Femoral Shaft Fractures

Epidemiology

 

Usually young patients

- 15 - 40

 

15% compound

 

Aetiology

 

High velocity injury

- MBA

- MVA

- pedestrian v car

- fall from height

 

Emergency Managment

 

EMST principles

- need for transfusion not uncommon

- hypotension from isolated closed femoral fracture unlikely

 

Beware

- ipsilateral NOF / pelvic fracture / acetabular fracture / dislocation

- knee injury

- floating knee / ipsilateral tibial fracture

 

Thorough neurovascular exam

- incidence vascular injury 1%

 

Temporary femoral traction splints

- ring against ischium

- velcro around foot

- pneumatic traction

- can only be applied for 12 hours or so

 

Thomas Splint

 

Compound wound

 

Betadine pack

Tetanus

Antibiotics

 

Winquist Classification

 

Type 1

- minimal or no comminution

 

Femoral Shaft Fracture No comminution

 

Type 2

- < 50% comminution

 

Type 3

- 50 - 100% comminution

- inherently unstable as < 50% contact between major fragments

- need supplemental fixation / must be locked

 

Femoral Fracture Type 3

 

Type 4

- segmental comminution

- no contact or inherent stability between proximal and distal fragments

 

Associated injuries

 

Femoral Shaft Fracture with Neck Fracture

 

Up to 10% concurrence

- can be missed on plan film

- splints can obscure

 

Assessment

- carefully review pelvic xrays

- order CT if required

- assess carefully on II when intra-operatively

 

Knee

 

De Campos et al 1994 Clinical Orthopedics

- 5% ACL, 2.5% PCL

- 20% LM tears, 12% MM tears

 

Always assess knee after femoral stabilisation

 

Femoral Fracture + ACL Reconstruction

 

Floating Knee

 

Ipsilateral Femur + tibial fracture

 

Floating Knee 1Floating Knee 2

 

Operative Management Issues

 

Surgical Timing

 

Bone et al JBJS Am 1989

- stabilisation within 24 hours

- decreased pulmonary complications

- decreased length hospital stay

 

Damage Control Orthopaedics

 

Concept

- avoid second hit to severely injured patients

- stabilise femoral fracture as quickly as possible

- usually simple external fixator

- allow return to ICU for warming / stabilisation

- when stable, definitive fixation

 

Indications

- head injuries

- thoraco-abdominal injuries

- multiple injuries

 

IL-6

- cytokine shown to be elevated in multitrauma

- suggested delay definitive treatment until drops

- approximately day 6

 

Results

 

Pape et al J Orthop Trauma 2002

- retrospective study of polytrauma patients at risk of multi-organ failure

- patients treated with ETC (early total care)(IMN femur) v

- DCO (early stabilisation femur external fixation with later IMN)

- significant reduction in incidence of multiorgan failure

- significant reduction ARDS (15% down to 9%)

- no increased rate of local complications (infection, non union)

 

Bhandari J Orthop Trauma 2005

- external fixator converted to IMN within 2 weeks

- 1.7% infection rate

 

Surgical Options

 

ORIF / plate

External fixation

IMN - antegrade / retrograde / reamed / unreamed

 

External Fixation

 

Indications

- severely contaminated wound

- Damage Control Orthopaedics

- complex femoral fracture with vascular injury

 

Technique

- 2 x half pins proximally

- 2 x half pins distally

- 2 x bars

 

Timing of conversion to IMN

 

Harwood et al J Orthop Trauma 2006

- compared 111 femur fractures treated with immediate IMN to 81 DCO

- DCO femurs more likely to be grade 3 compound

- increased pin site infections in external fixation

- no significant increase in deep infection rates if converted within 2 weeks

 

Plate v IMN

 

Results

 

Bosse et al JBJS Am 1997

- compared plate v reamed IM nail (117 v 104)

- patients multiply injured (femur + thoracic injury)

- no evidence that a reamed femoral IMN increased risk of ARDS in this group

 

Plate

 

Indications

- associated proximal / distal femoral fracture

- vascular injury

- medulla too narrow for IMN

- paediatric population

 

Problem

- tension side / load bearing

- significant disruption to blood supply required

- plate will break early if union not achieved

 

Results

 

Giessler et al Orthopedics 1995

- 71 femurs diaphyseal fractures

- 93% union at 16 weeks

- recommended bone grafting at same time

 

Technique

- large fragment plate

- minimum 8 cortices each side of fracture

- need periord of NWB

 

Reamed v Unreamed IMN

 

Femoral Nail0001Femoral Nail0002

 

Results

 

Non union / Canadian Study Group JBJS Am 2003

- multicentred randomised trial

- non union rates reamed v unreamed IMN

- 8 / 106 (7.5%) smaller unreamed femoral nail nonunion

- 2 / 121 (1.7%) larger reamed femoral nail nonunion

 

