Please rate topic.
Average 4.4 of 73 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 23-year-old man undergoes intramedullary nailing for a comminuted right femur fracture. Three weeks after surgery, CT scans are performed to assess for rotational malalignment. In Figure A, the angular rotation of the right femoral neck is internal rotation of 13° while the angular rotation of the left femoral neck is external rotation of 13°. In Figure B, the angular rotation of the right and left femoral condyles is external rotation of 17° and 3°, respectively. At revision surgery, in order to correct the rotational malalignment, the right distal femur must be rotated which of the following?
Internally by 20°
Externally by 20°
Internally by 14°
Externally by 14°
Internally by 40°
Select Answer to see Preferred Response
This patient has an external rotation deformity of 40° of the distal fragment of the right femur. Correction would entail rotating the distal fragment internally by 40°.
The right femoral neck (RFN) is internally rotated (IR) by 13° to the horizontal (IR13). The left femoral neck (LFN) is externally rotated (ER) by 13° to the horizontal (ER13). The right distal fragment (RDF) is ER17. The left distal fragment (LDF) is ER3. Bringing both femoral necks to ER0/IR0 gives the absolute amount of rotation of the distal fragment to the horizontal. To do this, the RFN has to EXTERNALLY rotate 13° and the LFN has to INTERNALLY rotate 13°. Thus, RDF has a total of ER(13+17)=ER30, and LDF has IR(13-3)=IR10 to the horizontal. To correct the RDF from ER30 to IR10, internal rotation of 40° must occur.
Malrotation is the most common cause of limb deformity after nailing. To avoid this, patients should be examined for rotation and limb length after insertion of static interlocks, before leaving the operating room. Correction is easier to perform prior to fracture union. Drill-hole cutout is possible if correction<20° if the previous distal locking site is to be used because of the proximity of the new interlock to the previous interlock. To avoid this, (1) use alternative locking holes or the dynamic locking slot, or (2) advance or retract the nail to avoid previous locking sites.
Lindsey et al. reviewed rotational malalignment after femoral nailing. The incidence of rotational malalignment was 27.6%. Normal femoral neck anteversion (angle of the femoral neck relative to the transverse axis through the femoral condyles) is 11-13°. Some patients have up to 15° difference in version between limbs.
Jaarsma et al. reviewed rotational malalignment after nailing of 76 femoral fractures. The incidence of rotational malalignment >=15° was 28%. Patients with an ER malalignment (n = 12) had more functional problems than patients with a IR malalignment (n = 9).
Answer 1: This answer would be correct if LFN was IR13, and LDF was IR3, giving absolute LDF rotation of ER10. Then to correct ER30 (right) to ER10 (left), internal rotation of 20° would be needed.
Answers 2, 4: The RDF is more externally rotated. Correction must involve internal rotation.
Answer 3: This answer would be correct if LFN was IR13, giving absolute LDF rotation of ER16. Then to correct ER30 (right) to ER16 (left), internal rotation of 14° must occur.
Lindsey JD, Krieg JC
J Am Acad Orthop Surg. 2011 Jan;19(1):17-26. PMID: 21205764 (Link to Abstract)
Lindsey, JAAOS 2011
Jaarsma RL, Pakvis DF, Verdonschot N, Biert J, van Kampen A.
J Orthop Trauma. 2004 Aug;18(7):403-9. PMID: 15289684 (Link to Abstract)
Jaarsma, JOT 2004
Please rate question.
Average 2.0 of 68 Ratings
A 25-year-old male presents following a motor vehicle collision with a Glasgow Coma Scale of 7. Subsequent imaging in the trauma bay demonstrates a bifrontal cerebral contusion, an L4 burst fracture, multiple rib fractures, an LC-1 type pelvic ring injury, a femoral shaft fracture, and an open ipsilateral tibial shaft fracture. He is intubated and an intracranial pressure monitor is placed which consistently measures 30mm Hg. He is normotensive with a lactate of 1.5 after 2 liters of crystalloid and 1 unit of packed red blood cells. Which of his injuries would most dictate a temporizing approach with external fixation of his femoral shaft fracture instead of reamed intramedullary nailing?
L4 burst fracture
Bifrontal cerebral contusion
Open ipsilateral tibia fracture
LC1 pelvic ring injury
In the setting of a severe closed head injury such as a bifrontal cerebral contusion with elevated intracranial pressures, external fixation of a femoral shaft fracture is indicated to limit the risk of intraoperative hypotension and decreased cerebral perfusion pressure.
Immediate reamed nailing remains the standard treatment for the vast majority of femoral shaft fractures, however patients with multiple injuries with incomplete resuscitation and patients with severe intracranial trauma may benefit from a damage control approach with external fixation.
Anglen et al retrospectively reviewed the intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in patients undergoing femoral nailing. The authors found a significant decrease in intraoperative CPP, especially in those patient undergoing femoral nailing in the first 24 hours, however they were unable to demonstrate a link between the decreased CPP and poor patient outcomes.
Pietropaoli et al examined the effects of intraoperative hypotension on patients with blunt head trauma. The authors found that 32% of patients experienced intraoperative hypotension (systolic blood pressure less than 90mm Hg) and those patients with a hypotensive episode had an 82% mortality and significantly worse outcomes on the Glasgow Outcomes Scale.
McKee et al conducted a retrospective cohort study comparing matched groups of patients with femoral shaft fractures with and without a closed head injury. In contrast to previous studies, the authors found no significant difference in outcome between the groups including mortality, hospital length of stay or neuropsychologic testing.
Illustration A shows a femoral shaft fracture treated with external fixation.
Answer 1, 3-5: Immediate reamed nailing would not change the outcome of any of these injuries
Anglen JO, Luber K, Park T.
J Trauma. 2003 Jun;54(6):1166-70. PMID: 12813339 (Link to Abstract)
Anglen, JTACS 2003
Pietropaoli JA, Rogers FB, Shackford SR, Wald SL, Schmoker JD, Zhuang J.
J Trauma. 1992 Sep;33(3):403-7. PMID: 1404509 (Link to Abstract)
Pietropaoli, JTACS 1992
McKee MD, Schemitsch EH, Vincent LO, Sullivan I, Yoo D.
J Trauma. 1997 Jun;42(6):1041-5. PMID: 9210538 (Link to Abstract)
McKee, JTACS 1997
Average 4.0 of 8 Ratings
A 24-year-old male sustains the isolated injuries shown in Figures A and B during a high-speed motor vehicle accident. On physical examination, the overlying skin is intact and there is no evidence of a Morel-Lavallée lesion. Which of the following surgical techniques is considered to have the highest rate of fracture malreduction with this combined injury?
Antegrade cephalomedullary nail
Retrograde intramedullary nail and 3 cannulated screws
Retrograde intramedullary nail and sliding hip screw
Antegrade intramedullary nail and 3 cannulated screws
Plate fixation of the diaphyseal fracture and 3 cancellous screws
Figures A and B show displaced ipsilateral femoral neck and shaft fractures. Fixation with a single implant, such as an antegrade cephalomedullary device, has been shown to have the highest rate of fracture malreduction with displaced fractures.
Approximately 5% of femoral shaft fractures are accompanied by ipsilateral neck fractures. Fixation methods to stabilize these fractures may be accomplished by using a single implant or two separate implants. Single implant techniques are thought to reduce operative time and blood loss by simultaneously fixing nondisplaced fractures. With displaced fractures, single implant techniques have been shown to have a higher rate of malreduction of at least one of the two fractures. Two separate implant devices are recommended in these scenarios.
Bedi et al. examined a retrospective cohort of 40 patients with ipsilateral femoral neck and shaft fractures. They showed that using a single cephalomedullary device for fixation of both femoral shaft and neck fractures led to a significantly higher rate of fracture malreduction (3 of 9), in comparison to a staged, two implant strategy (0 of 28) (P = 0.01).
