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http://upload.orthobullets.com/topic/1040/images/key image.jpg
http://upload.orthobullets.com/topic/1040/images/anterior bow.jpg
http://upload.orthobullets.com/topic/1040/images/linea aspera.jpg
http://upload.orthobullets.com/topic/1040/images/thigh compartments.jpg
http://upload.orthobullets.com/topic/1040/images/biomechanics_of_femoral_shaft_fracture.jpg
Introduction
  • High energy injuries frequently associated with life-threatening conditions
  • Epidemiology
    • incidence
      • 37.1 per 100,000 person-years
  • Mechanism
    • traumatic
      • high-energy
        • most common in younger population
        • often a result of high-speed motor vehicle accidents
      • low-energy
        • more common in elderly
        • often a result of a fall from standing
        • gunshot 
  • Associated conditions
    • orthopaedic
      • ipsilateral femoral neck fracture
        • 2-6% incidence 
        • often basicervical, vertical, and nondisplaced
        • missed 19-31% of time
      • bilateral femur fractures q
        • significant risk of pulmonary complications
        • increased rate of mortality as compared to unilateral fractures
Anatomy
  • Osteology
    • largest and strongest bone in the body
    • femur has an anterior bow
    • linea aspera 
      • rough crest of bone running down middle third of posterior femur
      • attachment site for various muscles and fascia
      • acts as a compressive strut to accommodate anterior bow to femur
  • Muscles
    • 3 compartments of the thigh
      • anterior
        • sartorius
        • quadriceps
      • posterior
        • biceps femoris
        • semitendinosus
        • semimembranosus
      • adductor
        • gracilis
        • adductor longus
        • adductor brevis
        • adductor magnus 
  • Biomechanics
    • musculature acts as a deforming force after fracture
      • proximal fragment
        • abducted
          • gluteus medius and minimus abduct as they insert on greater trochanter
        • flexed
          • iliopsoas flexes fragment as it inserts on lesser trochanter
      • distal segment
        • varus
          • adductors inserting on medial aspect of distal femur
        • extension
          • gastrocnemius attaches on distal aspect of posterior femur
Classification
 
 Winquist and Hansen Classification
Type 0  • No comminution
Type I  • Insignificant amount of comminution

Type II  • Greater than 50% cortical contact
Type III  • Less than 50% cortical contact  
Type IV  • Segmental fracture with no contact between proximal and distal fragment
 
OTA Classification
32A - Simple  • A1 - Spiral
 • A2 - Oblique, angle > 30 degrees
 • A3 - Transverse, angle < 30 degrees
 
