Fracture of the Femur
Fracture of the Femur
A 19-year-old man was struck by a car while riding his motorcycle, and thrown 5 feet. When paramedics arrived on the scene within 10 minutes of the accident, the patient was alert and oriented to time, place, event, and person. After immobilization and transfer to the emergency room (ER), an evaluation by the ER team and the general surgeons found only an isolated injury of his right thigh. The patient is complaining of pain in his right thigh, which appears to be swollen and deformed. An x-ray reveals a mid-shaft femur fracture.
What is the orthopaedic management of this patient in the ER?
View the correct answer.
<p>Once the patient's airway, breathing, and circulation (ABCs) are cleared by the general surgeons, a secondary survey should be carried out that rules out the significant injuries often associated with the great deal of force required to fracture the femur, the longest bone in the body. This survey should include an examination of the cervical, thoracic, and lumbar spine, the pelvis, and the upper and lower extremities. A thorough neurovascular examination should be performed, consisting of a motor, sensory, and vascular (pulses) assessment. The skin should be examined to ensure it is not an open fracture, and the thigh should also be examined to rule out a compartment syndrome. Findings of compartment syndrome include pain, pallor, paresthesia, pulselessness, and poikilothermia (coldness). The compartments may or may not be distended. The earliest and most reliable indicator is pain out of proportion to the injury when the toes are passively flexed (checking the anterior compartment) and extended (checking the posterior compartments).</p>
What percent of femoral shaft fractures are open fractures?
View the correct answer.
<p>Winquist and colleagues<sup type="ref">[1]</sup> reported that 16.5% of 520 femoral shaft fractures were open. Of those, 88.4% were type I, according to the Gustilo-Anderson classification of open fractures<sup type="ref">[2,3]</sup>:</p><p><blockquote><table border="1"><tr align="left" valign="TOP"><td>Type</td><td>Size of Wound</td><td>Level of Contamination</td><td>Soft Tissue Injury</td><td>Bone Injury</td></tr><tr align="left" valign="TOP"><td>I</td><td>< 1 cm</td><td>Minimal</td><td>Minimal</td><td>Simple, no comminution</td></tr><tr align="left" valign="TOP"><td>II</td><td>1-10 cm</td><td>Moderate</td><td>Moderate</td><td>Minimal comminution; minimal periosteal stripping</td></tr><tr align="left" valign="TOP"><td>IIIA</td><td>> 10 cm</td><td>High</td><td>Severe, crush; soft tissue coverage possible</td><td>Moderate to high comminution; moderate periosteal stripping</td></tr><tr align="left" valign="TOP"><td>IIIB</td><td>> 10 cm</td><td>High, barnyard</td><td>Severe, crush; requires soft tissue reconstruction</td><td>High comminution; high periosteal stripping</td></tr><tr align="left" valign="TOP"><td>IIIC</td><td>> 10 cm</td><td>High</td><td>Severe, crush; vascular injury requiring repair</td><td>High comminution; high periosteal stripping</td></tr></table></blockquote></p>
How much blood loss do you expect from a femoral shaft fracture?
View the correct answer.
<p>Lieurance and colleagues<sup type="ref">[4]</sup> followed 53 patients with isolated femur fractures. The estimated blood loss in the study group averaged 1276 cc. Twenty-one (39.6%) patients required transfusion during their initial hospitalizations, averaging 2.5 units packed red blood cells. Admission hematocrit, preoperative, and total estimated blood loss were statistically significant variables in determining the need for transfusion. Fracture patterns, classified as high- or low-energy, did not correlate with pre- or intraoperative blood loss, incidence of transfusion, delay to surgery, or duration of hospital stay. Preoperative hemorrhage was a stronger predictor of the need for transfusion than was intraoperative blood loss.</p>
In addition to x-rays of the femur and thigh, what other x-rays would you order as part of the preoperative work-up?
View the correct answer.
