Fractures of Femur

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Fractures of Femoral N

Neck Intertrochantric FFractures (Pertrochanteric) Subtrochantric

Garden’s classification of femoral neck fractures Intertrochanteric fractures – Kyle classification


(a) Stage I: incomplete (socalled abducted or impacted) – the femoral head in this case is in slight valgus. Types 1 to 4 are arranged in increasing degrees of instability and complexity.
(b) Stage II: complete without displacement. Russel-Taylor Classification
(c) Stage III: complete with partial displacement – the fragments are still connected by the posterior retinacular attachment; the Intertrochanteric fractures are almost always treated by early Type I: Fractures do not extend into piriformis fossa:
femoral head trabeculae are no longer in line with those of the innominate bone.
(d) Stage IV: complete with full displacement – the proximal fragment is free and lies correctly in the acetabulum so that the
internal fixation – not because they fail to unite with conservative Type IA: Lesser trochanter is attached to the proximal fragment
Type IB: Lesser trochanter is detached from the proximal fragment
trabeculae appear normally aligned with those of the innominate. treatment (they unite quite readily), but :
Fracture of neck of femur is an orthopedic emergency due to risk of a vascular necrosis.
necrosis 1- to obtain the best possible position Type II: Fractures that extend into the piriformis fossa:
Type IIA: No significant comminution or fracture of lesser trochanter
1) Initial treatment consists of : 2- to get the patient up and walking as soon as possible thereby Type IIB: Significant comminution of the medial femoral cortex and
- pain-relieving measures reduce the complications associated with prolonged recumbency. loss of continuity of lesser trochanter
- simple splintage of the limb.
A) Conservative treatment : ORIF is the treatment of choice.
- If operation is delayed, a femoral nerve block may be helpful.
- Indication: who are too ill to undergo anaesthesia; Early :
In Garden I , II (impacted fractures) : can be left to unite ,,but safer fixation without reduction
reductio is better. - traction
tion in bed until there is sufficient reductio
reductionn of pain to allow mobilization. - Traction may help to reduce blood loss and pain.
In Garden III , IV ( displaced fractures) : will not unite without internal fixation It is an interim measure until the patient, especially if elderly
and with multiple medical problems, is stabilized and
Indication of operation : B) Surgical treatment : prepared for surgery.
1- In young patients operation is urgent; interrup'on of the blood supply will produce irreversible cellular changes a<er 12 h. 1- Reduction :
2- In older patients also , the longer the delay the greater is likelihood of complications 1) If Postero-medical
medical cortex at lesser trochanter in continuous 1- Reduction : Open reduction
anatomical reduction :
2) Reducation: 2- Fixation: internal fixation :
- Closed reduction .
- IF a stage I, II , fracture
racture is manipulated (closed reduction) , then checked by x-ray.
x (a) an intramedullary nail, with a proximal interlocking
- If fails open reduction & manipulation of the fragments.
- If a stage III or IV , cannot be reduced closed : screw, that can be directed into the femoral head , if :
• If patient under 60 years of age open reduction. 2) If comminuted fracture , where anatomical reduction proves impossible : - the fracture is very comminuted or unstable,
• If pa'ent over 70 years if two careful attempts at closed reduction fail, prosthetic a) valgus osteotomy (non
(non-anatomical reduction) to allow the proximal - if one suspects that operative dissection
di may
replacement : fragment to abut securely against the femoral shaft have compromised bone viability.
1- Hemiarthroplasty , inserted with or without cement. b) Arthroplasty . - preferable for a pathological fracture;
2- Total hip replacement,, If : (b) Dynamic Compression Screw (DCS) -plate
plate device.
(1) if treatment has been delayed for some weeks and acetabular damage is suspected, 2- Fixation: (95 degree)

(2) in pa'ents with metasta'c disease or Paget’s disease. 1) Dynamic Hip Screw (DHS) (135 degree), if troachntric + lesser trochantric fracture (unstable).).
3- Healing :
3) Fixation : 2) Reconstruction Nail, if associated wit
with subtroachntric, shaft & lower femur fracture .
- It's usually associated with non-union.
union.
- with cannulated screws :
3- Healing : - So, additionof of bone grafts may hasten union.
union
• 3 cannulated scews - one screw to support the inferior portion of the neck.
-two
two screw, centrally in level striking the ant. & post. cortices of - The addition of bone grafts may hasten union of the medial cortex.
4- Rehabilitation:
femoral neck. 4- Rehabilitation : patient is allowed partial weightbearing (with crutches)
• Dynamic compression screw ( DCS ) (95 degree) , which attaches to femoral shaft. - Exercises
xercises are started on the day after operation until union is secure.
4) Rehabilitation: - the patient allowed partial weightbearing using crutches.
- From the first day patients should sit up in bed or in a chair. - Breathing Exercise
- Encouraged
ncouraged to begin walking (with crutches or a walker) as soon as possible.

