FEMORAL SHAFT FRACTUTES - PowerPoint Presentation

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FEMORAL SHAFT FRACTUTES

The femoral shaft is well padded with muscles- an advantage in protecting the bone from all but the most powerful forces but a disadvantages in that fractures are often severely displaced by muscle pull making reduction difficult.

Mechanism of injury:

This is essentially a fracture of young adults and usually results from a

high energy injury

.

Diaphyseal

fractures in elderly patients should be considered

pathological

until proved otherwise.

In children under 4 years of age, the possibility of

physical abuse

must kept in mind.

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Clinical features:

There is

swelling

and

deformity

of limb with

painful movement

with sign of

blood loss

, its important to exclude

neurovascular problems

and other limb or pelvic fractures with high risk of multisystem injury in the patient.

x-ray:

It may be difficult to obtain adequate views in accident and emergency room setting which can postponed until better positioning are possible,

but never forget to x-ray of the hip and knee also chest x-ray in ARDS.

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Femoral shaft # with hip dislocation

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EMERGENCY TREATMENT

:

At the site of the

accident,

shock

should be treated by

iv fluids and blood

and the fracture splinted before the patient is moved by

Thoma’s

splint with skin traction

until the patient transported to the hospital.

DEFINITIVE TREATMENT

:

1-

TRACTION AND

BRACING:indications

:-

a-

fractures in

children,

b

-

contraindications to

anaesthesia,and

c-

lack of suitable skill or facilities for internal fixation.

it is

apoor

choice for elderly

patients,for

pathological fractures and those with multiple

injuries.the

traction take long time

(10-14weeks)for adults.

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Skeletal traction

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2-

OPEN REDUCTION AND

PLATING:indications

:

a-

the combination of shaft and femoral neck fractures and

b-

a shaft fracture with an associated vascular injury.

c-shaft # in growing children

3-INTRAMEDULLARY NAILING:

It is a method of choice for most femoral shaft

fractures,this operation done closed reduction of fracture under screen(fluoroscopy) apply suitable size with or without reaming,with locking screws can be inserted transversly at the proximal and distal ends;this controls rotation with good stability even for subtrochanteric and distal-third fractures. 4-EXTERNAL FIXATION: indications:- a-the treatment of severe open injuries,b-management of patients with multiple injuries where there is need to reduce operating time,c-dealing with severe bone loss by the technique of bone transport, d- treating femoral fractures in adolescents.

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Plating of femur

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Locked intramedullary nailling

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External fixation

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OPEN FRACTURES

Open femoral fractures should be carefully assessed for

1-skin loss2-wound contamination.3-muscle ischemia and 4- vessels and

nerves

.the

immediate treatment is similar to that of closed

fractures.

antibiotics

and wound

debridment

should done with little

delay,the

major decision is how to stabilize the

fracture.with small,clean wounds and little delay from time of injury,the fracture can be treated as for aclosed injury with addition of prophylactic antibiotics BUT, with large wounds,contaminated wounds,skin loss or tissue destruction,internal fixation should be avoided.after debridment, the wound should be left open and the fracture stabilized by applying an external fixation.

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FEMORAL RACTURES IN CHILDREN

Infants

need no more than 1 or 2 weeks in balanced traction followed by a

spica

for another 3 or 4

weeks.

children

up to 10 years

can be treated in

asimilar

manner,allowing

twice as long in traction and then 6 weeks in a

spica.

teenager may require even longer in traction before changing to a spica,however,if satisfactory reduction cannot be obtained or held,internal fixation(plate and secrews or flexible intra medullary nails)or by external fixation.

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COMPLICATIONS:EARLY

GENERAL

: such as blood loss(1-2 liters),shock, fat embolism and acute respiratory distress are common in high energy injuries.

VASCULAR

INJURY

:it

is takes the priority and the vessel must be repaired or grafted without

delay.at

the same

operation,the

fracture is secured by

interal

fixation.

THROMBOEMBOLISM

:

prolonged traction in bed predisposed to thrombosis,movement and exercise are important in preventing this;they can be supplemented by foot compression devices or prophylactic doses of anticoagulants.INFECTION : in open injuries and following internal fixation, there’s always risk of infection, prophylactic antibiotics and careful attention to the principles of fracture surgery kept the incidence below 2%.