<p>An anterior-posterior x-ray of the pelvis should be obtained to rule out an ipsilateral femoral neck fracture. A mid-shaft femur fracture in a high-energy trauma victim should prompt a careful search for an ipsilateral fracture of the femoral neck, which will be present in 5% of patients. This incidence may be increasing, and the injury pattern is missed 30% of the time.<sup type="ref">[5]</sup> A CT scan of the femoral neck may be helpful in high-risk patients such as those with associated fractures of the acetabulum, the distal femur, or the patella.<sup type="ref">[6]</sup> Early diagnosis will allow better general management and early fixation of the neck fracture. X-rays of the knee should also be taken to ensure that the fracture does not extend into that joint.</p>
If you detect ipsilateral femoral neck and shaft fractures, what are the surgical treatment options for this injury pattern?
View the correct answer.
<p>Nonoperative treatment of femoral shaft fractures, with the possible exception of an elderly patient who might not survive an operation or would be at great risk for morbidity associated with recovery bedrest, is never indicated. There are several surgical treatment options:</p><p><ul><li>A standard anterograde intramedullary nail with cannulated screw fixation of the femoral neck. The disadvantage of this option is that the nail must be placed very carefully so that the cannulated screw can be "snuck" around it into the neck and head. The advantage is that the knee joint is not violated, as when a retrograde nail is used, and that the fracture site is not opened, as when a plate is used.</li><li>A reconstruction nail. The disadvantage of this option is that a reconstruction nail is a more difficult implant to place. The advantage is that only 1 or 2 cannulated screws are required, instead of 3, as with an anterograde nail. The knee joint is not violated, as when a retrograde nail is used, and the fracture site is not opened, as when a plate is used.</li><li>A retrograde femoral nail with cannulated screw fixation of the femoral neck. The advantage of this option is that the retrograde nail does not reach the neck area, so it is much easier to place the cannulated screws. The disadvantage is that the knee joint is violated.</li><li>Plating of the shaft and cannulated screw fixation of the femoral neck. The advantage of this option is that it makes it easier to place the cannulated screws. The disadvantage is that the fracture is opened, increasing the risk of infection, delayed union, and nonunion.</li></ul></p>
What is the approximate curvature of radius of an adult femur?
View the correct answer.
<p>The curvature of radius of an adult femur is between 109 cm<sup type="ref">[7]</sup> and 114.4 cm,<sup type="ref">[8]</sup> which becomes important in nail selection. The radius of curvature of the femur should be matched as well as possible to the radius of curvature of the nail.</p>
What is the most appropriate entry point of a nail?
View the correct answer.
<p>The nail should run in the medullary canal, and the most appropriate area for proximal access into the canal is the junction of the femoral neck and the greater trochanter slightly anterior to or in the pyriformis fossa.<sup type="ref">[8]</sup> The starting point should be posterior to the midline of the femur. Anterior nail placement will increase hoop stresses, which in turn are more likely to lead to the bursting of the proximal femur during nail insertion.<sup type="ref">[9]</sup></p>
What geometric and mechanical parameters affect the insertion procedure and the resultant stresses generated?
View the correct answer.
<p>There are 6 parameters:</p><p><ul><li>rigidity of the nail</li><li>curvature of the nail</li><li>curvature of the femur</li><li>position of the starting hole</li><li>reamed diameter of the nail</li><li>length of the proximal femoral component</li></ul></p>
After finishing the nailing of a femur fracture, what additional x-rays or examinations should you perform before leaving the operating room?
View the correct answer.