Peljovich et al. reviewed the presentation and management of ipsilateral femoral neck and shaft fractures. To reduce complications of AVN, malunion and nonunion, they suggest obtaining anatomic reduction and rigid fixation of the femoral neck fracture first with 3 cannulated screws, blade plate, or sliding hip screw. The shaft fracture can then be reduced and stabilized with either retrograde intramedullary femoral nailing or plating.
Answers 2,3,4,5: Fixation of femoral neck and shaft fractures using two separate implant devices has a lower rate of malreduction. No study to date has conclusively demonstrated superiority of any particular combination of devices in long-term studies.
Bedi A, Karunakar MA, Caron T, Sanders RW, Haidukewych GJ.
J Orthop Trauma. 2009 Apr;23(4):249-53. PMID: 19318867 (Link to Abstract)
Bedi, JOT 2009
Peljovich AE, Patterson BM.
J Am Acad Orthop Surg. 1998 Mar-Apr;6(2):106-13. PMID: 9682073 (Link to Abstract)
Peljovich, JAAOS 1998
Average 4.0 of 13 Ratings
A 34-year-old male presents after falling off a roof at his job. He has an obvious deformity of his left lower extremity, and injury radiographs are shown in Figures A and B. He has no other injuries. Which of the following definitive treatment algorithms will most likely lead to the best outcomes in this patient?
Closed reduction and percutaneous screw fixation of the femoral neck, followed by reamed antegrade nailing of the femur fracture
Reamed antegrade nailing of the femoral shaft fracture, followed by open reduction and percutaneous screw fixation of the femoral neck fracture
Reamed retrograde nailing of the femoral shaft fracture, followed by closed reduction and percutaneous screw fixation of the femoral neck
Open reduction and screw fixation of the femoral neck, followed by reamed retrograde nailing of the femoral shaft fracture
Open reduction and screw fixation of the femoral neck, followed by plating of the femoral shaft fracture
The clinical presentation is consistent with a femoral shaft fracture with an ipsilateral femoral neck fracture. Of the options presented, the most appropriate treatment is open reduction and lag screw fixation of the femoral neck fracture followed by reamed retrograde nailing of the femoral shaft fracture.
Ipsilateral femoral neck/shaft fractures are an uncommon injury estimated to occur in 2-6% of all femoral shaft fractures. It is generally agreed upon that due to the potentially devastating complications of the femoral neck fracture in young patients, the neck fracture should be treated first and the shaft fracture second. Anatomic reduction of the femoral neck fracture is paramount in obtaining successful healing, and therefore open reduction is recommended in the setting of fracture displacement. Provisional reduction of the femoral neck fracture, followed by antegrade nailing with subsequent addition of definitive fixation of the femoral neck is also acceptable.
Peljovich et al. present a review article on ipsilateral femoral neck and shaft fractures. The treatment algorithm they propose consists of first treating the femoral neck fracture, and then addressing the femoral shaft fracture with retrograde nailing. They also highlight the risk and benefits of each treatment approach.
Watson et al. reviewed 13 patients who had healing complications after undergoing surgical fixation of their ipsilateral femoral neck and shaft fractures. They found that lag screw fixation of the femoral neck fracture and reamed intramedullary nailing for shaft fracture stabilization were associated with the fewest complications. Therefore, this approach was recommended as the treatment of choice.
Figures A and B demonstrate an ipsilateral comminuted femoral shaft fracture, and a displaced femoral neck fracture. Illustrations A-C show an example of a femoral shaft fracture with an ipsilateral femoral neck fracture treated with lag screws of the femoral neck fx and retrograde nailing.
Answer 1: Open reduction of the femoral neck fracture with anatomic alignment is preferred to closed reduction in this case.
Answer 2,3: The femoral neck fracture should be addressed first.
Answer 5: Nailing of the femoral shaft fracture would be preferred initially in this case to prevent disruption of the biology and fracture healing around the comminuted segments.
Watson JT, Moed BR
Clin. Orthop. Relat. Res.. 2002 Jun;(399):78-86. PMID: 12011697 (Link to Abstract)
Watson, CORR 2002
Average 4.0 of 18 Ratings
A 22-year-old male sustains the injury seen in Figures A and B as the result of a motor vehicle collision. He subsequently undergoes the procedure shown in Figures C and D with a 12 millimeter nail. When would full weight-bearing be allowed after surgery?
After consolidation is seen
Comminuted femoral shaft fractures treated with statically locked intramedullary nails of appropriate diameter can be treated with immediate weight-bearing, with little risk of nail/screw breakage or deformity. Immediate range of motion and weight-bearing can be extremely beneficial to short-term patient outcomes, especially in polytrauma patients.
Brumback et al.(1988) reviewed 133 dynamically locked femoral nails and report that 10.5% lost fixation and/or reduction postoperatively. They recommend reviewing high-quality radiographs to determine fracture characteristics, and note that dynamic fixation only be considered for transverse fracture patterns.
Brumback et al.(1988) performed a prospective series of 97 patients with statically locked femoral nails, and they report that 98% of these went on to successful union without additional procedures, and the 2% with nonunions were successfully treated with later conversion to dynamic interlocking. They also found that no implant failure or deformity occurred with early walking or weight-bearing.
Brumback et al.(1999) reviewed the biomechanics of immediate weight-bearing after statically locked intramedullary nails are used in a segmental femur model, and they found that it would be safe. They then looked at immediate weight-bearing of these fractures after statically locked nail insertion in a series of 35 patients, and found no loss of reduction or implant failure with immediate weight-bearing.
Figures A and B show a comminuted, segmental femoral shaft fracture, while Figures C and D show the immediate postoperative radiographs of this patient after intramedullary nailing.
Answers 2-5: Delay in weight-bearing is not required for this injury pattern, if treated with an appropriate diameter statically locked intramedullary nail.
Brumback RJ, Reilly JP, Poka A, Lakatos RP, Bathon GH, Burgess AR.
J Bone Joint Surg Am. 1988 Dec;70(10):1441-52. PMID: 3198668 (Link to Abstract)
Brumback, JBJS 1988
Brumback RJ, Uwagie-Ero S, Lakatos RP, Poka A, Bathon GH, Burgess AR.
J Bone Joint Surg Am. 1988 Dec;70(10):1453-62. PMID: 3198669 (Link to Abstract)
Brumback RJ, Toal TR Jr, Murphy-Zane MS, Novak VP, Belkoff SM.
J Bone Joint Surg Am. 1999 Nov;81(11):1538-44. PMID: 10565645 (Link to Abstract)
Brumback, JBJS 1999
HPI - Collided with a car while he was riding a motor bike 2 days ago.
How would you treat this injury?
Average 3.0 of 17 Ratings
A 25-year-old male sustained a closed midshaft femur fracture following a motor vehicle collision. He is taken to the operating room for supine intramedullary nail fixation of the fracture. Figure A is a lateral fluoroscopic view of the distal femur taken just prior to distal interlocking screw placement. What change in position (with the C-arm stationary) would be expected to produce a perfect lateral view of the interlocking hole?
Raising the leg
Lowering the leg
Internal (or external) rotation of the leg
Abduction (or adduction) of the leg
Interlocking of intramedullary nails using fluoroscopy requires attention to detail. A true lateral of the intramedullary nail is present when "perfect circle" views of interlocking holes are present. Once perfect circles are obtained, the drill can be advanced parallel to the fluoroscopic beam.
Knowledge of the implications of the appearance of the interlocking holes when "perfect circles" are not present can be helpful in minimizing the number of manipulations and fluoroscopic exposure. Widening of the interlocking hole in the proximal-distal direction (as is seen in this case) signifies the need for an adjustment in the abduction/adduction plane. Similarly, widening of the interlocking hole in the anterior-posterior plane signifies the need for an adjustment in the internal/external rotation plane (Answer 3).
