Femoral Shaft Fractures Pathway Posted: 9/30/2019 ID: (C101292)

Femoral Shaft Fracture in 27M

PRESENTATION

POLLS

26,309

OUTCOMES

EVIDENCE

Comments

CASE DESCRIPTION

AGE	27 / Male
CC	Right thigh pain
HPI	A 27-year-old male is involved in MVC at 50 mph.
PMH	N/A PMH Social ETOH
PE	RLE - inspection shows thigh swelling and deformity with ecchymosis - 2+ DP and PT pulse - 5/5 ankle DF/PF and EHL

AGE/GENDER:

27 / Male

CHIEF COMPLAINT:

Right thigh pain

HISTORY OF PRESENT ILLNESS:

A 27-year-old male is involved in MVC at 50 mph.

PAST MEDICAL HISTORY:	N/A PMH Social ETOH
PHYSICAL EXAM:	RLE - inspection shows thigh swelling and deformity with ecchymosis - 2+ DP and PT pulse - 5/5 ankle DF/PF and EHL
DIAGNOSIS:	Femoral Shaft Fracture in 27M

Pre-procedure IMAGES:

https://upload.orthobullets.com/cases/101292/ba94c4bf-831f-4938-a505-4e6d98e79461_zc_1.jpg

https://upload.orthobullets.com/cases/101292/4718b953-869d-4f21-9b74-613831734fff_zc_2.jpg

https://upload.orthobullets.com/cases/101292/c2089e44-738a-438a-9a38-f241ce3c6c09_zc_3.jpg

https://upload.orthobullets.com/cases/101292/9d8f8ddf-2e0c-4c3a-8e2c-49a349a9ec8e_zc_4.jpg

POLLS

OB Community

1) Would you get additional imaging of the Femoral FX to determine treatment?

No - Current Xrays are sufficient

Yes - Additional Xray views

Yes - CT scan

Yes - Additional Xray views + CT scan

Outside my area of expertise - best if I don't vote

Other

Submit

2) Would you get additional imaging to rule out an Ipsilateral Femoral Neck FX?

No - Current Xrays are sufficient

Yes - preop Additional Xray views ONLY

Yes - preop Fine-cut CT ONLY

Yes - preop Additional Xray views + Fine-cut CT

Yes - intraop Fluoroscopic views ONLY

Yes - preop Additional Xray views + intraop Fluoroscopic views

Yes - preop Additional Xray views + Fine-cut CT + intraop Fluoroscopic views

Outside my area of expertise - best if I don't vote

Other

Submit

3) Would you use a classification system to guide your treatment of the femur fx?

No - a classification system does not help me determine treatment

Yes - Winquist classification system

Yes - OTA classification system

Outside my area of expertise - best if I don't vote

Other

Submit

4) How would you manage this patient?

Nonoperative - Skeletal traction until union

Operative

Outside my area of expertise - best if I don't vote

Other

Submit

5) If you chose Operative management, would you temporize this patient prior to definitive fixation?

I would not choose operative management

No - I would operate acutely (within 12 hours)

Yes - temporize short-term with Buck's external traction

Yes - temporize short-term with Skeletal traction

Yes - temporize short/long term with External Fixation

Outside my area of expertise - best if I don't vote

Other

Submit

6) If you choose to temporize with Skeletal Traction, what type would you use?

I would not temporize with Skeletal Traction

Distal Femoral Traction Pin

Proximal Tibial Traction Pin

Calcaneal Traction Pin

Outside my area of expertise - best if I don't vote

Other

Submit

7) If you choose Operative management, what Definitive Fixation technique would you use?

I would not choose operative management

External fixation

Intramedullary nail fixation (IM Nail fixation)

ORIF (plate, screws, wires)

IM Nail fixation + ORIF (plate, screws, wires)

Outside my area of expertise - best if I don't vote

Other

Submit

8) If you choose IM Nail fixation or External fixation, would you perform Open Reduction of the fracture site?

I would not choose IM Nail fixation or External Fixation

Yes

Outside my area of expertise - best if I don't vote

Other

Submit

9) If you choose IM Nail fixation, what approach would you use?

I would not choose IM Nail fixation

Antegrade - Trochanteric entry

Antegrade - Piriformis entry

Antegrade - Lateral entry

Retrograde

Outside my area of expertise - best if I don't vote

Other

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10) If you choose IM Nail fixation, how would you position the patient and what table would you use?

I would not choose IM Nail fixation

Lateral patient position - Fracture table

Lateral patient position - Radiolucent flattop table

Supine patient position - Fracture table

Supine patient position - Radiolucent flattop table

Outside my area of expertise - best if I don't vote

Other

Submit

11) If you choose IM Nail fixation, what would be your PRIMARY method to get your femoral LENGTH correct?

I would not choose IM Nail fixation

Preop Templating - Nail length using contralateral femur

Intraop Open - Direct visualization of Fx reduction

Intraop Fluoro - Imaging of Fx reduction

Intraop Flouro - Radiopaque ruler measurement vs. contralateral femur

Clinical inspection - Palpate plantar surface of foot/ankle vs. contralateral side

Clinical inspection - Measure length of leg vs contralateral side with string or ruler (Greater troch. to Lateral mal.)

Outside my area of expertise - best if I don't vote

Other

Submit

12) If you choose IM Nail fixation, what would be your PRIMARY (most valuable) method to get your femoral ROTATION correct?

I would not choose IM Nail fixation

Preop Templating - Nail-screw angle vs. Contralateral

Intraop Fluoro - Cortical Thickness

Intraop Fluoro - Lesser trochanter profile (LTP)

Intraop Fluoro - Femoral neck horizontal angle (NHA)

Intraop Fluoro - True lateral technique (TLT)

Clinical Inspection - Look at direction foot is pointing vs. contralateral side

Clinical Inspection - Look at skin wrinkling

Outside my area of expertise - best if I don't vote

Other

Submit

14) In this patient, if you choose IM Nail fixation, how long would you prescribe postoperative DVT prophylaxis?

I would not choose IM Nail fixation

I would NOT prescribe DVT prophylaxis

Until the patient is ambulatory

1 week postop

2 - 4 weeks postop

5 - 7 weeks postop

8 - 10 weeks postop

11 - 12 weeks postop

Outside my area of expertise - best if I don't vote

Other

Submit

CASE OUTCOMES

PROCEDURE 1: Intramedullary Nailing of Right Femoral Shaft Fx
Intra-procedure P1
Post-procedure P1

EVIDENCE (69)

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