FEMUR FRACTUREBy : DR. SAEED AHMED

ASSITANT PROFESSOR PIMS ORTHO AND TRAUMA DEPARTEMENT

CLASSIFICATION Femoral Head Fractures Femoral Neck Fractures Intertrochanteric Fractures Subtrochanteric Fractures Femoral Shaft Fractures Distal Femur Fractures

BLOOD SUPPLY OF FEMUR HEAD Femoral head has 3 sources of arterial

supply  extracapsular arterial ring

medial circumflex femoral artery (main supply to the head)from profunda femoris

lateral circumflex femoral arteryascending cervical branchesartery to the ligamentum teres

from the obturator artery or MCFA supplies perifoveal area

FEMUR HEAD FRACTURE Associated with hip dislocations -- Anterior hip dislocation. -- Posterior hip dislocation.

location and size of the fracture fragment and degree of comminution depend on the position of the hip at the time of dislocation.

MECHANISM Impaction, avulsion or shear forces involved

unrestrained passenger MVA (knee against dashboard)

falls from height sports injury industrial accidents

5-15% of posterior hip dislocations are associated with a femoral head fracture because of contact between femoral head and

posterior rim of acetabulum anterior hip dislocations usually associated

with impaction/indentation fractures of the femoral head

CLASSIFICATION OF FEMUR HEAD FRACTURE

Pipkin ClassificationType I Fx below fovea/ligamentum (small)

Does not involve the weightbearing portion of the femoral head

  

Type II Fx above fovea/ ligamentum (larger)Involves the weightbearing portion of the femoral head 

   

Type III Type I or II with associated femoral neck fxHigh incidence of AVN

 

Type IV Type I or II with associated acetabular fx (usually posterior wall fracture)

 

PRESENTATION History

frontal impact MVA with knee striking dashboard fall from height 

Symptoms localized hip pain unable to bear weight other symptoms associated with impact

Physical exam inspection

shortened lower limb with large acetabular wall fractures, little to no rotational asymmetry is

seen posterior dislocation

limb is flexed, adducted, internally rotated anterior dislocation

limb is flexed, abducted, externally rotated neurovascular

may have signs of sciatic nerve injury

IMAGING STUDIES Radiographs

recommended views AP pelvis, lateral hip and Judet views

both pre-reduction and post-reduction inlet and outlet views

if acetabular or pelvic ring injury suspected CT scan

indications after reduction to evaluate:

concentric reduction loose bodies in the joint acetabular fracture femoral head or neck fracture

TREATMENT Nonoperative

hip reduction indications

acute dislocations reduce hip dislocation within 6 hours

technique obtain post reduction CT

TDWB x 4-6 weeks, restrict adduction and internal rotation indications

Pipkin I undisplaced Pipkin II with < 1mm step off no interposed fragments stable hip joint

technique perform serial radiographs to document maintained reduction

Operative --ORIF

indications Pipkin II with > 1mm step off if performing removal of loose bodies in the joint associated neck or acetabular fx (Pipkin type III and IV) polytrauma irreducible fracture-dislocation Pipkin IV

treatment dictated by characteristics of acetabular fracture

small posterior wall fragments can be treated nonsurgically and suprafoveal fractures can then be treated through an anterior approach

Arthroplasty

indicationsPipkin I, II (displaced), III, and

IV in older patients

Fractures that are significantly

displaced, osteoporotic or comminuted

FEMORAL NECK FRACTURES

Mechanismhigh energy in young patients low energy falls in older patients

Osteology normal neck shaft-angle 130 +/- 7 degrees normal anteversion 10 +/- 7 degrees

Blood supply to femoral head   major contributor is medial femoral

circumflex (lateral epiphyseal artery) some contribution to anterior and inferior head

from lateral femoral circumflex some contribution from inferior gluteal artery small and insignificant supply from artery of

ligamentum teres displacement of femoral neck fracture will disrupt

the blood supply and cause an intracapsular hematoma (effect is controversial)  

