Makindo Medical Notes.com

Related Subjects: |Fractured Neck of Femur |Fractured Shaft Femur |Supracondylar Femur Fractures |Femoral fractures and Injuries

About

• Suggests high forces, if not then consider pathological fracture
• Causes include osteoporosis, tumour , or Paget's or infection.

Aetiology

• Femur is the longest and strongest bone in your body.
• Fracture suggests extreme forces e.g. Car crashes.
• The long, straight part of the femur is called the femoral shaft.

Types

• Transverse fracture. the break is at right angles to the long axis of the bone going across the femoral shaft.
• Oblique fracture. This fracture is at an acute angle to the long axis of the bone.
• Spiral fracture. The fracture line encircles the shaft and the mechanism is a twisting force to the thigh.
• Comminuted fracture. The bone has broken into three or more pieces. Suggests high amounts of force.
• Open fracture. Bone fragments penetrate the skin. Cause other soft tissue damage. There is a higher risk for complications and take a longer time to heal.

Clinical

• Usually associated with major trauma e.g. car accident, falls from heights and gunshot wounds.
• Severe pain, inability to walk, the leg appears shorter and not straight

Complications

• Compartment syndrome may need fasciotomy to relieve pressure
• Delayed union, nonunion, and arthritis
• Osteomyelitis especially with open fractures
• Fat embolism
• Venous thromboembolism
• Femoral/Popliteal artery damage from sharp ends of bones

Investigations

• X-ray: hip, femur, knee
• Computed tomography for selected patients

Management

• ABCDE as per ATLS. Check distal pulses and neurology. Good analgesia. Sterile dressing to open wounds. Attempt gentle traction to reduce gross deformities and place either in a long-leg splint or in skeletal traction. as await surgery
• Open wounds: Tetanus vaccination should be updated. Give IV antibiotics e.g. Augmentin or clindamycin. Consult Orthopaedics. Need debridement and wound care as soon as is possible to reduce the risk of infection.
• Operative management: most femoral shaft fractures require surgery for optimal outcome. Open fractures are a priority. They urgently need to be cleansed and require immediate surgery to prevent infection.
• Reduction: Skeletal traction is a pulley system of weights and counterweights that holds the broken pieces of bone together. It keeps your leg straight and often helps to relieve pain. External fixation uses metal pins or screws applied to the bone above and below the fracture site. These are attached to a bar outside the skin. This holds the bones whilst awaiting definitive surgery.
• Rehabilitation can usually begin following operative management.
• VTE prophylaxis usually with LMWH. Antibiotics as indicated

Operative management

• Fixation: Commonest technique is Intramedullary nailing by which a metal rod is inserted into the marrow canal of the femur. The rod passes across the fracture to keep it in position. This is inserted either at the hip or the knee through a small incision and screwed to the bone at both ends. holds the bone in the proper position during healing. They are usually made of titanium.
• Plates/Screws: bones are realigned and then held together with special screws and metal plates attached to the cortex of the bone. Preferred for fractures that extend into either the hip or knee joints.

References