axial loads of weight bearing, but also to tremendous bending
forces because of the eccentric load application to the femoral head (Fig. 15.1). Strain-
gauge studies in vivo (Schatzker et al. 1980) confirmed Pauwel’s and the AO/ASIF
contention that the bending forces cause the medial cortex to be loaded in compression
and the lateral cortex in tension. Furthermore, they showed that the compressive
stresses in the medial cortex are significantly higher than tensile stresses in the lateral
cortex. An appreciation of this asymmetrical loading pattern is important in
determining the suitability of internal fixation devices for fixation of these fractures,
in understanding the causes and the prevention of failure of these devices, and in
appreciating the causes of nonunion or malunion. Factors important for the stability of
a reduction and fixation, in order of importance, are the following: 1. Degree of
comminution 2. Level of the fracture 3. Pattern of the fracture

As we have emphasized elsewhere the stability of a reduction depends on structural

continuity. A simple fracture that is reduced anatomically and fixed with the aid of
compression is stable and shows little tendency to redisplacement. Under load, the
forces are conducted directly from one fragment to the other, with relatively little stress
being borne by the internal fixation. In a comminuted fracture, on the other hand,
where the cortex opposite the plate ("the medial buttress") is deficient or where a
segment of bone is so shattered that structural stability and continuity cannot be
restored, the forces of loading are borne almost entirely by the internal fixation. The
reduction is unstable, and the only factor preventing redisplacement is the internal
fixation. Hence, failure is common. The internal fixation pulls out of bone, breaks
because of overload, or undergoes fatigue failure because of cyclic loading. Thus,
medial cortical comminution (shattered medial buttress) and segmental comminution
stand out as the most important causes of failure.

Subtrochanteric fractures should be treated by open reduction and stable internal

fixation, as this is the only form of treatment which ensures a high percentage of
satisfactory results (Schatzker Fig. 15.2. Characteristic deformity following a
subtrochanteric fracture. There is anterior and lateral bowing of the proximal shaft
combined with external rotation and shortening Fig. 15.3. a The varus bow of the shaft
causes the tip of the greater trochanter to rise above the center of rotation of the femoral
head. This causes a functional varus deformity of the hip and abductor insuffi ciency.
b The deformity has been corrected by means of an osteotomy. A wedge with a lateral
and anterior base had to be resected to achieve correction in two planes a b SCHA_15-
Schatzker.indd 369 19.04.2005 14:28:31 Uhr 370 J. Schatzker 15.3 Indication for
Open Reduction and Internal Fixation and Waddell 1980; AO Fracture
Documentation, The AO Foundation, Davos, Switzerland). Nonoperative methods are
not only fraught with all the serious complications of prolonged bed rest; in adults, as
already indicated, they also frequently fail to reestablish acceptable alignment of the
fragments. Undoubtedly in the past, the zeal of many surgeons was tempered by the
unhappy memory of a frustrating surgical experience of trying to put together a badly
comminuted subtrochanteric fracture. New techniques of reduction and fixation have
evolved which make reduction and fixation of these fractures very much easier.

Femur Shaft Fracture

Femoral shaft fractures occur in 10–37 / 100.000 patients per year (1, 37), and mainly
male young patients are affected (median age 27 years) compared to the fracture of the
elderly in female patients (median age 80 years). In multiple injured patients femoral
fractures account for up to 30%, with open femoral fractures found in 11,5 in 100,000
injured persons (2). Genesis / Epidemiology Main trauma mechanism for femoral shaft
fractures is a direct fall on the affected limb (37). A direct impact trauma mechanism
or high-energy trauma leads to simple shaft fractures with related extensive soft tissue
damage. Rotational or wedge type shaft fractures are due to an indirect trauma
mechanism with minor soft tissue damage. Large segmental bone defects or
comminuted shaft fractures are seen after gunshots or explosive trauma exposure with
significant soft tissue damage. Another genesis of femur fractures is carcinogenic.
Osteolytic or osteoblastic metastasis can lead to pain and immobilisation due to a
pathologic femur fracture. Surgical therapy is focused on immediate fracture
stabilisation offering a durable and solid fixation. Parallel increasing numbers of
fatigue femur fractures are observed following a long-term therapy with
bisphosphonates in osteoporotic patients leading to atypical femur fractures,
prevalently in the subtrochanteric region. Limited reports estimate biphosphonate
related atypical subtrochanteric fractures with one per 1000 fractures per year (26).
Postulated pathophysiology for these atypical fractures is an increase of advanced
glycated end-products, increased mineralisation and the accumulation of
microfractures in the region of maximal tensile loading (34). Overall blood loss in
closed fractures is 0.5–1.5 litres, and development of a compartment syndrome is
found in 1% of all trauma cases. 2–5% of open femoral shaft fractures are seen in
multiple injured patients.

