Introduction  

Fractures of the femur are relatively common, with diaphyseal injuries occurring in the younger age group
and fractures of the hip and distal metaphysis predominating in the elderly. Fortunately, the majority of the
bone has a good blood supply and most fractures are amenable to surgical fixation.

Fractures of the proximal femur (Hip)

Broadly speaking, there are two types of fractures – intra-capsular and extra-capsular. Their incidence is
increasing with the increase in the elderly population, and is predominately due to age related osteopenia
and increased susceptibility to falls. The risk may be reduced by exercise, quitting smoking, avoiding
sedatives, reducing caffeine intake, treating impaired vision, maintaining bone density (postmenopausal
women should consider hormonal replacement and calcium supplements) and reducing home hazards
(Cummings et al. 1995, Cauley et al. 1995).

Intracapsular hip fractures

The anatomy is important. The proximal femoral epiphysis ,°7 °fuses at age 16 (skeletal maturity). The
neck shaft angle is 130 (Turen 1996). The calcar is the posteromedial portion of the 7 °anteversion 10
upper femur and critical for the mechanical stability of this region. The blood supply of the femoral head is
critical and vulnerable, accounting for the complications of fractures in this region viz. avascular necrosis
(AVN) (Lavernia et al. 1999) and non-union. The femoral head is principally supplied by the medial and
lateral femoral circumflex arteries, with a contribution from the gluteal arteries, forming an extracapsular
arterial ring at the base of the neck. The major branch of this arterial ring is the lateral epiphyseal artery,
which runs in the posterior retinaculum and supplies to a large extent the femoral head.

A fracture of the femoral neck disrupts this blood supply to the head to a varying extent depending upon
the degree of displacement. In marked displacement there is a tear of the posterior retinaculum, whereas if
less displaced, the expanding haematoma may cause a problem due to tamponade.

Evaluation

Symptoms may be mild especially in the older patient if there is impaction or incomplete displacement.
Otherwise there is hip or groin pain with shortening and external rotation of the leg. The multi trauma
patient must be carefully evaluated for such injuries.

X-rays

Standard Antero-posterior hip and a cross-table lateral radiographs are required, to adequately assess
both the injury and degree of displacement. Sometimes the fracture is not obvious and a bone scan, CT or
MRI is required.

Classification

Garden's classification remains the gold standard (Fig. 18.1). Types I and II are non- displaced with a low
rate of subsequent Avascular Necrosis (AVN), with the converse being true for types III and IV. Pauwel's
system is based on the angle between the fracture line and the horizontal, post-reduction, and reflects
stability, not displacement..

Treatment

The aim of treatment is restoration of function. This should entail reduction and fixation of fractures in
patients who are relatively fit with a reasonable life expectancy. The elderly or infirm patients, with
displaced fractures, are usually treated by hemiarthroplasty using an uncemented prosthesis e.g. Austin-
Moore, though undisplaced fractures may still be fixed.

Non-or minimally displaced fractures have a lower risk of AVN and non-union than displaced fractures.
These risks are higher in younger patients with displaced fractures, reflecting the magnitude of the injury.

It is important to achieve a good reduction to avoid failure of fixation and subsequent avascular necrosis.

Key points

• The adequacy of reduction and the density of the head and neck are the key features determining
stability after fixation.

Methods available for reduction and fixation include gentle manipulation under Image Intensifier control,
followed by fixation with either three parallel cannulated screws or a compression screw plate device
,placing a large compression screw in middle of the head on both AP and Lateral views, supplemented
with a 4.5mm screw in superior head for rotational control. If the decision is made not to reduce and fix,
then a hemiarthroplasty can be performed, usually in a Garden III or IV fracture in an elderly unfit patient.

Total Hip Replacement should be reserved for cases of delayed treatment in patients otherwise suitable for
reduction and fixation, and in cases where there is significant pre-existing degenerative change in the hip
joint. This is relatively rare. It may also be the treatment of choice in Rheumatoid Arthritis, renal failure or
metastatic disease.

Key points

• If the decision is made to reduce and fix the fracture, this should be done as soon as possible
(Swiontkowski 1994).

