Fractures
of the shaft of the femur
Fractures of the shaft of the femur can occur in any age group. In young
children the spiral fracture of the femur is one of the fractures which occurs
commonly in nonaccidental injury but rarely at any other time. The force
required to cause a spiral fracture of a child’s femur is so great that it
Causes of fractures of the shaft of the femur
• In children, may be nonaccidental injury
• In adolescents, usually high-velocity injury
• In the elderly, may be pathological
Treatment
in children
This fracture heals very quickly in children and the fracture can be
stabilised with nonoperative means (Fig. 23.24). In children under the age of 2
years, vertical skin traction can be used to hang the legs off the bed. Static
traction can be used and the legs raised until the child’s bottom is floating
just off the bed. Surprisingly, the children do not find this traction
uncomfortable and nursing is easy. It is easy to tell when the fracture has
united as the child starts spinning around and hanging off the bed by its legs.
In the young child the femur is capable of considerable remodelling, so a
perfect reduction is not necessary.
Treatment of fractured shaft of femur
• In infants — gallows traction
• In children and adolescents — balanced traction
• In adults and the elderly — locked nail
Treatment
of the fractured shaft of femur in the child before epiphyseal closure
If there is still growth potential in the femur then internal fixation
should be avoided as this may cause damage to the epiphyseal growth plate. The
Treatment
of fractured femur in the adult
Traction for fractured mid-shaft femur can also be used in the adult but
requires that the patient stay in bed for 12—16 weeks. Once the fracture has
been settled into a satisfactory position there is no reason why the last
weeks of this traction should not be carried on at home where the patient can be
nursed by his or her family (Fig. 23.26). Traction may also offer some
advantages when the fracture is open and the femur heavily contaminated. There
will inevitably be an increased risk of infection if plating or an
intramedullary nail is used, and it may be advisible to leave the patient on
traction at least for a few days until the wound has settled down. However,
this is not an excuse for failing to be aggressive about removing all
contaminated tissue from the wound at the time of the accident (débridement).
The wound should be left open, and re-exploring and clearing away of dead or
contaminated tissue should continue until the wound is clean. An external
fixator can be applied to the lateral side of
If
a plate is to be used then it should be very heavy duty and the exposure will
need to be extensive, as there will need to be at least four holes for fixation
of the plate above the fracture and four holes below the fracture. If the
fracture is spiral then lag screws will need to be placed to draw the fragments
together, either through or separate from the plate. If the medial cortex is
deficient then this will need to be buttressed with bone graft and great care
will need to be taken when mobilising the femur as the plate will be vulnerable
to bending loads. The femoral shaft is ideally suited to an intramedullary nail
which, if the equipment and expertise is available, can be introduced closed
from the proximal end and then locked both proximally and distally. This will
give adequate stability to both bending and rotation forces to allow the patient
to weight-bear immediately (partial weight-bearing if it is an unreamed nail)
and to leave hospital as soon as they have recovered from the surgery and are
able to walk safely. The operation must be performed with great care as the
complication rate even in the best hands is high. The common complications are
listed in Table 23.7.
Alternatives
to intramedullary nailing
A simpler alternative to intramedullary nailing is the use of rush pins
introduced through the lateral and/or medial condyles of the femur. Rush pins
are flexible rods which can be passed into the femur through a small skin
incision at the knee and which are slightly curved so that by twisting them they
can be used to cross the fracture site and pass up into the femoral neck. The
femur can be stacked with rush nails until a relatively tight fixation is
obtained. Four or five rush nails passed up the femur are not as strong as an
intramedullary nail and are particularly poor at controlling rotation. They do,
however, prevent translation at the fracture site but do not prevent impaction.
Although they are relatively simple to insert they do tend to back out, and a
patient should certainly not be encouraged to more than toe touch with the leg
until the fracture has started to unite.
Metastases
in the femur which have not yet fractured
Wherever possible, secondaries in the femur or any other long bone
should be referred to an orthopaedic department before the pathological fracture
occurs. They are much easier to manage at this stage than they are after the
fracture has occurred through the lytic lesion. It is said that the femur is at
imminent risk of pathological fracture if a lytic lesion has eroded more than
half the thickness of the cortex or there is erosion over more than 2 cm of the
cortex. If either of these signs is present then immediate action needs to be
taken to stabilise the femur before it breaks. Before embarking on surgery
X-rays should be taken of the whole length of both femurs as there is likely to
be more than one metastatic lesion and this may affect the choice of surgery.
The purpose of the surgery is to fix the bones so that they do not break, so
that the last weeks or months of the patient’s life are not spent in pain and
disabled. However, the patient must be warned of the risks of the surgery which
are high (particularly death from pulmonary embolus). As soon as the bones are
fixed the patient can be transferred back to medical care for radiotherapy or
cytotoxic drugs, depending on the most appropriate management.
Indications
for prophylactic fixing of lytic lesions in the femur
•
50 per cent of the cortex eroded
•
> 2 cm invaded
• Check for other lesions
Supracondylar
fractures of the femur
Supracondylar fractures occur in young adults involved in very
high-energy accidents or in the elderly who fall awkwardly. There are many
different patterns of fracture, but not uncommonly a fracture line enters the
knee joint through the intercondylar notch creating an unstable Yshaped fracture. The X-rays may be difficult to interpret because the fracture line
down into the knee joint may be hidden behind the patella but a careful check
must be made for this as it alters the surgery required. In the elderly
neurovascular compromise is unusual, but in the young high-velocity accident the
popliteal vessels and nerves lie close to the fracture and may easily be
damaged.
The
nonoperative management of the supracondylar fracture of the femur
This fracture is normally unstable. It is too close to the knee joint to
manage in plaster and even in traction the distal fragment tends to flex.
Operative
management of supracondylar fractures
Special plates have been designed for the management of supracondylar
fractures, and it is a fracture where preoperative planning, of drawing out of
the fragments on tracing paper and then fitting templates to the reduced
fragments allows a logical operation to be designed.
If
there is an intercondylar fracture this may need to be fixed first with large
lag screws and then a blade plate introduced to attach the distal fragment to
the proximal. Bone grafting may be needed on the medial side if there is a
defect. Internal fixation allows early mobilisation of the knee but
weight-bearing may need to be protected with a cast brace until union has been
achieved.
• Nonoperative treatments lead to malunion and stiffness
• Plan surgery with templates drawn on to tracings of X-rays
• Mobilise early