Anatomy

Long tubular bone, anterior bow, flair at

femoral condyles.The longest and

strongest bone.
Blood supply
Metaphyseal vessels
nutrient artery
medullary arteries in intramedullary canal

Femur Fracture
Common injury due to major violent

trauma
More common in people < 25 yo or
>65 yo
Mechanism traumatic
high-energy

most common in younger population

result of high-speed RTA
low-energy

more common in elderly often a result of a fall

Femur Fracture
Classification
AO/OTA Femur Diaphysis - Bone segment

32

Femur Fracture
Classification
Winquist and Hansen
Classification
Type 0 - No comminution
Type 1 - Insignificant butterfly fragment

with transverse or short oblique fracture

Type 2 - Large butterfly of less than
50% of the bony width, > 50% of cortex
intact
Type 3 - Larger butterfly leaving less
than 50% of the cortex in contact
Type 4 - Segmental comminution-

Clinicaly
Symptoms pain in thigh,NWB
Physical exam inspection
tense, swollen ,deformated thigh
affected leg often shortened
External rotated,abducted
must record and document distal

neurovascular status

Femur Fracture
Management
Initial traction with portable traction splint or

transosseous pin and balanced suspension

Timing of surgery is dependent on:
Resuscitation of patient
Other injuries - abdomen, chest, brain
Isolated femur fracture

Femur Fracture
Management
Diaphyseal fractures are

managed by intramedullary
nailing through an antegrade
or retrograde insertion site
Proximal or distal 1/3
fractures may be managed
best with a plate or an
intramedullary nail depending
on the location and
morphology of the fracture

Femur Fracture Antegrade

Nailing
Antegrade nailing gold

standard
Highest union rates with reamed nails
Extraarticular starting point
improved rehabilitation

Antegrade nailing problems:

Varus alignment of proximal fractures
Can be difficult with obese or multiply

injured patients
not indicated for use with ipsilateral
femoral neck fracture

Femur Fracture Antegrade

Nailing
Antegrade nailing
approach

3 cm incision proximal to the

greater trochanter in line with
the femoral canal

Femur Fracture Antegrade

Nailing

Femur Fracture Antegrade

Nailing

Femur Fracture Retrograde

Nailing
Retrograde nailing advantages
Easier in large patients to find

starting point
Better for combined fracture patterns
(ipsilateral femoral neck,
tibia,acetabulum)
Union approaching antegrade nails
when reamed

Retrograde nailing problems:

Union rates are slightly lower, more

dynamizing with small diameter nails

Intra-articular starting point

Femur Fracture Retrograde

Nailing
Approach
2 cm incision starting at distal

pole of patella
medial parapatellar
transtendinous approaches

Femur Fracture Retrograde

Nailing
Entry point:
center of intercondylar notch
on AP view
extension of Blumensaat's
line on lateral

Femur Fracture Retrograde

Nailing
Pros
technically easier
union rates comparableto those of

antegrade nailing
no increased rate of septic knee with
retrograde nailing of open femur fractures
Cons
knee pain
increased rate of interlocking screw
irritation
cartilage injury
cruciate ligament injury with improper
starting point

Antegrade v Retrograde Comparisons

Equal union rates
Tornetta, JBJS (B), 2000
Ricci, JOT, 2001
Ostrum, JOT, 2000

Obese
Non-Obese
BMI >30 BMI <30
Ante OR Time

94

62

P<.003

Retro OR Time

67

62

nss

Ante Fluoro

247

135

P<.03

Retro Fluoro

76

63

nss

Tucker M. JOT 2007

ORIF With Plate

Indications

ipsilateral neck fracture requiring screw fixation

fracture at distal metaphyseal-diaphyseal junction
inability to access medullary canal

Outcomes

inferior when compared to IM nailing due to increased rates

of:

infection
nonunion
hardware failure

External Fixator for

Femoral Shaft Fracture
Multiply injured patient
Complex distal femur

fracture
Dirty open fracture
Vascular injury

Femur Fracture
Complications Non union

Incidence <10%
Risk factors
-postoperative use of nonsteroidal
anti-inflammatory drugs
-smoking is known to decrease bone
healing

Femur Fracture
Complications
Hardware failure
Malunion - shortening, malrotation, angulation
Infection < 1%
Neurologic, vascular injury,
Heterotopic ossification

Thank You