Raising or lowering the leg (Answer A and B) should not have major effects of the appearance of the interlocking hole. Similarly, magnification of the C-arm (Answer D) will not affect the appearance. Internal/external rotation will result in widening in the anterior-posterior plane (as this dimension is currently adequate). Abduction or adduction will result in creating "perfect circles" (Answer 4). The position of the leg may hint to which of these is correct. If further widening occurs in the proximal-distal direction, the opposite maneuver will correct to the proper position.
Average 4.0 of 30 Ratings
Which of the following is an advantage of computer-assisted navigation used to place medullary nail interlocking screws compared to a freehand techinque?
Reduced fluoroscopy time
More reliable placement of interlocking screws through the nail
Reduced procedure time
Increased quality of fluoroscopic images
Improved accuracy of screw length
Computer-assisted navigation has been shown to reduce radiation exposure for surgeons when performing interlocking of medullary nails compared to free-hand technique.
Ricci et al compared two fluoroscopic navigation tracking technologies, optical and electromagnetic versus standard freehand fluoroscopic targeting, in a standardized foam block model for placement of interlocking screws. They found that fluoroscopy time (seconds) and number of fluoroscopy images were significantly less when using the computer-guided systems than for freehand-unguided insertion. Average distance of pin placement from the target in the foam blocks was significantly greater for controls than for each of the navigated systems.
Suhm et al performed a prospective controlled clinical study to compare fluoroscopic guidance with fluoroscopy-based surgical navigation for distal locking of intramedullary implants. The surgical navigation group showed increased procedure time, but equivalent precision with reduced radiation exposure. There was no significant difference in the technical reliability between both groups.
Ricci WM, Russell TA, Kahler DM, Terrill-Grisoni L, Culley P.
J Orthop Trauma. 2008 Mar;22(3):190-4. PMID: 18317053 (Link to Abstract)
Ricci, JOT 2008
Suhm N, Messmer P, Zuna I, Jacob LA, Regazzoni P.
Injury. 2004 Jun;35(6):567-74. PMID: 15135275 (Link to Abstract)
Suhm, INJURY 2004
Average 2.0 of 18 Ratings
A 22-year-old male undergoes retrograde intramedullary nailing for the injury seen in Figure A. Which of the following would place branches of the femoral nerve and deep femoral artery at greatest risk during placement of the interlocking screw seen in Figure B?
Anterior to posterior placement above the lesser trochanter
Anterior to posterior placement below the lesser trochanter
Lateral to medial placement above the lesser trochanter
Lateral to medial placement below the lesser trochanter
Open placement with blunt dissection down to bone
Branches of the deep femoral artery and femoral nerve are most at risk during placement of anterior to posterior interlocking screws below the level of the lesser trochanter as seen in Figure B.
Riina et al performed a cadaveric study examining the neurovascular structures at risk during proximal interlocking of retrograde femoral nails and found that the first division of the femoral nerve crossed the femur on average approximately 4cm distal to the piriformis fossa. In addition, the femoral artery was closest to the medial aspect of the femur 4cm distal to the lesser trochanter. The authors recommend placement of interlocking screws proximal to the lesser trochanter to minimize risk of iatrogenic neurovascular injury.
Brown et al attempt to define relative safe zones (RSZs) for placement of both lateral-medial and anterior-posterior interlocking screws of femoral nails in patients with acetabular fractures with reference to the location of the femoral neurvascular structures at the level of the lesser trochanter. The authors found that the available safe zone for placement of anterior-posterior screws decreased more than 50% in the setting of hematoma from acetabular fracture, and they recommend blunt dissection to bone and use of a single incison between the proximal interlocking holes to minimize risk to these structures.
Handolin et al present two case reports of injury to the deep femoral artery with proximal interlocking screws during retrograde nailing. Based on their experiences, the authors advocate for blunt dissection to bone to avoid entrapment of critical structures when places these screws.
Illustration A shows a cadaveric dissection and illustration of the numerous branches of the deep femoral artery and femoral nerve as they cross the femur from medial to lateral on the anterior surface just below lesser trochanter. The view is of the anterior thigh from the medial aspect. The sartorius has been cut and reflected and the retractors are beneath the rectus femoris.
Riina J, Tornetta P 3rd, Ritter C, Geller J.
J Orthop Trauma. 1998 Aug;12(6):379-81. PMID: 9715443 (Link to Abstract)
Riina, JOT 1998
Brown GA, Firoozbakhsh K, Summa CD.
J Orthop Trauma. 2001 Aug;15(6):433-7. PMID: 11514771 (Link to Abstract)
Brown, JOT 2001
Handolin L, Pajarinen J, Tulikoura I.
Acta Orthop Scand. 2003 Feb;74(1):111-3. PMID: 12635806 (Link to Abstract)
Handolin, ACTA 2003
Average 4.0 of 29 Ratings
A 34-year-old male is involved in a motor vehicle collision and sustains several orthopaedic injuries. Figure A shows a red line representating a fracture of the proximal femur. This fracture orientation is most often present when found concomitantly with which of the following orthopaedic injuries?
Ipsilateral acetabular fracture
lumbar spine burst fracture
Ipsilateral femoral shaft fracture
Anterior-posterior compression pelvic injury
Ipsilateral calcaneus fracture
Femoral neck fractures are seen less than 10% of the time with femoral shaft fractures, but they are frequently missed on initial evaluation. When present, the pattern is typically nondisplaced, vertical, and basicervical.
The review article by Peljovich and Patterson note that the femoral shaft component of the combined injury is typically in the middle third and is often comminuted.
The article by Tornetta et al reports that they reduced the delay in diagnosis of concomitant femoral neck fractures by 91% by instituting a protocol that included: dedicated AP internal rotation plain radiograph, a fine (2-mm) cut CT scan through the femoral neck, an intraoperative fluoroscopic lateral radiograph prior to fixation, as well as postoperative AP and lateral radiographs of the hip in the operating room prior to awakening the patient.
The article by Wiss et al noted that 18% of their ipsilateral femoral neck/shaft cohort developed a symptomatic varus nonunion requiring a valgus osteotomy. It is significant to note that in this study, the shaft fractures were fixed prior to definitive neck stabilization, and the review article by Peljovich emphasizes that the neck fracture should be treated first and the shaft fracture second.
Tornetta P, Kain MS, Creevy WR
J Bone Joint Surg Am. 2007 Jan;89(1):39-43. PMID: 17200308 (Link to Abstract)
Tornetta, JBJS 2007
Wiss DA, Sima W, Brien WW.
J Orthop Trauma. 1992;6(2):159-66. PMID: 1602335 (Link to Abstract)
Wiss, JOT 1992
Average 4.0 of 24 Ratings
Which of the following factors is most associated with malrotation during antegrade or retrograde femoral nailing?
Level of primary fracture line
Use of a piriformis starting portal
Closed reduction technique
Femoral malrotation after intramedullary nailing is unfortunately a possibility with either antegrade or retrograde nailing techniques. Malrotation and iatrogenic length changes are most common when comminution is present, as cortical reads are inherently limited.
Hufner et al report that malrotation (internal or external >15 degrees) was seen in 22% of their patients via CT scan after intramedullary nailing. There was a significant difference depending on the time of surgery, with significantly more malrotation during the night shift. Increased fracture comminution also significantly increased malrotation rates.
1,2,3,5: No significant increases were seen with the other answers listed above.
Hufner T, Citak M, Suero EM, Miller B, Kendoff D, Krettek C, Citak M
J Orthop Trauma. 2011 Apr;25(4):224-7. PMID: 21399472 (Link to Abstract)
Hufner, JOT 2011
Average 3.0 of 21 Ratings
A 29-year-old male sustained a mid-shaft femur fracture in a motorcycle accident. Which of the following is associated with approximately 5% of patients sustaining this injury?
Ipsilateral femoral neck fracture
Ipsilateral posterolateral corner injury
Pudendal nerve injury
Ipsilateral superficial femoral artery injury
Ipsilateral femoral neck fractures are seen in 1-9% of femoral shaft fractures and the femoral neck must be properly imaged either preoperatively or intraoperatively in any patient with a femoral shaft fracture. Dedicated hip films, possibly including an internal rotation AP, should be obtained before entering the OR.
