Femoral Shaft Fracture

Dwitya Oktina Dewi

definition
Fracture is a break of in the structural
continuity of bone.
The long, straight part of the femur is
called the femoral shaft.
When there is a break anywhere along this
length of bone, it is called a femoral shaft
fractures

Mechanism of Injury
Usually a fracture of young adult
Result from a high energy injury
For elderly considered pathological

Fracture pattern
Spiral fall in which the foot is anchored
while a twisting force is transmitted to the
femur
Transverse and Oblique angulation or
direct violence and particulary common in
road accident
Communited or Segmental severe
violence

Pathological Anatomy
Proximal shaft femur proximal fragment
is flexed, abducted and externally rotated
because of gluteus medius and iliopsoas
pull, the distal fragment is frequently
adducted
Mid shaft fracture proximal fragment is
flexed and externally rotated, abduction is
less marked
Lower third fracture proximal fragment
adducted and the distal fragment is tilted
by gastrocnemius pull

Winquist and Hansen Classification

Clinical feature
swelling and deformitiy of the limb, painful.
Combination of femoral shaft and tibial
shaft fractures of the same side floating
knee high risk of multi system injury
Effect of blood loss life threatening
dominate clinical picture

Physical examination
Look :
Wound,Deformity(Shortening/Rotation/Angultion), Hematom,
Spalk
Feel :
Crepitus felt at splint, Tenderness,Neurovascular disturbance,
Paresthesia, Warm
Move :
ROM (Joint above & Joint below = Active Pasive =
Adduction, Abduction, Extention, Flextion)

X-Ray
Can be show whether a bone is intact or
broken
Never forget to x-ray the knee and hip as
well

TREATMENT

Principles of treatment
Principle of treatments are :
1. restoration of alignment, rotation
and length
2. preservation of blood supply to aid
union and prevent infection
3. rehabilitation of the extremity and
the patients

Emergency Treatment
Traction with a splint first aid, Use for :
control pain
Reduces bleeding
Make transfer eaisier
Syok maintenance and restore blood
volume

Definitive Treatment
Non operative
Traction
Femoral brace
Spica cast
Operative
External fixation
Internal fixation

Traction
Reduce and hold most fracture in
reasonable alignment except upper third of
femur
Chief drawback length of time spent in
bed (10-14 weeks for adult)

Traction
Indications :
Fractur in children
Contrindication to anaesthesia
Lack of suitable skill or facilities for
internal fixation
Poor chioce for :
- Elderly patient
- Pathological fracture
- Multiple injury

Traction
Children
Skin traction without a splint
Infant less than 12 kg gallows
traction, no more 2 kg weight should be
used
Older children russlles traction or
thomas splint
Consolidation 6-12 weeks

Traction
Adult
Skin traction in adult only for
emergency fracture immobilization in
the field & to facilitate transportation
Fore definitive treatment require
skeletal traction through a pin or a
tightly strung Kirschner wire behind the
tibial tubercle.
With splint thomas splint
Without splint perkins traction

Cast or brace
Cast or brace are used after traction ( at
about 8 week in adult)
Fracture upper half femur plaster spica
Fracture lower half of femur cast
bracing
This type protection is needed until
fracture has consolidated (16-12 weeks)

Internal fixation
A. Intramedullary nail
1.Open technique
2.Closed technique
B. Interlocking intramedullary nail
1.Reamed
2.Unreamed
C. Plate fixation

Plate and screw fixation

Comparatively easy way of obtaining
accurate reduction and firm fixation but
high complication rate because of wide
open exposure of the fracture site
now days they use MIPO (minimal
invasive plate osteosynthesis)

Plate and screw fixation

Indications :
Fracture at either end of the femoral
shaft, especially with extension into
supracondylar and pertrochanteric
areas
Shaft femur in a growing child
A fracture with vascular injury which
required repair
Extremely narrow medullary canal
where IM nailing is impossible or
difficult.

 Advantages :
Ability to obtain an anatomic reduction
in appropriate fracture patterns.
Lack of additional trauma to remote
locations such as the femoral neck, the
acetabulum, and the distal femur.

 Disadvantages :
x Need for an extensive surgical
approach with its associated blood loss,
risk of infection, and soft tissue insult.
x Decreased vascularization beneath the
plate and the stress shielding of the
bone spanned by the plate.
x The plate is a load bearing implant;
therefore, higher rate of implant failure.

Intramedullary nail
The methode of choice of most femoral shaft femur
Must be attempt in appropiate facilities and expertise are
available
Important detil :
Reamed nail have lower need for revision surgery when
compared to unreamed nail
Select nail that approximately the size of the medula
isthmus so it fill the canal reasonably well
Consider alternative meanx of fracture fixation if the
isthmus is so narrow

Intramedullary nail
Use nail with sufficient length
Insertion : antegrade
retrograde
retrograde The major advantage
the ease in properly identifying the
starting point.
obese patient;
when there are bilateral femoral
shaft fracture;
when there tibial shaft fracture at
the same side

Intramedullary nail
Open medullary nailing :
Feasible alternative when facilities for
closed nailing are lacking

External fixation
Treatment of severe open injuries
Management patient with multiple injury
where there is a need to reduce operating
time
The need to deal with severe bone loss by
technique of bone transport
Treatment femoral fracture in adolescent

Complications
EARLY
Shock
Fat embolism and ARDS
Thromboembolism
Infection
LATE
Delayed union and non-union
Malunion
Joint stiffness
Refracture and implant failure

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