FRACTURES FEMUR

 
FRACTURES FEMUR

Introduction

The femur bone is the largest bone in the body which extended from hip joint above to the knew joint below it is divided into upper proximal part which contains the head neck greater and lesser trochanters shaft and distal or lower part which contains medial and lateral epicondyles

blood supply of femoral head

anatomy of the femur bone

this is from1-  Retnacular branches from medial and lateral femoral circumflux arteries pass proximally within the joint capsule to anastamosis at junction of neck and articular surface which is the main source of supply the retinacular vessels are easily to disrupted in intracapsular fractures leading to avascular necrosis of the head  2- vessels travelling up the diaphysis 3- an artery in the ligamentum teres small contribution to no contribution in elderly

TYPES OF FEMUR FRACTURES 
it can be divided as follow 1- proximal femur fractures 2- fractures of femoral shaft 3- distal femoral fractures 4- Femoral head fractures

 FRACTURES OF PROXIMAL FEMUR
IT has two types
 Intracapsular fractures or fracture neck femur which subdivided into subcapital fractures cervical and basal fractures
Extracapsular fracture which is subdivided into intertrochanteric fractures basal and subtrochanteric fractures

INTRACCAPSULAR FRACTURE OF PROXIMAL FEMUR

CAUSES
as the femoral bone strong bone and surrounded by strong muscles of the thigh so it needs high energy injuries to become fractured in healthy patient as motor car accident or motor vehicles fall from high  or minor trauma or low energy fall  as in patient with bone diseases as estoporosis or bone tumors and this is known as pathological fractures
predisposing  factors as osteoporosis especially in postmenopasual women chronic alcholoism in young patients or other chronic medical conditions as postural hypotension


Classification of the intracapsular fractures
Garden,s classification

based on the integrity of trabecular lines in anteroposterior projections
stage I  impacted fracture medial cortical trabeculae intact but angulated undisplaced
stage II  complete but undisplaced fracture medial cortical trabeculae interrupted but not angulated 
stage III  complete partially displaced fracture with loss of trabeculae alignment
 stage IV  completely displaced fracture

Clinical pictures
as in any fractures there is history of trauma either motor car accident or fall from high or minor trauma in estoporotic patient there is pain and tendreness in the hip region may associated with swelling skin of soft tissue injuries connted with exterior called open fracture
 the leg lies shortened and externally rotateddue to the unbalanced influence of the external rotators and the psoas muscle
 neurovascular injuries may be present

Investigations
plain X rays anteroposterior view of the pelvis and lateral view of the affected hip  in some patients there are clear clinical signs of fracture but radiographs are inconclusive in this case the radiographs should be repeated in 48 - 72 hours or alternatively isotopic bone scanning or magntic resonance imaging MRI  will clarify the diagnosis

  treatment
Undisplaced intracapsular fracture Garden I and II
Internal fixation with two or three parallel hip screws  there is small risk of avascular necrosis AVN or non union if this occurs cannulated screws may be revised to a hemiarthroplasty or total hip replacement THR

Displaced intracapsular fracture Garden III and IV
 in elderly patient above65 years
fracture reduction and sliding hip screw bipolar hemiarthroplasty or total hip replacement

in young fut patients aged less than 65 years
urgent reduction and internal fixation by sliding hip screw or total hip replacement
risk of vascular necrosis is higher for Garden III and IV fractures but accurate reduction gives excellent results in a proportion of patients

postoperative complications of intracapsular fracrure
 Infection -Dislocation-Femoral stem loosing and thigh pain - Acetabular erosion
Avascular necrosis and fracture non union are more common in the severely displaced fractures the necrosis may not be visible radiographically for up to 18-24 months the best treatment is total hip replacement if the condition is symptomatic and the patient,s condition allows

Extracapsular fractures of proximal femur
these fractures occur from the basal part of the femoral neck to about 5 cm below the lesser trochanter they include 
Intertrochanteric -Basal - Subtrochanteric