Daffner et al reported that in 11 of 20 cases of combined femoral shaft and neck fractures, the initial preoperative radiographs did not demonstrate the femoral neck fracture. Intraoperative fluoroscopy should also be used to evaluate for a femoral neck fracture both before (to evaluate for unrecognized fx) and after (to evaluate for iatrogenic fx) IM nailing.
Tornetta et al also describe using preoperative CT scans to evaluate for a femoral neck fracture and found that they were able to reduce the number of missed ipsilateral femoral neck fractures.
Daffner RH, Riemer BL, Butterfield SL.
Skeletal Radiol. 1991;20(4):251-4. PMID: 1853215 (Link to Abstract)
Daffner, SRAD 1991
Average 3.0 of 28 Ratings
A 26-year-old male sustains a femoral shaft fracture treated with the implant shown in Figure A. Postoperatively, what muscular deficits can be expected at medium and long-term follow-up?
Weakness with hip abduction and knee flexion
Weakness with hip abduction and knee extension
Weakness with knee flexion and knee extension
Weakness with hip external rotation and hip abduction
Weakness with hip external rotation and hip flexion
Figure A shows a femoral shaft fracture treated with an antegrade femoral nail. Long term deficits are weakness with knee extension (quadriceps) and hip abduction (glutei muscles).
The referenced study by Kapp et al noted long term quadriceps weakness as well as decreased bone mineral density in the femur (femoral neck by 9%, the lateral cortex by 20% and the medial cortex by 13%). It is unclear whether this is due to the injury, treatment, or a combination of both.
The second referenced study by Archdeacon et al also noted weakness in hip abduction, which showed time dependent improvement. He reports that increased early ipsilateral trunk lean is associated with worse recovery of abduction strength.
Kapp W, Lindsey RW, Noble PC, Rudersdorf T, Henry P.
J Trauma. 2000 Sep;49(3):446-9. PMID: 11003321 (Link to Abstract)
Kapp, JTACS 2000
Archdeacon M, Ford KR, Wyrick J, Paterno MV, Hampton S, Ludwig MB, Hewett TE.
J Orthop Trauma. 2008 Jan;22(1):3-9. PMID: 18176158 (Link to Abstract)
Archdeacon, JOT 2008
Average 1.0 of 153 Ratings
Antegrade femoral nailing has an increased rate of which of the following when compared to retrograde femoral nailing?
Subsequent operative procedures
In the referenced study by Ricci et al, antegrade femoral nailing was shown to have an increased rate of hip pain as compared to retrograde femoral nailing, while having a similar rate of union, time to union, rate of malalignment, and operative time. Hip pain was signficantly higher in the antegrade nailing group, while knee pain was significantly greater in the retrograde group.
The referenced study by Winquist et al noted a 99.1% union rate with intramedullary nailing.
The referenced study by Moed et al noted a 6% nonunion rate in non-reamed retrograde femoral nailing with nail dynamization at 6-12 weeks and early weightbearing.
Ricci WM, Bellabarba C, Evanoff B, Herscovici D, DiPasquale T, Sanders R.
J Orthop Trauma. 2001 Mar-Apr;15(3):161-9. PMID: 11265005 (Link to Abstract)
Ricci, JOT 2001
Winquist RA, Hansen ST Jr, Clawson DK.
J Bone Joint Surg Am. 1984 Apr;66(4):529-39. PMID: 6707031 (Link to Abstract)
Winquist, JBJS 1984
Moed BR, Watson JT, Cramer KE, Karges DE, Teefey JS.
J Orthop Trauma. 1998 Jun-Jul;12(5):334-42. PMID: 9671185 (Link to Abstract)
Moed, JOT 1998
Average 3.0 of 16 Ratings
A 38-year-old male was struck by a truck and sustained the injury seen in figure A. Treating this injury with an intramedullary nail with a larger radius of curvature can lead to what complication?
Posterior perforation of the distal femur
Comminution of the fracture site
Iatrogenic femoral neck fracture
Anterior perforation of the distal femur
According to the study by Egol et al, the average femoral anterior radius of curvature was 120 cm (+/- 36 cm), and currently available femoral nails have a greater radius of curvature (i.e. more straight). This mismatch has been shown to lead to an increased risk of perforation of the anterior distal femur as the nail is impacted into the canal.
The referenced study by Tencer et al noted an increased risk of iatrogenic femoral fracture with anterior starting point >6mm from the anatomic axis. They recommend starting in line with the femoral axis, or just a few millimeters anterior in order to minimize this risk.
Illustration A depicts anterior femoral cortex penetration secondary to nail/femur radius of curvature mismatch.
Tencer AF, Sherman MC, Johnson KD.
J Biomech Eng. 1985 May;107(2):104-11. PMID: 3999706 (Link to Abstract)
Egol KA, Chang EY, Cvitkovic J, Kummer FJ, Koval KJ
J Orthop Trauma. 2004 Aug;18(7):410-5. PMID: 15289685 (Link to Abstract)
Egol, JOT 2004
Average 4.0 of 15 Ratings
Reamed femoral intramedullary nailing is associated with a higher rate of which of the following, as compared to nonreamed nailing for distal femoral shaft fractures?
Need for transfusion
Reamed intramedullary femoral nailing is associated with a higher rate of union than nonreamed femoral nailing.
The reference by the Canadian group randomized 224 patients to reamed vs. unreamed femoral nails and found that the relative risk of nonunion was 4.5x greater without reaming, and nonunion was also greater with the use of a small-diameter nail.
The referenced article by Tornetta et al randomized 81 patients to reamed or unreamed nails and found more intraoperative technical complications in the group without reaming. There was no statistical difference in OR time, transfusion requirement or pulmonary complications between the groups. This study showed the overall union rate was similar but when they selected out distal femur fractures, the reamed group healed faster.
The reference by Brumback et al is a review of reamed v. nonreamed nailing, with discussions of reaming techniques and the importance of proper reamer technology and usage.
Tornetta P 3rd, Tiburzi D.
J Orthop Trauma. 1997 Feb-Mar;11(2):89-92. PMID: 9057141 (Link to Abstract)
Tornetta, JOT 1997
Brumback RJ, Virkus WW
J Am Acad Orthop Surg. 8(2):83-90. PMID: 10799093 (Link to Abstract)
Brumback, JAAOS 2000
Canadian Orthopaedic Trauma Society.
J Bone Joint Surg Am. 2003 Nov;85-A(11):2093-6.PMID: 14630836 (Link to Abstract)
Canadian, JBJS 2003
Average 3.0 of 26 Ratings
Your 25-year-old patient complains of anterior knee pain after retrograde femoral nailing for a diaphyseal fracture and asks you why you didn’t perform antegrade nailing as he has seen on the internet. You tell him that retrograde nailing is your preferred technique over antergrade nailing for diaphyseal femoral fractures because it has been shown to have which of the following?
Increased rate of union
Decreased rate of infection
Shorter operative time
Lower rates of hip pain
Lower rates of knee pain
Patients with retrograde femoral nails commonly have knee pain, while antegrade nails commonly have hip pain, abductor weakness and heterotopic ossification of the abductors.
Ostrum’s randomized prospective study of 100 patients with reamed femoral nails found 22% of antegrade nail patients had proximal hip pain, weak hip abductors or trendelenburg gait. No significant difference was found in set-up time, operative time, knee motion or pain, or infection rates.
Ricci performed a retrospective study of 293 fractures and found that the antegrade femoral nail group had more hip pain (10% vs 4%) and the retrograde nail group had more knee pain (36% vs 9%). There was no difference in healing, malunion, non-union or other complications.
Tornetta performed a randomized controlled comparison of 69 femur fractures and found more problems of length and rotation using a retrograde nailing. There was no difference in time to union, operating time, blood loss, complications, size of nail or reamer, or transfusion requirements.
