Femoral Shaft Fractures

Epidemiology

 

Usually young patients

- 15 - 40

 

15% compound

 

Aetiology

 

High velocity injury

- MBA

- MVA

- pedestrian v car

- fall from height

 

Emergency Managment

 

EMST principles

- need for transfusion not uncommon

- hypotension from isolated closed femoral fracture unlikely

 

Beware

- ipsilateral NOF / pelvic fracture / acetabular fracture

- knee injury / ACL or other ligament injury

- floating knee / ipsilateral tibial fracture

 

Thorough neurovascular exam

- incidence vascular injury 1%

 

Thomas splint

- ring against ischium

- velcro around foot

- pneumatic traction

- can only be applied for 12 hours or so

 

Thomas SplintThomas Splint

 

Carbon traction splints

 

Femur carbon traction splint

 

Balanced Traction

 

Balanced traction

 

Compound wound

 

Compound femur

 

Betadine pack

Tetanus

Antibiotics

 

Winquist Classification

 

Type 1                                                                                                                      

- minimal or no comminution                                                                                                                                            

Femoral Shaft Fracture No comminution                    

 

Type 2  

- < 50% comminution

Femur fracture

 

Type 3

- 50 - 100% comminution 

- inherently unstable

- needs distal locking

Femoral fracture

 

Type 4

- segmental comminution

- no contact or inherent stability

 

Associated injuries

 

Femoral Shaft Fracture with Neck Fracture

 

Up to 10% concurrence

- can be missed on plan film

- splints can obscure

 

Assessment

- carefully review pelvic xrays

- order CT if required

- assess carefully using fluoroscopy during surgery

 

Knee

 

Byon et al. Injury 2018

- 87 knee ligament injuries in 429 femoral shaft fractures (20%)

- 20 PCL, 11 ACL, 16 MCL, 8 LCL and 32 multiligament knee injuries

- always assess knee after femoral stabilisation

https://pubmed.ncbi.nlm.nih.gov/29887503/

 

Femoral Fracture + ACL Reconstruction

 

Floating Knee

 

Ipsilateral femur + tibial fracture

 

Floating Knee 1Floating Knee 2

 

Operative Management Issues

 

Surgical Timing

 

Early fixation < 24 hours

- indicated for isolated injuries

- reduce risk of pulmonary complications

 

Harvin et al. J Trauma Acute Care Surg 2012

- compared early stabilisation (<24 hrs) with delayed (>24 hrs)

- retrospective review of 1,376 patients

- early IMN associated with decreased pulmonary complications such as pneumonia / PE / ARDS

- decreased length hospital stay

https://pubmed.ncbi.nlm.nih.gov/23188236/

 

Damage Control Orthopaedics

 

Concept

- severely injured polytrauma patients

- head / chest / abdominal / pelvic injuries

- patients have elevated cytokines (IL-6) in multitrauma

- avoid second hit of surgery during this period

- second hit may be associated with ARDS and multi-organ failure

 

Technique

- stabilise femoral fracture with simple external fixator

- allow return to ICU for warming / stabilisation

- delay definitive treatment until inflammatory state reduces

- approximately day 6

 

Results

 

Pape et al J Orthop Trauma 2002

- retrospective study of polytrauma patients at risk of multi-organ failure

- patients treated with early IMN femur v DCO (early stabilisation femur external fixation with later IMN)

- significant reduction in incidence of multiorgan failure

- significant reduction ARDS (15% down to 9%)

- no increased rate of local complications (infection, non union)

https://pubmed.ncbi.nlm.nih.gov/12352480/

 

Surgical Options

 

1. External fixation

2. IMN

3. Plate

 

1. External Fixation

 

Indications

- severely contaminated wound

- Damage Control Orthopaedics

- complex femoral fracture with vascular injury

 

AO Surgery Technique

- safe zone is lateral

https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/femoral-shaft/simple-spiral-middle-1-3-fractures/temporary-external-fixator#aftertreatment-following-temporary-external-fixation

 

Timing of conversion to IMN

 

Harwood et al J Orthop Trauma 2006

- two groups

- 81 patients treated with early IMN

- 111 patients treated with external fixation converted to IMN at mean of two weeks

