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Trauma

Femoral shaft fracture - patterns and fixation

Comminuted shaft fracture with butterfly fragment, shaft and neck injury, proximal shaft fracture.

46 questions 6 source pages 2 images 1 fact-check flags

Images appear with the first question taken from each source page — tap a question to open it.

46 questions
Q1Describe the femoral shaft fracture and degree of comminution on X-ray.▸
  • Comminuted femoral shaft fracture with a large butterfly fragment and <50% cortical contact
  • No associated femoral neck fracture
  • Proximal fragment is abduction and ER (abducted and externally rotated)
  • Winquist-Hansen type 3
  • XR views required: entire bone + one joint above and below
Q2Describe the Winquist and Hansen classification.▸
  • 0: no comminution
  • 1: small butterfly fragment
  • 2: large butterfly fragment, cortical contact >50%
  • 3: large butterfly fragment, cortical contact <50%
  • 4: gross comminution
Q3How is bilateral femur fracture managed?▸
  • DCO in unstable/selected borderline patients to reduce the second hit (inflammatory response against surgery)
  • Hemostasis, revascularisation, decompression, decontamination, stabilisation
  • Definitive surgery: IM nail with distal and proximal locking
Q4How do you determine rotation during femoral nailing?▸
  • Cortical thickness
  • Lesser trochanter and knee X-ray, compare both sides
  • Replicate the anteversion of the contralateral side
  • Anterior bowing compared with the contralateral side
Q5Describe the AO classification of femoral shaft fractures.▸
  • A simple
  • B wedge
  • C comminuted
Q6How common is a concomitant femoral neck fracture with a femoral shaft fracture, and what is the prognosis?▸
  • High energy trauma; 5-10% of femoral shaft fractures have a concomitant femoral neck fracture
  • Prognosis of the neck fracture is usually better than isolated NOF (usually undisplaced)
Q7What is the aim and sequence of fixation for ipsilateral femur shaft and neck fractures?▸
  • Aim: anatomical reduction + stable fixation, prevent complications
  • Dual construct preferred (some studies show high failure rates with a single construct)
  • Priority is the neck to prevent AVN; fix the neck first
Q8How is an undisplaced neck fracture managed?▸
  • Recognised before nailing: A+P hip screws + centre nail, or hip screw + DHS + long plate, or hip screw x3 + retrograde nail/lateral plate
  • Recognised after nailing: miss-a-nail technique
Q9How is a displaced neck fracture managed?▸
  • Recognised before nailing: ORIF of NOF with cannulated screw/DHS, then retrograde nailing
  • Recognised after nailing: remove sliding hip screw then reduction then fix +/- augment
Q10What are the indications for retrograde nailing?▸
  • Reduce time for positioning: bilateral femur fracture
  • Reduce further insult to concomitant fractures: acetabular fracture, NOF, spine fracture
  • Same incision: floating knee, fracture patella, periprosthetic TKR fracture
Q11What are the contraindications to retrograde nailing?▸
  • Open fracture
  • Stiff knee
  • Patella baja
Q12What factors decide between retrograde and antegrade nailing?▸
  • Injury factors: fracture location, entry site condition, associated injury (e.g. concomitant tibial fracture - cannot use traction table), pre-existing proximal implant
  • Patient factors: knee ROM, (obesity)
  • Cons of retrograde nail: infection will cause septic arthritis
Q13What is the risk of a cephalomedullary nail for combined shaft and neck fractures?▸
  • Compared with two separate devices for each fracture, the cephalomedullary nail risks displacing either fracture while introducing the nail
Q14What injuries are associated with femoral shaft fracture?▸
  • Hip dislocation, femoral neck fracture, knee fracture
Q15What injuries are shown on this AP X-ray of the right hip and proximal femur?▸
  • Femoral shaft fracture: short oblique, medially angulated, laterally translated, no bone contact
  • Right hip dislocation (AP view cannot tell anterior vs posterior)
  • Small bony fragment inferior to the femoral head, could be femoral head or acetabular fracture
  • No femoral neck fracture
Q16What is the initial management and what takes priority?▸
  • MOI: RTA/FFH; high energy trauma then ATLS; check open wound and NV status (sciatic nerve)
  • If stable: stabilise with Thomas splint, then go for CT scan to see where the bony fragment come from
  • Hip dislocation takes priority
  • Unstable: DCO; stable: ETC (anatomical reduction, stable fixation, early mobilisation)