Fractur Shaft of FFemur


Definitive treatment Immobilization following the traction :
In the multiply injured patient: Once the fracture is sticky (at about 8 weeks in adults) traction is replaced by :
Stabilization
tabilization with an external fixator the fixator can be exchanged for an intramedullary nail - Cast or brace , and the patient allowed up and partial weightbearing.
when the patient’s condition stabilizes.
- The timing of this second procedure is problematic :
- For fractures in the upper half of the femur, plaster spica is the safest but it will
Some guidance can be sought from measurement of circulating levels of interleukin-6, a pro- almost certainly prolong the period of knee stiffness.
inflammatory cytokine when the levels start to decrease, it should be safe to perform - For fractures in the lower half of the femur, cast-bracing is suitable.
‘second hit’ interven'ons. Clinically this occurs around 55–7 days a<er admission. This type of protection is needed until the fracture
re has consolidated (16–24
(16 week)
A) Conservative treatment : A) Surgical treatment : ORIF
Traction, bracing and spica casts : 1-- Reduction : Open reduction
- Traction can reduce and hold most fractures in reasonable alignment,
except those in the upper third of the femur. 2-- Fixation : Internal fixation
The chief drawback is : 1- Interlocking Intramedullary nail
The length of 'me spent in bed (10
(10–14 weeks for adults) with the a6endant - It is the method of choice for most femoral shaft fractures.
Winquist’s classification problems of keeping the femur aligned until sufficient callus has formed. - It controls rotation and length, and ensures stability even for
The Winquist and Hansen classification is based on comminution; To over come this drawback : by changing to a (around 6–8 weeks) : subtrochanteric and distal third fractures.
- fracture instability increase with increasing grades of comminution. - Plaster spica or – 2- Plate and screw fixation : The main indications for plates are :
- most useful for determining the need for interlocking nails. - Functional bracing – in the case of lower third fractures – when the fracture is - fractures at either end of the femoral shaft, especially those with
‘sticky’. extensions into the supracondylar or pertrochanteric areas,
In Type 1: only a tiny cortical fragment. (small insignificant comminution)
- a shaft fracture in a growing child, ( we can better used non-rigid
non Nancy nail )
In Type 2: the ‘butterfly fragment’ is larger but there is s'll at least 50 % The main indications for traction are :
- a fracture with a vascular injury which requires repair.
cortical contact between the main fragments. - fractures in children;
Usually not used because :
In Type 3: the bu6erfly fragment involves more than 50 % of the bone - contraindications to anaesthesia; and
• Long skin incision will be needed
width. - lack of suitable skill or facilities for internal fixation.
• Many screws will be needed above & below fracture site.
In Type 4: is a segmental fracture.(no
(no contact between
betw proximal & distal fragm.) It is a poor choice for :
- elderly patients, 3- Reconstruction Nail: indication :
Descriptive Classification - for pathological fractures and - if associated with trochantric , subtroachntric & lower femur fractures .
- Open versus closed - for those with multiple injuries.
- If segmental stracture as no 2 plates in same fracture.
- Location: proximal, middle, or distal one-third
one A) Traction in children
- Pattern: spiral, oblique, or transverse For young children, skin traction without a splint is usually all that is needed. Healing: Fracture usually heals within 20 weeks
- Angulation: varus, valgus, or rotational deformity • In newborn: (assess child abuse) : "Crede's method" 3-- Rehabilitation :
- Displacement: shortening or translation - Femur reduced & fixed by tongue depressor and thigh flexed on - The patient is allowed up as soon as he or she is comfortable and knee
- Comminuted, segmental, or butterfly fragment abdomen and fixed to it for 2 weeks by adhesive plaster. movement exercises are encouraged to prevent tethering by the half pins.
• Infants ( <4 years ) less than 12 kg in weight: "Gallows tracAon" - Partial weightbearing is usually possible immediately but this will depend on
- are most easily managed by suspending the lower limbs enough to the x-ray appearance of callus – this may take some 'me (more than 6 weeks)
raise the buttocks from the bed. (but no > 2 kg used)
Emergency treatment • Older children ( 5 – 15 years ) :
The risk of systemic complications in these high energy energies - are better suited to Russell’s traction or use of a Thomas’ splint. External fixation , The main indications for external fixation are
can be significantly reduced by early stabilization of the fracture: (1) treatment of severe open injuries;
- Fracture union will have progressed sufficiently by 2–4 weeks (depending (2) management of pa'ents with mul'ple injuries
juries where there is a need to
3- Traction with a splint : on the age of the child) to permit a hip spica to be applied and the child is reduce operating time and prevent the ‘second hit’; and
is first aid for a patient with a femoral shaft fracture. It is applied then allowed up. (3) the need to deal with severe bone loss by the technique of bone transport.
at the site of the accident, and before the patient is moved. - Consolidation is usually complete by 6–12 weeks. (4) trea'ng femoral fractures in adolescents
B) Traction in Adults :
4- A Thomas’ splint: Not performed except in certain situations as: those very ill for anesthesia Treatment of open fractures
This temporary stabilization helps to control pain, reduces 1- Adults require skeletal traction (8–10 kg for an adult) through a pin or a Open femoral fractures should be carefully assessed for
bleeding and makes transfer easier. tightly strung Kirschner wire behind the tibial tubercle. (1) skin loss; (2) wound contamina'on;
2- The limb is usually supported on a Thomas’ splint . (3) muscle ischaemia; and (4) injury to vessels and nerves.
5- Shock should be treated; blood volume is restored and skeletal traction without a splint (Perkins’ traction) has the advantages - The immediate treatment is similar to that of closed fractures;
maintained, and a definitive plan of action instituted as soon of producing less distortion of the fracture - In
I addition, the patient is started on intravenous antibiotics.
as the patient’s condition has been fully assessed. Rehabilitation : • The wound will need cleansing
- While the patient is in traction, joint mobility must be preserved by • Stabilization of open femoral shaft fractures :
encouraging movement & exercise. - is best achieved with locked intramedullary nails
Monitoring : - Unless there is heavy contamination or bone loss – in which case
Thee position of the fragment should be checked repeatedly by xx-ray. external fixation is preferable. ( This only used in our hospital )

