Femur Fracture

November 26, 2015 at 11:00 am | Posted in Uncategorized | Leave a comment

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P/s: This note is not entirely mine. Credit should be given entirely to the Appley textbook, Netter’s concise Orthopaedic anatomy and of course what my beloved lecturers told me during the teachings in the ward ☺

1. Neck of Femur #
MOI
Elderly: usually after trivial trauma.
Young age: high velocity injury (MVA or fall)

Classification:
➡Garden
➡ Anatomical (subcapital, transcervical, and base cervical)
✳ subcapital & transcervical is intracapsular.
Why it’s important?
Healing problem.
1. Less blood supply
2. Synovium wash the hematoma (initial stage for # healing)
3. No contact with soft tissue hence callus etc cannot form.
✳ transcervical higher risk for AVN

Tx:
Young ➡ head preserving as much as possible. IF (cannulated screw as soon as possible). Closely reduce the # and IF.
Why head preserving?
1. Younger age, hence can withstand revision surgery (if any).
2. Risk of implant wear and tear.

Elderly ➡ Garden 1 & 2 go for IF. Why? Risk of revision surgery is lower. Undisplaced should always be treated as it can easily go to Garden 4.
Garden 3 & 4 Thompson hemiarthroplasty.
Why? No need for revision surgery and risk of wear and tear is lower.
However, drawback is longer surgery time, more blood loss and higher risk of infection.
✴ there’s even argument that for all NOF # in elderly go for hemiarthroplasty.

Complications
1. AVN
– must treat fast if head preserving (preferably less than 12 hrs)
– why AVN? Anatomy of the blood supply.
⏩ median and lateral circumflex artery (retrograde blood flow, easily interrupted when #)
⏩ interamedullary artery (always interrupted in #)
⏩ arteries of the ligamentum teres (in elderly aboyt 20% is not existence)
– can only discharge patient from follow up after 2 years.
– risk of AVN (Apply) 10% in non-displaced # and 30% in displaced #.
2. General complication of bed ridden.
3. Secondary OA
4. Non-union

Additional notes:
🔵 off CBD prior to hemiarthroplasty as it can predispose to UTI. Urine should be sterile prior to op. Check with UFEME.
🔵 implant life span about 20 years. Life expectancy in Malaysia, Male 70 years old, Female 73 years old. Hence mx using prosthesis is for those who are 60 y/o and above.

2. Intertrochanteric #
Usually in osteoporotic bone. Shortening more marked than NOF # and easier to heal.
Why? Because it is extracapsular.

Classification: Evans (degree on displacement & comminution, where it will interfere with stability. Less stability, harder surgery, easier to get malunion)
Type 1: Not displaced
Type 2: 2 parts
Type 3: 3 parts (maybe GT or LT segment)
Type 4: 4 parts (severely comminuted)

Tx:
CRIF (proximal femoral nail PFN, IM nail with proximal locking screw), esp if # involve LT as plate cannot be placed properly.
OR in the case of fail CR
Medically unsuitable for surgery ➡ non-operative

Complications:
1. General complications of bed ridden
2. Malunion (however usually didn’t interfere with function)

3. Subtrochanteric #
Subtrochanteric area: Area between LT and 5 cm distal to it.

Blood loss maybe higher than in NOF or intertroc # as higher blood supply (lateral and medial circumflex artery from profunda femoris artery)

# may extend to the intertrochanteric area (influence management)

MOI:
Elderly ➡ trivial fall (osteoporosis)
Young ➡ high velocity trauma
Maybe pathologic # secondary to mets etc…

Tx:
ORIF (anatomical reduction will get best contact between fragments)
Dynamic hip screw

4. Shaft #
MOI:
Usually high energy trauma.
In elderly with trivial trauma, pathological until proven otherwise.
In child less than 4 y/o, suspect child abuse.

How to predict the displacement and angulation?
➡ Proximal shaft #, proximal part tend to be in abduction, flexion and externally rotated.
Why? effect of the gluteus and illiopsoas muscle.
➡ Midshaft #, less abduction
➡ Distal shaft #, distal fragments in adduction, proximal tilted due to gastrocnemius pull.

It’s an emergency 🆘
Why? Risk of hypovolumic shock. Bleeding can be up to 2 litres from the profunda femoris arteries.

Classification (Winquist – according to the degree of comminution and stability)
Type 1: Comminution less than 25%
Type 2: <50%
Type 3: <75%
Type 4: more than 75%
It influences the management.
Only type 1 can be managed with plating.

X-Ray ➡ AP and Lateral with knee and hip x-ray.
Why?
1. High energy injury. Usually can cause injury to knee and hip.
2. Deformity following # can mask hip dislocation.
3. Avoid missed # (NOF #, or else patient will develop AVN)

Tx:
Initially at ED:
Splinting, analgesia, adequate hydration (6 pint NS), put on traction.

All requires CRIF. OR in certain cases.
💟 IM nail – the best implant, weight sharing, not rigid hence promote callus formation (healing by secondary intention)
💟 Plating – previously a rigid fixation, load sparing, may cause osteoporosis of bone underneath the plate due to disuse of bone.
Now, MIPO technique (Minimally invasive plate osteogenesis)
➡ put at the submuscular plane, hence less rigid. Allow healing by secondary intention.
➡ less scar, less risk of infection.
Plating is indicated in:
1. Peadiatric patient
2. # with vascular injury
3. # at distal part of femur
4. # with FES. (Faster, and plating didn’t need reaming, decrease the likelihood of worsening the FES)
💟 External fixator – in open fracture, LRS.

Complications:
1. FES
2. Compartment syndrome
3. Hypovolumic shock
4. Complications of prolong immobilization.

Late ➡ malunion, non-union, infection (in open #)

5. Distal Femur #/Supracondylar #
Distal part will usually be pulled by the gastrocnemius muscle (become extended, hence can injure the popliteal vessels)

MOI:
Young ➡ high energy injury
Elderly ➡ osteoporotic bone

Classification (AO)
Type A: Extraarticular (purely supracondylar #)
Type B: Unicondylar #
Type C: Supracondylar + intercondylar fissure

Mx
Extraarticular – plating or nailing.
Intraarticular – anatomical reduction + locking plate.

Undisplaced can be treated conservative, however risk of prolong bed rest, hence IF is still the treatment of choice.

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