Special situation

Ipsilateral hip and femoral shaft fractures

Use an intramedullary (IM) nail with provision for oblique screws to be placed up the femoral neck
(Reconstruction nail) or consider IM nail with cannulated cancellous screws placed in front of and behind
the nail.
Author's Preferred Treatment

• Garden I & II fractures. Proceed to three parallel cannulated screws using a percutaneous
technique. Consider performing an anterior capsulotomy to decompress the haemarthrosis

• Garden III and IV. If fit, reduce and fix as above, or if unfit/demented perform an hemiarthroplasty.

• In young patients - preserve the femoral head at all costs. This will entail an emergency reduction
and fixation

• In patients who are demented and non-ambulatory with a valgus impaction fracture, one can
consider non-operative management, though there is a risk of subsequent displacement

Complications

Avascular necrosis may occur in a significant proportion of cases and may ultimately require prosthetic
replacement if symptomatic degenerative changes develops.

Non-union can be treated by either refixation or grafting or prosthetic replacement.

Other complications include Infection dislocation and deep vein Thrombosis

Key points

• Early adequate reduction is the key to reducing the risk of AVN.

Femoral head fractures

These fractures usually occur in high-energy injuries in the younger patient, often associated with a
dislocation of the hip joint. Loss of congruency of the femoral head may result in premature degenerative
change. Computerised Tomography is the most useful imaging modality.

Classification

Pipkin devised the following classification for fractures associated with posterior dislocations:-

• Type 1 Fracture caudad to fovea centralis

• Type 2 Fracture cephalad to fovea centralis

• Type 3 Type 1 or 2 with associated femoral neck fracture

• Type 4 Type 1,2 or 3 with associated acetabular fracture

Treatment

Treatment of these fractures is dictated by their type: -

• Type 1 Primary closed reduction followed by 6 weeks traction with range of motion exercises. If
the fragment blocks reduction of the hip joint it mat be excised via a small arthrotomy.
 • Type 2 Primary closed reduction of the joint followed by CT scan to determine adequacy of
reduction of the fragment. If inadequate, ORIF should be performed though this is a complex
undertaking for even experienced hip surgeons.

• Type 3 In younger patients the femoral neck fracture should be fixed and the head fracture dealt
with by either fixation or excision depending on its size. In the elderly,

• consider primary prosthetic replacement.

• Type 4 Primary consideration is given to the acetabular fracture, with the femoral head fracture
being dealt with subsequently as previously described.

• Key points

• In young patients where there is a fracture of the head and neck, urgent ORIF is required

• All patients should have post-reduction CT to assess adequacy of reduction.

Extracapsular ( Intertrochanteric) hip fractures (Koval 1998)

Most require Open Reduction and Internal Fixation (ORIF) .Stability must be obtained, ideally by restoring
the posteromedial buttress. Unstable fracture patterns are seen where there is loss of this buttress,
subtrochanteric extension of the fracture, or a reverse oblique fracture pattern.

Evaluation

Patients may present in severe pain with shortening and external rotation of the leg, but this may be
absent if there is minimal displacement.

X-rays

Standard Antero-posterior hip and cross-table lateral radiographs internal rotation°are required, sometimes
augmented with a 15 view.

Classification

Use the Evans-Jensen system (Fig. 18.2).

Treatment

The surgical options are either an Intra-medullary device such as the Gamma nail, or a sliding hip screw
systems e.g. Dynamic Hip Screw – DHS (Fig. 18.3).

Author's preferred technique

Sliding hip screw

Place the patient on fracture table and achieve reduction by applying traction with the leg internally
rotated. Check the reduction in two orthogonal planes using Image Intensification (I.I.). The fracture may
require additional manipulation to obtain reduction.

Access to the proximal femur is gained via a straight lateral approach, through the iliotibial band, splitting
vastus lateralis and ligating the perforating branches of the femoral artery. Using a 135-degree jig, a guide
wire is introduced into the middle of the femoral head, stopping 5mm from the subchondral bone in both
AP and Lateral views using II. A second parallel wire should be introduced superiorly to prevent rotation
during reaming, tapping and screw insertion. The appropriate length screw is selected. A reamer is used to
create the appropriate shaped hole and the screw is introduced after tapping. A 135-degree plate is then
applied over the screw (short barrel if screw <80mm). This plate is then loosely clamped to the femoral
shaft, traction is released to allow some impaction, and the plate fixed using cortical screws. A
Compression set screw may be added to initiate compression but should be removed.