Causes
the injury is usually caused by a low enegy fall it can be seen in an oesteoarthritic stiff hip as the force is concentrated in the pretrochanteric region at the time of the fall the fractures occur distal to the insertion of the joint capsule through an area of well vascularised metaphyseal bone so disruption of the blood supply to the femoral head is rare or unlikely except in the higher energy markedly displaced fractures
in subtrochanteric fractures required usually high energy injuries
 
Classification
classification is based on the number of fragments produced by the fracture
Undisplaced-two part
Displaced-two part
Three part involving the greater trochanter
Three part involving the lesser trochanter
Four part
Reversed obliquity
 
  Clinical picturs
pain and tenderness may be only manifestation in undisplaced fracture
in displaced fracture the limb will be externally rotated and shortened as in intracapsular fracture external bruising can be extensive and sufficient to require fluid replacement for shock in some patient

Investigations
plain X rays an anteroposterior view of the pelvis with a lateral view of rhe affected hip will confirm the diagnosis

Treatment

all cases unless unfit for operation require reduction and internal fixation with device that transmits force from the femoral head to the femoral shaft as
 Dynamic hip screw DHS  the screw is inserted into the neck and head and slides freely in the barrel of the plate which is secured to femoral shaft this allow fractures to compress
Intramedullar nail fixation device similar to DHS  but force is transmitted to the short proximal imtramedullary nail
Complications
as any fractures as non union mal union instability avscular necrosis but rare

FEMORAL SHAFT FRACTURES
 
Causes

in young patient need sever trauma eg motor car accident fall from height or motorcycle accident and frquently associated with multisystem trauma  and may result with blood loss of 1000-1500 ml and more if open fracture
in elderly patient may occur after minor fall
spiral fractures of the femur in infants are almost pathognomic of non accident injury

Clinical pictures
as any fractures beside the following the limb is usually deformed and extermely swollen neurovascular injuries are uncommon but the fracture angulation can compromise the limb vascularity untill the deformity is corrected
Investigations
 plain X rays of the whole femur and pelvis are essential for diagnosis

Treatment
first aid treatment includes the identification of associated injuries correction of hypovolaemia and temporary splinting of the fracture using Thomas splint with skin traction
femoral fractures should be stabilised as soon as possible
these fractures are treated by intramedullary nailing but external fixation or compression plating may be used in some cases

in children femoral fractures can be treated with reduction and skin traction  and Thomas splint gallows  traction for infants under 3 years or hip spica for young children or stabilisation with multiple flexible intramedullay nails in children above 5 years also external fixation or compression plating are other options
 a small degree of malunion is acceptable as there is great potential for remodelling during growth

Complications
as any fractures beside delayed or non union but the main problems are systemic secondary to oligamia and the fat embolism syndrome

DISTAL FEMUR FRACTURES
these included supracondylar fracture and intercondylar T or Y shaped femoral fractures
 
Causes
result from high energy trauma in adults also cam occur in elderly patient with severe oestoporosis
 the muscle attachments of the distal femur mean that these fractures are unstable

 Clinical pictures
 as any fractures pain and tenderness over distal part of the femur also may associated with swelling or bruises  inability to walking and also cross deformity is usually found and there may be associated with neurovascular injury in the popliteal fossa 
 Investigations
 Plain X ray for diagnosis and planning of treatment

Treatment
open reduction and internal fixation surgical fixation  either by condylate plate or retrograde intramedullary nail or  above total knee replacement  traction can be used in supracondylar fractures but it is cumbersome in the older patient and has 50% malunion or non union rate

Complications
 as any fractures beside failure of fixation non union malunion post traumatic arthritis

Femoral head fractures
these are extremely rare and carry poor prognosis they usually occur with hip joint dislocation and often required CT scanning or  MRI  to clarify the configuration of the fractures the fracture invariably requires fixation to restore congruency of the femoral head and reduce the risk of post traumatic arthritis

tags:fractures,femur