Femur

Distal Femur Fractures

AO Classification

 

Supracondylar

 

Distal Femoral FractureSupracondylar Femur Fracture Retrograde Nail0002

 

Distal femoral fractureDistal Femur Fracture Lateral

 

Unicondylar

 

Distal Femur Fracture Medial

 

Intracondylar

 

Distal Femur Fracture

 

Distal Femur Fracture Intercondylar 1Distal Femur Fracture Intercondylar  2Distal Femur Fracture Intercondylar CT

 

Management

 

Non operative Management

 

Issue

 

Difficult

- cannot immobiise joint above

- need to keep knee stiff

 

Operative Management

 

Options

 

1.  Retrograde nail

2.  Plate

3.  Tumour prosthesis

 

1.  Retrograde Nail

 

Supracondylar Femur Fracture Retrograde Nail0001Supracondylar Femur Fracture Retrograde Nail0001

 

Advantage

- small incision

- good for floating knee

- load sharing

 

Supracondylar Femur Fracture Retrograde Nail0003Supracondylar Femur Fracture Retrograde Nail0004

 

Disadvantage

- more difficult for intra-articular fractures

- technically difficult to perfectly restore alignment

 

Indications

- distal 1/3

- floating knee

 

Technique

 

Set up

- patient supine

- put knee over radiolucent triangle / bundle of gowns

- allows entry to knee

- ensure II for AP and lateral of knee and AP of hip for proximal locking screw

 

Entry point

- medial parapatella approach

- entry above ACL origin

- slightly medial

- ensure central in AP and lateral

- awl / 3.2 mm guide wire

- ream for enlarged end of retrograde nail

 

Pass guide wire

- measure length

 

Ream & Insert nail

- distal locking performed

- proximal AP locking under II control

 

Retrograde Nail Proximal0001Retrograde Nail Proximal0002

 

Results

 

Iannacone et al J Orthop Trauma 1994

- 41 distal femur fractures treated with retrograde nail

- 4 non unions requiring revision fixation

- 4 fatigue fractures of the IMN; changed to using minimum 12 and 13 mm rods

 

Case Nonunion

 

Retrograde Nail Nonunion0003Retrograde Nail Nonunion0004Retrograde Nail Nonunion0001Retrograde Nail Nonunion0002

 

Supracondylar Nonunion TKR0001Supracondylar Nonunion TKR0002

 

2.  Plate

 

Distal Femur Fracture Medial ORIFSupracondylar Plate ORIFSupracondylar Plate Lateral

 

 

Advantage

- easier to fix intracondylar extension

- can be done MIPO / minimally invasive plate osteosynthesis

- plates anatomically contoured so can restore mechanical axis

 

Technique

 

Position

- patient supine on radiolucent table with II

- place distal femur over radiolucent triangle / drapes

- reduces fracture

 

Incision

- incision over lateral distal femoral condyle

- longitudinal

- through skin and soft tissue

- divide ITB

- elevate vastus lateralis

- down to bone

 

Reduce intra-articular portion if required

- can elevate patella to assess reduction

- compress with bone reducing forcep

- 6.5 mm cannulated screws

- anterior and posterior to plate

- ensure not in joint / above blumensaat's

- ensure not in PFJ (distal femur is trapezoidal)

 

MIPO plate technique

- percutaneously elevate muscle off femur with elevator

- insert appropriate length plate (4 cortical screws above) with targeter

- temporarily fix distal plate to distal fragment

- if place screws parallel to joint line, the plate will be in correct valgus

- temporarily fix proximal plate percutaneously with temporary fixation screws

- obtain an indirect reduction

- check aligment and plate position AP and lateral

- attach plate with screws

 

Results

 

Schutz et al Arch Orhop Traum Surg 2005

- 62 patients average age 52 years treated with LISS plate

- union achieved in 85% patients

- 6 required bone grafting, 3 required revision of components

 

Tumour Prosthesis

 

Elderly osteoporotic patient

- unreconstructable distal femur

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 / dislocation

- knee injury

- floating knee / ipsilateral tibial fracture

 

Thorough neurovascular exam

- incidence vascular injury 1%

 

Temporary femoral traction splints

- ring against ischium

- velcro around foot

- pneumatic traction

- can only be applied for 12 hours or so

 

Thomas Splint

 

Compound wound

 

Betadine pack

Tetanus

Antibiotics

 

Winquist Classification

 

Type 1

- minimal or no comminution

 

Femoral Shaft Fracture No comminution

 

Type 2

- < 50% comminution

 

Type 3

- 50 - 100% comminution

- inherently unstable as < 50% contact between major fragments

- need supplemental fixation / must be locked

 

Femoral Fracture Type 3

 

Type 4

- segmental comminution

- no contact or inherent stability between proximal and distal fragments

 

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 on II when intra-operatively

 

Knee

 