Q17Describe damage control orthopaedics in this situation.▸
  • Attempt CR +/- OR; insert Schanz screws into proximal femur avoiding the canal, connect to rod
  • OR approach depends on the direction of dislocation
  • External fixation of the femoral shaft
  • Definitive surgery: plate/nail
Q18What are the fracture features and diagnosis on this X-ray of the proximal thigh?📷▸
AP Xray of prxoimal thigh showing fracture over proximal shaft
AP Xray of prxoimal thigh showing fracture over proximal shaft
  • Transverse fracture over the lateral cortex of the proximal shaft with medial spike, no comminution
  • Evidence of beaking over the lateral cortex
  • Diagnosis: atypical femoral fracture (AFF)
Q19Describe the 2013 ASBMR case definition of AFF.▸
  • MUST be along the femoral diaphysis from distal to the lesser trochanter to proximal to the supracondylar flare
  • Plus at least 4 of 5 major features; no minor features required
  • Major: minimal/no trauma; origin at lateral cortex, transverse (may become oblique medially)
  • Complete fracture may have a medial spike; incomplete involves only the lateral cortex
  • Major: beaking (periosteal/endosteal thickening of lateral cortex); not or minimally comminuted
Q20What are the minor features of AFF?▸
  • Delayed healing
  • Prodromal pain
  • Generalised increase in cortical thickness
  • Bilateral
Q21What history and management apply to AFF?▸
  • History: prodromal symptoms, symptoms on the other side, history of bisphosphonates
  • Stop BP and switch to another agent
  • Treat fracture side with a long cephalomedullary nail; surveillance of the contralateral side
  • Warn about nonunion/malunion (8%)
Q22What is the association between AFF and bisphosphonates?▸
  • More common with long-term BP (median 7 years); 1.78/100,000/year with exposure <2 years, rising with 8-9 years exposure
  • Risk of AFF declines when BP stopped (70%/yr since last use); RR 2-128, AR <50/100,000 person-years
  • Asian 8x risk; oral BP stop after 5 years, IV after 3 years
Q23How is the contralateral limb surveyed?▸
  • Clinical + radiological; pain + normal X-ray then rule out referred pain, bone scan
  • Pain + beaking then prophylactic nailing
  • Beaking then MRI for bone marrow oedema; if MRI positive or stress osteolysis on X-ray then nail (protected weight bearing if patient declines operation)
Q24What is the QEH experience with AFF?▸
  • 20% bilateral (UK 7%)
  • 30% prodromal pain (UK 40%)
  • Nonunion 8%
Q25What did Schilcher 2014 NEJM show about bisphosphonates and AFF?▸
  • Risk of atypical femoral fracture during and after bisphosphonate use (2014, New England journal of medicine) by Schilcher on 5300 Swedish men and women
  • Risk-benefit ratio for prolonged use >5 years would be inverted
  • Preventive effect likely lasts several years after cessation, whereas AFF risk decreases rapidly (70%/yr since last use)
  • Unclear benefit for age >80; 2020 NEJM: absolute risk of AFF remains very low vs fracture risk reduction
Q26Describe the distal femoral fracture configuration and articular involvement on X-ray.▸
  • Displaced fracture over the metaphyseal region of the femur with a vertical split on AP extending to the articular surface
  • Some comminution
  • AO complete articular fracture type C
Q27What is the initial assessment and local examination in this distal femoral fracture?▸
  • ATLS, primary and secondary survey, rule out fracture in the same limb; AMPLE history
  • Locally: skin (impingement, wound), compartment, NV injury (popliteal artery tethered in this region)
  • Systemic: secondary survey
Q28What further imaging is required?▸
  • XR whole femur to make sure there is no synchronous fracture and to check for proximal implant
  • CT scan to delineate fracture pattern, r/o Hoffa fracture (40%)
  • XR contralateral side for preop templating
Q29What are the aims of management?▸
  • Anatomical reduction of the articular surface
  • Stable fixation of the articular block and the shaft for secondary bone healing
  • Restore rotation, coronal and sagittal alignment, and length
  • Allow early mobilisation; timing ETC
Q30Describe the surgical approaches.▸
  • Lateral parapatellar approach with arthrotomy for joint visualisation
  • Or lateral approach: Gerdy tubercle to midaxial line, incise ITB, elevate VL anteromedially from the intermuscular septum, ligate perforators (superolateral geniculate artery)
  • +/- medial subvastus approach if double plating: plane between sartorius and VMO, then ligate the descending genicular artery