<p>A postoperative anterior-posterior x-ray of the pelvis should be obtained to rule out an iatrogenic femoral neck fracture. Simonian and colleagues<sup type="ref">[10]</sup> reviewed 4 iatrogenic femoral neck fractures in 315 consecutive closed intramedullary nailings using the AO/ASIF universal femoral nail. In those patients with an increased (> 135°) neck-shaft angle, in whom the nail had been inserted beyond the tip of the greater trochanter, there was a greater risk of iatrogenic neck fracture. The authors suggested that the medial prong of the AO insertion jig, with its medial overhang of 2-3 mm, may impinge on the superior aspect of a valgus femoral neck during final impaction, causing a neck fracture. This can be avoided by leaving the end of the nail above the tip of the trochanter.</p><p>In addition, an examination of the knee ligaments should be performed to rule out injury. Femoral shaft fractures are associated with injuries to the ipsilateral knee in 15% to 55% of cases, leaving a high index of suspicion necessary to identify these lesions.<sup type="ref">[11]</sup> In a study of 47 patients with closed femoral shaft fractures, there were 12 medial meniscal injuries, including 5 tears, and 13 lateral meniscus injuries, with 8 tears. Two patients had tears of both menisci. Complex and radial tears were more common than peripheral or bucket-handle tears. Examination under anesthesia revealed ligamentous laxity in 23 patients (49%). DeCampos and colleagues<sup type="ref">[12]</sup> studied 40 adults with closed diaphyseal femoral fractures. In 21 (52.5%) patients, there was greater than grade I laxity, and significant arthroscopic findings included 19 partial (48%) and 2 complete (5%) anterior cruciate injuries, and 2 partial (5%) and 1 complete (2.5%) posterior cruciate injuries. In all, 22 patients (55%) had significant arthroscopic findings.</p><p>Finally, rotation of the operated limb should be examined to ensure that the fracture was locked in a rotationally acceptable position.</p>
In a patient with a pulmonary injury, which is preferred: a reamed or unreamed nailing?
View the correct answer.
<p>Studies from Europe suggest that reamed intramedullary nailing in patients with pulmonary trauma have a deleterious effect on pulmonary function, but neither animal nor human studies have reproduced those results in North America. Bosse and colleagues<sup type="ref">[13]</sup> compared intramedullary nailing and reaming with plating femoral shaft fractures in patients with or without a thoracic injury. The occurrence of adult respiratory distress syndrome in patients with a femoral fracture but no thoracic injury did not depend on whether the fracture had been treated with a nail (118 patients) or a plate (114 patients). Likewise, the frequency of adult respiratory distress syndrome, pneumonia, pulmonary embolism, failure of multiple organs, or death for the patients who had a femoral fracture and a thoracic injury was similar in the 2 groups. The authors concluded that the use of intramedullary nailing with reaming for acute stabilization of fractures of the femur in multiply injured patients who have a thoracic injury does not appear to increase the occurrence of adult respiratory distress syndrome, pulmonary embolism, failure of multiple organs, pneumonia, or death.</p>
What is the nonunion rate following reamed intramedullary nailing of the femur?
View the correct answer.
<p>The rate of nonunion is 1%.<sup type="ref">[1,14]</sup> The most common cause is wound infection, distraction, or inadequate stabilization. If there is no evidence of infection, exchange nailing is the treatment of choice. The new nail should be at least 2 mm thicker than the one being replaced.<sup type="ref">[15]</sup></p>
Imagine another scenario: While the patient is awaiting surgery, you get a call from a nurse informing you that the patient's behavior has changed. The last set of vital signs showed that the patient was tachycardic and tachypneic. A bedside examination demonstrates a change in mental status and petechiae in his axillae, neck and chest, and conjunctivae. What is the clinical scenario described here?
View the correct answer.
<p>The patient has developed fat embolism syndrome (FES), caused by active substances and fat released from the bone marrow that primarily affect the brain and lung tissues. The exact etiology is not very well understood, but it occurs more often in patients with closed lower extremity fractures.<sup type="ref">[17]</sup> Among patients with all fractures, the incidence is 8.75%, with a mortality rate of 2.5%.<sup type="ref">[18]</sup> Sixty percent of cases are seen in the first 24 hours, and 90% are seen within 72 hours.<sup type="ref">[19]</sup> The most reliable laboratory test is an arterial oxygenation on room air. If the PO<sub>2</sub> is less than 60 mmHg, it is indicative of FES. The treatment is mainly supportive (oxygenation and mechanical ventilation).</p>
Made possible through an unrestricted educational grant from Smith & Nephew.