Supracondylar Fracture
ractures
Conservative Surgery
Indications : B-Surgery Operative treatment with internal fixation can enable accurate fracture
1- if the patient is young or (Elderly pa'ents tend not do as well with the 6 weeks of enforced reduction, especially of the joint surface, and early movement.
recumbency.) 1- Reduction : Open reduction
2- the facilities and skill to treat by internal fixation are absent.
2- Fixation: internal fixation :
1- Closed reduction (by traction):
a- If the fracture is only slightly displaced and extra-articular
extra articular or 1. For the type A &
If it reduces easily with the knee in flexion : - Locked intramedullary nails, which are introduced retrograde through the intercondylar notch
- It can be treated satisfactorily by skeletal traction through the proximal tibia; 2. For type B fractures (single condylar fracture):
The AO classification of supracondylar fractures
Type A : Extra-articular fractures have no articular splits and are truly - The limb is cradled on a Thomas’ splint with a knee flexion piece and movements - held with Kirschner wires preparatory to inserting Compression Screws (CS)
‘supracondylar’.
Type A1: Simple, two-part supracondylar fracture
are encouraged. 3. Simpler
impler type C fractures (T or Y shaped fracture ):
Type A2: Metaphyseal wedge - Locked intramedullary nails, which are introduced retrograde through the intercondylar notch
Type A3: Comminuted supracondylar fracture b- If the distal fragment is displaced
displa by gastrocnemius pull :
Type B : Uni-Condylar fractures are simply shear fractures of one of the
a second pin above the knee, and vertical traction, will correct this. - Or best fixed with a Dynamic (95 degree) condylar screw and plate.
condyles; and
Type B1: Lateral condyle, sagi6al 4. For severely comminuted type C fractures
Type B2: Medial condyle, sagi6al - Locked intramedullary nails, which are introduced retrograde through the intercondylar notch
Type B3: Coronal 2- Immobilization & rehabilitation :
Type C: Bi-Condylar fractures have supracondylar and intercondylar fissures . - At 4–6 6 weeks, when the fracture is beginning to unite, traction can be they provide adequate stability, even in the presence of osteoporotic bone,
Type C1: Noncomminuted supracondylar “T” or “Y” fracture
Type C2: Comminuted supracondylar fracture replaced by a cast-brace and N.B Reconstruction Nail, if associated with trochantric , subtroachntric & shaft fractures.
Type C3: Comminuted supracondylar and intercondylar fracture - the patient allowed up and partially weightbearing with crutches. Dynamic Compression Screw (DCS) , can also used (remember the indication of this screw )
rehabilitation :
- Unprotected
tected w
weight bearing is not permitted until thee fracture have
consolidated
lidated ( usually around 12 weeks).

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