[38] Femoral Shaft Fracture Flashcards
Why are femoral shaft fractures so serious?
Because the femur is a highly vascularised bone, so large volumes of blood (up to 1500ml) can be lost when fractured
Why is the femur a highly vascularised bone?
Due to its role in haematopoiesis
What is the blood supply to the femoral shaft?
Penetrating branches of profunda femoris artery
How might femoral shaft fractures be further complicated?
- Open
- Associated with neurovascular injury
In what settings are femoral shaft fractures most commonly seen?
- High-energy trauma
- Fragility fractures
- Pathological fractures
- Bisphosphonate-related fractures
What is the classic bisphosphonate related fracture of the femoral shaft?
A transverse fracture in the proximal femur
How will a patient with femoral shaft fracture present?
- Pain in the thigh and/or hip/knee pain
- Unable to weight bear
- In severe cases, obvious deformity
What do you need to assess with femoral shaft fracture?
- Skin
- Neurovascular examination
- Secondary survey
Why is it important to assess the skin with femoral shaft fractures?
May be open or threatened
The proximal fragment is invariably pulled into flexion and external rotation, which can further tent the skin
What are the signs that the skin is threatened with femoral shaft fracture?
- Tethered
- White
- Non-blanching
How should patients presenting following major trauma be investigated and managed?
As per ATLS protocol
What investigations are included in the ATLS protocol?
Routine urgent bloods, including coagulation and G&S
What further bloods may be sent in femoral shaft fracture?
When pathological cause is suspected, further work up bloods such as serum calcium may be needed
What imaging may be done in femoral shaft fracture?
- Plain film radiograph
- CT scanning
What x-ray views are required with femoral shaft fracture?
AP and lateral view of entire femur, including hip and knee
When might further imaging via CT scanning be done in femoral shaft fracture?
If polytrauma is suspected
What is the first priority in managing patients with femoral shaft fractures?
As per ATLS guidelines, A-E assessment, stabilise patient, ensure appropriate fluid resuscitation
What pain relief may be required for femoral shaft fracture?
Often opioid analgesia +/- regional blockade, e.g. fascia iliac block
What management do femoral shaft fractures require for the actual bone?
Immediate reduction and immobilisation
Why is reducing the fracture to near anatomical alignment important in femoral shaft fractures?
Will ensure appropriate haematoma formation, as well as reducing pain
How is reduction and immobilisation of femoral shaft fracture achieved?
In-line traction
Give an example of a traction splint
Kendrick traction splint
When are Kendrick traction splints used in femoral shaft fractures?
In suspected or isolated fractures of mid-shaft femur
What are the contraindications to traction splinting for femoral shaft fractures?
- Hip or pelvic fractures
- Supracondylar fractures
- Fractures of ankle or foot
- Partial amputation
What definitive management do most femoral shaft fractures require?
Surgery
When might femoral shaft fractures not require surgery?
In undisplayed femoral shaft fractures in patients with significant co-morbidities
What may be used in undisplayed femoral shaft fractures in patients with significant co-morbidities?
Long-leg casts
How soon should femoral fractures be surgically fixed?
Within 24-49 hours (sooner id open)
How can most isolated cases of femoral shaft fractures be managed?
Integrate intramedullary nail
What may be required for femoral shaft fracture in unstable polytrauma or open fractures?
External fixation, with subsequent delayed conversion to intramedullary nail
What are the common complications of a femoral shaft fracture?
- Nerve or vascular injury
- Malunion, delayed union, or non-union
- Infection
- Fat embolism
What nerves may be injured in femoral shaft fractures?
- Pudendal (around 10%)
- Femoral
What increases the risk of non-union of femoral shaft fractures?
- Smoking
- Increased post-op use of NSAIDs
What are the more long-term complications of femoral shaft fracture?
- Hip flexor or knee extensor weakness
- Limb stiffness
- Re-fracture
What reduces the complications of femoral shaft fracture?
Early mobilisation following intra-medullary nailing
