Femoral shaft fractures

Classification of femoral shaft fractures

A = Simple fractures

A1 Simple spiral fracture
A2 Simple oblique fracture (>30°)
A3 Simple transverse fracture (<30°)

B = Fracture with wedge fragment

B1 Fracture with spiral wedge
B2 Fracture with flexion wedge
VZ Fracture with fragmented wedge

C = Compound fractures

C1 Complex spiral fracture
C2 Complex segmental fracture
SZ Complex irregular fractures

7.1. Perthes disease

Aseptic disease of the epiphysis of the femoral head, which occurs during the development of the hip joint (the epiphysis has not yet closed), as well as ischemic necrosis of the epiphysis of the femoral head are most common. Back in 1910, Legg (USA), Calve (France) and Perthes (Germany) described this disease. In childhood, ischemic necrosis occurs in the center of ossification of the epiphysis of the femoral head, resulting in the formation of a flat hip joint, deforming osteitis of the pelvic bone, epiphyseal osteochondropathy, epiphysitis of the femoral head, and all this is called Legg-Calvé-Perthes disease. The causes and mechanism of this disease are not yet clear, and there is still no consensus on this issue. The generally accepted point of view is that ischemia of the femoral head leads to necrosis of its epiphysis. There are different opinions regarding the causes of ischemia. Some scientists argue that necrosis of the epiphysis of the head of the femur is associated with the blood supply to its head, which is not yet perfect in childhood, and under the influence of external factors, a partial or complete cessation of blood flow occurs, leading to necrosis of the head. Others, based on the measurement of intraosseous venous pressure, have established that, in addition to arterial obstruction in this disease, the cause of necrosis is stagnation of blood in the veins, which contributes to insufficient supply of intraosseous arteries, resulting in increased intraosseous pressure and ischemic necrosis of the epiphysis of the femoral head. Some scientists have put forward the idea that synovitis or other inflammatory diseases of the joint cause swelling (edema) of the soft tissues around the hip joint and synovial membranes, exudation occurs, pressure inside the joint increases, which leads to necrosis of the epiphysis.

Cumulative chronic ischemic necrosis of the femoral head with unclear causes can slow down the development of the epiphysis or stop its growth, and continued growth of soft tissue due to nutrition from synovial fluid is manifested in small foci of bone formation and the proliferation of cartilaginous tissue, which is called hidden Perthes disease. During the recovery stage, with repeated vascularization of the cartilage tissue of the femoral head and intracartilaginous ossification, the new bone tissue formed under the cartilage is quite thin and fragile, and a bone fracture may occur under load or shearing force.

According to Salter, ischemic necrosis of the femoral head itself is a complication of ischemia, and in cancellous bone, due to intraosseous fractures and collapse, the blood vessels are compressed. This point of view coincides with the opinion of the authors that due to the destruction of the structure of the femoral head, the blood vessels are compressed, creating ischemia, as a result of which necrosis of the femoral head occurs. Long-term destruction of trabeculae and necrosis of the bone marrow as a result of destruction of the structure of the epiphysis, together with the accumulation of metabolic products, prevent the ingrowth of new capillaries, which slows down the process of re-vascularization, and under the influence of tension a flat head of the femur is formed. Bone resorption due to epiphysitis and the reaction of the synovial membrane during bone metabolism, accompanied by cramps and muscle contracture, affect the formation of the femoral head - outward subluxation occurs and the femoral head takes on a flat or saddle shape.

The authors of the monograph believe that the concentration of stress in the epiphysis of the femoral head contributes to the destruction of the bone structure in it, changes the tension in the epiphysis, as a result of which the normal distribution of the capillary system in the bone encounters obstacles, the nutrition of the bone and the strength of the trabeculae, their rigidity, and mechanical properties are gradually disrupted are lost. A large number of fat drops accumulate in the resulting lacunae, blood sinusoids disappear in the bone marrow cavity and the structure of the cartilage is destroyed, the circulatory system inside the bone is subject to increased obstruction, and the death of the endothelium seriously accelerates the necrosis of the femoral head. Cracks, sequestration or collapse occur in the surface layer of the femoral head. Obstruction of the blood vessels causes necrosis of the epiphysis of the femoral head.