A 19-year-old man was struck by a car while riding his motorcycle, and thrown 5 feet. When paramedics arrived on the scene within 10 minutes of the accident, the patient was alert and oriented to time, place, event, and person. After immobilization and transfer to the emergency room (ER), an evaluation by the ER team and the general surgeons found only an isolated injury of his right thigh. The patient is complaining of pain in his right thigh, which appears to be swollen and deformed. An x-ray reveals a mid-shaft femur fracture.
What is the orthopaedic management of this patient in the ER?
Once the patient's airway, breathing, and circulation (ABCs) are cleared by the general surgeons, a secondary survey should be carried out that rules out the significant injuries often associated with the great deal of force required to fracture the femur, the longest bone in the body. This survey should include an examination of the cervical, thoracic, and lumbar spine, the pelvis, and the upper and lower extremities. A thorough neurovascular examination should be performed, consisting of a motor, sensory, and vascular (pulses) assessment. The skin should be examined to ensure it is not an open fracture, and the thigh should also be examined to rule out a compartment syndrome. Findings of compartment syndrome include pain, pallor, paresthesia, pulselessness, and poikilothermia (coldness). The compartments may or may not be distended. The earliest and most reliable indicator is pain out of proportion to the injury when the toes are passively flexed (checking the anterior compartment) and extended (checking the posterior compartments).
View the correct answer.
<p>Once the patient's airway, breathing, and circulation (ABCs) are cleared by the general surgeons, a secondary survey should be carried out that rules out the significant injuries often associated with the great deal of force required to fracture the femur, the longest bone in the body. This survey should include an examination of the cervical, thoracic, and lumbar spine, the pelvis, and the upper and lower extremities. A thorough neurovascular examination should be performed, consisting of a motor, sensory, and vascular (pulses) assessment. The skin should be examined to ensure it is not an open fracture, and the thigh should also be examined to rule out a compartment syndrome. Findings of compartment syndrome include pain, pallor, paresthesia, pulselessness, and poikilothermia (coldness). The compartments may or may not be distended. The earliest and most reliable indicator is pain out of proportion to the injury when the toes are passively flexed (checking the anterior compartment) and extended (checking the posterior compartments).</p>
What percent of femoral shaft fractures are open fractures?
Winquist and colleagues reported that 16.5% of 520 femoral shaft fractures were open. Of those, 88.4% were type I, according to the Gustilo-Anderson classification of open fractures:Type Size of Wound Level of Contamination Soft Tissue Injury Bone Injury I < 1 cm Minimal Minimal Simple, no comminution II 1-10 cm Moderate Moderate Minimal comminution; minimal periosteal stripping IIIA > 10 cm High Severe, crush; soft tissue coverage possible Moderate to high comminution; moderate periosteal stripping IIIB > 10 cm High, barnyard Severe, crush; requires soft tissue reconstruction High comminution; high periosteal stripping IIIC > 10 cm High Severe, crush; vascular injury requiring repair High comminution; high periosteal stripping
View the correct answer.
<p>Winquist and colleagues<sup type="ref">[1]</sup> reported that 16.5% of 520 femoral shaft fractures were open. Of those, 88.4% were type I, according to the Gustilo-Anderson classification of open fractures<sup type="ref">[2,3]</sup>:</p><p><blockquote><table border="1"><tr align="left" valign="TOP"><td>Type</td><td>Size of Wound</td><td>Level of Contamination</td><td>Soft Tissue Injury</td><td>Bone Injury</td></tr><tr align="left" valign="TOP"><td>I</td><td>< 1 cm</td><td>Minimal</td><td>Minimal</td><td>Simple, no comminution</td></tr><tr align="left" valign="TOP"><td>II</td><td>1-10 cm</td><td>Moderate</td><td>Moderate</td><td>Minimal comminution; minimal periosteal stripping</td></tr><tr align="left" valign="TOP"><td>IIIA</td><td>> 10 cm</td><td>High</td><td>Severe, crush; soft tissue coverage possible</td><td>Moderate to high comminution; moderate periosteal stripping</td></tr><tr align="left" valign="TOP"><td>IIIB</td><td>> 10 cm</td><td>High, barnyard</td><td>Severe, crush; requires soft tissue reconstruction</td><td>High comminution; high periosteal stripping</td></tr><tr align="left" valign="TOP"><td>IIIC</td><td>> 10 cm</td><td>High</td><td>Severe, crush; vascular injury requiring repair</td><td>High comminution; high periosteal stripping</td></tr></table></blockquote></p>
How much blood loss do you expect from a femoral shaft fracture?