32B - Wedge  • B1 - Spiral wedge
 • B2 - Bending wedge
 • B3 - Fragmented wedge

32C - Complex  • C1 - Spiral
 • C2 - Segmental
 • C3 - Irregular

 
Presentation
  • Initial evaluation
    • Advanced Trauma Life Support (ATLS) should be initiated
  • Symptoms
    • pain in thigh
  • Physical exam
    • inspection
      • tense, swollen thigh
        • blood loss in closed femoral shaft fractures is 1000-1500ml 
          • for closed tibial shaft fractures, 500-1000ml
        • blood loss in open fractures may be double that of closed fractures
      • affected leg often shortened
      • tenderness about thigh
    • motion
      • examination for ipsilateral femoral neck fracture often difficult secondary to pain from fracture
    • neurovascular
      • must record and document distal neurovascular status
Imaging
  • Radiographs
    • recommended views
      • AP and lateral views of entire femur
      • AP and lateral views of ipsilateral hip
        • important to rule-out coexisting femoral neck fracture
      • AP and lateral views of ipsilateral knee
  • CT
    • indications
      • may be considered in midshaft femur fractures to rule-out associated femoral neck fracture
Treatment
  • Nonoperative
    • long leg cast
      • indications
        • nondisplaced femoral shaft fractures in patients with multiple medical comorbidities
  • Operative
    • antegrade intramedullary nail with reamed technique 
      • indications
        • gold standard for treatment of diaphyseal femur fractures
      • outcomes
        • stabilization within 24 hours is associated with
          • decreased pulmonary complications (ARDS)
          • decreased thromboembolic events
          • improved rehabilitation
          • decreased length of stay and cost of hospitalization
        • exception is a patient with a closed head injury
          • critical to avoid hypotension and hypoxemia  
          • consider provisional fixation (damage control)
    • retrograde intramedullary nail with reamed technique
      • indications
        • ipsilateral femoral neck fracture 
        • floating knee (ipsilateral tibial shaft fracture) 
          • use same incision for tibial nail
        • ipsilateral acetabular fracture
          • does not compromise surgical approach to acetabulum
        • multiple system trauma
        • bilateral femur fractures
          • avoids repositioning
        • morbid obesity
      • outcomes
        • results are comparable to antegrade femoral nails
        • immediate retrograde or antegrade nailing is safe for early treatment of gunshot femur fractures 
    • external fixation with conversion to intramedullary nail within 2-3 weeks
      • indications
        • unstable polytrauma victim 
        • vascular injury
        • severe open fracture
    • ORIF with plate
      • indications
        • ipsilateral neck fracture requiring screw fixation
        • fracture at distal metaphyseal-diaphyseal junction
        • inability to access medullary canal
      • outcomes
        • inferior when compared to IM nailing due to increased rates of:
          • infection 
          • nonunion 
          • hardware failure
Surgical Techniques
  • Antegrade intramedullary nailing    
    • approach
      • 3 cm incision proximal to the greater trochanter in line with the femoral canal
    • technique
      • starting points
        • piriformis entry   
          • pros
            • colinear trajectory with long axis of femoral shaft
          • cons
            • starting point more difficult to access, especially in obese patients
            • causes the most significant damage to
              • abductor muscles and tendons
                • may result in abductor limp
              • blood supply to the femoral head
                • may result in AVN in pediatric patients
        • trochanteric entry
          • pros
            • minimizes soft tissue injury to abductors
            • easier starting point than piriformis entry nail
          • cons
            • not colinear with the long axis of femoral shaft
            • must use nail specifically designed for trochanteric entry
              • use of a straight nail may lead to varus malalignment
      • reaming
        • reamed nailing superior to unreamed nailing, with:
          • increased union rates
          • decreased time to union
          • no increase in pulmonary complications
        • indications for unreamed nail
          • consider for patient with bilateral pulmonary injuries
      • interlocking screws
        • technique
          • computer-assisted navigation for screw placement decreases radiation exposure
          • widening/overlap of the interlocking hole in the proximal-distal direction
            • correct with adjustment in the abduction/adduction plane
          • widening/overlap of the interlocking hole in the anterior-posterior plane
            • correct with adjustment in the internal/external rotation plane
    • postoperative care
      • weight-bearing as tolerated 
      • range of motion of knee and hip is encouraged
    • pros
      • 98-99% union rate
      • low complication rate
        • infection risk 2%
    • cons
      • not indicated for use with ipsilateral femoral neck fracture
      • increased rate of HO in hip abductors with antegrade nailing
      • increased rate of hip pain compared with retrograde nailing
      • mismatch of the radius of curvature of the femoral shaft and intramedullary nails can lead to anterior perforation of the distal femur
  • Retrograde intramedullary nailing  
    • approach
      • 2 cm incision starting at distal pole of patella
      • medial parapatellar versus transtendinous approaches
      • nail inserted with knee flexed to 30-50 degrees
    • technique
      • entry point
        • center of intercondylar notch on AP view
        • extension of Blumensaat's line on lateral
          • posterior to Blumensaat's line risks damage to cruciate ligaments
    • postoperative care
      • weight-bearing as tolerated
      • range of motion of knee and hip is encouraged
    • pros
      • technically easier
      • union rates comparable to those of antegrade nailing
      • no increased rate of septic knee with retrograde nailing of open femur fractures
    • cons
      • knee pain
      • increased rate of interlocking screw irritation
      • cartilage injury
      • cruciate ligament injury with improper starting point
  • External fixation with conversion to intramedullary nail within 2-3 weeks
    • technique
      • safest pin location sites are anterolateral and direct lateral regions of the femur
      • 2 pins should be used on each side of the fracture line
    • pros
      • prevents further pulmonary insult without exposing patient to risk of major surgery
      • may be converted to IM fixation within 2-3 weeks as a single stage procedure
    • cons
      • pin tract infection
      • knee stiffness
        • due to binding/scarring of quadriceps mechanism
  • Special considerations
    • ipsilateral femoral neck fracture
      • priority goes to fixing femoral neck because anatomic reduction is necessary to avoid complications of AVN and nonunion
      • technique
        • preferred methods
          • screws for neck with retrograde nail for shaft
          • screws for neck and plate for shaft
          • compression hip screw for neck with retrograde nail for shaft
        • less preferred methods
          • antegrade nail with screws anterior to nail
            • technically challenging
Complications
  • Heterotopic ossification
    • incidence
      • 25%
    • treatment
      • rarely clinically significant
  • Pudendal nerve injury
    • incidence
      • 10% when using fracture table with traction
  • Femoral artery or nerve injury
    • incidence
      • rare
    • cause
      • can occur when inserting proximal interlocking screws during a retrograde nail
  • Malunion and rotational malalignment          
    • most accurately determined by the Jeanmart method 
      • angle between a line drawn tangential to the femoral condyles and a line drawn through the axis of the femoral neck
      • malrotation up to 15 degrees is usually well tolerated
    • incidence
      • proximal fractures 30%
      • distal fractures 10%
    • risk factors
      • use of a fracture table increases risk of internal rotation deformities when compared to manual traction
      • fracture comminution   
      • night-time surgery
    • treatment
      • if noticed intraoperatively, remove distal interlocking screws and manually correct rotation
      • if noticed after union, osteotomy is required
  • Delayed union
    • treatment
      • dynamization of nail with or without bone grafting
  • Nonunion
    • incidence
      • <10%
    • risk factors
      • postoperative use of nonsteroidal anti-inflammatory drugs
      • smoking is known to decrease bone healing in reamed antegrade exchange nailing for atrophic non-unions 
    • treatment
      • reamed exchange nailing
  • Infection
    • incidence
      • < 1%
    • treatment
      • removal of nail and reaming of canal
      • external fixation used if fracture not healed
  • Weakness
    • quadriceps and hip abductors are expected to be weaker than contralateral side
  • Iatrogenic fracture etiologies 
    • risk factors
      • antegrade starting point 6mm or more anterior to the intramedullary axis
        • however, anterior starting point improves position of screws into femoral head
      • failure to overream canal by at least .5mm
  • Mechanical axis deviation (MAD)  
    • lengthening along the anatomical axis of the femur leads to lateral MAD
    • shortening along the anatomical axis of the femur leads to medial MAD
  • Anterior cortical penetration 
 

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