Tornetta P, Tiburzi D
J Bone Joint Surg Br. 2000 Jul;82(5):652-4. PMID: 10963159 (Link to Abstract)
Tornetta, BJJ 2000
Ostrum RF, Agarwal A, Lakatos R, Poka A
J Orthop Trauma. 2000 Sep-Oct;14(7):496-501. PMID: 11083612 (Link to Abstract)
Ostrum, JOT 2000
Average 3.0 of 23 Ratings
A 26-year-old male presents after a motor vehicle accident. Work-up reveals a closed left femoral shaft fracture, and an ipsilateral posterior wall fracture. He undergoes intramedullary nailing of the femur, and open reduction internal fixation of the posterior wall. He is treated with 25 mg of indomethacin three times daily for 6 weeks following an initial dose on the evening of surgery for heterotopic ossification prophylaxis. Which of the following is true regarding this post-operative treatment protocol?
It is associated with an increased rate of femoral shaft nonunion
It has no affect on the healing time of the posterior wall fracture
It is associated with a faster time to union
Indomethacin is superior to radiation treatment in the prevention of heterotopic ossification
There is a decreased rate of revision surgery needed when indomethacin is administered post-operatively
Heterotopic ossification (HO) prophylaxis with indomethacin has been shown to increase the risk of long-bone nonunion.
Indomethacin therapy has been shown to be an effective means of preventing HO formation, however literature has shown that it increases the risk of long bone and acetabular nonunion. Indomethacin works primarily by inhibiting IGF-1, which is a different mechanism from other NSAID's which typically inhibit the COX enzymes. IGF-1 is important for bone healing, and its inhibition may be a risk factor for delayed bone healing.
Burd et al performed a study to determine if patients with an acetabular fracture, who received indomethacin for prophylaxis against HO, were at risk of delayed healing or nonunion of any associated fractures of long bones. The study group consisted of 112 patients who had sustained at least one concomitant fracture of a long bone; of which 36 needed no prophylaxis, 38 received focal radiation and 38 received indomethacin. When comparing patients who received indomethacin with those who did not, a significant difference was noted in the rate of long bone nonunion (26% vs 7%).
Jordan et al performed a study to document the efficacy of variable treatment durations with indomethacin prophylaxis for HO and its effect on union of the posterior wall (PW) in operatively treated acetabular fractures. Patients were randomly assigned to one of four treatment groups: (1) placebo for 6 weeks, (2) 3 days of indomethacin followed by placebo for a total of 6 weeks, (3) 1 week of indomethacin followed by 5 weeks of placebo, and (4) 6 weeks of indomethacin and followed for 1 year. The authors concluded that the use of prophylactic postoperative indomethacin increases the incidence of symptomatic nonunion of the PW as assessed by CT scan and pain VAS.
2-Based on the Jordan et al reference, indomethacin increases the risk of posterior wall nonunion
3-There is no evidence that treatment with indomethacin decreases time to union
4-There is no definitive evidence that indomethacin is superior to radiation in the prevention of HO. Recent data actually is in favor of radiation treatment both to prevent nonunion, and its superiority in preventing HO formation.
5-Indomethacin increases the risk of nonunion, which would therefore increase the need for re-operation.
Burd TA, Hughes MS, Anglen JO.
J Bone Joint Surg Br. 2003 Jul;85(5):700-5. PMID: 12892193 (Link to Abstract)
Burd, BJJ 2003
Average 4.0 of 28 Ratings
Postoperative varus alignment of a subtrochanteric femur fracture treated with an intramedullary nail has been shown to be related to which of the following factors?
Use of a piriformis entry nail through a greater trochanteric entry portal
Use of a greater trochanteric entry nail through a piriformis entry portal
Use of a lateral entry nail through a piriformis entry portal
Use of a femoral distractor device to obtain reduction
Use of a fracture table to obtain reduction
Usage of a piriformis (straight) nail through a greater trochanteric entry portal will bring the fracture into varus, as the greater trochanteric entry site's axis is lateral to the femoral shaft, and advancement of the nail causes the two axes to become colinear, leading to varus. The referenced study by Ostrum notes that usage of a greater trochanteric starting point is safe in obese patients; he recommends usage of a larger incision and maximum leg adduction.
The referenced study by Winquist et al is a classic review of femoral nailing, and emphasizes the importance of starting point selection and fracture reduction to maximize clinical outcomes (99.1% union rate in their series of 520 patients).
Orthopedics. 1996 Apr;19(4):337-40. PMID: 8786925 (Link to Abstract)
Ostrum, ORTHO 1996
The greatest amount of iatrogenic injury to the piriformis tendon is associated with which of the following?
Antegrade piriformis entry femoral nailing
Antegrade greater trochanteric entry femoral nailing
Retrograde femoral nailing
External fixation of a femoral shaft fracture
Open reduction and internal fixation of an intertrochanteric fracture
There is an increased rate of injury to the piriformis tendon, medial femoral circumflex artery branches, gluteus minimus, and superior gluteal nerve branches are noted with the piriformis starting site. Increased injury to the gluteus medius is seen with a greater trochanteric starting point.
The referenced study by Dora et al noted increased injury to the piriformis tendon with a piriformis starting point (as compared to a more lateral insertion site).
The classic referenced article by Johnson et al notes that anterior placement of the starting point >6mm over the recommended start leads to increased hoop stresses and possible burst-type fractures.
The classic referenced study by Winquist et al reviewed their series of 520 femur fractures treated by antegrade nailing; they report a 99.1% union rate.
Dora C, Leunig M, Beck M, Rothenfluh D, Ganz R.
J Orthop Trauma. 2001 Sep-Oct;15(7):488-93. PMID: 11602831 (Link to Abstract)
Dora, JOT 2001
Johnson KD, Tencer AF, Sherman MC.
J Orthop Trauma. 1987;1(1):1-11. PMID: 3506582 (Link to Abstract)
Johnson, JOT 1987
Average 4.0 of 16 Ratings
In patients with ipsilateral femoral neck and shaft fractures, what percent of femoral neck fractures are diagnosed on a delayed basis if fine cut CT is not utilized?
Ipsilateral femoral neck and shaft fractures occur in high energy injuries, with a reported incidence of 2.5-9%. The diagnosis of neck fracture is delayed in 19%-31% of patients. The neck fracture line is almost vertical and nondisplaced, or minimally displaced in 26% to 59% of cases. Two major complications, AVN of the femoral head and non-union of the neck result from neck fracture; therefore, it takes precedence. Dedicated protocols of femoral neck fracture detection have been described and include: dedicated preoperative hip radiographs, pelvic/hip CT scan, and intraoperative fluoroscopic examination.
The referenced article by Bennet et al is a case series of 42 patients with ipsilateral femoral neck-shaft fractures; 31% of the neck fractures were initially missed but none developed femoral head AVN.
The referenced article by Wolinsky et al is an excellent review of this injury. They also report that evaluation of these fractures with plain radiographs can be nondiagnostic 19% to 50% of the time when the majority of the fractures are minimally or nondisplaced.
Illustration A depicts a radiograph of an ipsilateral femoral shaft and vertical, minimally displaced femoral neck fracture.
Bennett FS, Zinar DM, Kilgus DJ.
Clin Orthop Relat Res. 1993 Nov;(296):168-77. PMID: 8222421 (Link to Abstract)
Bennett, CORR 1993
Wolinsky PR, Johnson KD.
Clin Orthop Relat Res. 1995 Sep;(318):81-90. PMID: 7671535 (Link to Abstract)
Wolinsky, CORR 1995
Average 2.0 of 28 Ratings
A 22-year-old male sustains the injury shown in Figure A. When placing an antegrade intramedullary nail with manual traction in a supine position, which of the following is true when compared to placement of a nail using a fracture table?
Increased operative time
Decreased internal malrotation deformities
Increased external malrotation deformities
Increased pudendal nerve injury
Increased need for revision
Figure A shows a proximal (supraisthmal) femoral shaft fracture.