Besides swelling, instability and deformity of the leg, the affected limb will present
shortened and with malrotation. The patient is unable to lift the leg or flex the knee
joint. Clinical evaluation includes inspection and documentation of the soft tissue
condition and the neurovascular condition. If no peripheral pulse is palpable
ultrasound investigation is mandatory. In 40% of all cases ligamentous and menisceal
collateral injuries of the knee are documented (4). Additional, and often overseen,
femoral neck fractures are found in 2.5–6% of all femoral shaft fractures. In high
velocity injuries ipsilateral hip dislocation and acetabular fractures have to be
excluded. The combination of ipsilateral femoral shaft and tibial shaft fractures,
producing a ‘floating knee’, signals a high risk of multi-system injury in the patient.
The effects of blood loss and other injuries, some of which can be life-threatening,
may dominate the clinical picture.

Classification systems should guide the surgeon in his treatment options and predict
outcome. Femoral shaft fractures are generally classified to the alphanumeric coding
system of the AO (28), (see Fig. 1). A type: simple fracture, with 2 fragments A1:
spirale, A2: oblique, A3: transverse. B type: more than 2 fracture fragments, but the
main parts are still in contact B1: spirale, B2: oblique, B3: transverse. C type: complex
fracture type, the fracture fragments are not in contact to each other C1: 1 or 2 spirale
wedges, C2: oblique or transverse, multi étagère, C3: complex, comminuted, with
segmental bone defect. Further sub-classifications, which are more specific are known.
Especially for the subtrochanteric region numerous ones have been introduced over
the years to classify femur fractures of that part. But the lack of reproducibility
concludes inaccuracy and reliability in use, as they are mainly descriptive with little
bearing on management and outcome
Treatment Femur Fracture
The fracture pattern will give a guide for the emergency care and treatment. For
immediate control of pain, bleeding and shock management fracture reduction
maintains blood volume, and a definite plan of action can be instituted as soon as the
patient’s condition has been fully assessed. As femoral fractures are frequently seen
in multiple injured patients discussions of a stepwise treatment scheme have already
raised in the 1970ies. In this decade several studies highlighted the effectiveness of
early definite treatment or Early Total Care (ETC) of femoral shaft fractures as this
deduced pulmonary complications, mortality and hospital Length of Stay (LoS). But
this statement was later questioned in chest or head injured patients following the two–
hit hypothesis (21). First a traumatic event is followed by a second event (early surgery
and blood loss induces inflammatory changes that may increase both morbidity and
mortality), which leads to an overwhelming inflammatory response accumulating in
acute respiratory distress syndrome (ARDS) or multi organ failure (MOF) (21, 30).
Scalea et al. (30) later proposed the Damage Control Orthopaedics (DCO) strategy
with achieving early skeletal stability by placement of external fixators and a delayed
definite surgical treatment. This management reduces the second hit by minimizing
blood loss and anaesthesia time. Further discussions enrolled the often difficult
definition of declaring multiple injured patients as medical stable or instable.
Therefore the term Borderline patient was implemented (21), in which an increased
pulmonary risk for extensive surgical treatment in the early posttraumatic time frame
is stated. Several literature reviews and multi-disciplinary studies have been presented
comparing outcome between ETC and DOC, but still no evidence is found (25). A
potential benefit is found for early definite treatment of multiple injured patients on
the incidence of ARDS and LoS (7). No benefit was shown for early treatment on
mortality (18). Subtrochanteric femur fractures are generally treated after the
surgeon’s personal preference, but fixation devices can be divided into intramedullary
or extraFig. 3. 61-year-old woman with a pathological femoral shaft fracture
(metastasis of a breast cancer) who received surgical treatment in another facility,
initially with a plate ostesynthesis, followed by compound synthesis due to implant
failure. Transfer to our tertiary unit with a broken plate. Decision was made to change
the concept towards reamed antegrade nailing. 3 months later the patient represented
again with a painful leg and radiographic documentation of the broken IM Nail (at the
most proximal one of the distal locking screws g, h). For re-fixation of the fracture a
plate osteosynthesis was chosen medullary implants. Numerous studies comparing
outcome between extramedullary (plates, gliding screws) and intramedullary
(Interlocking nails) devices show different results regarding non-union or implant
failure. The dynamic hip screw (DHS) has been reported to be the most effective of
the extramedullary implants and could be used for subtrochanteric fractures if the
fracture extends into the trochanteric region (3). In general four different techniques
for intramedullary nailing for the fixation of open fractures in long bones are known
(12): 1. unreamed, unlocked: e.g. Ender nail, low infection rate, mechanically
insufficient, 2. reamed, unlocked nailing: relies on overreaming to provide stability
through bone-nail surface contact, high infection rate, 3. reamed locked nailing:
limited reaming, stability due to interlocking screws, 4. unreamed nailing: relies on
interlocking screws, better outcome, but higher incidence of screw breakage. The
intramedullary nail fixation still represents the gold standard in the management of
femoral fractures (Fig. 2). Despite the location of the fracture site, intramedullary
nailing offers sufficient stability with early functionality in a short and minimally
invasive surgical procedure (Fig. 3). The principle of this fixation technique goes back
on to the Kuentscher wires (13) with intramedullary bridging of the fracture site. In
per- and subtrochanteric femoral fractures devices with a gliding mechanism and
additional stabilization of the collum– diaphysis angle is used. A combination of these
features is represented in the design proximal femur nails (e.g. PFN-A) and antegrade
or lateral femoral nails (e.g. AFN, LFN, DePuy Synthes®, Oberdorf, Switzerland).
Usually an antegrade placement of the intramedullary nails is most widely performed
(Fig. 4). The retrograde nailing technique finds more popularity nowadays and is
probably indicated in obese patients (easier entry point), ipsilateral femoral neck
fractures, ipsilateral tibial shaft fractures (one approach), instable vertebral, hip or
acetabular fractures (no crossing of approaches) and in pregnant patients (less
radiographic dose). Since today no evidence has proven better outcome for retrograde
versus antegrade nailing position (35). No essential differences between antegrade and
retrograde technique could be detected regarding pain, complication rate, Fig. 5. A 35-
year-old polytraumatized man sustained an ipsilateral pertrochanteric and femoral
shaft fracture after a car crash. After initial stabilization with an external fixator
definite stabilization was performed with a long proximal femoral nail (PFN-A) and
cerclage wiring.

