Femoral Fractures

FRACTURES OF THE FEMUR
DR. CODRIN HUSZAR University Hospital Bucharest
FEMORAL NECK FRACTURES
Fractures of the femur
Epidemiology
250,000 Hip fractures annually (U.S.A.)
Expected to double by 2050

medications, malnutrition
At risk populations Elderly: poor balance&vision, osteoporosis, inactivity,
incidence doubles with each decade beyond age 50
higher in white population Other factors: smokers, small body size, excessive caffeine Young: high energy trauma
APPLIED ANATOMY
Physeal closure age 16 Neck-shaft angle ~ 135 Anteversion ~15
APPLIED ANATOMY
APPLIED ANATOMY
CLASSIFICATION Garden (1961) Type I

Valgus impacted or incomplete
CLASSIFICATION Garden (1961) Type II

Complete Non-displaced
CLASSIFICATION Garden (1961) Type III

Complete Partial displacement
CLASSIFICATION Garden (1961) Type IV

Complete Full displacement
10
CLASSIFICATION Pauwels (1931)
11
Functional Classification
Stable Impacted (Garden I) Non-displaced (Garden II) Unstable Displaced (Garden III and IV)
12
DISPLACEMENT
Shortening Adduction External rotation Fractures of the femur

13
COMPLICATIONS
IMMEDIATE
EARLY
LATE
GENERAL shock
LOCAL
DVT infection
GENERAL
Pressure sores Urinary / respiratory infections
LOCAL
AVN NonU
Fixation failure
Artritis Joint stiff.
14
Treatment
Goals
Improve outcome over natural history Minimize risks and avoid complications Return to pre-injury level of function Provide cost-effective treatment
15
Treatment
OPTIONS : Operative IF Hemiarthroplasty Total Hip Replacement Non-operative very limited role
16
Treatment Decision Making Variables
Patient Characteristics
Young (arbitrary physiologic age < 65)
High energy injuries
High Pauwels Angle (vertical shear pattern)

Elderly
Often multi-trauma
Lower energy injury Comorbidities Pre-existing hip disease
Fracture Characteristics
Stable Unstable
17
Treatment Young Patients

(Arbitrary physiologic age < 65)
Non-displaced fractures
Displaced fractures
At risk for secondary displacement Urgent IF recommended Patients native femoral head best AVN related to duration and degree of displacement Irreversible cell death after 6-12 hours Emergent CRIF recommended
18
19
20
Treatment Elderly Patients
Operative vs. Non-operative
Displaced fractures
Unacceptable rates of mortality, morbidity, and poor

outcome with non-operative treatment [Koval 1994]
Non-displaced fractures
Standard of care is operative for all

femoral neck fractures
Unpredictable risk of secondary displacement
Non-operative tx may have developing role in select

patients with impacted/ non-displaced fractures [Raaymakers 2001]
21
Treatment Pre-operative Considerations
Surgical Timing
Surgical delay for medical clearance in

relatively healthy patients probably not warranted
Surgical delay up to 72 hours for medical
Increased mortality, complications, length of stay
stabilization warranted in unhealthy patients
22
Non-displaced Fractures
INTERNAL FIXATION - standard of care Predictable healing
Minimal complications Relatively quick procedure Early mobilization

Minimal blood loss
Partial / unrestricted weight bearing
23
Nonunion < 5% AVN < 8% Infection < 5%
Displaced Fractures Hemiarthroplasty vs. IF
IF : Complications
Nonunion 10 -33% AVN 15 33% Loss of reduction / fixation failure 16%
24
Displaced Fractures Hemiarthroplasty vs. IF
Hemi associated with
Lower reoperation rate (6-18% vs. 20-36%) Improved functional scores Less pain More cost-effective Slightly increased short term mortality
Literature supports hemiarthroplasty for displaced fractures [Lu-yao JBJS 1994]
25
Arhroplasty
Hemiarthroplasty unipolar / bipolar cemented / uncemented

Total arthroplasty (degenerative changes affecting the acetabulum)
26
Thompson
Moore
Hemiarthroplasty (unipolar)
27
Total arthroplasty
28
Total arthroplasty
29
30
TROCHANTERIC FRACTURES
31
Incidence
250,000 Hip Fractures a Year (U.S.A.)
Double by 2040 to 500,000

50% are Intertrochanteric Fractures
32
Demographics
90% >65y/o F>M
Peak @ 80y/o
33
Etiology
Osteoporosis
Low energy fall
Common
Rare
High Energy
34
Femoral trochanteric area :
Extra-capsular femoral neck 2.5 cm below the inferior border of the lesser trochanter
35
Classification Stability
Posteromedial cortex Cominution
36
Pertrohanteric fracture
37
Extracapsular femoral neck base fracture
38
Comminuted pertrochanteric fracture
39
Intertrochanteric fracture (reverse obliquity fracture)
40
Trochantero diaphyseal fractures
41
Subtrochanteric fracture
42
EVANS Classification
43
COMPLICATIONS
IMMEDIAT E GENERAL shock
EARLY
LOCAL DVT infection GENERAL
Pressure sores Urinary / respiratory infections
LATE
LOCAL Malunion NonUnion Fixation failure
44
Goals of Treatment
Obtain Reduction
Good position Internal Fixation Mechanically Adequate Permit Immediate Transfers & Early Ambulation
45
ORIF : Sliding Hip Screw + Side Plate (DHS)
46
CRIF : Intramedullary Sliding Hip Screw
47
48
49
Introduction du clou et forage du col
50
51
Photos J. Chouteau
52
Photos J. Chouteau
53
54
ENDER elastic nails
55
DIAPHYSEAL FRACTURES
56
Demographics. Etiology
Common injury due to major violent trauma
(elderly : simple falls)