Lieurance and colleagues followed 53 patients with isolated femur fractures. The estimated blood loss in the study group averaged 1276 cc. Twenty-one (39.6%) patients required transfusion during their initial hospitalizations, averaging 2.5 units packed red blood cells. Admission hematocrit, preoperative, and total estimated blood loss were statistically significant variables in determining the need for transfusion. Fracture patterns, classified as high- or low-energy, did not correlate with pre- or intraoperative blood loss, incidence of transfusion, delay to surgery, or duration of hospital stay. Preoperative hemorrhage was a stronger predictor of the need for transfusion than was intraoperative blood loss.
View the correct answer.
<p>Lieurance and colleagues<sup type="ref">[4]</sup> followed 53 patients with isolated femur fractures. The estimated blood loss in the study group averaged 1276 cc. Twenty-one (39.6%) patients required transfusion during their initial hospitalizations, averaging 2.5 units packed red blood cells. Admission hematocrit, preoperative, and total estimated blood loss were statistically significant variables in determining the need for transfusion. Fracture patterns, classified as high- or low-energy, did not correlate with pre- or intraoperative blood loss, incidence of transfusion, delay to surgery, or duration of hospital stay. Preoperative hemorrhage was a stronger predictor of the need for transfusion than was intraoperative blood loss.</p>
In addition to x-rays of the femur and thigh, what other x-rays would you order as part of the preoperative work-up?
An anterior-posterior x-ray of the pelvis should be obtained to rule out an ipsilateral femoral neck fracture. A mid-shaft femur fracture in a high-energy trauma victim should prompt a careful search for an ipsilateral fracture of the femoral neck, which will be present in 5% of patients. This incidence may be increasing, and the injury pattern is missed 30% of the time. A CT scan of the femoral neck may be helpful in high-risk patients such as those with associated fractures of the acetabulum, the distal femur, or the patella. Early diagnosis will allow better general management and early fixation of the neck fracture. X-rays of the knee should also be taken to ensure that the fracture does not extend into that joint.
View the correct answer.
<p>An anterior-posterior x-ray of the pelvis should be obtained to rule out an ipsilateral femoral neck fracture. A mid-shaft femur fracture in a high-energy trauma victim should prompt a careful search for an ipsilateral fracture of the femoral neck, which will be present in 5% of patients. This incidence may be increasing, and the injury pattern is missed 30% of the time.<sup type="ref">[5]</sup> A CT scan of the femoral neck may be helpful in high-risk patients such as those with associated fractures of the acetabulum, the distal femur, or the patella.<sup type="ref">[6]</sup> Early diagnosis will allow better general management and early fixation of the neck fracture. X-rays of the knee should also be taken to ensure that the fracture does not extend into that joint.</p>
If you detect ipsilateral femoral neck and shaft fractures, what are the surgical treatment options for this injury pattern?
Nonoperative treatment of femoral shaft fractures, with the possible exception of an elderly patient who might not survive an operation or would be at great risk for morbidity associated with recovery bedrest, is never indicated. There are several surgical treatment options:
A standard anterograde intramedullary nail with cannulated screw fixation of the femoral neck. The disadvantage of this option is that the nail must be placed very carefully so that the cannulated screw can be "snuck" around it into the neck and head. The advantage is that the knee joint is not violated, as when a retrograde nail is used, and that the fracture site is not opened, as when a plate is used.
A reconstruction nail. The disadvantage of this option is that a reconstruction nail is a more difficult implant to place. The advantage is that only 1 or 2 cannulated screws are required, instead of 3, as with an anterograde nail. The knee joint is not violated, as when a retrograde nail is used, and the fracture site is not opened, as when a plate is used.