GARDEN CLASSIFICATION

GARDEN CLASSIFICATION

PRESENTATION Symptoms

impacted and stress fractures slight pain in the groin or pain referred along the

medial side of the thigh and knee displaced fractures

pain in the entire hip region Physical exam

impacted and stress fractures no obvious clinical deformity minor discomfort with active or passive hip range of

motion, muscle spasms at extremes of motion pain with percussion over greater trochanter

displaced fractures leg in external rotation and abduction, with shortening

Radiographs recommended views

obtain AP pelvis and cross-table lateral, and full length femur film of ipsilateral side

consider obtaining dedicated imaging of uninjured hip to use as template intraop

traction-internal rotation AP hip is best for defining fracture type 

Garden classification is based on AP pelvis CT

helpful in determining displacement and degree of comminution in some patients

Nonoperative observation alone

indicationsmay be considered in some

patients who are non-ambulators, have minimal pain, and who are at high risk for surgical intervention

cannulated screw fixation  indications

nondisplaced transcervical fxGarden I and II fracture patterns in the

physiologically elderlydisplaced transcervical fx in young patient

considered a surgical emergency achieve reduction to limit vascular insult reduction must be anatomic, so open if

necessary

sliding hip screw or cephalomedullary nail indications

basicervical fracture vertical fracture pattern in a young patient

biomechanically superior to cannulated screws consider placement of additional cannulated screw above sliding

hip screw to prevent rotation hemiarthroplasty  

indications debilitated elderly patients metabolic bone disease

total hip arthoplasty       indications

older active patients patients with preexisting hip osteoarthritis

more predictable pain relief and better functional outcome than hemiarthroplasty

arthroplasty for Garden III and IV in patient < 85 years

INTERTROCHANTERIC FRACTURES

Extracapsular fractures of the proximal

femur between the greater and lesser

trochanters.

MECHANISM

elderly low energy falls in osteoporotic patients

younghigh energy trauma

OSTEOLOGY intertrochanteric area exists between greater

and lesser trochanters  made of dense trabecular bone calcar femorale

vertical wall of dense bone that extends from posteromedial aspect of femoral shaft to posterior portion of femoral neck 

Determines stability

CLINICAL PRESENTATION Physical Exampainful,

shortened, externally rotated lower extremity

IMAGING Radiographs

recommended views AP pelvis AP of hip, cross table lateral full length femur radiographs

CT or MRIuseful if radiographs are negative but

physical exam consistent with fracture

TREATMENT sliding hip compression screw

indications stable intertrochanteric fractures

outcomes equal outcomes when compared to intramedullary hip screws for

stable fracture patterns intramedullary hip screw (cephalomedullary

nail)  indications

stable fracture patterns unstable fracture patterns  reverse obliquity fractures  

56% failure when treated with sliding hip screw subtrochanteric extension lack of integrity of femoral wall 

associated with increased displacement and collapse when treated with sliding hip screw

TREATMENT Arthroplasty indications

severely comminuted fracturespreexisting symptomatic degenerative

arthritisosteoporotic bone that is unlikely to hold

internal fixationsalvage for failed internal fixation

SUBTROCHANTERIC FRACTURES

Subtrochanteric typically defined as area from lesser trochanter to 5cm distal fractures with an associated intertrochanteric component may be called intertrochanteric fracture with

subtrochanteric extensionperitrochanteric fracture

CLINICAL PRESENTATION Symptoms

hip and thigh pain inability to bear weight

Physical exampain with motion typically associated with obvious deformity

(shortening and varus alignment)flexion of proximal fragment may threaten

overlying skin

Radiographs views

AP and lateral of the hip AP pelvis full length femur films including the knee

additional views traction views may assist with defining fragments in

comminuted patterns but is not required findings

bisphosphonate-related fractures have  lateral cortical thickening transverse fracture orientation medial spike lack of comminution

TREATMENT Nonoperative

observation with pain management indications

non-ambulatory patients with medical co-morbidities that would not allow them to tolerate surgery

limited role due to strong muscular forces displacing fracture and inability to mobilize patients without surgical intervention

Operative intramedullary nailing (usually cephalomedullary) 

indications historically Russel-Taylor type I fractures newer design of intramedullary nails has expanded indications most subtrochanteric fractures treated with IM nail 

fixed angle plate  indications

surgeon preference associated femoral neck fracture narrow medullary canal pre-existing femoral shaft deformity