1 femur fracture/ 10,000 people (U.S.A.) More common in young people Motor vehicle, motorcycle, auto-pedestrian, aircraft, and gunshot wound accidents are most
frequent causes
57
Complications
! High energy trauma :

Haemoragic shock (1 1.5L) Associated fractures Politrauma
58
COMPLICATIONS
IMMEDIATE
GENERAL
SHOCK FAT EMBOLISM
EARLY
LOCAL
DVT INFECTION U / R TRACT INFECTIONS PE
LATE
LOCAL
DELAYED / NONUNION
MALUNION
LOCAL
OPEN
FRACTURE
GENERAL
PRESSURE SORES
NEURO-VASC
INJURIES
MUSC.
INTERPOSITION
FIXATION FAILURE
JOINT STIFFNES OSTEITIS
59
Femur Fracture Management
Initial traction with portable traction splint or transosseous pin and balanced suspension Shock treatment / Politrauma care Timing of surgery is dependent on:
Resuscitation of patient Other injuries - abdomen, chest, brain Isolated femur fracture
60
Femur Fracture Management
Antegrade nailing is still the gold standard
61
62
La mise en place dun clou ncessite un alsage de la cavit mdullaire toujours rtrcie au tiers moyen Fractures of the femur
Reaming
63
Locking
64
Blood Supply
Reaming / nail insertion destroys intramedullary endosteal blood supply Periosteal blood flow increases Medullary blood supply is re-established over 8-12 weeks if spaces left in canal by implant Unreamed intramedullary nailing decreases blood flow less; restoration of endosteal blood flow earlier but equal to reamed canal at 12 weeks
65
Femur Fracture Reaming
Reaming of the femoral shaft fracture
Multiple studies demonstrate that the thoracic

injury is the major determinant of pulmonary complications, NOT the use of a reamed IM nail
Charash J Trauma 1994 Van Os J Trauma 1994 Ziran J Trauma 1997 Bone Clin Orthop 1998 Bosse JBJS 79A 1997
66
External fixation
Open fractures Vascular injuries
67

Femoral Fractures

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Femoral Fractures

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FRACTURES OF THE FEMUR

DR. CODRIN HUSZAR University Hospital Bucharest

FEMORAL NECK FRACTURES

Fractures of the femur

250,000 Hip fractures annually (U.S.A.)

Expected to double by 2050

At risk populations Elderly: poor balance&vision, osteoporosis, inactivity,

incidence doubles with each decade beyond age 50

Fractures of the femur

Physeal closure age 16 Neck-shaft angle ~ 135 Anteversion ~15

Fractures of the femur

Fractures of the femur

Fractures of the femur

CLASSIFICATION Garden (1961) Type I

Fractures of the femur

CLASSIFICATION Garden (1961) Type II

Fractures of the femur

CLASSIFICATION Garden (1961) Type III

Fractures of the femur

CLASSIFICATION Garden (1961) Type IV

Fractures of the femur

CLASSIFICATION Pauwels (1931)

Fractures of the femur

Shortening Adduction External rotation Fractures of the femur

Fractures of the femur

Fractures of the femur

Treatment Decision Making Variables

Young (arbitrary physiologic age < 65)

High energy injuries

High Pauwels Angle (vertical shear pattern)

Lower energy injury Comorbidities Pre-existing hip disease

Treatment Young Patients

Fractures of the femur

Fractures of the femur

Treatment Elderly Patients

Operative vs. Non-operative

Unacceptable rates of mortality, morbidity, and poor

Standard of care is operative for all

Unpredictable risk of secondary displacement

Non-operative tx may have developing role in select

Fractures of the femur

Treatment Pre-operative Considerations

Surgical delay for medical clearance in

Surgical delay up to 72 hours for medical

Increased mortality, complications, length of stay

stabilization warranted in unhealthy patients

Fractures of the femur

INTERNAL FIXATION - standard of care Predictable healing

Minimal complications Relatively quick procedure Early mobilization

Nonunion < 5% AVN < 8% Infection < 5%

Displaced Fractures Hemiarthroplasty vs. IF

Nonunion 10 -33% AVN 15 33% Loss of reduction / fixation failure 16%

Fractures of the femur

Displaced Fractures Hemiarthroplasty vs. IF

Hemi associated with

Literature supports hemiarthroplasty for displaced fractures [Lu-yao JBJS 1994]

Fractures of the femur

Hemiarthroplasty unipolar / bipolar cemented / uncemented

Fractures of the femur

Fractures of the femur

Fractures of the femur

Fractures of the femur

250,000 Hip Fractures a Year (U.S.A.)