A retrograde femoral nail with cannulated screw fixation of the femoral neck. The advantage of this option is that the retrograde nail does not reach the neck area, so it is much easier to place the cannulated screws. The disadvantage is that the knee joint is violated.
Plating of the shaft and cannulated screw fixation of the femoral neck. The advantage of this option is that it makes it easier to place the cannulated screws. The disadvantage is that the fracture is opened, increasing the risk of infection, delayed union, and nonunion.
View the correct answer.
<p>Nonoperative treatment of femoral shaft fractures, with the possible exception of an elderly patient who might not survive an operation or would be at great risk for morbidity associated with recovery bedrest, is never indicated. There are several surgical treatment options:</p><p><ul><li>A standard anterograde intramedullary nail with cannulated screw fixation of the femoral neck. The disadvantage of this option is that the nail must be placed very carefully so that the cannulated screw can be "snuck" around it into the neck and head. The advantage is that the knee joint is not violated, as when a retrograde nail is used, and that the fracture site is not opened, as when a plate is used.</li><li>A reconstruction nail. The disadvantage of this option is that a reconstruction nail is a more difficult implant to place. The advantage is that only 1 or 2 cannulated screws are required, instead of 3, as with an anterograde nail. The knee joint is not violated, as when a retrograde nail is used, and the fracture site is not opened, as when a plate is used.</li><li>A retrograde femoral nail with cannulated screw fixation of the femoral neck. The advantage of this option is that the retrograde nail does not reach the neck area, so it is much easier to place the cannulated screws. The disadvantage is that the knee joint is violated.</li><li>Plating of the shaft and cannulated screw fixation of the femoral neck. The advantage of this option is that it makes it easier to place the cannulated screws. The disadvantage is that the fracture is opened, increasing the risk of infection, delayed union, and nonunion.</li></ul></p>
What is the approximate curvature of radius of an adult femur?
The curvature of radius of an adult femur is between 109 cm and 114.4 cm, which becomes important in nail selection. The radius of curvature of the femur should be matched as well as possible to the radius of curvature of the nail.
View the correct answer.
<p>The curvature of radius of an adult femur is between 109 cm<sup type="ref">[7]</sup> and 114.4 cm,<sup type="ref">[8]</sup> which becomes important in nail selection. The radius of curvature of the femur should be matched as well as possible to the radius of curvature of the nail.</p>
What is the most appropriate entry point of a nail?
The nail should run in the medullary canal, and the most appropriate area for proximal access into the canal is the junction of the femoral neck and the greater trochanter slightly anterior to or in the pyriformis fossa. The starting point should be posterior to the midline of the femur. Anterior nail placement will increase hoop stresses, which in turn are more likely to lead to the bursting of the proximal femur during nail insertion.
View the correct answer.
<p>The nail should run in the medullary canal, and the most appropriate area for proximal access into the canal is the junction of the femoral neck and the greater trochanter slightly anterior to or in the pyriformis fossa.<sup type="ref">[8]</sup> The starting point should be posterior to the midline of the femur. Anterior nail placement will increase hoop stresses, which in turn are more likely to lead to the bursting of the proximal femur during nail insertion.<sup type="ref">[9]</sup></p>
What geometric and mechanical parameters affect the insertion procedure and the resultant stresses generated?
There are 6 parameters:
rigidity of the nail
curvature of the nail
curvature of the femur
position of the starting hole
reamed diameter of the nail
length of the proximal femoral component
View the correct answer.
<p>There are 6 parameters:</p><p><ul><li>rigidity of the nail</li><li>curvature of the nail</li><li>curvature of the femur</li><li>position of the starting hole</li><li>reamed diameter of the nail</li><li>length of the proximal femoral component</li></ul></p>
After finishing the nailing of a femur fracture, what additional x-rays or examinations should you perform before leaving the operating room?