Q31How is the articular block reduced and compressed?▸
  • K-wire as joystick, pointed reduction, mini-pelvic clamp; adjuncts: co-linear clamp, cerclage wires
  • Reference pins: pin 1 parallel to anterior femoral cortex (axial), pin 2 parallel to joint line (coronal)
  • K-wire at junction of anterior 1/4 and posterior 3/4, 2cm from joint line; lag screws for interfragmentary compression
Q32Describe the MIPO plating technique and parameters.▸
  • Connect articular block to metaphysis; bolster under the knee to relax gastrocnemius
  • Plate span ratio 1:3 comminuted, 1:8 not comminuted; plate screw ratio 1/2
  • Working length of plate at least double the fracture length
  • Bone graft the void; assess alignment (7.3mm screw parallel to joint line, cable method, Blumensaat line)
Q33What are the cons of non-operative management of a distal femoral fracture?▸
  • Stiffness
  • Malunion
  • Bedbound patient
Q34What other fixation options exist for distal femoral fractures?▸
  • LISS plate, angled blade plate, DCS
  • Retrograde nail with at least 6cm distal fragment
Q35How is reduction assessed intra-operatively?▸
  • Varus/valgus: the 7.3mm screw in the plate parallel to the joint line
  • Coronal alignment: cable method
  • Rotation by checking lesser trochanter, or comparing cortical thickness
  • Sagittal: Blumensaat line-shaft angle
Q36What is the rehabilitation protocol after distal femoral fixation?▸
  • Passive ROM
  • NWB for 6 weeks
  • FWB by 8-10 weeks
  • Treat osteoporosis if needed
Q37How do you manage an associated neurovascular injury?▸
  • Primary aim is to revascularise the limb
  • Early vascular surgeons, vascular shunt, followed by skeletal stabilisation
  • +/- prophylactic fasciotomy if warm ischaemic time >6 hrs
Q38What is the evidence for MIPO plating and how does it work?▸
  • Baumgaertel Injury 1998 introduced biological plating: indirect reduction and bridge plating superior to direct anatomical fixation for bone healing
  • Increase the working length of the construct - evenly distributed forces over a long segment, sharing strain between fragments
Q39How can an elderly patient be allowed to weight bear immediately?▸
  • Double plating
  • Shortening of the fracture
  • IM nail (prerequisite: fracture line >6cm from joint line)
  • Megaprosthesis or nail plate construct
Q40Describe the periprosthetic fracture in relation to the TKR components on X-ray.📷▸
XR:
XR:
  • Supracondylar femur fracture distal to the upper edge of the anterior flange of the femoral component
  • Shortening and apex anterior angulation; transverse, not comminuted
  • TKR posterior stabilised, no sign of loosening, patella not replaced, no notching
  • Osteopenia
  • Su type II; Rorabeck type II
Q41What TKR-specific history and examination findings are important?▸
  • Premorbid functional status; details of TKR (implant model, timing, posterior sacrificing or retaining)
  • Ipsilateral THR; pre-existing pain, stiffness, infection; mechanism of injury
  • PE: soft tissue wound/impingement, distal NV status, compartment syndrome
Q42What imaging is required to assess the implant and distal bone stock?▸
  • XR of the whole bone
  • CT: assess loosening and how much bone stock is left distally
Q43What are the aims of definitive management?▸
  • Stable fixation of implant and fracture
  • Restore mechanical axis to avoid abnormal stresses on the implant
  • Allow early weight bearing
Q44How do you manage a loose implant?▸
  • Revision arthroplasty with a long stem to bypass at least 2 cortical diameters (prefer cementless)
  • 2/3 zonal fixation
  • Address massive bone loss when removing the old TKR; prepare allograft
  • Always standby constrain or even megaprosthesis
Q45How do you manage a well-fixed implant?▸
  • Locking plate - better restoration of alignment; nail entry/alignment is restricted by the notch; more distal fixation screws
  • +/- medial plate for poor bone
  • Retrograde nail for posterior cruciate retaining TKR
  • Not recommended in ipsilateral THR as a stress riser in the unprotected femoral shaft
Q46What is the immediate management of a periprosthetic distal femoral fracture?▸
  • Back slab and analgesics
  • Ex fix if the initial soft tissue is compromised

Fact check

AFF incidence is 100 per 100,000/year with 8-9 years of bisphosphonate exposure — imprecise — The source (Dell 2012 JBMR) reports 113.1 per 100,000/year for 8-9.9 years exposure; the 1.78/100,000/year figure for <2 years matches — source
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