Chapter 38- Fractures Of The Femur

Question 1

Which proximal femoral fractures are common in the elderly ?

Answer 1

Femoral neck, isolated trochanteric, intertrochanteric fractures

Question 2

Which proximal femoral fractures are common in young people

Answer 2

Femoral head and subtrochanteric fractures

Question 3

In fracture of the proximal femur, what would a clue to a pathological process be?

Answer 3

Pre existing ache or discomfort in the hip or thigh region

Question 4

What is the cause of femoral head fractures

Answer 4

Caused by dislocation or subluxation of the hip joint with a piece of head being split off by the acetabular rim.
Spontaneous reduction is frequent

Question 5

What is the treatment of small fragment femoral head fractures (fracture line below the fovea)

Answer 5

Leave Alone if not trapped between articulating surfaces

Question 6

What is the treatment for large fragment femoral head fractures (fracture line above the fovea)

Answer 6

• undisplaced: internal fixation (best) or traction for 3-6 weeks
• displaced: closed or open reduction followed by fixation

Question 7

What is the blood supply to the femoral head?

Answer 7

Predominantly via large posterior retincular artery. Only small supply comes from medulla or the ligamentum teres

Question 8

What are the two groups of neck of the femur fractures?

Answer 8

• Undisplaced (Garden I and II)

- displaced (Garden III and IV)

Question 9

Clinical presentation of fractures of the neck of the femur

Answer 9

• usually an elderly patient (females>males)
• pain in groin and hip region
• unable to bear weight
• leg lies in external rotation and is shortened

Question 10

Have a high index of suspicion of neck of the femur fractures if clinical signs suggest fracture but it is not visible on X-ray. If doubt still exists what other investigations could you do?

Answer 10

• Ask for AP tomograms

- doubt still exists- get a bone scan after 72 hours

Question 11

What complications are associated with the non-operative management of neck of the femur fractures

Answer 11

• lung complications
• pressure sores
• DVT and pulmonary emboli
• increased osteopenia
• non-union and AVN (incidence of AVN increased if reduction and fixation delayed for more than 12 hours)
• renal calculi
• depression.

Question 12

What is the treatment of neck of the femur fractures?

Answer 12

• apply simple skin traction on admission, optimize for surgery
  -undisplaced fracture: within 12 hours, internal fixation with sliding screw and plate
  Displaced: under 65 years- within 12 hours, closed reduction on fracture table, internal fixation sliding screw and plate
  Over 65- hemi or total joint replacement
• rehabilitation

Question 13

Presentation of isolated trochanteric fractures

Answer 13

• Caused by direct blow over trochanter, usually in a fall

- pain may prevent patient from walking

Question 14

Treatment of isolated trochanteric fractures

Answer 14

Symptomatic and partial weight bearing ambulation

Question 15

What are the two types of inter-trochanteric fractures seen on X-ray

Answer 15

• Stable fractures: continuity of the medial cortex

- unstable fractures: medial cortex is comminuted (usually lesser trochanter is pulled off by iliopsoas attachment)

Question 16

Treatment of inter-trochanteric fractures

Answer 16

Closed reduction and internal fixation with sliding screw and plate

Question 17

What is the treatment of subtrochateric fractures

Answer 17

• Children: closed reduction and traction- placing the femoral shaft and maintaining it in the same position as the proximal fragment (flexion and abduction). Failure of closed reductions- open reduction and internal fixation
• adults: ORIF

Question 18

How much blood may be lost in a shaft of femur fracture

Answer 18

1.5 L. Of blood is lost into the surrounding soft tissue envelope

Question 19

Treatment of shaft of femur fractures in children <2years or 15 kg

Answer 19

Bryant’s or fallow traction- skin traction applied to both limbs and the limbs suspended in a frame with the buttocks ‘only just’ off the bed

Question 20

Treatment of shaft of the femur fractures in children >2years

Answer 20

Apply skin traction and Thomas splint
Pop spica
Tobruk splint
Internal fixation with plate and screws or IM nail- especially in the older child

Question 21

Treatment of shaft of the femur fractures in adults

Answer 21

• Splintage: if immediate surgery not possible. Apply skeletal traction with up to 10 kg weight on a Thomas splint at time of admission. After 7-10 days or when length is restored- reduce weight to 3-4 kg.
• internal fixation: transverse/stable fractures: unlocked nail.
  Oblique/comminuted/unstable fractures: locked nail
• traction: if unfit for surgery or if fracture configuration or injuries defy internal fixation.

Question 22

What is the definition of distal femur fractures

Answer 22

Within 7-10 cm of the joint

Question 23

Definition of a distal femoral fracture?

Answer 23

Within 7-10 cm of the joint

Question 24

What is the treatment of supracondylar fractures

Answer 24

• Internal fixation is the method of choice
• Traction: Flexion of the knee using a Pearson knee piece in conjunction with a Thomas splint or over a foam block pillow. Resistant posterior shift- 2nd Denham pin through a distal fragment, through which anterior traction is applied (for less than 2- 3 weeks)

Question 25

What two types of medial/lateral condyle fractures are there?

Answer 25

• Saggital (most common)

- Coronal (often avascular)

Question 26

What shape is a intercondylar fracture

Answer 26

-Y shaped

Question 27

What is the treatment for condylar fractures?

Answer 27

• Internal fixation
• Exo skeleton: if soft tissue injury or complexity of comminution
• Traction