Femoral Shaft Fractures

Question 1

In femoral shaft fractures what is the incidence of femoral neck fractures and how often are they missed?

Answer 1

Incidence: 2-6%
Missed: 20-30%
They are often basicervical, vertical and nondisplaced

Question 2

What presenting factors are increased in bilateral compared to unilateral femoral shaft fractures?

Answer 2

Increased rates of initial hypotension, mortality, open skull fractures, and pelvic fractures

Question 3

Which classification system describes femoral shaft fractures?

Answer 3

Winquist and Hansen:
0- Non displaced
I- minimal comminution
II- >50% cortical contact
III- >25% cortical contact
IV- No cortical contact; segmental

Question 4

In a high energy femoral shaft fracture what radiographs should be obtained?

Answer 4

1) AP/Lat femur
2) AP/Lat ipsilateral hip
3) AP/Lat ipsilateral knee
4) Trauma series: AP chest, AP pelvis, Lateral c-spine

Question 5

IM nailing of femur shaft fractures within 24hrs of injury are a/w?

Answer 5

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

Except in closed head injuries; consider DCO

Question 6

In a patient with a major head injury and a femoral shaft fracture, intraoperative hypotension during femoral fixation has been associated with?

Answer 6

Decreased (worse) Glascow coma score at discharge

Question 7

What are indications for retrograde nailing of femoral shaft fractures?

Answer 7

1) ipsilateral femoral neck fracture
2) floating knee (ipsilateral tibial shaft fracture); use same incision for tibial nail
3) ipsilateral acetabular fracture; does not compromise surgical approach to acetabulum
4) multiple system trauma
5) bilateral femur fractures; avoids repositioning
6) morbid obesity

Question 8

When would plating be an indication for a femoral shaft fracture?

Answer 8

1) ipsilateral neck fracture requiring screw fixation
2) fracture at distal metaphyseal-diaphyseal junction
3) inability to access medullary canal

Question 9

What are the outcomes of ORIF of femoral shaft fractures with plates vs IM nailing?

Answer 9

Inferior d/t increased rates of:

1) infection
2) non-union
3) hardware failure

Question 10

Antegrade femoral nailing has an increased rate of which of the following when compared to retrograde femoral nailing?

Answer 10

hip pain

retrograde has increased incidence of knee pain

Question 11

What are the pros and cons of a piriformis entry nail for femoral neck fractures?

Answer 11

Pros:
Colineal with femoral shaft
Cons:
More abductor trauma
Can lead to AVN in peds
More difficult in obese pts

Question 12

When using a trochanteric entry nail, placement of the starting point more lateral will lead to what deformity?

Answer 12

Varus

Question 13

How does reamed compared to unreamed nailing of femoral shaft fractures?

Answer 13

Reamed a/w:

1) increased union rates
2) decreased time to union
3) no increase in pulmonary complications

Question 14

When would unreamed nailing of femur fractures be considered?

Answer 14

Pt with bilateral pulmonary injuries

Question 15

What is an advantage of computer-assisted navigation used to place medullary nail interlocking screws compared to a freehand technique?

Answer 15

Decreased fluoro time

Question 16

When can pts with a comminuted femoral shaft fractures treated with statically locked intramedullary nails of appropriate diameter be WBAT?

Answer 16

Immediately

Question 17

In a patient with a femoral shaft fracture with ipsilateral femoral neck, what is the order that the fractures are stabilized?

Answer 17

1) Femoral neck
2) Femoral shaft
Fixation options:
screws for neck with retrograde nail for shaft
screws for neck and plate for shaft
compression hip screw for neck with retrograde nail for shaft

Question 18

During external fixation of the femur what are the safest locations for pin placement?

Answer 18

Anterolateral and direct lateral

Question 19

During retrograde IM nailing of femoral shaft fracture which screw position places branches of the femoral nerve and deep femoral artery at greatest risk during placement of the interlocking screw?

Answer 19

Proximal AP screw below the lesser trochanter

Question 20

What are risk factors for rotational deformity when placing IM nail for femoral shaft fxs?

Answer 20

1) Fx table vs free leg
2) Comminution
3) Night-time surgery

Question 21

What are intraoperative tricks to avoid rotational deformities during IM nailing of femoral shaft fractures?

Question 22

What relationship does lengthening/shortening along the anatomical axis of the femur have to mechanical axis deviation (MAD)?

Answer 22

Lengthening: Lateral deviation of MAD
Shortening: Medial deviation of the MAD

Question 23

In femoral shaft fractures how is fracture location related to risk of rotational deformity?

Answer 23

Proximal tends towards internal malrotation (relative as proximal fragment is externally rotated)
Distal fractures tend towards external malrotation (proximal fragment pulled medially and internal rotation)

Question 24

In retrograde nailing of periprosthetic distal femur fractures what deformity is common?

Answer 24

Hyperextension (recurvatum)

Starting point tends to be more posterior

Question 25

What is the common fracture characteristics of a the femoral neck fractures when a/w concomitant femoral shaft fxs?

Answer 25

nondisplaced, basicervical, vertically oriented fracture line