Executive Editor: Chris Colton, Rick Buckley

Authors: Peter V Giannoudis, Hans Christoph Pape, Michael Sch├╝tz

Femur shaft - Wedge, Intact, distal 1/3 fractures

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Glossary

General considerations

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the strongest mechanical fixation and is the best treatment for early mobilization.

Nonoperative treatment is undertaken only temporarily. Nonoperative treatment is reserved for exceptional cases, e.g. if the general medical condition does not allow safe anesthesia.

Plate fixation, whether performed open or closed, with DCS or LISS, is dependent upon surgeon experience and resources available.

Nonoperative treatment with limited resources
Indication summary Skill Equipment
Neither facilities, nor skills, for surgical treatment available Basic surgical experience, no specialized skills Basic equipment only

Femoral shaft fractures are normally treated operatively, using intramedullary nailing.

They should only be considered for nonoperative fracture treatment if there are neither facilities, nor skills, for surgical treatment

Temporary Thomas splint
Indication summary Skill Equipment
Damage control (medically unfit for surgery, usually temporary) Basic surgical experience, no specialized skills Basic equipment only

Further indications

  • Limited operative resources

Advantages

  • Stabilization when immediate surgery is not possible or practical

Disadvantages

  • Failure to follow AO principles
Temporary external fixator
Indication summary Skill Equipment
Patient or soft tissues unsuitable for definitive internal fixation Some specialized surgical experience Simple surgical and imaging resources

Further indications for external fixation

  • Salvage after major complications following internal fixation

Contraindication

  • Osteoporosis (relative contraindication)

Advantage

  • Rapidly applied provisional treatment

Disadvantages

  • Pin-track infection
  • May interfere with procedures for soft-tissue reconstruction
  • High risk of nonunion/malunion when used for definitive treatment
MIO - Bridge plating (LISS or LCP)
Indication summary Skill Equipment
Polytrauma with chest injury Highly experienced and skilled surgeon Full specialized surgical and imaging resources

The choice between DCS and LISS will depend on surgeon's experience and resources.

Further indications

  • All patients where intramedullary nailing is contraindicated, but the patient is fit for surgery

Contraindications

  • Severe open fractures of the distal femur
  • Patient not medically fit for surgery

Advantages

  • Fracture can be reduced (length, angular and rotational control are obtained)
  • Reduced incidence of fat embolization compared to IM nailing

Disadvantages

  • Greater blood loss
  • Exposure of fracture zone / risk of interference with healing process
  • Larger operative soft-tissue trauma
  • Risk of malrotation
  • Risk of varus and/or valgus malposition
  • Demanding surgical procedure/ Closed reduction is more challenging than open reduction
MIO - Bridge plating (DCS)
Indication summary Skill Equipment
Polytrauma with chest injury, limited operative resources Some specialized surgical experience Full specialized surgical and imaging resources

The choice between DCS and LISS will depend on surgeon's experience and resources.

Further indications

  • All patients where intramedullary nailing is contraindicated, but the patient is fit for surgery

Contraindications

  • Severe open fractures of the distal femur
  • Patient not medically fit for surgery

Advantages

  • Fracture can be reduced (length, angular and rotational control are obtained)
  • Reduced incidence of fat embolization compared to IM nailing

Disadvantages

  • Exposure of fracture zone / risk of interference with healing process
  • Larger operative soft-tissue trauma
  • Risk of malrotation
  • Risk of varus and/or valgus malposition
  • Demanding surgical procedure/ Closed reduction is more challenging than open reduction
ORIF - Bridge plating (DCS)
Indication summary Skill Equipment
Polytrauma with chest injury, limited operative resources Some specialized surgical experience Full specialized surgical and imaging resources

Further indications

  • All patients where intramedullary nailing is contraindicated, but the patient is fit for surgery

Contraindications

  • Severe open fractures of the distal femur
  • Patient not medically fit for surgery

Advantages

  • Fracture can be reduced (length, angular and rotational control are obtained)
  • Reduced incidence of fat embolization compared to IM nailing

Disadvantages

  • Exposure of fracture zone / risk of interference with healing process
  • Larger operative soft-tissue trauma compared to closed nailing or plating
  • Risk of malrotation
  • Risk of varus and/or valgus malposition
  • Demanding surgical procedure/ Closed reduction is more challenging than open reduction
Antegrade nailing
Indication summary Skill Equipment
Closed isolated fractures, most open fractures, and stable polytrauma Some specialized surgical experience Full specialized surgical and imaging resources

Indications

  • All patients with femoral shaft fractures except those not fit for definitive surgery
  • Closed fractures
  • Gustilo types I & II open, and clean IIIA fractures
  • Polytrauma patients in stable condition

Contraindications

  • Polytrauma patients in unstable condition
  • Occluded intramedullary canal
  • Gustilo type III B and C open fractures

Advantages over other techniques

  • Less invasive procedure / indirect reduction
  • Fracture can be reduced (length, angular and rotational control are obtained)
  • Better biomechanical properties
  • Rapid mobilization of patients postoperatively
  • Minimal blood loss

Disadvantages against other techniques

  • Risk of iatrogenic femoral neck fracture
  • Risk of fat embolization
  • Risk of malrotation
Retrograde nailing
Indication summary Skill Equipment
Middle or distal third fractures, "floating knee", obesity, polytrauma Highly experienced and skilled surgeon Full specialized surgical and imaging resources

General Indications

  • Polytrauma patients in stable condition

Relative Indications (retrograde vs. antegrade nailing)

  • Bilateral lower extremity fractures
  • Ipsilateral femoral neck and shaft fractures
  • Concomitant ipsilateral acetabular / pelvic ring fractures
  • Fracture below hip prosthesis

Contraindications

  • Polytrauma patients in unstable condition
  • Occluded intramedullary canal
  • Gustilo type III B and C open fractures

Advantages over other techniques

  • Less invasive procedure / indirect reduction
  • Minimizes soft-tissue damage
  • Fracture can be reduced (length, angular and rotational control are obtained)
  • Better biomechanical properties
  • Rapid mobilization of patients postoperatively
  • Minimal blood loss

Disadvantages

  • Risk of iatrogenic intraarticular damage to the knee joint
  • Risk of fat embolization
  • Difficult control of proximal fracture fragment in more proximal fractures
  • Risk of damage to the anterior cruciate ligament
  • Risk of malrotation – angular deformity
  • Risk of damage to the patellar tendon
  • Risk of chronic knee pain
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v2.0 2018-07-05