Key points

• Do not place screw in anterosuperior part of femoral head

Other situations:

• In unstable fracture patterns, in the younger patient, one may consider reduction of the
posteromedial fragment with a lag screw, to prevent excessive screw-barrel slide and consequent
limb shortening.

• Basi-cervical fractures with fracture lines proximal to or at the intertrochanteric line, may require a
supplementary cancellous anti-rotation screw, parallel to the lag screw

• Subtrochanteric extension of the fracture requires the use of a longer plate or a 95-degree
sliding screw plate.

• A Displaced greater trochanter may be reattached using either a cerclage wire or trochanteric
capture plate.

Post-operative weight bearing is dictated by the stability of the fixation, but protected as pain allows is the
norm. Prophylaxis against Deep Venous Thrombosis (DVT) may be used with a recent multinational study
suggesting that aspirin is a suitably efficacious agent .The first year mortality after Hip fracture may be as
high as 40%. If the fixation fails it may be revised or sliding screw device and bone grafting. replaced by
a 95

Subtrochanteric femoral fractures

These are potentially problematic fractures as this region is subject to large bending stresses. The
presence of cortical rather than cancellous, metaphyseal bone may also mean that fractures take longer to
unite. Fixation is more technically demanding than inter-trochanteric fractures. The initial evaluation is
however the same as stated above.

Key points

• Problem fractures because of high bending stresses in this region and the presence of cortical
bone (slow to heal).

• Aim for anatomic alignment not anatomic reduction (Wiss 1999)

Classification

These fractures are described regarding their position relative to the lesser trochanter, their degree of
comminution and their displacement. A commonly used classification is that of Russel-Taylor:-

• 1A - lesser trochanter intact;

• 1B - lesser trochanter involved;

• 2A - Fracture extends from lesser trochanter towards the isthmus, with a secondary extension
into the piriformis fossa.

• 2B - Fracture extending to the greater trochanter, with comminution of the medial cortex.

Treatment
Treatment options include:-

• Fractures at or above the lesser trochanter can be fixed using either a 95-degree DCS plate or a
second-generation reconstruction IM nail.

• A standard interlocking nail can be used if the fracture is below the level of the lesser trochanter;
This does however place the implant at a mechanical disadvantage

Author's preferred technique

Dynamic Compression Screw plate 1. Consider ORIF using a 95 in cases where the fracture is
subtrochanteric but above the lesser trochanter, where there is marked comminution or where there is
reverse obliquity of fracture. Note that it can be difficult to place an IM nail after adducting the leg on the
traction table with the patient supine. (Fig 18.4).

Pre-op planning is useful with three –dimensional reconstruction CT. The entry point landmark is lateral
and proximal to the most prominent part of greater trochanter, allowing placement of the lag screw in
inferior half of the head. The patient should be supine on the fracture table. Image Intensification is
required. Using the direct lateral approach, as described above, place the guide wires using the 95 degree
jig. After appropriate reaming, insert the lag screw, apply the plate to shaft and reduce shaft fragments
onto plate. Final fixation to plate is achieved using cortical screws. Eight to ten cortices are recommended
below the fracture. Autogenous bone grafting to the area of the medial buttress may be considered.
Weight bearing should be protected until callous is visible

2. 2nd Generation Reconstruction nail (Smith & Nephew) (Russell 1998)

This device is recommended for fractures involving the lesser trochanter but not the greater trochanter, as
the latter may compromise the proximal locking device. The patient is placed supine on traction and the
leg adducted. The distal leg is rotated to realign with the upper femur in Asians). A Direct lateral approach
is used. The°anteversion , up to 30°(15 entry point is 3mm anterior to piriformis fossa. Use a guide-pin,
overream the guide pin, then insert a bent-tip, 3.2mm guide wire to gain access to the femoral canal.
Adjust the leg position to reduce the fracture. Advance the guide guide wire across the fracture and then
ream over the guide-wire.

