أ. د حسان النعمانى

استاذ - رئيس الجامعة - جامعة سوهاج

كلية الطب

العنوان: العنوان الشخصى : ش الجمهورية بسوهاج -عنوان العمل : مبنى الادارة المركزية - الدور الثالث -جامعة سوهاج

إعجاب

Fracture shaft femur

2018-10-21 19:31:17 |

Introduction

High energy injuries frequently associated with life-threatening conditions
Epidemiology
- incidence
  - 37.1 per 100,000 person-years
Mechanism
- traumatic
  - high-energy
    - most common in younger population
    - often a result of high-speed motor vehicle accidents
  - low-energy
    - more common in elderly
    - often a result of a fall from standing
    - gunshot
Associated conditions
- orthopaedic
  - ipsilateral femoral neck fracture
    - 2-6% incidence
    - often basicervical, vertical, and nondisplaced
    - missed 19-31% of time
  - bilateral femur fractures
    - significant risk of pulmonary complications
    - increased rate of mortality as compared to unilateral fractures

Anatomy

Osteology
- largest and strongest bone in the body
- femur has an anterior bow
- linea aspera
  - rough crest of bone running down middle third of posterior femur
  - attachment site for various muscles and fascia
  - acts as a compressive strut to accommodate anterior bow to femur
Muscles
- 3 compartments of the thigh
  - anterior
    - sartorius
    - quadriceps
  - posterior
    - biceps femoris
    - semitendinosus
    - semimembranosus
  - adductor
    - gracilis
    - adductor longus
    - adductor brevis
    - adductor magnus
Biomechanics
- musculature acts as a deforming force after fracture
  - proximal fragment
    - abducted
      - gluteus medius and minimus abduct as they insert on greater trochanter
    - flexed
      - iliopsoas flexes fragment as it inserts on lesser trochanter
  - distal segment
    - varus
      - adductors inserting on medial aspect of distal femur
    - extension
      - gastrocnemius attaches on distal aspect of posterior femur

Classification

Winquist and Hansen Classification
Type 0	• No comminution
Type I	• Insignificant amount of comminution
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

OTA Classification
32A - Simple	• A1 - Spiral • A2 - Oblique, angle > 30 degrees • A3 - Transverse, angle < 30 degrees
32B - Wedge	• B1 - Spiral wedge • B2 - Bending wedge • B3 - Fragmented wedge
32C - Complex	• C1 - Spiral • C2 - Segmental • C3 - Irregular

Presentation

Initial evaluation
- Advanced Trauma Life Support (ATLS) should be initiated
Symptoms
- pain in thigh
Physical exam
- inspection
  - tense, swollen thigh
    - blood loss in closed femoral shaft fractures is 1000-1500ml
      - for closed tibial shaft fractures, 500-1000ml
    - blood loss in open fractures may be double that of closed fractures
  - affected leg often shortened
  - tenderness about thigh
- motion
  - examination for ipsilateral femoral neck fracture often difficult secondary to pain from fracture
- neurovascular
  - must record and document distal neurovascular status

Imaging

Radiographs
- recommended views
  - AP and lateral views of entire femur
  - AP and lateral views of ipsilateral hip
    - important to rule-out coexisting femoral neck fracture
  - AP and lateral views of ipsilateral knee
CT
- indications
  - may be considered in midshaft femur fractures to rule-out associated femoral neck fracture

Treatment

Nonoperative
- long leg cast
  - indications
    - nondisplaced femoral shaft fractures in patients with multiple medical comorbidities
Operative
- antegrade intramedullary nail with reamed technique
  - indications
    - gold standard for treatment of diaphyseal femur fractures
  - outcomes
    - stabilization within 24 hours is associated with
      - decreased pulmonary complications (ARDS)
      - decreased thromboembolic events
      - improved rehabilitation
      - decreased length of stay and cost of hospitalization
    - exception is a patient with a closed head injury
      - critical to avoid hypotension and hypoxemia
      - consider provisional fixation (damage control)
- retrograde intramedullary nail with reamed technique
  - indications
    - ipsilateral femoral neck fracture
    - floating knee (ipsilateral tibial shaft fracture)
      - use same incision for tibial nail
    - ipsilateral acetabular fracture
      - does not compromise surgical approach to acetabulum
    - multiple system trauma
    - bilateral femur fractures
      - avoids repositioning
    - morbid obesity
  - outcomes
    - results are comparable to antegrade femoral nails
    - immediate retrograde or antegrade nailing is safe for early treatment of gunshot femur fractures
- external fixation with conversion to intramedullary nail within 2-3 weeks
  - indications
    - unstable polytrauma victim
    - vascular injury
    - severe open fracture
- ORIF with plate
  - indications
    - ipsilateral neck fracture requiring screw fixation
    - fracture at distal metaphyseal-diaphyseal junction
    - inability to access medullary canal
  - outcomes
    - inferior when compared to IM nailing due to increased rates of:
      - infection
      - nonunion
      - hardware failure

