Workup for Femoral Shaft Frx

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- See:
      - IM Nailing Technique:

 - PreOp Planning for IM Nailing:
          - Fracture Classification
          - Open Femur Frx
          - Comminuted Frx
          - Proximal Frx:
          - Distal Frx:
 - Associated Injuries:
          - Frx - Menu
          - Hip Dislocation
          - Femoral Neck Frx 
                 - need to proactively determine whether a femoral neck fracture is present;
                 - references:
                        - Accuracy of reduction of ipsilateral femoral neck and shaft fractures--an analysis of various internal fixation strategies.
                        - Diagnosis of femoral neck frx in patients with a femoral shaft fracture: Improvement with a standard protocol. JBJS Am 2007;89:39-43
                        - Fracture of the ipsilateral neck of the femur in shaft nailing: The role of CT in diagnosis. J Bone Joint Surg Br 1998;80:673-678. 
                        - A retrospective review of high-energy femoral neck-shaft fractures.
          - Knee Ligament Injury
          - C-spine
          - Spine
          - Pelvis / Abdomen:
                 - Delayed Internal Fixation of Femoral Shaft Fracture Reduces Mortality Among Patients with Multisystem Trauma
          - Pulmonary:
                 - fat embolism syndrome:
                 - references:
                       - Early unreamed intramedullary nailing of femoral fractures is safe in patients with severe thoracic trauma. 
                       - Thoracic trauma and early intramedullary nailing of femur fractures: are we doing harm?
                       - Effects of changing strategies of frx fixation on immunologic changes and systemic complications after multiple trauma: Damage control orthopedic surgery.
                       - Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients).
          - Vascular Injury
          - Timing of Surgery in Orthopaedic Patients with Brain Injury 
                 - references:
                       - Timing of femur fracture fixation: effect on outcome in patients with thoracic and head injuries. 
                       - Fixation of femoral fractures in multiple-injury patients with combined chest and head injuries
                       - Effects of a femoral shaft fracture on multiply injured patients with a head injury

 - Systems:
          - Neuro (see Glasgow)
          - Cranio-Maxillo-Facial
          - Spine
          - Cardiac
          - Renal
          - Compartments
          - Hepatic / GI:
          - Coag
  - Checklist:
          - Consent: Open vs Closed Reduction
          - Posting
                  - Blood & Cell Saver
                  - Implant Selection (Synthes)
                  - Positioning
                  - Table type and Flouro (specify locations of each in the room)
          - Skeletal Traction
                  - skeletal traction w/ 25 lbs (or more) will bring frx out to length;
                  - generally skeletal traction is necessary w/ delayed treatment;
                  - following insertion of skeletal traction, it is necesary to document that frx is out to length w/ portable lateral radiograph;
          - Blood: 2 units
          - Prophylactic ATB
          - DVT prophylaxis
          - X-rays and Template
          - Planned Incision
          - Anesthesia & Cardiology Consults
          - Misc: antibiotic beads for open frx;

- Initial Orders:
       - NPO p Midnight x Meds
       - IVF D5W LR at 100 ml/hr (in stable patients use D5W 1/2 NS w/ 20 KCl)
       - 2 large bore IV
       - Foley
       - Monitoring;
                - EKG and/or Continuous Cardiac Monitoring;
                - Continuous Pulse Ox monitoring;
       - PreOp Labs:
                - Type & Cross 2-4 units pRBC and/or FFP
                - Musculoskeletal Labs:
                - Urinalysis
       - Meds (Trade Names)
               - Prophylactic ATB
               - DVT prophylaxis
               - Steroids:
                     - for neurological deficits
                     - for FES prophylaxis
               - Heparin 5000 units SQ q8 hrs
               - Insulin (1/2 NPH dose) + S.S. - Accu Check in AM and on call
               - Zantac
               - Morphine
               - Tetanus or Pneumovax if appropriate;
       - Traction: (Buck's vs. Skeletal)
       - Decubiti Prophylaxis:  Egg Crate / Pillow and turn 20 deg q2hr
       - Hiboclens Shower and Bactroban to nares q12 hrs until OR
       - Cleocin solution 300 mg per 100 ml NS q6hr as mouth wash





- Misc:
    - Mechanism: high energy injuries from MVA or GSW, or Pathologic frx;
         - fails in tensile strain;
         - common mech is bending Transverse frx;
         - pathologic frx are more commonly spiral after torsion strain;