Insert the nail with the jig attached. Align the proximal locking holes with the femoral head in the correct
anteversion. Distal locking is obligatory and best done by a freehand technique. Protected weight bearing
is recommended until evidence of union is apparent, in an effort to minimize implant failure.

Complications
Delayed union, malunion, nonunion, infection and fixation failure are seen. Related factors are inadequate
ORIF, involvement of posteromedial cortex, inappropriate weight bearing and extension into
intertrochanteric region.

Femoral shaft fractures

It is generally accepted that fractures of the femoral diaphysis are best treated by a reamed locked
intramdullary nail.

Evaluation
Obvious shortening, rotation and /or angulation of the femur may be present. These are usually high-
energy injuries so the patient should be managed along Advanced Trauma Life Support (ATLS) guidelines
to exclude life-threatening and pelvic/hip injuries, especially hip dislocation. Thorough neurovascular
assessment is required as is haemodynamic monitoring as even closed injuries may account for a 2-3 unit
blood loss.

Key points

• Exclude life-threatening and pelvic/hip injuries (especially hip dislocation).

Classification
Standard is Winquist and Hansen (Fig. 18.5).
Treatment
Traction
Still safe and predictable but prolonged hospitalization is required.This is both expensive and exposes the
patient to the risks of prolonged recumbency. It is best reserved for those not suitable for ORIF or where
the equipment or expertise to fix is not available. Use skeletal traction with later cast-brace. There are
associated problems of shortening, malrotation and knee stiffness.

External Fixation

This is rarely indicated. It is used mainly in cases where ORIF is not feasible or if there is a severe open
fracture. Pin tract problems are frequent.

Plating

This is now seldom performed, but may be useful when IM nailing is not possible. May be suitable in
children to stablise the femur in the presence of associated vascular, pelvic or hip injuries. Use a direct
lateral approach.

Intramedullary Nail

Regarded as the best technique, allowing early mobilization, thus avoiding prolonged hospitalization and
knee/hip stiffness. Most shaft fractures are best nailed using a closed reamed statically locked system
The nail will only need to be dynamized if evidence occurs of delayed union. Aim to operate within 24
hours once critical conditions such as head or chest injuries have been optimized. The most commonly
used method uses an antegrade approach with the patient supine on a traction table. Image intensification
is mandatory. Some use the femoral distractor to both reduce and hold the femur during nailing.

Note

• That unreamed nails although offering a reduced surgical time are slower to heal. They may also
be prone to implant failure

• In adolescents, one may consider using flexible retrograde nails, inserted proximal to the distal
femoral growth plate.

• There may be an increased incidence of infection if nailing is performed post external fixation.

• Open fractures require urgent debridement and intra-venous antibiotics and stabilization by
insertion of a reamed nail.

Author's preferred technique

• Patient supine or lateral decubitus .

• Measure the appropriate length from either the other limb or a standardized radiograph. Use of
 the fracture table is recommended

• Reduce fracture using traction and a reduction device, such as the F-bar, if necessary.

• The incision should be gently curved posteriorly as it progresses proximally from the greater
trochanter, to account for the anterior femoral bow when introducing the guidewire, reamers, and
the nail.

• Entry point is centred on canal in both projections (use a curved awl). Then pass T-shaped awl.

• Insert guide-wire, check with image intensification in two planes to make sure it is in distal shaft,
ream, and exchange with straight wire via a plastic sheath for insertion of nail.

• Lock proximally. This will be either transversely or diagonally, depending upon the system used.

• Freehand distal lock (k-wire centred on hole, indent, then drill).

Special Situations
Ipsilateral neck and shaft fractures
Stabilize neck fracture with screws then nail or use a 2nd generation (Reconstruction) nail. This is a
difficult technique.

Gunshot wounds

These should be aggressively debrided and stabilized using a locked nail. Sequential debridement may
be required. Stabilizing the skeleton affords the best environment for soft tissue healing.

