Femoral Shaft Fractures ORDiaphyseal Femur Fractures

The femur is the largest and strongest bone and has a good blood supply. Because of this and its protective surrounding muscle, the shaft requires a large amount of force to fracture. Once a fracture does occur, this same protective musculature usually is the cause of displacement, which commonly occurs with femoral shaft fractures.

The types of femoral shaft fractures are as follows:

Type I – Spiral due to twisting injury. Type II - Transverse and oblique due to

angulations or direct violence. Type III - Comminuted due to severe violence

( combinations of direct and indirect force). Type IV - Segmental fracture in more than one

place in the femur. Type V – butterfly fractures. Type VI - Open.

Pathophysiology Diaphyseal fractures result from

significant force transmitted from a direct blow or from indirect force transmitted at the knee.

Pathologic fractures may occur with relatively little force. These may be the result of bone weakness from osteoporosis or lytic lesions.

Causes Trauma Lytic lesions

Cancerous metastasis Paget disease Bone cysts

Osteoporosis

Classification Femoral-shaft fractures can be

classified by location, as follows: proximal third, middle third, distal third, and the junctions of the segments, among others. Geometry of the fracture, displacement, alignment, comminution, open versus closed status, and the amount of soft tissue damage are also used

Winquist-Hansen classification 0 - No comminution, simple transverse or

oblique I - Small butterfly fragment, minimal to no

comminution II - Butterfly fragment with at least 50% of

the circumference of the cortices of the 2 major fragments intact

III - Butterfly fragment with 50-100% of the circumference of the 2 major fragments comminuted

IV - Segmental comminution, all cortical contact is lost

Gustilo and Anderson classification of open fractures

Grade I - Clean skin opening, less than 1 cm, most often occurring from inside to out, with minimal soft tissue damage (eg, chicken bite)

Grade II - Skin opening of more than 1 cm, extensive soft tissue damage

Grade III - Massive soft tissue damage more than 10 cm in length; may include skin, muscle, neurovascular structures; most often high-energy mechanism of injury; includes any open fracture that has not been treated within 8 hours

Grade IIIA - Massive soft tissue damage, adequate bone coverage, minimal periosteal stripping, often occurs with gunshot injuries and often comminuted

Grade IIIB - Massive soft tissue damage with exposed bone and periosteal stripping requiring soft tissue flap coverage, associated with heavy contamination.

Grade IIIC - Vascular injury requiring repair

Clinical History The usual history of diaphyseal femur

fractures is that of trauma.  If the history does not consist of trauma, one should suspect a pathologic bone condition. Clinically, the injury is most often apparent. Pain, swelling, shortening, and deformity are usually present in the region.

Because of the high association of other injuries, the advanced trauma life support (ATLS) protocol should be followed. As always, a neurovascular assessment should be completed, though this type of injury is rare with femoral-shaft fractures.

Physical Conduct a thorough examination to rule

out associated injury. Hip fractures and ligamentous knee injuries commonly are observed in association.

At the site of fracture, tenderness on examination and visible deformity typically are noted.

The extremity may appear shortened, and crepitus may be noted with movement.

The thigh is often swollen secondary to hematoma formation.

Perform a thorough vascular examination on the extremity. Signs of vascular compromise should prompt arteriography and a vascular surgery consult. Physical signs of arterial injury include the following:

1. Expanding hematoma 2. Absent or diminished pulses 3. Progressive neurologic deficits in a

closed fracture

Because of extensive blood supply to the musculature surrounding the femur, diaphyseal fractures may be associated with significant blood loss (ie, 1 L or more) and resulting tachycardia and hypotension.

Test distal neurologic function, though examination is frequently unreliable because of the amount of pain associated with these fractures. Nerve injury is rare because of protective surrounding musculature.

Laboratory Studies In cases of diaphyseal femur

fracture, laboratory studies appropriate for a trauma patient may need to be ordered depending on the situation.

The hemoglobin and hematocrit level should be monitored because of the relatively large amount of blood that can be lost into the compartments of the upper leg. However, the amount of blood lost with an isolated femur fracture should not cause clinically significant hypotension. If this occurs, bleeding from another site should be suspected.

Culture and sensitivity results may be obtained in cases of open fractures to determine the optimal antibiotic treatment after empiric therapy, although some believe that this is of little benefit because of gross contamination of the wound.

If a pathologic fracture is suspected, a more extensive workup is needed.

Imaging Studies In diaphyseal femur fracture, traction or

splinting should be applied prior to radiographs to prevent further soft tissue damage. Ensure that no radiopaque material obscures

the femur; otherwise, pathologic findings or a nondisplaced neck fracture could easily be missed.