A postoperative anterior-posterior x-ray of the pelvis should be obtained to rule out an iatrogenic femoral neck fracture. Simonian and colleagues reviewed 4 iatrogenic femoral neck fractures in 315 consecutive closed intramedullary nailings using the AO/ASIF universal femoral nail. In those patients with an increased (> 135°) neck-shaft angle, in whom the nail had been inserted beyond the tip of the greater trochanter, there was a greater risk of iatrogenic neck fracture. The authors suggested that the medial prong of the AO insertion jig, with its medial overhang of 2-3 mm, may impinge on the superior aspect of a valgus femoral neck during final impaction, causing a neck fracture. This can be avoided by leaving the end of the nail above the tip of the trochanter.In addition, an examination of the knee ligaments should be performed to rule out injury. Femoral shaft fractures are associated with injuries to the ipsilateral knee in 15% to 55% of cases, leaving a high index of suspicion necessary to identify these lesions. In a study of 47 patients with closed femoral shaft fractures, there were 12 medial meniscal injuries, including 5 tears, and 13 lateral meniscus injuries, with 8 tears. Two patients had tears of both menisci. Complex and radial tears were more common than peripheral or bucket-handle tears. Examination under anesthesia revealed ligamentous laxity in 23 patients (49%). DeCampos and colleagues studied 40 adults with closed diaphyseal femoral fractures. In 21 (52.5%) patients, there was greater than grade I laxity, and significant arthroscopic findings included 19 partial (48%) and 2 complete (5%) anterior cruciate injuries, and 2 partial (5%) and 1 complete (2.5%) posterior cruciate injuries. In all, 22 patients (55%) had significant arthroscopic findings.Finally, rotation of the operated limb should be examined to ensure that the fracture was locked in a rotationally acceptable position.
View the correct answer.
<p>A postoperative anterior-posterior x-ray of the pelvis should be obtained to rule out an iatrogenic femoral neck fracture. Simonian and colleagues<sup type="ref">[10]</sup> reviewed 4 iatrogenic femoral neck fractures in 315 consecutive closed intramedullary nailings using the AO/ASIF universal femoral nail. In those patients with an increased (> 135°) neck-shaft angle, in whom the nail had been inserted beyond the tip of the greater trochanter, there was a greater risk of iatrogenic neck fracture. The authors suggested that the medial prong of the AO insertion jig, with its medial overhang of 2-3 mm, may impinge on the superior aspect of a valgus femoral neck during final impaction, causing a neck fracture. This can be avoided by leaving the end of the nail above the tip of the trochanter.</p><p>In addition, an examination of the knee ligaments should be performed to rule out injury. Femoral shaft fractures are associated with injuries to the ipsilateral knee in 15% to 55% of cases, leaving a high index of suspicion necessary to identify these lesions.<sup type="ref">[11]</sup> In a study of 47 patients with closed femoral shaft fractures, there were 12 medial meniscal injuries, including 5 tears, and 13 lateral meniscus injuries, with 8 tears. Two patients had tears of both menisci. Complex and radial tears were more common than peripheral or bucket-handle tears. Examination under anesthesia revealed ligamentous laxity in 23 patients (49%). DeCampos and colleagues<sup type="ref">[12]</sup> studied 40 adults with closed diaphyseal femoral fractures. In 21 (52.5%) patients, there was greater than grade I laxity, and significant arthroscopic findings included 19 partial (48%) and 2 complete (5%) anterior cruciate injuries, and 2 partial (5%) and 1 complete (2.5%) posterior cruciate injuries. In all, 22 patients (55%) had significant arthroscopic findings.</p><p>Finally, rotation of the operated limb should be examined to ensure that the fracture was locked in a rotationally acceptable position.</p>
In a patient with a pulmonary injury, which is preferred: a reamed or unreamed nailing?