Thus, necrosis of the epiphysis of the femoral head is associated with stress concentration, dissociation of the structure of the head, obstruction of blood circulation within it and increased resistance to blood flow due to deformation of blood vessels, which accelerates the destruction of the bone structure and forms a vicious circle. Some scientists divide the process of this disease into 4 stages: Stage I is the period of synovitis, when the synovial membranes of the hip joint swell, fill with blood, the amount of synovial fluid increases, the pressure inside the joint increases, and there are no inflamed cells. The period of synovitis lasts 1-4 weeks and is not easy to detect; Stage II is the period of ischemic necrosis, when partial or complete necrosis occurs in the center of ossification, at this time the structure of the trabeculae does not undergo changes, it is clearly visible, but the bone density is increased, and due to the lack of filling of the bone marrow space with unstable bone substance, the trabeculae do not crack and do not collapse, forming a dense layer, which can be seen on an x-ray. In the metaphysis, near the necrotic center of ossification, decalcification is noticeable, bone density is reduced or cystic degeneration, development occurs too quickly, body weight becomes too large compared to normal development, children often experience varus position of the femoral neck or pathological fracture; for example, with a shearing force, a rupture of the epiphysis is created;

Stage III is a period of fragmentation and restoration, when the necrotic head of the femur is absorbed and a slow process of new bone growth and repair occurs, granulation fibrous tissue grows from the bone marrow and fills the area affected by necrosis, completing the restoration process. A feature of this period is the expansion of the joint space in the hip joint. During the recovery process, the osteoclast is activated, and the osteoblast slows down its activity; in the process of accelerated resorption, the growth of new bone in the necrosis zone slows down and deformation of the femoral neck or bone fracture as a result of epiphysiolysis can easily occur. It has been established that the dead bone of the metaphysis is resorbed under the epiphyseal line of the femoral neck, creating a disturbance in its development along the longitudinal line, leading to a disorderly expansion of the epiphyseal line. The epiphyseal plate becomes unstable, plasticity increases due to excess collagen fiber inside the new bone, and under the influence of external forces, deformation of the femoral neck and its bending into the pelvis can occur. Stage IV is a period of healing or deformation when newly grown bone replaces dead bone and newly formed immature young trabeculae are mixed and compressed with dead bone. The X-ray image shows the appearance of goblet defects, and in the center of ossification there is a mushroom-shaped deformation: the head of the femur becomes not only large (giant pelvis syndrome), but also flat, protruding from the acetabulum and acquiring a mushroom shape. Subluxation occurs in the hip joint, and after growing up, secondary osteoarthritis often occurs, the joint space narrows and pain is felt in the pelvic area.

The clinical manifestations of this disease are as follows: pain → lame gait → inability to bear the load → limited function of the hip joint. In the chronic latent course of the disease, subjective symptoms are often invisible and neglected. The age at which the disease occurs varies from 3 to 12 years, but there are cases at 15 years, and the ratio between boys and girls is 4:1. Judging by the available materials, this disease tends to be hereditarily transmitted, and the natural course of the disease lasts approximately 4 years. In the initial period, patients feel: discomfort in the pelvic area, rigidity as resistance to performing passive movements of the limbs, pain in the groin area, pain on the inside of the thigh and knee joint. The gait becomes heavy, but after rest the pain softens. During synovitis, the body bends and rotates outward, causing the hip joint cavity to expand and relieve pain. The gait is often with a tilted pelvis or a limp due to the unequal length of the limbs; with increasing pain, contracture of the gluteal and thigh muscles occurs. Unfortunately, parents go to the doctor only when their sick children experience pain and already have a limping gait.

Treatment of femoral shaft fractures

The main treatment method for such fractures is surgery. Femoral shaft fractures with a short oblique or transverse fracture line in the middle third are best stabilized with a metal rod and reaming of the medullary canal. After repositioning the fragments, the bone marrow canal is drilled out along the guide and a rod of appropriate size is inserted.

For comminuted fractures, osteosynthesis with a blocked rod or a wide plate is advisable. The method involves closed reduction of a fracture using a distractor without separating fragments from soft tissues and without damaging the periosteum.