The likelihood of nondisplaced neck fractures increases with femur fractures because some of the energy is dispersed from the fracture site.

Depending on the situation, an entire trauma series may be needed. The initial investigation of a femur fracture should involve an anteroposterior (AP) pelvic view, as well as AP and lateral views of the knee that shows the entire femur.

Baseline chest images may also be needed to compare with later images to help in the diagnosis of a fat embolism.

As always, poor-quality images are not acceptable.

Treatment Emergency treatment1. ABC.2. Temporary splintage ( Thomas

splint).3. analgesia.

Conservative Therapy In cases of diaphyseal femur

fracture, skin traction and splinting are used in the field in emergent situations to provide comfort for the patient and to prevent any further soft tissue damage.

Skeletal traction is seldom used in modern practice and is usually only a temporary treatment or a treatment in young children.

A pin is placed in the distal femur or proximal tibia, upon which traction can be placed against the patient's own weight. Skeletal traction is usually combined with one of many splinting systems.

The main goal in traction is to regain the anatomic length of the limb. If a knee injury is associated with the fracture, the pin should be placed in the distal femur to avoid further injury. In most other cases, the proximal tibia is the choice location. The amount of traction needed varies with a patient's unique situation.

Internal fixation is still the treatment of choice for most closed injuries and some open because of the higher union rate, lower rate of complications, lower morbidity, earlier weight bearing, shorter hospital stay, and better control of alignment.

However, in some situations, such as when the hardware is not available or the patient cannot undergo surgery relatively soon, temporary skeletal traction may be a viable choice.

In the rare instance in which an adult is treated with skeletal traction and splinting as the definitive treatment, at least 6 weeks of spica casting is needed after radiographs show significant healing.

Possible disadvantages include less-than-ideal control of fragments, prolonged bed rest and hospital stays, difficult nursing care, high cost, limited rehabilitation, potential of pin-tract infection, and possible tethering of the quadriceps muscle.

Cast bracing is more of a historical treatment in light of the options available in modern orthopedics. Cast braces were usually applied after a period of traction. The advantage is an earlier return to motion. The cast brace helps to reduce the load on the fracture and helps to counteract deforming forces.

Only relative indications exist today; these include distal-third fractures or comminuted fractures in patients who are not surgical candidates and as supplemental support for nonrigid internal fixation.

Surgical Therapy The

American College of Surgeons Committee on Trauma has recommended that femoral shaft fractures in polytrauma patients be treated within 2-12 hours after injury, provided they are hemodynamically stable. Studies have also shown the significant benefit of intervention within the first 24 hours.

Immediate fixation has been shown to decrease fatalities, respiratory complications, multisystem organ failure, and the length of ICU stays in most patients. The type of early fixation used can be debated, but the timing appears to be what makes the difference

Intramedullary rod placement (interlocking nail)

External fixation. Plating.

Open fractures The treatment of open fractures is

also not without some controversy. Gustilo class I, II, and IIIA fractures treated with standard reamed antegrade nailing is supported by a wealth of literature.

Grade IIIB and IIIC fractures should be treated with external fixation after initial debridement, which can be exchanged later for another modality if needed. Serial debridement and delayed closure are required..

If the surgeon believes that the intramedullary canal is grossly contaminated, intramedullary nailing should be avoided

Treatment initiated within the first 8 hours has shown to decrease the incidence of infection. Because of the higher rate of infection in any open fracture that has gone untreated for longer than 8 hours, the injury should be treated as a grade III open fracture by using external fixation.

Antibiotics must be administered.

Complications general complications like

1. Shock (hemorrhagic, neurogenic and septic).2. ARDS.3. Fat, pulmonary and thrombo embolism.4. DVT,5. Crush syndrome.6. Multiorgan failure.7. Death.

All of these are more common in the polytrauma patient than in others.

Local complications. As with any surgical procedure, femoral-shaft stabilization with surgical intervention is associated with complications. The most common complications include 1. Infection.2. Malunion. 3. Delayed union (e.g. generally no signs of

healing at 3 months). 4. Nonunion (no signs of healing at 6 months). 5. Pain from hardware.

1.

Less common complications include Neurovascular injury. Hemorrhage. Compartment syndrome. Repeat fracture. Component (metal) failure.

Complex fracture femur1. Fracture associated with vascular

injury.2. Fracture associated with knee

injury.3. Floating knee.4. Combined neck and shaft fractures.5. Multiple injuries.6. Pathological fractures.7. Periprosthetic fractures.