PROXIMAL FEMUR FRACTURE IN PAEDIATRICS

ANATOMY OF FEMUR Growth centers of the proximal

femurproximal femoral epiphysis accounts for 13-15% of leg length accounts for 30% length of femur proximal femoral physis grows 3 mm/yr entire lower limb grows 23 mm/yr

trochanteric apophysis traction apophysis contributes to femoral neck growth disordered growth

injury to the GT apophysis leads to shortening of the GT and coxa valga

overgrowth of the GT apophysis leads to coxa vara

TREAMENT

Nonoperative --spica cast in abduction, weekly radiographs for 3wks indications Type IA, II, III, IV, nondisplaced, <4yrs

TREAMENT Operative emergent ORIF, capsulotomy, or joint

aspiration  indications

open hip fracture vessel injury where large vessel repair is required concomitant hip dislocation or significant displacement, especially type I

may decrease the rate of AVN (supporting data equivocal) closed reduction internal fixation (CRIF)/ percutaneous

pinning (CRPP) indications

Type II, displaced postop spica (abduction and internal rotation) x 6-12wk

Type III and IV, displaced and older children open reduction and internal fixation (ORIF)

indications Type IB

pediatric hip screw / DHS indications

Type IV

FEMORAL SHAFT FRACTURES Definition. femoral shaft fracture is defined as a

fracture of the diaphysis occurring between 5 cm distal to the lesser trochanter and 5 cm proximal to the adductor tubercle

High energy injuries frequently associated with life-threatening conditions

MECHANISM OF SOF FRACTURE

Traumatichigh-energy

most common in younger population often a result of high-speed motor vehicle

accidents low-energy

more common in elderly often a result of a fall from standing gunshot 

OSTEOLOGY OF FEMUR DIAPHYSIS largest and strongest bone in the body femur has an anterior bow  linea aspera 

rough crest of bone running down middle third of posterior femur

attachment site for various muscles and fascia

acts as a compressive strut to accommodate anterior bow to femur

Femur FractureClassification

AO/OTA Femur Diaphysis - Bone segment 32

CLINICAL PRESENTATION Advanced Trauma Life Support (ATLS) should be initiated Symptoms

pain in thigh Physical exam

inspection tense, swollen thigh

blood loss in closed femoral shaft fractures is 1000-1500ml  for closed tibial shaft fractures, 500-1000ml

blood loss in open fractures may be double that of closed fractures affected leg often shortened tenderness about thigh

motion examination for ipsilateral femoral neck fracture often difficult

secondary to pain from fracture neurovascular

must record and document distal neurovascular status

IMAGING recommended views AP and lateral views of entire femur AP and lateral views of ipsilateral hip

important to rule-out coexisting femoral neck fracture  

AP and lateral views of ipsilateral knee

TREATMENT Nonoperative

long leg cast indications

nondisplaced femoral shaft fractures in patients with multiple medical comorbidities

Operative antegrade intramedullary nail with reamed technique 

indications gold standard for treatment of diaphyseal femur fractures

outcomes stabilization within 24 hours is associated with

decreased pulmonary complications (ARDS) decreased thromboembolic events improved rehabilitation decreased length of stay and cost of hospitalization

exception is a patient with a closed head injury critical to avoid hypotension and hypoxemia   consider provisional fixation (damage control) 

TREAMENT Retrograde intramedullary nail with

reamed technique indications

ipsilateral femoral neck fracture floating knee (ipsilateral tibial shaft fracture) 

use same incision for tibial nail ipsilateral acetabular fracture

does not compromise surgical approach to acetabulum

multiple system traumabilateral femur fractures

avoids repositioningmorbid obesity

ORIF with plate indications

ipsilateral neck fracture requiring screw fixation

fracture at distal metaphyseal-diaphyseal junction

inability to access medullary canal

DISTAL FEMUR FRACTURES Defined as fxs from articular surface to

5cm above metaphyseal flare Mechanism

young patients high energy with significant displacement

older patients low energy in osteoporotic bone with less

displacement

OSTEOLOGY anatomical axis of distal femur is 6-7

degrees of valgus lateral cortex of femur slopes ~10

degrees, medial cortex slopes ~25 degrees

CLASSIFICATION OF DISTAL FEMUR Supracondylar

Intercondylar

IMAGING Radiographs

obtain standard AP and Lat traction views

AP, Lat, and oblique traction views can help characterize injury CT

obtain with frontal and sagittal reconstructions useful for

establish intra-articular involvement identify separate osteochondral fragments in the area of the

intercondylar notch identify coronal plane fx (Hoffa fx)   