It is advisable to fix large fragments using cortical screws. first, they are fixed to the main fragments with cortical screws, after which the fracture is stabilized with a wide metal plate. The plate is first fixed to the proximal fragment with 1–2 screws inserted into round holes, then to the distal fragment with a screw through an oblong hole. If possible, create compression along the fracture line.

To maintain blood circulation in the periosteum, limited contact plates with the ability to lock screws (LCP) are used. An intramedullary nail with a femoral screw or an intramedullary nail with an autorotation mechanism can also be used.

The average period of restoration of working capacity after osteosynthesis of the femoral diaphysis is 3–4 months.

Publications in the media

Hip fractures account for 6.4% of all fractures. Classification • Fracture of the proximal femur • Isolated fracture of the greater trochanter • Fracture of the diaphysis of the femur (upper, middle, lower third) • Fractures of the distal femur. Fractures of the proximal femur • Medial (cervical) fracture can be valgus and varus •• Capital fracture (head fracture) •• Subcapital fracture (at the base of the head) •• Transcervical (transcervical) or basal fracture • Lateral (trochanteric) fracture •• Intertrochanteric fracture •• Pertrochanteric fracture •• Isolated fracture of the lesser trochanter Frequency - 25% of the total number of femur fractures. Fractures of the femoral neck and trochanteric fractures are observed mainly in women over 60 years of age • Causes: indirect injury - fall on the greater trochanter • Clinical picture •• Pain in the groin area, aggravated by leg movements •• External rotation of the limb, impossibility of internal rotation •• Shortening limbs •• Pain with axial load (tapping on the heel or in the area of the greater trochanter) •• Symptom of “stuck heel” - the patient cannot lift or hold a raised and straightened leg, but bends it at the knee and hip joints so that the heel slides along the support •• The diagnosis is confirmed by x-ray examination in two projections. A violation of the integrity of the bone is revealed, as well as additional signs: in varus fractures, the greater trochanter is located above the Roser-Nelaton line; in displaced fractures, the Schumacher line, connecting the apex of the greater trochanter with the anterior superior iliac spine, passes below the umbilicus • Complications: false joint of the femoral neck , avascular necrosis of the femoral head

Treatment of femoral neck fractures is predominantly surgical - osteosynthesis with a metal pin, threaded rods, endoprosthetics. In the treatment of intertrochanteric and pertrochanteric fractures, skeletal traction, plaster cast and osteosynthesis are used. Prevention of pulmonary complications, bedsores.

Fractures of the femoral shaft • Causes: direct trauma • Pathomorphology. When the upper third of the diaphysis is fractured, the proximal fragment moves forward and outward, the distal fragment moves inward and posteriorly; a fracture in the middle third is characterized by a displacement along the length • Clinical picture : pain, dysfunction, shortening of the limb, deformity, outward rotation of the foot, pathological mobility • Complications : traumatic shock, fat embolism, significant blood loss • Treatment •• Immobilization is used for birth injuries in children; traction according to Shede •• Skeletal traction for the tibial tuberosity or femoral condyle •• External or internal osteosynthesis •• Surgical treatment is used for open, complicated fractures, with unsuccessful conservative treatment (soft tissue interposition).

Fractures of the distal femur • Causes: direct trauma on the lateral surface of the knee joint, fall onto the knee joint, fall from a height onto straight legs • Pathomorphology. Condylar fractures are intra-articular injuries accompanied by hemarthrosis. In case of supracondylar fractures, the short distal fragment is displaced posteriorly due to the traction of the gastrocnemius muscle, which creates a threat of compression or damage to the popliteal artery • Clinical picture : swelling, deformation, pain, pathological mobility of the fragments. X-ray confirms the diagnosis • Treatment: •• For hemarthrosis - puncture of the knee joint •• Non-displaced fractures - plaster cast •• For displaced fragments - immediate reposition with skeletal traction, if indicated - osteosynthesis •• Surgical treatment if conservative methods are ineffective •• Early prescription of physiotherapy (UHF, magnetic therapy), exercise therapy.

ICD-10 • T93.1 Consequence of hip fracture • S72 Fracture of the femur.