ARDS / Canadian Study Group J Orthop Trauma 2006

- multicentred randomised trial reamed v unreamed

- incidence ARDS in multiply injured patients

- 151 unreamed v 171 reamed nails within 24 hours

- very low incidence of ARDS in both groups

- not statistically significant

- need some 35 000 patients to detect difference

 

Locked v Unlocked IMN

 

Unusual not to lock distally

- gives rotational stability

 

If stable transverse fracture / > 50% cortical apposition

- can dynamically lock

 

Retrograde nail

 

Retrograde Femoral NailRetrograde Femoral Nail Lateral

 

Indications

- floating knee (single incision for femoral and tibial nail

- obesity - difficult access to trochanter

- pregnancy - minimise radiation to pelvis

- patella fracture (able to ORIF with same incision)

- ipsilateral pelvic / acetabular / NOF fracture

 

Outcome

- similar rates union

- may have slightly higher incidence knee pain

 

Floating Knee 1Floating Knee 2Floating Knee 3

 

NOF (Neck of Femur) + Femoral shaft fracture

 

Must pay attention first to meticulous NOF ORIF

 

Options

1.  Pin and Plate NOF / Retrograde Nail

2.  Pin and Plate NOF / Plate femur

3.  Reconstruction Nail

- difficult to anatomically reduce NOF

- increased incidence NOF non union

4.  Antegrade IMN in place before diagnosis of NOF fracture

- if undisplaced, can place screws anterior to nail

- if displaced must remove nail

 

Dislocated Hip + Femoral shaft fracture

 

1.  Simple dislocation

- may be able to reduce hip with proximal steinman pin

- then IMN femur / retrograde or antegrade

- or plate femur

 

2.  Dislocation with Pipkin

- may need anterior approach to ORIF femoral head fracture

- may be best to plate / retrograde nail femur

 

3.  Dislocation with posterior acetabular fracture

- may need posterior approach to acetabulum

- consider plating femur / distal femoral or tibial steinman pin

- delayed ORIF posterior wall

 

Distal femoral condylar fracture + shaft fracture

 

Options

1.  Screws anterior and posterior to retrograde nail

2.  Distal Locking plate

 

Bilateral Femur Fractures

 

High risk of complications

- blood loss

- nerve injury

- ARDS (double risk unilateral)

- mortality risk (5x unilateral)

- non union

 

Management

- IMN one femur

- assess patient stability

- IMN nail other femur or external fixation / delayed nail

 

Complications

 

Nerve Palsy

 

Pudenal nerve palsy most ommon

- up to 15%

- usually transient

- related to longer traction times

- may be related to the use of smaller posts

 

Malrotation

 

Incidence

 

Common

- need attention to patella and foot position prior to distal locking

 

Diagnosis

 

A.  Clinically

- point both patellas to the ceiling

- foot internally or externally rotated compared to uninjured leg

 

B.  CT

 

Femoral Nail Malrotation CT 1Femoral Nail Malrotation CT 2

 

Management

- remove distal locking screws

- correct rotation

- insert new distal locking screws

 

Distal femoral breach

 

Distal femoral breachDistal Breach ORIF

 

Non union

 

Incidence

- uncommon

- increased with unreammed nails

 

Definition

- not united after 6 months

- no progression for 3 months

 

Options

1.  Dynamisation

2.  Exchange nailing +/- bone graft

3.  Remove nail / plate + bone graft

4.  Augmentation with plating and bone grafting

5.  External Fixation

 

1.  Dynamisation

 

Indication

- stable fractures

- non comminuted / non segmental

 

Wu J Trauma 1997

- 24 nails dynamised 4 - 12 months

- union in 50%

 

2.  Exchange nailing

 

Femoral Non unionExchange Nail Bone Graft

 

Technique

- remove old nail

- ream up to larger size

- insert new larger nail

 

Weresh et al J Orthop Trauma 2000

- 19 patients at least 6 months post

- union in only 50%

 

3.  Removal Nail / Plating / Bone Graft

 

Bellabarab J Orthop Trauma 2001

- 100% union rate

- augment with bone graft

 

4.  Augment with Plate + Bone Graft

 

Ueng J Trauma 1997

- 17 patients, 100% union

 

Infected Non union

 

Management

- removal of nail

- irrigation +++

- antibiotic nail / cover IMN with antibiotic cement

- 6 weeks IV antibiotics

- definitive nail / External fixator

 

Infected Femoral Nail 1Infected Femoral Nail2Infected Femoral Nail3Infected Femoral Nail4

 

Infected Femoral Nail United APInfected Femoral Nail United Lateral

 

Refracture

 

No evidence increased risk if nail removed > 1 year