- Proximal Frx
- Distal Frx
- Rotational Alignment
- Deforming Forces:
- muscular forces deform the femur after fracture;
- abductor muscles:
- abducts proximal femur following subtrochanteric & high proximal shaft fractures;
- proximal 1/3 frx of shaft are also flexed & externally rotated by action of iliopsoas's pull on lesser trochanter;
- adductor muscles:
- span most shaft frxs & exert strong axial & varus load to bone;
- distal shaft frx, esp those extending into supracondylar region, tend to angulate into recurvatum thru pull of gastrocnemius;
- traction: (skeletal traction)
- while traction may be require to bring the fracture fragments out to length, excessive traction may produce a stretch injury
of the sciatic or peroneal nerves or pressure on the pudendal nerves;
- ref: Pudendal nerve palsy in trauma and elective orthopaedic surgery
- reduction at frx site:
- if reduction can't be obtained, consider opening frx site:
- early Seattle experience w/ 245 comminuted frx revealed infection & non union rate using cerclage wiring (w/ opening of frx site);
- Frx of Distal 1/3:
- frx of the distal 1/3 of the shaft pose a special reduction problem.
- in supine portion, distal frag angulates posteriorly due to deformation of gastrocnemius;
- in lateral position, distal fragment sags into valgus angulation.
- guidepin should be aimed directly at intercondylar notch on AP view of the femur before reaming and nailing of the distal fragment.
- reaming of the distal fragment down to the anticipated distal tip of nail is unnecessary and may compromise the purchase of the nail on the cancellous bone of the distal third of the shaft.
Intraoperative reduction techniques for difficult femoral fractures.
A vascular complication of trochanteric-entry femoral nailing on a fracture table