De Campos et al 1994 Clinical Orthopedics

- 5% ACL, 2.5% PCL

- 20% LM tears, 12% MM tears

 

Always assess knee after femoral stabilisation

 

Femoral Fracture + ACL Reconstruction

 

Floating Knee

 

Ipsilateral Femur + tibial fracture

 

Floating Knee 1Floating Knee 2

 

Operative Management Issues

 

Surgical Timing

 

Bone et al JBJS Am 1989

- stabilisation within 24 hours

- decreased pulmonary complications

- decreased length hospital stay

 

Damage Control Orthopaedics

 

Concept

- avoid second hit to severely injured patients

- stabilise femoral fracture as quickly as possible

- usually simple external fixator

- allow return to ICU for warming / stabilisation

- when stable, definitive fixation

 

Indications

- head injuries

- thoraco-abdominal injuries

- multiple injuries

 

IL-6

- cytokine shown to be elevated in multitrauma

- suggested delay definitive treatment until drops

- 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 ETC (early total care)(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)

 

Bhandari J Orthop Trauma 2005

- external fixator converted to IMN within 2 weeks

- 1.7% infection rate

 

Surgical Options

 

ORIF / plate

External fixation

IMN - antegrade / retrograde / reamed / unreamed

 

External Fixation

 

Indications

- severely contaminated wound

- Damage Control Orthopaedics

- complex femoral fracture with vascular injury

 

Technique

- 2 x half pins proximally

- 2 x half pins distally

- 2 x bars

 

Timing of conversion to IMN

 

Harwood et al J Orthop Trauma 2006

- compared 111 femur fractures treated with immediate IMN to 81 DCO

- DCO femurs more likely to be grade 3 compound

- increased pin site infections in external fixation

- no significant increase in deep infection rates if converted within 2 weeks

 

Plate v IMN

 

Results

 

Bosse et al JBJS Am 1997

- compared plate v reamed IM nail (117 v 104)

- patients multiply injured (femur + thoracic injury)

- no evidence that a reamed femoral IMN increased risk of ARDS in this group

 

Plate

 

Indications

- associated proximal / distal femoral fracture

- vascular injury

- medulla too narrow for IMN

- paediatric population

 

Problem

- tension side / load bearing

- significant disruption to blood supply required

- plate will break early if union not achieved

 

Results

 

Giessler et al Orthopedics 1995

- 71 femurs diaphyseal fractures

- 93% union at 16 weeks

- recommended bone grafting at same time

 

Technique

- large fragment plate

- minimum 8 cortices each side of fracture

- need periord of NWB

 

Reamed v Unreamed IMN

 

Femoral Nail0001Femoral Nail0002

 

Results

 

Non union / Canadian Study Group JBJS Am 2003

- multicentred randomised trial

- non union rates reamed v unreamed IMN

- 8 / 106 (7.5%) smaller unreamed femoral nail nonunion

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

 

ARDS / Canadian Study Group J Orthop Trauma 2006

- multicentred randomised trial reamed v unreamed

- incidence ARDS in multiply injured patients

- 151 unreamed v 171 reamed nails within 24 hours

- very low incidence of ARDS in both groups

- not statistically significant

- need some 35 000 patients to detect difference

 

Locked v Unlocked IMN

 

Unusual not to lock distally

- gives rotational stability

 

If stable transverse fracture / > 50% cortical apposition

- can dynamically lock

 

Retrograde nail

 

Retrograde Femoral NailRetrograde Femoral Nail Lateral

 

Indications

- floating knee (single incision for femoral and tibial nail

- obesity - difficult access to trochanter

- pregnancy - minimise radiation to pelvis

- patella fracture (able to ORIF with same incision)

- ipsilateral pelvic / acetabular / NOF fracture

 

Outcome

- similar rates union

- may have slightly higher incidence knee pain

 

Floating Knee 1Floating Knee 2Floating Knee 3

 

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

4.  Antegrade IMN in place before diagnosis of NOF fracture

- if undisplaced, can place screws anterior to nail

- if displaced must remove nail

 

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

- 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

 

Distal femoral condylar fracture + shaft fracture

 

Options

1.  Screws anterior and posterior to retrograde nail

2.  Distal Locking plate

 

Bilateral Femur Fractures

 

High risk of complications

- blood loss

- nerve injury

- ARDS (double risk unilateral)

- mortality risk (5x unilateral)

- non union

 

Management

- IMN one femur

- assess patient stability

- IMN nail other femur or external fixation / delayed nail

 

Complications

 

Nerve Palsy

 

Pudenal nerve palsy most ommon

- up to 15%

- usually transient

- related to longer traction times

- may be related to the use of smaller posts

 

Malrotation

 

Incidence

 

Common

- need attention to patella and foot position prior to distal locking

 

Diagnosis

 

A.  Clinically

- point both patellas to the ceiling

- foot internally or externally rotated compared to uninjured leg

 