Surgical Techniques

Antegrade intramedullary nailing
- approach
  - 3 cm incision proximal to the greater trochanter in line with the femoral canal
- technique
  - starting points
    - piriformis entry
      - pros
        
        colinear trajectory with long axis of femoral shaft
      - cons
        
        starting point more difficult to access, especially in obese patients
        
        causes the most significant damage to
        
        abductor muscles and tendons
        
        may result in abductor limp
        
        blood supply to the femoral head
        
        may result in AVN in pediatric patients
    - trochanteric entry
      - pros
        
        minimizes soft tissue injury to abductors
        
        easier starting point than piriformis entry nail
      - cons
        
        not colinear with the long axis of femoral shaft
        
        must use nail specifically designed for trochanteric entry
        
        use of a straight nail may lead to varus malalignment
  - reaming
    - reamed nailing superior to unreamed nailing, with:
      - increased union rates
      - decreased time to union
      - no increase in pulmonary complications
    - indications for unreamed nail
      - consider for patient with bilateral pulmonary injuries
  - interlocking screws
    - technique
      - computer-assisted navigation for screw placement decreases radiation exposure
      - widening/overlap of the interlocking hole in the proximal-distal direction
        
        correct with adjustment in the abduction/adduction plane
      - widening/overlap of the interlocking hole in the anterior-posterior plane
        
        correct with adjustment in the internal/external rotation plane
- postoperative care
  - weight-bearing as tolerated
  - range of motion of knee and hip is encouraged
- pros
  - 98-99% union rate
  - low complication rate
    - infection risk 2%
- cons
  - not indicated for use with ipsilateral femoral neck fracture
  - increased rate of HO in hip abductors with antegrade nailing
  - increased rate of hip pain compared with retrograde nailing
  - mismatch of the radius of curvature of the femoral shaft and intramedullary nails can lead to anterior perforation of the distal femur
Retrograde intramedullary nailing
- approach
  - 2 cm incision starting at distal pole of patella
  - medial parapatellar versus transtendinous approaches
  - nail inserted with knee flexed to 30-50 degrees
- technique
  - entry point
    - center of intercondylar notch on AP view
    - extension of Blumensaat's line on lateral
      - posterior to Blumensaat's line risks damage to cruciate ligaments
- postoperative care
  - weight-bearing as tolerated
  - range of motion of knee and hip is encouraged
- pros
  - technically easier
  - union rates comparable to those of antegrade nailing
  - no increased rate of septic knee with retrograde nailing of open femur fractures
- cons
  - knee pain
  - increased rate of interlocking screw irritation
  - cartilage injury
  - cruciate ligament injury with improper starting point
External fixation with conversion to intramedullary nail within 2-3 weeks
- technique
  - safest pin location sites are anterolateral and direct lateral regions of the femur
  - 2 pins should be used on each side of the fracture line
- pros
  - prevents further pulmonary insult without exposing patient to risk of major surgery
  - may be converted to IM fixation within 2-3 weeks as a single stage procedure
- cons
  - pin tract infection
  - knee stiffness
    - due to binding/scarring of quadriceps mechanism
Special considerations
- ipsilateral femoral neck fracture
  - priority goes to fixing femoral neck because anatomic reduction is necessary to avoid complications of AVN and nonunion
  - technique
    - preferred methods
      - screws for neck with retrograde nail for shaft
      - screws for neck and plate for shaft
      - compression hip screw for neck with retrograde nail for shaft
    - less preferred methods
      - antegrade nail with screws anterior to nail
        
        technically challenging

Complications

Heterotopic ossification
- incidence
  - 25%
- treatment
  - rarely clinically significant
Pudendal nerve injury
- incidence
  - 10% when using fracture table with traction
Femoral artery or nerve injury
- incidence
  - rare
- cause
  - can occur when inserting proximal interlocking screws during a retrograde nail
Malunion and rotational malalignment
- most accurately determined by the Jeanmart method
  - angle between a line drawn tangential to the femoral condyles and a line drawn through the axis of the femoral neck
  - malrotation up to 15 degrees is usually well tolerated
- incidence
  - proximal fractures 30%
  - distal fractures 10%
- risk factors
  - use of a fracture table increases risk of internal rotation deformities when compared to manual traction
  - fracture comminution
  - night-time surgery
- treatment
  - if noticed intraoperatively, remove distal interlocking screws and manually correct rotation
  - if noticed after union, osteotomy is required
Delayed union
- treatment
  - dynamization of nail with or without bone grafting
Nonunion
- incidence
  - <10%
- risk factors
  - postoperative use of nonsteroidal anti-inflammatory drugs
  - smoking is known to decrease bone healing in reamed antegrade exchange nailing for atrophic non-unions
- treatment
  - reamed exchange nailing
Infection
- incidence
  - < 1%
- treatment
  - removal of nail and reaming of canal
  - external fixation used if fracture not healed
Weakness
- quadriceps and hip abductors are expected to be weaker than contralateral side
Iatrogenic fracture etiologies
- risk factors
  - antegrade starting point 6mm or more anterior to the intramedullary axis
    - however, anterior starting point improves position of screws into femoral head
  - failure to overream canal by at least .5mm
Mechanical axis deviation (MAD)
- lengthening along the anatomical axis of the femur leads to lateral MAD
- shortening along the anatomical axis of the femur leads to medial MAD
Anterior cortical penetration

المرفقات

1540150275 - ipsilateral neck_shaft.jpg 0

الواجبات

Femoral neck fractures

2018-10-21 19:43:16 | Fracture shaft femur

$Femoral neck fractures$

Introduction Epidemiology * increasingly common due to aging population * women > men * whites > blacks * United states has highest incidence of hip fx rates worldwide * most expensive fracture to treat on per-person basis Mechanism * high energy in young patients * low energy falls in older pat... إقراء المزيد

تواصل معي

العنوانالعنوان الشخصى : ش الجمهورية بسوهاج -عنوان العمل : مبنى الادارة المركزية - الدور الثالث -جامعة سوهاج
رقم الهاتف1002554984
الفاكس932332761
البريد الإلكترونيhassan.noaman@med.sohag.edu.eg

جميع البيانات و المستندات الموجوده لكل موقع من مواقع الاعضاء تقع صحتها قانونيا و أدبيا على العضو نفسه

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