- at time of surgery, pin sites excised, washed, and overdrilled

- no difference in deep infection rates between two groups

https://pubmed.ncbi.nlm.nih.gov/16648699/

 

2. Antegrade Femoral Nail

 

Femoral Nail0001Femoral Nail

 

Reamed v Unreamed IMN

 

Nonunion rates

 

Canadian Orthopaedic Trauma Society (COTS) JBJS Am 2003

- multicentred randomised trial

- non union rates reamed v unreamed IMN

- 8 / 107 (7.5%) smaller unreamed femoral nail nonunion

- 2 / 121 (1.7%) larger reamed femoral nail nonunion

https://pubmed.ncbi.nlm.nih.gov/14630836/

 

Li et al. Medicine 2016

- meta-analysis of 8 RCT and 1078 patients

- reamed nails had shorter times to union

- reamed nails had reduced rates of nonunion and reoperation

- no increased rates of ARDS, mortality or blood loss with reaming

https://pubmed.ncbi.nlm.nih.gov/27442651/

 

ARDS

 

Canadian Orthopaedic Trauma Society (COTS) J Orthop Trauma 2006

- multicentred randomised trial reamed v unreamed

- incidence ARDS in multiply injured patients

- 3/63 reamed v 2/46 unreamed developed ARDS

- very low incidence of ARDS in both groups

- not statistically significant

https://pubmed.ncbi.nlm.nih.gov/16825962/

 

Trochanteric v Piriformis Entry Point

 

Kumar et al. Injury 2019

- systematic review of 9 studies

- trochanteric entry reduced OR time, fluoroscopy time, reduced abductor weakness, better functional outcome

- similar union rates

https://pubmed.ncbi.nlm.nih.gov/31358301/

 

3. Femoral Plate

 

Indications

- associated proximal / distal femoral fracture

- vascular injury

- medulla too narrow for IMN

- paediatric population

- treatment of non union

 

Issues

- tension side / load bearing

- significant disruption to blood supply required

- plate will break early if union not achieved

 

Technique

- large fragment plate

- minimum 8 cortices each side of fracture

- need periord of NWB

 

Results

 

Giessler et al Orthopedics 1995

- 71 femurs diaphyseal fractures

- 93% union at 16 weeks

- recommended bone grafting at same time

https://pubmed.ncbi.nlm.nih.gov/7479404/

 

Difficult Scenarios

 

1. Floating Knee

 

Single incision at knee

- retrograde femoral nail

- tibial IMN if appropriate

 

High complication rates including non union / malunion, knee stiffness and hetertopic ossification

 

https://pubmed.ncbi.nlm.nih.gov/30910244/

 

https://pubmed.ncbi.nlm.nih.gov/29885963/

 

Floating Knee 1Floating Knee 2Floating Knee 3

 

2. NOF (Neck of Femur) + Femoral shaft fracture

 

Must pay attention first to meticulous NOF ORIF

 

Options

1.  Pin and Plate NOF / Retrograde Nail

2.  Pin and Plate NOF / Plate femur

3.  Reconstruction Nail

- difficult to anatomically reduce NOF

- increased incidence NOF non union

 

Difficult scenario

- antegrade IMN in place before diagnosis of NOF fracture

- if undisplaced, can place screws anterior to nail

- if displaced must remove nail

 

Results

 

Ostrum et al. CORR 2014

- 95 cases treated with proximal screws / sliding hip screws inserted first

- retrograde IMN second

- 98% union rate femoral neck

- 91% union rate femoral shaft

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4117883/pdf/11999_2013_Article_3271.pdf

 

Vumedi video

https://www.vumedi.com/video/combined-femoral-neck-and-shaft-fractures-how-not-to-miss-techniques-of-reduction-fixation/

 

3. Dislocated Hip + Femoral shaft fracture

 

1.  Simple dislocation

- may be able to reduce hip with proximal steinman pin

- then IMN femur / retrograde or antegrade

- or plate femur

 

2.  Dislocation with Pipkin fracture

- may need anterior approach to ORIF femoral head fracture

- may be best to plate / retrograde nail femur

 