Studies from Europe suggest that reamed intramedullary nailing in patients with pulmonary trauma have a deleterious effect on pulmonary function, but neither animal nor human studies have reproduced those results in North America. Bosse and colleagues compared intramedullary nailing and reaming with plating femoral shaft fractures in patients with or without a thoracic injury. The occurrence of adult respiratory distress syndrome in patients with a femoral fracture but no thoracic injury did not depend on whether the fracture had been treated with a nail (118 patients) or a plate (114 patients). Likewise, the frequency of adult respiratory distress syndrome, pneumonia, pulmonary embolism, failure of multiple organs, or death for the patients who had a femoral fracture and a thoracic injury was similar in the 2 groups. The authors concluded that the use of intramedullary nailing with reaming for acute stabilization of fractures of the femur in multiply injured patients who have a thoracic injury does not appear to increase the occurrence of adult respiratory distress syndrome, pulmonary embolism, failure of multiple organs, pneumonia, or death.
View the correct answer.
<p>Studies from Europe suggest that reamed intramedullary nailing in patients with pulmonary trauma have a deleterious effect on pulmonary function, but neither animal nor human studies have reproduced those results in North America. Bosse and colleagues<sup type="ref">[13]</sup> compared intramedullary nailing and reaming with plating femoral shaft fractures in patients with or without a thoracic injury. The occurrence of adult respiratory distress syndrome in patients with a femoral fracture but no thoracic injury did not depend on whether the fracture had been treated with a nail (118 patients) or a plate (114 patients). Likewise, the frequency of adult respiratory distress syndrome, pneumonia, pulmonary embolism, failure of multiple organs, or death for the patients who had a femoral fracture and a thoracic injury was similar in the 2 groups. The authors concluded that the use of intramedullary nailing with reaming for acute stabilization of fractures of the femur in multiply injured patients who have a thoracic injury does not appear to increase the occurrence of adult respiratory distress syndrome, pulmonary embolism, failure of multiple organs, pneumonia, or death.</p>
What is the nonunion rate following reamed intramedullary nailing of the femur?
The rate of nonunion is 1%. The most common cause is wound infection, distraction, or inadequate stabilization. If there is no evidence of infection, exchange nailing is the treatment of choice. The new nail should be at least 2 mm thicker than the one being replaced.
View the correct answer.
<p>The rate of nonunion is 1%.<sup type="ref">[1,14]</sup> The most common cause is wound infection, distraction, or inadequate stabilization. If there is no evidence of infection, exchange nailing is the treatment of choice. The new nail should be at least 2 mm thicker than the one being replaced.<sup type="ref">[15]</sup></p>
Imagine another scenario: While the patient is awaiting surgery, you get a call from a nurse informing you that the patient's behavior has changed. The last set of vital signs showed that the patient was tachycardic and tachypneic. A bedside examination demonstrates a change in mental status and petechiae in his axillae, neck and chest, and conjunctivae. What is the clinical scenario described here?
The patient has developed fat embolism syndrome (FES), caused by active substances and fat released from the bone marrow that primarily affect the brain and lung tissues. The exact etiology is not very well understood, but it occurs more often in patients with closed lower extremity fractures. Among patients with all fractures, the incidence is 8.75%, with a mortality rate of 2.5%. Sixty percent of cases are seen in the first 24 hours, and 90% are seen within 72 hours. The most reliable laboratory test is an arterial oxygenation on room air. If the PO2 is less than 60 mmHg, it is indicative of FES. The treatment is mainly supportive (oxygenation and mechanical ventilation).
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<p>The patient has developed fat embolism syndrome (FES), caused by active substances and fat released from the bone marrow that primarily affect the brain and lung tissues. The exact etiology is not very well understood, but it occurs more often in patients with closed lower extremity fractures.<sup type="ref">[17]</sup> Among patients with all fractures, the incidence is 8.75%, with a mortality rate of 2.5%.<sup type="ref">[18]</sup> Sixty percent of cases are seen in the first 24 hours, and 90% are seen within 72 hours.<sup type="ref">[19]</sup> The most reliable laboratory test is an arterial oxygenation on room air. If the PO<sub>2</sub> is less than 60 mmHg, it is indicative of FES. The treatment is mainly supportive (oxygenation and mechanical ventilation).</p>
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