The referenced article by Stephen et al is a randomized controlled trial between manual traction and fracture-table traction for the reduction and nailing of femoral shaft fractures in terms of quality of the reduction, operative time, complications, and functional status of the patient in eighty-seven patients. Internal malrotation was significantly more common when the fracture table had been used: twelve (29%) of the forty-two femora were internally rotated by >10° compared with three (7%) of the forty-five treated with manual traction. Mean operative time was also less in the manual traction group.
The referenced study by Wolinsky et al also found that use of a traction table significantly increased the anesthesia time, total operating room time, prep and drape time, and overall surgical time as compared to manual traction.
Stephen DJ, Kreder HJ, Schemitsch EH, Conlan LB, Wild L, McKee MD
J Bone Joint Surg Am. 2002 Sep;84-A(9):1514-21. PMID: 12208906 (Link to Abstract)
Stephen, JBJS 2002
Wolinsky PR, McCarty EC, Shyr Y, Johnson KD.
J Orthop Trauma. 1998 Sep-Oct;12(7):485-95. PMID: 9781773 (Link to Abstract)
Wolinsky, JOT 1998
Average 2.0 of 56 Ratings
A trauma patient presents with a major head injury and femoral shaft fracture. He undergoes early fixation of the femur fracture with a prolonged period of intraoperative hypotension. What is the most likely outcome to be expected post-operatively in this patient?
Increased risk of post-operative bleeding
Increased risk of pneumonia
Decreased IV fluid administration
Lower Glasgow Coma Scale scores at the time of discharge from hospital
Improved central nervous system outcomes at the time of discharge from hospital
Prolonged periods of hypoxia and hypotension are associated with lower GCS scores in polytrauma patients with major head injuries.
The timing of fracture fixation in polytrauma patients with major head injuries has been controversial. Most studies support early fixation despite some literature reporting adverse affects on CNS outcomes. This is largely related to hypoxemia and hypotension intraoperatively, as well as greater fluid administration, which should be avoided. Hypoxia and hypotension are associated with lower GCS scores at the time of discharge.
In a study by Jaicks et al found a lower discharge GCS in the early fracture fixation group compared with the late group. However, they also found that this association was due to hypoxemia and hypotension.
The referenced study by Scalea et al reviewed 171 patients with pelvic or lower extremity fractures and head injuries; they showed no difference in CNS outcomes or mortality in patients who underwent early fixation.
Brundage et al showed improved outcomes (including high GCS scores at time of discharge) in those who had early fixation of femoral shaft fractures in the head-injured patient.
Answer 1: There is no direct correlation between intra-operative bleeding and post-operative bleeding. They is literature to support that hypotension my decrease bleeding at the time of surgery.
Answer 2: There is no direct correlation between early fixation rates and post-operative pneumonia.
Answer 3: Intraoperative hypotension is correlated with increased IV fluid administration.
Answer 4: Intraoperative hypotension is associated with decreased central nervous system outcomes.
Jaicks RR, Cohn SM, Moller BA.
J Trauma. 1997 Jan;42(1):1-5; discussion 5-6. PMID: 9003250 (Link to Abstract)
Jaicks, JTACS 1997
Scalea TM, Scott JD, Brumback RJ, Burgess AR, Mitchell KA, Kufera JA, Turen C, Champion HR.
J Trauma. 1999 May;46(5):839-46. PMID: 10338401 (Link to Abstract)
Scalea, JTACS 1999
Brundage SI, McGhan R, Jurkovich GJ, Mack CD, Maier RV.
J Trauma. 2002 Feb;52(2):299-307. PMID: 11834992 (Link to Abstract)
Brundage, JTACS 2002
Average 1.0 of 102 Ratings
A 33-year-old female sustains the injury shown in Figure A. Compared to antegrade nailing of this injury, retrograde nailing has been shown to have an increased amount of which of the following?
Symptomatic distal interlocking screws
Final knee range of motion
Figure A shows a femoral shaft fracture, which can be appropriately treated with an intramedullary nail.
The referenced article by Ostrum et al reported that retrograde nailing had an increased rate of symptomatic distal interlocking screws, an increased rate of need for dynamization, longer union time, and less thigh pain than antegrade nailing. Union rate and knee range of motion were not significantly different between these two techniques.
Subsequent studies have found that union time does not significantly differ between antegrade and retrograde nailing.
Average 2.0 of 33 Ratings
A 32-year-old male sustains a closed head injury, a closed pelvic ring injury, as well as the bilateral open femoral fractures shown in Figures A-C. He remains borderline hypotensive with a base deficit of 4.9 after an exploratory laparatomy and splenectomy. After irrigation and debridement of his open fractures, what is the most appropriate treatment for this patient at this time?
Bilateral retrograde femoral nailing and pelvic binder application
Bilateral retrograde femoral nailing and anterior pelvic external fixation
Bilateral antegrade femoral nailing and pelvic binder application
Bilateral femoral external fixation and anterior pelvic external fixation
Bilateral femoral plating and anterior pelvic external fixation
Figure A shows a complex pelvic ring injury, while Figures B and C show bilateral femur fractures. Appropriate treatment of an unstable, head-injured patient with the above injuries includes prompt, judicious external fixation of his bilateral femoral fractures and pelvic ring injury. The advantages of early fracture fixation in patients with multiple injuries have been challenged recently, particularly in patients with head injury. External fixation (EF) has been used to stabilize pelvic fractures after multiple injury. It potentially offers similar benefits to intramedullary nail (IMN) in long-bone fractures and may obviate some of the risks. EF is a viable alternative to attain temporary rigid stabilization in patients with multiple injuries. It is rapid, causes negligible blood loss, and can be followed safely by IMN when the patient is stabilized.
The referenced article by Scalea et al found that external fixation for femur fractures is a viable alternative to attain temporary rigid stabilization in patients with multiple injuries.
Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN.
J Trauma. 2000 Apr;48(4):613-21; discussion 621-3. PMID: 10780592 (Link to Abstract)
Scalea, JTACS 2000
Average 3.0 of 22 Ratings
Which of the following has been shown to have similar biochemical and clinical characteristics as iliac crest autograft?
BMP-7 with collagen matrix carrier
Platelet rich plasma with allograft cancellous bone carrier
Femoral intramedullary reaming contents
In multiple studies, femoral intramedullary reaming debris has been shown to have similar biochemical characteristics as iliac crest autograft. Intramedullary reaming products have osteogenic potential with viable cells while BMP's are osteoinductive cytokines.
Hoegel et al found that the reamings had alkaline phospatase activity, indicating living osteoblasts. The amount of activity was independent of the reamer sizes and reamer design.
Frolke et al concluded that reaming debris supports callus building (healing) as much as conventional iliac crest bone grafting in an animal fracture gap model.
The video shows a retrograde femoral autograft harvest using the RIA system.
Hoegel F, Mueller CA, Peter R, Pfister U, Suedkamp NP.
J Trauma. 2004 Feb;56(2):363-7. PMID: 14960981 (Link to Abstract)
Hoegel, JTACS 2004
Frölke JP, Bakker FC, Patka P, Haarman HJ.
J Trauma. 2001 Jan;50(1):65-69; discussion 69-70. PMID: 11231672 (Link to Abstract)
Frölke, JTACS 2001
Average 4.0 of 19 Ratings
A patient undergoes the treatment seen in Figure A for a displaced intertrochanteric femoral fracture. With use of this construct, a starting point 3 mm anterior to the center of the piriformis fossa has which of the following benefits?
Improved placement of screws through the nail into the femoral head
Decreased risk of varus alignment
Decreased risk of joint penetration
Decreased risk of avascular necrosis of femoral head
Decreased risk of iatrogenic proximal femur fracture
Figure A shows an intertrochanteric fracture treated with a cephalomedullary device. A starting point slightly anterior to the piriformis fossa (starting point for standard antegrade femoral nail) has the benefit of improved placement of screws through the nail and into the femoral head. This is due to the fact that the hip is anteverted and the femoral neck arises from the anterior portion of the proximal femur. Therefore, by moving the nail anterior, that will increase the distance between the head screw and the posterior cortex of the neck and lead to a “straight” shot into the center of the femoral head.