2.5. Complication
After surgical management of femoral fractures early and late complications may
occur. Early complications are – shock, as up to 2 litres of blood can be lost even in a
closed fracture – nerve compression (pudendal nerve 5–9 %, sciatic nerve 1–2%) after
surgical positioning – compartment syndrome 1–2 % – infection 3–4%, prophylactic
antibiotics and careful attention to the principles of fracture surgery should be obtained
– deep venous thromboembolism 1–10% due to prolonged bed rest, prophylactic
anticoagulants should be given – arterial lung embolism in isolated femur fractures 2–
4%, in multiple injured patients 8–11%, which may result in ARDS as small fat emboli
being swept to the lungs Late complications are most commonly malrotation in up to
22%, with more than 15% of rotational malalignement in comminuted fractures (AO
type C) and surgical fracture fixation during night shifts (11). Surgical correction is
achieved after CT scan evaluation by re-placement of the intramedullary nail.
Declaration of a delayed fracture union or non-union can vary with the type of injury
and the method of treatment. It is seen in 1–5% after intramedullary fracture fixation
and in 10–15% after plate fixation. A review of literature to formulate evidence based
guidelines for the treatment of femoral shaft fracture nonunions, evidence for plating
is stated if a nail is the first treatment. After failed plate fixation, nailing has a 96%
union rate. After failed nailing, augmentative plating results in a 96% union rate
compared to 73% after exchanging intramedullary fixation devices (29). Knee joint
stiffness is due to soft-tissue adhesions during treatment or the knee joint may be
injured at the same time. Hence early physiotherapy and repeated evaluation of the
range of motion is mandatory. Critical voices of retrograde nailing being a high risk
for intraarticular knee infection could be corrected. In a retrospective multi-centre
study low risk for knee infection in retrograde nailing of open femoral fractures was
shown (1.1%) (20). Heterotopic ossifications are found in up to 25% at the nail
insertion point (14). Prophylactic, intermittent therapy with non-steroidal anti-
inflammatory drugs like Indomethacin may prevent these osseous formations. Tips &
Tricks To restore leg length, correct axis and rotation correct reduction of the fracture
is mandatory. After positioning of the patient on a traction table closed reduction of
the femoral fracture is gained by extension, ab- and adduction and external or internal
rotation of the leg. But especially in young and muscular patients and fracture lines in
the subtrochanteric region sufficient closed reduction can be difficult. Monocortical
placement of a Schanz’ screw or threaded K-wire can be helpful for external
manipulation of the distal fragment in a ‘joystick technique’. Use of the F-tool for
further support in closed reduction is equally recommendable. Mini-open reduction
with palpable control of the realigned fracture parts might be necessary in comminuted
fractures.
 BIBLIOGRAPHY

1. https://www.researchgate.net/publication/266788479_Estimating_the_global
_incidence_of_femur_fracture
2. https://en.wikipedia.org/wiki/Femoral_fracture
3. http://www.imiprotect.eu/documents/Requenaetal.IncidenceRatesandTrendso
fHipFemurFracturesinFiveEuropeanCountriesComparisonUsing.pdf
4. http://www.achot.cz/dwnld/achot_2011_1_10_19.pdf
5. http://eknygos.lsmuni.lt/springer/400/367-384.pdf
6. http://www.achot.cz/dwnld/achot_2015_1_22_32.pdf