38% incidence of Hoffa fx's in Type C fractures  preoperative planning

Angiography indicated when diminished distal pulses after gross

alignment restored

TREATMENT OF SUPRACONDYLAR FEMUR FRACTURE open reduction internal fixation indications

displaced fracture intra-articular fracture nonunion

goals need anatomic reduction of joint stable fixation of articular component to shaft preserve vascularity

technique (see below) postoperative

early ROM of knee important non-weight bearing or touch toe weight-bearing for 6-8

weeks quadriceps and hamstring strength exercises 

ORIF IN DISTAL FEMUR FRACTURE Blade Plate Fixation Dynamic Condylar Screw Placement Locked Plate Fixation

DISTAL FEMUR PLATES

DISTAL FEMUR PLATING

• retrograde IM nail • indications

• good for supracondylar fx without significant comminution

• preferred implant in osteoporotic bone• distal femoral replacement

• indications• unreconstructable fracture• fracture around prior total knee arthroplasty with

loose component

SHAFT OF FEMUR FRACTURE IN CHILDREN

MECHANISM correlated with age due to the

increasing thickness of the cortical shaft during skeletal growth and maturity falls most common cause in toddlershigh energy trauma is responsible for

second peak in adolescents MVC or ped vs vehicle

fractures after minor trauma can be the result of a pathologic processbone tumors, OI, osteopenia, etc.

CLASSIFICATION Descriptive classification

characteristics of the fracture transverse comminuted spiral etc.

integrity of soft-tissue envelope open closed fracture

Stability length stable fractures

are typically transverse or short oblique length unstable fractures

are spiral or comminuted fractures

TREATMENT OF DIAPHYSIS FEMUR FRACTURE Based on age and size of patient and

fracture pattern Guidelines provided by AAOS 

DISTAL FEMORAL PHYSEAL FRACTURES Physeal considerations of the knee

general assumptions leg growth continues until 

16 yrs in boys 14 yrs in girls

growth contribution leg grows 23 mm/year, with most of that

coming from the knee (15 mm/yr) proximal femur - 3 mm / yr (1/8 in) distal femur - 9 mm / yr (3/8 in) proximal tibia - 6 mm / yr (1/4 in) distal tibia - 5 mm / yr (3/16 in)

CLINICAL PRESENTATION Symptoms

unable to bear weight Physical exam

pain and swelling tenderness along the physis in the presence

of a knee effusionmay see varus or valgus knee instability on

exam

IMAGING MRI or ultrasound is now the diagnositic

modality of choice when confirmation of a physeal fracture is needed

follow up radiographs after 2-3 weeks of casting can be used as treatment if physeal injury is likely but not identifiable on injury films 

stress radiographs to look for opening of the physis were indicated in the past if there was suspicion of physeal injury 

SALTER-HARRIS CLASSIFICATION

TREATMENT OF DISTAL FEMUR FRACTURE Nonoperative

long leg casting   indications

stable nondisplaced fractures close clinical followup is mandatory 

TREATMENT OF DISTAL FEMUR Operative

closed reduction and percutaneous pinning followed by casting   indications

displaced Salter-Harris I or II fractures displaced fractures successfully reduced with closed

methods should still be pinned (undulating physis makes unstable following reduction)

technique  avoid multiple attempts at reduction avoid physis with hardware if possible

if physis must be crossed (SH I and SH II with small Thurston-Holland fragments), use smooth k-wires

SH II fracture, if possible, should be fixed with lag screws across the metaphyseal segment avoiding the physis 

postoperatively follow closely to monitor for deformity

ORIF IN DSTAL FEMUR FRACTURE indications

Salter-Harris III and IV in order to anatomically reduce articular surface

irreducible SHI and SHII fractures reduction often blocked by periosteum infolding

into fracture site techniques

If anatomic reduction cannot be obtained via closed techniques, incision over the displaced physis to remove interposed periosteum is necessary.