Johnson et al investigated the effect of starting hole position, fracture component length, reamed diameter, and nail type on the potential for femoral bursting and fracture instability. They found the most significant factor in the proximal femoral component was found to be the position of the starting hole. They found excessive anterior displacement greater than 6 mm from the neutral axis of the medullary canal consistently caused high hoop stresses at the level of the fracture, which can increase the possibility of iatrogenic fracture. Posterior starting points increase the risk of possible distal femur anterior cortex impingement/fracture.
Ostrum et al showed that lateral starting points should be avoided in order to avoid varus reduction when using a trochanteric antegrade nail in subtrochanteric fractures. They recommended a slightly medial starting point.
Ostrum RF, Marcantonio A, Marburger R
J Orthop Trauma. 2005 Nov-Dec;19(10):681-6. PMID: 16314714 (Link to Abstract)
Ostrum, JOT 2005
Average 2.0 of 47 Ratings
A 20-year-old male is involved in a motorcycle accident and presents with the injuries shown in Figures A-F. The left ankle injury is open medially, with a clean 3cm laceration, and the right femur and tibia are closed. He has no visceral or head injury, and is hemodynamically stable. He is cleared to go to the operating room. Without taking into account order of fixation, how should his injuries be treated?
Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and casting
External fixation of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF
Antegrade nailing of the femur, external fixation of the tibia and ankle after debridement
Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF
External fixation of the tibia and femur, and ankle debridement and external fixation
The patient is hemodynamically stable, has no other injuries, and is medically cleared for the operating room. Therefore, there is no need for damage control fixation.
Ostrum et al conducted a review of 20 patients treated by percutaneous stabilization for ipsilateral fractures of the femur and tibial shafts. All patients were treated with a retrograde femoral intramedullary nail and a small diameter tibial intramedullary nail through a 4-cm medial parapatellar tendon incision. Six of the tibial shaft fractures required revision surgery, and no patients reported signs or symptoms of knee pain. Ostrum concluded that although this is an excellent treatment option for patients with ipsilateral femoral and tibial shaft fractures, the tibial fracture complication rates remain high.
Franklin et al reviewed 38 cases of open ankle fractures that had been treated with immediate splinting, antibiotics, debridement, and internal fixation. They found that all of the fractures united, but three patients required subsequent ankle fusion because of cartilage damage noted at the initial operation. Of the thirty-five ankles with complete follow-up, the functional result was excellent in twenty-six and fair or poor in nine.
Clin Orthop Relat Res. 2000 Jun;(375):43-50. PMID: 10853152 (Link to Abstract)
Ostrum, CORR 2000
Franklin JL, Johnson KD, Hansen ST Jr.
J Bone Joint Surg Am. 1984 Dec;66(9):1349-56. PMID: 6438107 (Link to Abstract)
Franklin, JBJS 1984
Average 3.0 of 25 Ratings
Placing the starting point for an antegrade femoral nail too anterior to the axis of the medullary canal can most commonly lead to what intraoperative complication?
Loss of locking screw trajectory into the lesser trochanter
Creation of a recurvatum deformity
Iatrogenic fracture of the proximal fragment
Decrease in hoop stresses
Usage of an anterior starting point that is too anterior leads to creation of significant hoop stresses in the proximal segment, potentially leading to iatrogenic fracture of the proximal segment. The referenced study by Johnson et al reviews the topic of femoral bursting and he notes that even shifting 6mm too far anteriorly can lead to proximal femoral fracture creation. He also reported that overreaming the canal by at least 0.5mm diameter is necessary to decrease hoop stresses throughout the femur, likely due to a mismatch in the radius of curvature of the femur and intramedullary nail.
Average 4.0 of 22 Ratings
Which of the following variables has not been shown to be increased in patients who sustain bilateral femoral shaft fractures as compared to patients with unilateral femoral shaft fractures?
Hypotension upon initial evaluation
Open skull fractures
Bilateral femur fractures have not been shown to have increased rates of thoracic/chest wall injury. They have been shown to have increased rates of initial hypotension, mortality, open skull fractures, and pelvic fractures.
Due to their high-energy nature, bilateral femur fractures have increased rates of initial hypotension or hemodynamic instability, mortality, head injuries, abdominal injuries, pulmonary injuries, and other orthopaedic injuries.
Copeland et al. performed a retrospective analysis using their trauma registry data on consecutive blunt trauma patients with unilateral (800 patients) or bilateral (85 patients) femoral shaft fractures. Patients with bilateral femoral fractures had a significantly higher Injury Severity Score (30.2 versus 24.5, p < 0.05) and higher mortality rate (25.9 vs 11.7%, p < 0.014) than patients with unilateral femoral fractures. Bilateral fracture patients also had significantly more closed head injuries, open skull fractures, intra-abdominal injuries requiring surgical intervention, and pelvic fractures. Regression analysis of variables evident on admission revealed a significant correlation between bilateral femoral fractures and death; however, other factors (shock, closed head injury, and thoracic injury) had much stronger correlations with mortality. No increase in risk of thoracic injury was seen with bilateral injuries as compared to unilateral injuries.
Kobbe et al. also reviewed their trauma registry data on 776 patients with unilateral and 118 patients with bilateral femoral shaft fractures. They found that bilateral femur fracture patients has a higher ISS score, higher incidence of delayed pulmonary failure and multiple organ failure, and higher mortality. They also noted that patients with bilateral femoral shaft fractures have significantly more often severe abdominal injuries as well as severe blood loss which may account for the increased mortality rate.
Answer 1: Increased rates of hypotension upon admission are seen in the bilateral group.
Answer 2: Increased mortality rates have been reported in bilateral femur patients.
Answer 4: Increased rates of open and closed head injuries are noted in bilateral femur patients.
Answer 5: Increased rates of pelvic and other orthopaedic injuries are reported in the bilateral group.
Copeland CE, Mitchell KA, Brumback RJ, Gens DR, Burgess AR.
J Orthop Trauma. 1998 Jun-Jul;12(5):315-9. PMID: 9671181 (Link to Abstract)
Copeland, JOT 1998
Kobbe P, Micansky F, Lichte P, Sellei RM, Pfeifer R, Dombroski D, Lefering R, Pape HC; TraumaRegister DGU
Injury. 2013 Feb;44(2):221-5. doi: 10.1016/j.injury.2012.09.011. Epub 2012 Oct 4. PMID: 23040674 (Link to Abstract)
Kobbe, INJURY 2013
Average 1.0 of 204 Ratings
18 YO MALE, BIKE ACCIDENT.TRANSVERSE DIAPHYSEAL MIDDLE THIRD FEMURAL FRACTU...
Title: Nailing Femoral Shat Fractures: Starting Point Tips & Tricks Author: Anja...
Title: Short-Term Follow-Up of Pertrochanteric Fractures Treated Using the Proxi...
Title: IT Fractures, No Role For Plate Author: William M. Ricci, MD Duration: 12...
HPI - An 18 year old male presents for follow-up 6 months after suffering a transverse femur fracture in a motorcycle accident. He was treated with an external fixator as he was diagnosed with a pulmonary embolism soon after his admission.
How would you manage this patient at this point?
HPI - Pain and deformity of the right hip/proximal femur.
The patient underwent a cephalomedullary nailing of the fracture shown. Intra-op and post-op XRays are shown.
Is this a nonunion?
HPI - 8 weeks ago, patient suffered high energy injury as a front-seat passenger involved in a traffic accident (dashboard injury). He sustained a closed femoral shaft fracture (type 32-A3). Reamed IM nailing was performed three days after the injury.
What should be done at this point to manage this patient's problem?
HPI - A 58 year old male presents with pain, swelling, and inability to weight bear without support due to complications associated with a left femur fracture.