3.  Dislocation with posterior acetabular fracture

- may need posterior approach to acetabulum

- consider plating femur / distal femoral or tibial steinman pin

- delayed ORIF posterior wall

 

4. Distal femoral condylar fracture + shaft fracture

 

Options

1.  Screws anterior and posterior to retrograde nail

2.  Distal Locking plate

 

5. Bilateral Femur Fractures

 

Lane et al. Orthopedics 2015

- 72 patients

- high rate of complications

- mortality rate 6.9%

- increased risk of DVT and pulmonary complications

https://pubmed.ncbi.nlm.nih.gov/26186320/

 

Stavlas et al. Injury 2009

- systematic review 197 patients

- treated with bilateral reamed IMN

- fat embolism 4.1%

- ARDS 14%

- PE 7%

- suggest damage control orthopaedics

https://pubmed.ncbi.nlm.nih.gov/19775688/

 

6.  Segmental bone defects / critical bone defects

 

Management

- temporary fixation with nail / plate / ext fix

- cement spacer

- delayed Masquelet technique / induced membrane technique at 6 - 8 weeks

 

Morwood et al. J Orthop Trauma 2019

- 65 femurs with critical bone loss

- increased union, time to weight bearing with IMN v plate

- fewer grafting procedures and reoperations with IMN

https://pubmed.ncbi.nlm.nih.gov/31403558/

 

Trochanteric Entry Antegrade Femoral Nail Surgical Technique

 

Vumedi Video

https://www.vumedi.com/video/pearls-femoral-im-nailing/

 

Smith and Nephew Trigen TAN FAN

https://www.smith-nephew.com/global/assets/pdf/products/surgical/trigen_tan_fan.pdf

 

Position

- GA, IV ABx, transexamic acid

- traction table

- patient legs adducted, torso adducted

- allows access to GT

- flex and abduct other hip for image intensifier / fluoroscopy access

 

Entry

- incision proximal to GT

- split abductors in line

- palpate tip of GT

- check entry point on AP xray view

- check entry point on lateral xray view (junction anterior 1/3 posterior 2/3)

- entry with awl or 3.2 mm guide wire

- ensure wire doesn't penetrate medial cortex

- use proximal reamer for thickened proximal portion of nail

 

Pass guide wire

- ball tipped

- femoral fractures difficult to reduce with traction

- use reduction tool to reduce in AP and lateral views to pass guidewire

- if having difficulty +++, can perform miniopen incision to pass guide wire

- measure guide wire to determine nail length

 

Note typical deformity of proximal fragment which needs to be corrected

- flexed by psoas

- abducted by G medius

- externally rotated

 

Femoral Shaft Fracture Standard Displacement Lateral

 

Ream

- tight fit best

- nails come in 8.5, 10, 11 and 12 mm

- need to ream 1 - 2 mm larger than nail

 

Pass nail

- attach to proximal locking jig

- ensure drill passes through jig into proximal nail holes

- insert nail

- visualise with flurosocopy at fracture site

- ensure nail doesn't get caught on one cortex

- excessive hammering in this position can cause fracture

 

Locking

 

Proximal

- usually proximal locking first

- screw should purchase cortex of lesser trochanter

 

Femoral Nail Proximal Locking0001Femoral Nail Proximal Locking0002

 

Distal

- straighten out other leg / lower so can obtain lateral II

- perfect circle technique

- distal locking performed

 

Femoral Nail Distal Locking0001Femoral Nail Distal Locking0002

 

Rehabilitation

 

Arazi et al. J Trauma 2001

- 24 patients with comminuted femoral fractures allowed to weight bear in first 2 weeks

- all full weight bearing without aids by second month

- 100% union

- 2 slightly bent locking screws

https://pubmed.ncbi.nlm.nih.gov/11303169/
 

Complications of Femoral Nail

 

Nerve Palsy

 

Kao et al. 1993 J Orthop Trauma

- 15% incidence pudenal nerve palsy

- usually transient

- related to longer traction times

https://pubmed.ncbi.nlm.nih.gov/8433201/

 

Malrotation

 

Incidence

 

Unknown

> 100 may be prevalent in up to 40% of patients

Probably not relevant unless > 300

May be associated with anterior knee pain and/or hip pain

 