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LATE:

DELAYED UNION AND NON-UNION

:

It’s said that a

fractured femur should unite in

100 days plus or minus 20

.if union is delayed beyond this

time,an

exchange nailing is performed using

aslightly

larger

nail;in

addition,the

fracture may need bone grafting.

MALUNION: Fractures treated by traction and bracing often develop some deformity;no more than 15 degrees of angulation should be accepted.JOINT STIFFNESS: The knee is often affected after a femoral shaft fracture either due to injury of knee at the same time or stiffeness because of soft tissue adhesions during treatment;hence the importance of exercise and knee movements.REFRACTURE AND IMPLANT FAILURE .

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SUPRACONDYLAR FRACTURES OF THE FEMUR

These types of fractures are seen

in(a)young

adults,usually

as

aresult

of high-energy trauma and (b)

elderly,osteoporotic

individuals

.direct

violence is the usual

cause.the

fracture line is just above the

condyles,but

it may be branch off distally between them.the pull of the gastrocnemius attachments may tilt the distal fragment backwards. Clinical features: the knee is swollen and deformed;movement is too painful to be attempted.the tibial pulses should always be palpated. X-ray:the fracture is just above the femoral condyles and is transverse or comminuted.the distal fragment is often tilted backwards.the entire femur must be x-rayed so not to miss a proximal fracture or dislocated hip.

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TREATMENT

1-conservative:

if the fracture is only slightly displaced and extra-

articular

or if it reduces easily with knee in

flexion,it

can be treated easily by

skeletal traction

through the proximal tibia and the limb is cradled on a Thomas’ splint with knee in flexion piece and the movements are

encouraged.the

fracture may need vertical traction by apply second pin above

knee.

at

4-6weeks when the fracture is beginning to unite the traction can be replaced by a cast brace and partial weight bearing with crutches.2-operative:if closed reduction fail,open reduction and internal fixation with an angled compression device(dynamic condylar compression secrew and plate)or blade condylar plate and secrews.unprotected weight-bearing is not permitted until the fracture has consolidated(usually around 12 weeks).Locked intramedullary nails which are introduced retrograde through the intercondylar notch are also used for these fractures.

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Conservative treatment

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Operative treatment

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COMPLICATIONS:

EARLY

:-

ARTERIAL DAMAGE

: there’s a small but definite risk of arterial damage and distal

ischemia.careful

assessment of the leg and peripheral pulses is essential.

LATE

:-

JOINT

SYIFFNESS

:

knee

stiffness is almost

inevitable,along period of exercise is necessary but full movement is rarely regained. NON-UNION:knee increases the like of nonunion. This combination is difficult to treat and unless great care is exercised,the ultimate range of movement at the knee may be less than that at the fracture. OSTEOARTHRITIS(OA): supracondylar fractures often extend into the joint surface;anatomical reduction is necessary to reduce the risk of OA.

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FEMORAL CONDYLE FRACTURES

Condylar

fractures are often associated with

supracondylar

fractures where a distal extension into the knee joint may cause one or both

condyles

to be split

apart,they

also occur in

isolation:a

direct injury or a fall from a

hieght

may drive the tibia upwards into the

intercondylar

fossa. Pathological anatomy: This fractures are classified by AO (Muller ) classification into three groups of fractures:-A-Purely extra-articular,supracondylar fractures.B-Intra-articular fracture of one condyle-ysually the lateral one.C-Inta-articular bicondylar fractures,which are effectively also ‘supracondylar’.

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AO (MULLER) CLASSIFICATION

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Clinical features:

The knee is

swellen

and may be

deformed,there’s

a

tender

”doughy

” feel characteristic of a

haemoarthrosis

,the

joint is too painful to move but the foot should be examined to exclude nerve and arterial damage.

X-ray:

One femoral

condyle

may be fractured obliquely and shifted upwards or both condyles may split apart so that the fracture line is T or Y shaped.

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Treatment :

The

haemoarthrosis

must be

aspirated

as soon as

possible.because

the

articular

surface is involved,

accurate anatomical reduction

is

important,so

open reduction and internal fixation

are therefore often employed by cannulated secrews that fixed the articular fragments with blade plate or dynamic condylar screw and plate. The patient can begin knee exercises as soon possible to prevent the stiffness. Complications: 1-stiffness of the knee:-this is a common complication.it usually responds to prolonged physiotherapy, although movement may not be fully restored. 2-osteoarthritis:-as with other intra-articular fractures, secondary osteoarthritis is a late complication.