B.  CT

 

Femoral Nail Malrotation CT 1Femoral Nail Malrotation CT 2

 

Management

- remove distal locking screws

- correct rotation

- insert new distal locking screws

 

Distal femoral breach

 

Distal femoral breachDistal Breach ORIF

 

Non union

 

Incidence

- uncommon

- increased with unreammed nails

 

Definition

- not united after 6 months

- no progression for 3 months

 

Options

1.  Dynamisation

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

 

Wu J Trauma 1997

- 24 nails dynamised 4 - 12 months

- union in 50%

 

2.  Exchange nailing

 

Femoral Non unionExchange Nail Bone Graft

 

Technique

- remove old nail

- ream up to larger size

- insert new larger nail

 

Weresh et al J Orthop Trauma 2000

- 19 patients at least 6 months post

- union in only 50%

 

3.  Removal Nail / Plating / Bone Graft

 

Bellabarab J Orthop Trauma 2001

- 100% union rate

- augment with bone graft

 

4.  Augment with Plate + Bone Graft

 

Ueng J Trauma 1997

- 17 patients, 100% union

 

Infected Non union

 

Management

- removal of nail

- irrigation +++

- antibiotic nail / cover IMN with antibiotic cement

- 6 weeks IV antibiotics

- definitive nail / External fixator

 

Infected Femoral Nail 1Infected Femoral Nail2Infected Femoral Nail3Infected Femoral Nail4

 

Infected Femoral Nail United APInfected Femoral Nail United Lateral

 

Refracture

 

No evidence increased risk if nail removed > 1 year

Femoral Stress Fractures

Femoral Shaft Stress Fracture

 

Site

 

Usually mid or lower femur

 

Types

 

Tension

 

Lateral femur

- can progress to fracture

- high rate of non-union

- should ORIF

 

Stress Fracture Lateral

 

Femoral stress fractureFemoral Stress Fracture IMN

 

Compression 

 

Medial femur

- rare

- usually unite

- NWB

 

Stress Fracture Medial

 

Femoral Neck Stress Fractures

 

Aetiology

 

Athletes with increase activity / distance

Women with eating disorders /  amenorrhea

 

Types

 

Compression / inferior neck

- < 50% protective weight bear

- > 50% emergent ORIF

 

Tension side / superior neck

- emergent ORIF

 

Hip stress fractureFemoral Neck Stress Fracture

 

Hip Stress Fracture Axial CTHip Stress Fracture Coronal CT

 

Hip Stress FractureHIp Stress FractureHip Stress Fracture 3

 

 

 

Hoffa fracture

Definition

 

Coronal plane fracture of distal femoral condyle

- intra-articular

- often only attachment is posterior capsule

 

Epidemiology

 

Rare

 

Mechanism

 

Usually a severe valgus trauma

 

Xray

 

Usually lateral femoral condyle

 

Hoffa Fracture Xray

 

CT / MRI

 

CT

- aids surgical planning

 

MRI

- excludes associated LCL / MCL injury

 

Hoffa Fracture MCL Avulsion MRI 1Hoffa Fracture MCL Avulsion MRI 2

 

Management

 

Issue

 

Usually unstable

- needs ORIF

- can be associated with LCL injuries

 

Must preserve the posterior soft tissue for vascularity

 

Options

 

1.  Buttress screws + AP screws

 

Hoffa Fracture ORIF APHoffa Fracture Lateral

 

2.  Headless compression 6.5mm PA screws

 

Hoffa Fracture ORIF PA screws

 

 

 

 

 

 

 

Infected Femoral Fracture

Management

 

ABx coated IM nail + External Fixator

 

Infected Femoral Nail 1Infected Femoral Nail 2Infected Femoral Nail 3Infected Femoral Nail 4

 

 

 

 

 

Surgical Techniques

Surgical TechniquesAntegrade Femoral Nail

 

1.  Trochanteric Entry Antegrade Femoral Nail

 

Position

- GA, IV ABx

- traction table

- patient legs adducted, torso adducted

- allows access to GT

- flex and abduct other hip for II access

 

Entry

- incision proximal to GT

- split abductors in line

- palpate tip of GT

- check entry point on AP II view

- check entry point on lateral II 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 II 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

 

2.  Retrograde Nail

 

Retrograde Femoral NailRetrograde Femoral Nail Lateral

 

Indications

- distal 1/3

- floating knee

- obesity

 

Set up

- patient supine

- put knee over radiolucent triangle / bundle of gowns

- allows entry to knee

- can remove to allow proximal locking

- ensure II for AP proximally locking

 

Entry point

- medial parapatella approach

- entry above ACL origin

- slightly medial

- ensure central in AP and lateral

- awl / 3.2 mm guide wire

- ream for enlarged end of retrograde nail

 

Pass guide wire

- measure length

 

Ream & insert nail

- distal locking performed

- proximal AP locking under II control