LL: FEMUR SHAFT BONE FRACTURES

Question 1

General precautions to be observed when treating a patient with
a fracture

Answer 1

1. Keep fracture site supported
2. No excessive pain or movement at fracture site
3. Confirm weight-bearing status before mobilising

Question 2

FRACTURE OF THE SHAFT OF THE FEMUR PATHOPHYSIOLOGY

Answer 2

Occurs in all ages.

CAUSE
Fall with foot anchored → spiral fracture
Direct blow → transverse fracture
Gun-shot wound → comminuted fracture
Metastases → pathological fracture, usually upper ½

DEFORMITY
May be shortened due to the pull of quadriceps and hamstrings.
Proximal segment held in external rotation and abduction of the hip due to the
pull of gluteus medius and minimus as well as iliopsoas.

Question 3

COMPLICATIONS OF FRACTURE OF THE SHAFT OF THE FEMUR

Answer 3

Hypovolaemic Shock
The fracture is usually associated with major trauma and blood loss. A major
artery may be damaged by sharp fragments of bone.

Fat Embolus Syndrome
Although uncommon, fat embolus syndrome is most often associated with a
fractured femoral shaft

Associated knee injury
Soft tissue injury of the knee occurs in 25% of cases. This must be assessed
once the fracture has stabilised.

Associated injury of the pelvis and hip
The hip may be dislocated due to the nature of the trauma. The pelvis and hip
should always be X-rayed.

Delayed Union
Union usually only occurs at 4 months in adults. At 5 months, if the union is not
yet sufficient for the patient to weight-bear without protection, then union is
considered delayed and appropriate intervention must be commenced.
This may include the application of a plaster hip spica or a cast brace to allow the
patient to mobilise. If a nail was inserted and locked, unlocking the nail at one
end may offer a solution. In some cases, bone grafting may become necessary.

Knee stiffness
The patient often has difficulty in regaining full range of motion. This is usually
due to soft tissue adhesions. It usually responds well to treatment.

Question 4

FRACTURE OF THE SHAFT OF THE FEMUR

Which treatment is most preferred

Answer 4

Operative treatment is the treatment of choice.

Question 5

FRACTURE OF THE SHAFT OF THE FEMUR:

Conservative treatment & CONTRA-INDICATIONS AND PRECAUTIONS

Answer 5

Treatment
Skeletal traction via a Steinman pin through the tibial tuberosity.
This is usually applied for 6-8/52 and followed by a cast brace for 6-8/52.
Skin traction is also used.
In children less than 15kg, gallow’s traction is used.

CONTRA-INDICATIONS AND PRECAUTIONS
• General contra-indications
• Children in gallow’s traction must wear splints to maintain slight knee flexion
to prevent arterial spasm.

Question 6

FRACTURE OF THE SHAFT OF THE FEMUR:

Operative treatment & contraindications and precautions

Answer 6

Operative treatment
Intra-medullary nailing is done by a closed technique if possible, otherwise by
open technique. The nail is usually locked proximally and distally to prevent
rotation of the fracture fragments.
Disadvantages:
• the nail becomes load-bearing and is subject to mechanical failure
• no axial compression through the fracture site and this may delay union=
therefore dynamise the nail after 6-8/52 by removing either the distal or
proximal locking screws, whichever set is further from the fracture site.
The nail then becomes load-sharing and there will be some axial
compression through the fracture site.
The weight-bearing status of the patient depends on the type of
instrumentation used as well as the type and stability of the fracture.
Communication with the surgeon is imperative. The following are guidelines,
but should always be confirmed with the surgeon:
✓ Transverse fracture – inherently stable so PWB-FWB allowed postoperatively
✓ Bicortical contact at fracture site – longitudinally and laterally stable, can
mobilize PWB
✓ Unicortical contact at fracture site – longitudinally stable, but no lateral
stability (eg. Butterfly fragment), may need additional support before PWB
✓ Comminuted fracture – no longitudinal or lateral stability, may even be on
bedrest for 3/52 before mobilising NWB.
External fixators are only used in cases of extreme soft tissue injury as this is a semi-hazardous
zone.

CONTRA-INDICATIONS AND PRECAUTIONS
• Communicate with surgeon regarding weight-bearing status
• General contra-indication