Adolescents

Consider a plate, external fixation, or retrograde flexible nailing. If a standard IM nailing technique is used
care should be taken to avoid the proximal and distal growth plates.

Use a direct lateral approach

Vascular injuries

The aim is to stabilize the fracture, ideally with a nail or plate, and then perform the vascular repair. Some
vascular surgeons would advocate initial vascular shunting to reduce ischaemic time.

Complications
Fat emboli and Adult Respiratory Distress syndrome (ARDS) can be associated with reaming but one can
still proceed with immediate reamed nail in the presence of a chest injury, in order to stabilize the fracture
and reduce the risk of further pulmonary complications

Infection
This is unusual after IM nailing with rates ideally less than1%. If it occurs, it may be treated by
debridement, antibiotics and exchange nailing, with overreaming of the medullary canal to clear infected
granulation and fibrous tissue. A larger diameter nail is usually then inserted to maintain stability.

Nonunion

There is an incidence of less than 1%. Initial treatment is by exchange nailing

Malunion

Correct either early or by a corrective osteotomy later. Newer alternatives include the use of circular
frames and callotasis

Other complications

Compartment syndrome in the thigh is rare as is nerve injury from traction or positioning on the table.
Heterotopic ossification may occur adjacent to the entry point.

Supracondylar femoral fractures (fractures of the distal metaphysis)

These are high energy fractures in the distal 9cm of the femur in young adults or they are the result of
relatively minor trauma in the elderly. There may be shortening with varus or posterior angulation.

Anatomy
The medial condyle is larger in the AP plane than the lateral and extends further distally. The condylar
block is trapezoidal (posterior is wider >the anterior aspect). The shaft joins with the anterior half of the .
Beware the close°and the mechanical is 3°condyles. The anatomic axis is 9 relationship of the popliteal
neurovascular bundle and always check for associated injuries

Classification
In the AO classification this is area 3.3. It is further subdivided into -A: extra-articular, B: unicondylar and
C: bicondylar. These groups can again be further subdivided into smaller subsections.

Treatment
These fractures usually require reduction and fixation, with non-operative management reserved for
impacted or undisplaced fractures in the elderly, which may be treated in a plaster cast.

The newer intramedullary devices can be used in elderly patients where osteopenia would have
previously precluded internal fixation.
ORIF (Wiss 1999)

• This can be difficult surgery.

• The aim is to restore anatomy and joint congruency if there is an intra-articular component to the
fracture

Key points

• Surgery must not be delayed in open injuries and should be immediate if there is associated
vascular compromise or compartment syndrome..

Techniques recommended

DCS plate (a two-piece screw/plate system easier to use 1. 95 blade plate), augmented with bone graft
where than the 95 necessary.

2. Retrograde IM locked nail (supracondylar nail)

DCS

The DCS system is still preferred for most cases. One needs at least 4cm of intact medial femoral condyle
for the 6.5mm cancellous screw. Use a radiolucent table and straight lateral approach. Open the knee
joint. Place guide wires along distal and anterior condylar surfaces as guides. Reduce condylar articular
fragments first, fix with cancellous lag screws and then reduce the condylar segment to the shaft, ). Using
the 95 degreee plate guide insert the lag screw parallel to the articular surface and then apply and fix the
plate. Protected weight bearing should be observed for 8 weeks.

Retrograde IM locked nail (supracondylar nail) (Seligson 1998) (Fig. 18.6).

This is a good technique which is not as difficult as might be expected though not so useful if there is
distal articular comminution as in a type C fracture, unless one is prepared to perform open reduction of
joint surfaces. The fracture can usually be reduced by manual traction with the knee flexed over a bolster.
Image intensification is required so use a radiolucent table. The portal of entry is the intercondylar notch,
which is approached via a 3cm vertical skin incision over the patella tendon, which is either split in the line
of its fibres or retracted laterally. After using an awl to gain access to the canal, pass the guide wire across
the fracture, ream minimally and then gently insert the nail. Proximal and distal locking is accomplished
using the jig provided.

Complications

Complications include infection and non-union rates of up to 6% with a lower incidence of mal union and
implant failure. Post-operative knee stiffness may be prolonged but usually responds to physiotherapy.