FRACTURE FEMUR - Al-Kindy College of Medicine

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FRACTURE FEMUR
Lec.- 2
Sadeq Al-Mukhtar
Consultant orthopaedic surgeon
1- Fracture neck femur.
2- Intertrochanteric
fracture
3-Diaphyseal fracture.
Diaphyseal fractures are –
common in young adult and if
occurred in elderly, think of
pathological fracture,. Due to
thick muscles in the thigh this
makes the shaft fractured only by
severe trauma and causing
severe bleeding that may reach
about two liters of blood.
Types:1- Transverse fractures.
2- Spiral fractures.
3- Oblique fracture with or without
butterfly.
4- Comminuted fractures.
Clinical findings
- History of trauma.
- On examination:- there is shock ,
deformity, externally rotated limb,
swelling, tenderness with loss of
function.
- x-ray revels the fractures& its •
type.do AP and lateral view
Treatment :
Urgent: this includes treatment of shock and
dealing with other injuries of vital organs
regarding the fracture immobilized by Thomas
splint
Conservative :
Skeletal traction for 6 to 8 weeks followed by cast
bracing for other 6 to 8 weeks then
physiotherapy. Sometimes continueous traction
without cast bracing. regarding quadriceps and
hamstring during traction better to use lower
femoral skeletal traction .
Surgical treatment
Indications
1- failure of conservative treatment due to •
muscle(soft tissue)interposition or mal
alignment .
2- transverse fracture.
3- multiple fractures.
4- pathological fractures.
5- presence of any contraindication to
conservative treatment especially in elderly
patients.
6- vascular injuries associated with the
fracture.
Notes:
in regions of the world where •
intramedullary technique are not
available or where risks of surgery
are unacceptable, non-operative
treatment remain the treatment of
choice.
Types of surgical treatment :
1-open intramedullary nailing used in patients in whom closed reduction
and internal fixation are not possible as in arthrodesis or stiffness of
hip joint.its also used in patients whom the guide pin cant pass in the
canal as in presence of bony fragments in th canal ,also used in open
fractures where the ends of the bones aare exposed.
2-flexible nail :antgrade or retrograde flexible nailing of Enders nail
;single or multiple under fluoroscopic control (unreamed)
3-closed antigrade interlocked reamed nailing ,it has good results
especially if undreamed(less blood loss and decrease operation time).
4-closed retrograde nailing through lateral epicondyl area.
5- plate fixation;
Indications of plate fixation
- Inadequate experience with above
techniques or if fluoroscopy was not
available or if instruments and implants are
not available or if associated with vascular
injury and plating can be done through the
same approach.
- In non-union and mal-union in which the
canal is obstructed and sometimes
osteotomy or bone graft is needed.
- In the presence of arthrodesis of hip and
here nailing is difficult or impossible.
Extenal fixation
1- Compound fractures ,temporary or •
definitive treatment.
2- Multiply injured patient for rapid •
mobilization'
3- Fractures associated with vascular •
injury need to be repaired
Complications
Early:- shock, fat embolism ,DVT that causes
pulmonary , vascular injury, infection.
Late:1- Delayed union: If healing not occurs in within 3-4
months. It is treated by bone graft and IF.
2-Malunion: Up to 2 cm shortening and 10-15
degrees angulation is accepted but never rotation.
Treatment is corrective osteotomy and IF.
3- Joint stiffness; prevented by early mobilization
Supracondylar fracture
This is common in young adults
usually caused by direct violence.
Types; Simple and comminuted. It
may be associated with intraarticular extension T or Y
fracture.
Fracture femur in children
This is usually caused by direct trauma. Treatment is
almost always by conservative methods i.e skin
traction then if the fracture becomes stable, apply
pop for 4-6 weeks. Children less than 4 years; use
Gallows traction. Two cm shorting and up to 20
degrees angulation is accepted in children but again
no rotation.
Complications
- Malunion
- Leg length discrepancy usually shortening but
may be increase in length due to 1- Active healing
process( hyperaemia and hypervascularity).2Increased growth hormone secretion.
Treatment;
1- Young adults are usually treated •
conservatively by high tibial skeletal traction
in 90 degree flexed knee to cancel the action
of gastrocnemus muscle for 4-6 weeks.
2 –In elderly by IF; the types of fixation •
are ;
- Blade plate •
- Dynamic condylar screws •
- Other plates. •
Complications;
Early; Vascular injury, –
skin damage.
Late; Non-union,Knee
stiffness.
Condylar fractures
These are the same as supracondylar
fractures but always check distal
neurovascular function. It is usually caused
by direct injury to the knee. It takes T
or
Y shaped fracture.
On examination; Swelling, tender knee ,
doughy consistency due to hemoarthrosis
(rapid onset, to differentiate it from simple
knee effusion). Check x-ray to prove it.
Treatment
1- Conservative by skeletal traction 4-6 weeks.
2- Surgical treatment by internal fixation;
DCP, Compression screws with washers.
With posterior above knee slab followed by full
cast for 4-6 weeks followed by
physiothrerapy and gradual weight bearing.
Displacement of femoral
epiphysis
This occurs in children. It is type-2 salterHarris fracture. Caused by lateral or
hyperextension force.
Complications; Malunion leading to
deformity and growth disturbance (like any
epiphyseal injury).
Treatment
succeed or unstable, reduction under –
screen and percutaneous k-wire
followed by posterior above knee
slab.
Conservative
by manipulation under anaesthesia
and pop. If not succeed or unstable,
reduction under screen and
percutaneous k-wire followed by
posterior above knee slab.
–
Thank you

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