Diagnosis

 

A.  Clinical

- difficult

- probably best to assess internal and external rotation of the hip

- when swelling goes down can assess internal and external rotation of the foot

 

B.  CT

- axial cuts of the femoral neck and the femoral condyles

 

Femoral Nail Malrotation CT 1Femoral Nail Malrotation CT 2

 

Prevention

 

A.  Match cortices on the proximal and distal fragment

 

B. Both patellas pointing anterior

- match lesser trochanter position of  both hips

 

Treatment

 

A.  Early

- remove distal locking screws but leave in wires

- correct rotation based upon CT measurement

- insert new distal locking screws at the predetermined angle from previous screws

 

B.  Late

- may need osteotomy

 

Vergano 2020 Summary article

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944689/pdf/ACTA-91-03.pdf

 

Distal femoral breach

 

Causes

- insufficient curvature of femoral nail

- abnormal femoral curvature

- posterior starting point on the greater trochanter

 

Distal femoral breachDistal Breach ORIF

 

Non union

 

Femoral Non union

 

 

Incidence

- uncommon

- 1 - 2% with reamed nails

- increased with unreamed nails

 

Definition

- not united (3/4 cortices) after 6 months

- no progressive union for 3 months

 

Options

1.  Dynamisation / removal of distal locking screws

2.  Exchange nailing +/- bone graft

3.  Remove nail / plate + bone graft

4.  Augmentation with plating and bone grafting

5.  External Fixation

 

1.  Dynamisation

 

Indication

- stable fractures

- non comminuted / non segmental

- evidence of fracture gapping from over traction or bone resorption

 

Huang et al. Injury 2012

- 39 patients

- union rate 83% when dynamisation performed 10 - 24 weeks

- union rate 33% when dynamisation performed after 24 weeks

https://pubmed.ncbi.nlm.nih.gov/22841533/

 

Vaughn et al. World J Orthop 2018

- systematic review of exchange nail v dynamisation

- union rate dynamisation 66%

- exchange nail union rate 85%

- dynamisation good for delayed union

- exhange nail best for nonunion

https://pubmed.ncbi.nlm.nih.gov/30079298/

 

2.  Exchange nailing

 

Technique

- remove old nail

- ream up to larger size

- insert new larger nail

 

Swanson et al. J Orthop Trauma 2015

- 50 cases

- removal of nail, ream

- insertion of different manufacturer nail at least 2 mm bigger

- static locking

- early dynamisation if signs slow healing

- union in 100% at mean 7 months

https://pubmed.ncbi.nlm.nih.gov/24978947/

 

Tsang et al. Injury 2015

- risk factors for failure of exchange nail

- infection

- cigarette smoking

- may require repeat procedure

- technique eventually successful in 91%

https://pubmed.ncbi.nlm.nih.gov/26489394/

 

3.  Removal Nail / Plating / Bone Graft

 

Maimaitiyiming et al. Injury 2015

- 14 patients nonunion

- bone grafting and double plating

- union in 100% at mean of 5 months

https://pubmed.ncbi.nlm.nih.gov/25712702/

 

4.  Augment nail with Plate + Bone Graft

 

Medlock et al. Strategies Traumatic Limb Reconstruction 2018

- systematic review of augmentive plating v exchange nailing

- union rate 99.8% with augmentive plating

- 74% with exchange nail

https://pubmed.ncbi.nlm.nih.gov/30426320/

 

Infected Non union

 

Exchange Nail Bone Graft

 

Management

 

1.  Open debridement

- antibiotic beads

 

2. Removal of nail

- ream and irrigate

- antibiotic nail / cover IMN with antibiotic cement

- IV antibiotics

- definitive nail / external fixator

 

Pradhan et al. Injury 2017

- infection nonunion femoral shaft 21 patients

- infection eliminated in 100%

- union in 16/21, others required further surgery to obtain union

- 2 broken nails due to noncompliance with weightbearing

https://pubmed.ncbi.nlm.nih.gov/28802424/

 

Infected Femoral Nail 1Infected Femoral Nail2Infected Femoral Nail3Infected Femoral Nail4

 

Refracture

 

No evidence increased risk if nail removed > 1 year