Femoral Shaft Fracture Flashcards
Epidemiology of femoral shaft fractures
Common
4 per 10000 person-years
High-energy trauma
Femur and blood loss
It is a highly vascularised bone due to its role in haematopoesis and its size.
It’s supplied by penetrating branches of the profunda femoris artery.
Up to 1500 ml of blood can be lost when fractured.
Associated injury with FSF
Neurovascular injury
When are FSF seen?
High-energy trauma
Fragility fractures in the elderly by low-energy trauma
Pathological fractures from metastatic deposits or osteomalacia
Bisphosphonate-related fractures which are classically transverse fractures
Clinical features
Pain in thigh +/- hip or knee pain.
Unable to weight bear
Obvious deformity in severe cases
The pain is usually very very severe
Examinations
Assess the skin to see if it is open or threatened (tethered, white, non-blanching)
The proximal fragment is pulled into flexion and external rotation (by iliopsoas and gluteus medius and minimus) which can further tent the skin.
Also do a full neurovascular examination of lower limbs.
Check for both vascular and peripheral nerve injury as well as a thorough secondary survery.
What classification can be used in FSF
Winquist and Hansen classification
Explain Winquist and Hansen classification
Classifies the degree of comminunition to femoral shaft fractures.
Type 0 - No communition
Type I - Insignificant amount of communition
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
Dx
If mechanism was high-energy ensure you also assess other orthopaedic injuries like ankle, tibial shaft, tibial plateau, pelvis and spinal fractures
Ix
After major trauma should be investigated and managed as per the ATLS protocol.
Routine urgent bloods with coagulation and Group & Save should be sent.
If pathology is suspected also do serum calcium and possible cancer screening.
Plain film radiograph in AP and lateral view of the entire femur including hip and knee
CT imaging may be warranted if polytrauma is suspected and to further assess intra-articular or femoral neck fractures.
General management
ATLS protocol with A-E and stabilising the patient with fluid resus.
Pain relief with opioid analgesia +/- regional blockade like a fascia iliaca block.
If the fracture is open you should also give abx prophylaxis, tetanus and medical photography.
Immediate management after ATLS
Immediate reduction and immobilisation to near anatomic alignment by in-line traction to ensure that an appropriate haematoma is formed as well to reduce the pain.
Traction splinting like Kendrick traction splint are used in suspected or isolated fractures of the mid-shaft femur (but not in hip, pelvic, supracondylar, ankle, foot).
This is done prior to surgery in order to stabilise the patient.
Most femoral shaft fractures will require surgery.
Indications for non-surgical management
Undisplaced femoral shaft fractures in patients with significant co-morbidities.
Non-surgical management of femoral shaft fracture.
Long-leg casts
How quickly should surgical management be done from admission?
Surgically fixation should be done within 24-48h although sooner if open fracture.
When is antegrade intramedullary nail done?
In most isolated cases that are not too unstable and there is no polytrauma.
It has around a 98% union rate and a low rate of post-op complications
When do you do external fixation?
In unstable polytrauma or open fractures.
This is to ensure the patient is physiological optimised prior to definitive fixation.
Subsequent delayed conversion to intramedullary nail is usually done.