His initial surgery was 14 years ago, which was in the form of an IM Nail which was complicated by infection 3-4 months following surgery. This was treated with nail removal, debridement, local vancomycin-impregnated cement beads, IV antibiotics, and placement of the current femoral locking plate that remains in situ.
How would you mange this patient at this point?
HPI - A 39 year old female patient presents status post-MVA 10 months ago where she suffered a right femur fracture. This was treated with a intramedullary nail (Xrays shown).
History of suspected infection with +ve CRP, mild fever, and thigh pain with swelling 3 weeks post-operatively which was treated with antibiotics, no surgical debridement was done.
No history of wound discharge, or discharging sinus.
Patient presented to me 4 weeks ago with pain at fracture site. CRP was 1/24, now its 1/12 after 4 weeks of oral empirical antibiotics administration
Update: CRP is -ve now
How would you manage this patient?
HPI - 43M patient presents 3 years after a high energy right femur fracture sustained in a car accident.
The performed surgery was the dynamic locked intramedullary femoral nail. The dynamic screw was removed six weeks after the primary surgery, due to lack of dynamization, in order to promote healing of fracture.
Xrays and CT scans are shown.
HPI - 30M is transferred to your institution 10 days following a motor vehicle collision where he sustained an Open, highly comminuted left femoral shaft fracture.
The fracture was initially managed by another physician with application of an external fixator frame (Ilizarov apparatus) - see XRays attached.
How would you manage this injury?
HPI - Right hemiplegic patient with known absence of leg extension before a fall, but able to walk before with a walker.
Complaining of weak quadriceps since a fall 2 months ago and unable to walk since. Never had pain. Was treated conservatively for a partiel quadriceps rupture/atrophy seen on MRI (leg brace in extension for walking). Normal knee x-ray.
Finally had long leg x-ray done at 3 months because of progressive shortening of the limb to mesure the LLD ! Can now ambulate with a leg brace, but difficult. No pain.
What would be you preferred method of treatment at this time?
HPI - Fall from standing position on a ramp (inclined plane)
What is the best treatment?
HPI - Traffic accident 1 year ago
1.- Left femur: Bifocal fracture (shaft and femoral neck) treated with long gamma nail.
2.- Right femur: femoral shaft fracture treated with long femoral nail.
What is your preferred treatment for femoral neck and shaft fracture?
HPI - Pain in the knee present since 2 months postop; with stiffness in the knee in mornings. patient walks with a limp, but no pain in thigh when walking.
Should the patella implants be removed?
HPI - H/o fall down on LF thigh
Would you biopsy the non-union site to rule out infection?
HPI - 17-year-old male present to ER 10-days after gun shot wound to his left thigh. Inability to bear weight on affected limb.
For most femoral shaft fx secondary to GSW at your institution, what provisional treatment do you usually use to keep the femur "out-to-length" until definitive surgery?
HPI - RTA with severe pain and inability to bear weight on rt lower limb.
How would you treat this fracture?
HPI - Trapped his right leg in wheelchair while moving to bed - deformation, came to hospital after 2 days. Xray spiral distal femoral diaphysis fx 31A1.
What type of implant would you use for 1st operation?
HPI - Level fall 2 weeks ago, because of a operating room lack we could not fix it earlier.
HPI - A 26 years old male involved in RTA , generally stable , with closed comminuted proximal RT femur fracture and ipsilateral tibial shaft closd non displaed fracture
whats the best option to treat the femure fracture?
HPI - 20-year-old male with left thigh deformity , pelvic pain, splenic rupture after a car accident, hemodynamically instabile at presentation
HPI - 40-year-old healthy male with isolated lower extremity pain after a motorcycle collision.
HPI - The patient suffered this injury after road traffic accident , the pt is otherwise free
what is the best treatment option
HPI - Operated 2 times.
1st time non union with an intramedular nail no blocked proximal and distal
2nd time 1.5 years ago removal of the nail and plating with autograft, no compression of the non union site because of shortened lim
How would you treat this injury at this time.
HPI - He had closed fracture of R/ Femur following RTA in 2013. He was operated in a peripheral hospital and fixed with K nail and de rotation plate. He is now presented with pain and discharging sinus at he fracture site.
What will you do for this patient at this stage?
HPI - Patient had road side accident about 1yrs back when he sustained closed fracture Femur and tibia left side.Open Reduction and internal fixation was done with plates and screws.post operatively patient developed infection in femur for which implant had to be removed.
It has been 4 months now after implant removal.
There is stiffness at knee joint and abnormal mobility at fracture femur.
No evidence of infection at present with normal crp and esr
What should be the treatment for nonunion femur
HPI - History of road side accident 5 months back leading to closed fracture shaft femur.operated for C/R and I/F with ILN.Fracture still not united
What should be the treatment option
HPI - A 60 year old psychiatric patient (Schizophrenia) lived in an institution and mobilized independently, sustained a mechanical fall on her right femur.
HPI - fall from height
traction in Thomas splint for 12 days
Is this position accepted ?
HPI - Sustained fracture 8 months back. Underwent an open interlocking nailing and primary bonegrafting. 8 months after the primary surgery, radiographs fail to show any signs of healing.
What should be the treatment plan
HPI - An 83F presents to you 2 weeks after ORIF for a supracondylar left femur fracture after a fall downstairs. The patient was managed at a hospital in a neighboring city, but has come to you for follow-up as it is more convenient for her rather than travelling long distances for her follow-ups. This is her first follow-up since ORIF. The incision is CDI, with no drainage and no sign of infection; she would like to have her staples removed today.
She continues to complain of pain in the distal left thigh at the site of the fracture. She is unable to ambulate secondary to pain, and utilizes a wheelchair. She complains of pain with palpation at the fracture site around the incision.
An AP radiograph of the left thigh is shown.
After assessing this patient in fracture clinic, what is your next step?
HPI - pain at left hip ,increases on moving the left lower limb,5 cms of shortening,
what is treatment of choice now?
HPI - two years back patient had an accident and sustained Gustillo open III fracture Rt femur for which external fixator was applied.later on that was converted to Illizarov fixator but still not united.
now presented to us with gap union
How can this be treated??
HPI - falling from hieght
operated since 4,5 mounth
no visible callus and thereis a gap
How would you manage this femoral nonunion
HPI - Communited/segmental subtrochanteric femur fracture, treated by by closed reduction and internal fixation with trochanteric reconstruction nail. Patient has been non weight bearing
What would be your next treatment choice for this segmental subtrochanteric femur fracture
HPI - Pain in thigh,unable to bear weight,no signs of any infection
What would be your preferred method of treatment for this nonunion?
HPI - 3 years ago had a fall and fractured his left femur which had an intramedullary nail which bent.fracture site was opened and bent nail removed and interlocking nail inserted.
What would you perform for this case?
HPI - Motor bike accident. Developed compartment syndrome of R leg. Double incision Fasciotomy was done. No vascular injury. Later on developed DIC and recovered now.
Injuries are 1)Inter trochanteric # R femur
2)# shaft of the R femur
3)# R lateral tibial plateau
4)# R patella
5)# R tibial shaft & fibula
How to fix the femur & tibia?
( we dont have retrograde nails)
HPI - history of road traffic accident
how would you have treat this patient after the first nailing?
HPI - Road side accident on 25 feb 2012. Ipsilateral fracture neck femur and shaft treated by interlock nailing and cannulated screws.Bone grafting for shaft femur done on 19 July2012.Dynamization was done on 3rd dec2012
HPI - 42 YEARS OLD LADY , NO CO-MORBIDITY , SUSTAIN MVA 3 DAYS BACK , HEMODYNAMICALLY STABLE
WHAT WOULD BE THE BEST OPTION FOR HER femur fracture
HPI - pain deformity left femur after fall at home
elastic nailing or spica
HPI - Patient has Duchenne muscle dystrophy, bed ridden, severe osteoporosis. Fell down during care in bathroom
What is the best fixation option?
HPI - h/o fall from height
What implant(s) would you use for this fracture pattern?