[MUSIC] These computerised tomogram images show examples of extensive femoral fractures on both sides. In order to be able to understand femoral shaft fractures, it is helpful first of all to update our knowledge of the basic principles of anatomy. The femur is the longest and strongest bone in the human body. The shaft possesses a physiological antecurvature while the neck possesses antetorsion. 25% of the total height of a human being is defined by their thigh. Due to the central position of the thigh bone compared to the body, a whole series of muscles are attached to the thigh or have their origin at the thigh respectively. This means that muscles exert a very crucial influence on the dislocation of fragments in the event of a fracture occurring. Really essential vessels run along the thigh. This means that quite considerable loss of blood can occur in the event of a muscle or vessels being injured. Femoral shaft fractures usually occur following high speed trauma, for example after a fall from a great height. 30% of patients incur several injuries, with 1% being associated with severe soft tissue injuries. Compound fractures occur in 2-5% of case and up to 25% in polytraumatised patients. In the case of femoral shaft fractures, concomitant injuries frequently occur such as hip dislocations, acetabulum fractures, femoral neck fractures or knee joint injuries. >> Dr. Neumaier, The paramedics have just brought in a new patient. It was apparently the result of an accident at work... >> Mmhhmmhh. >> ...with an emergency doctor present on-site. Here are the initial documents. He first underwent treatment In Schneizlreuth Hospital, but has been transferred here due to the new regulation on the treatment of accidents. It appears to be a femur fracture, but the patient is stable. >> Dr. Lucke? >> He is on duty. >> Things are back to normal today. Neumaier >> Hello. >> Hello! >> Neumaier I hear you suffered an accident at work and have been transferred to us? >> Exactly. >> What exactly happened? >> Well, I work on a building site and we have an enormous metal carrier there for which the mounting broke and I then received the full impact of the thing on my leg. >> Did you suffer any injuries anywhere else? >> No, it just caught my leg. Yes, the emergency doctor drove me to Schneizlreuth and they thought that I had to be transferred here as it was some kind of special accident at work. >> Ok. Are you taking any medication of any kind? Anything at all? >> No. >> No, ok. We now need to take a look at the leg. >> Knowing the patient’s detailed medical history is important when treating femoral shaft fractures. This should be followed by a clinical examination in which the pains of the patient, any potential inability to move or shortening of the leg are recorded. As always, it is important to examine and record the blood flow, motor function and sensitivity. Doppler sonography is available as a form of imaging for establishing any potential vascular concomitant injury. The standard imaging procedure is an x-ray examination of the femur in two planes. If any lack of clarity exists, then liberal indication is to be made for computerised tomogram or CT angiography. >> Can you still move your toes? Is that still OK? >> Yes. >> Yes. Can you feel my hand down here? >> Mmhhmmhh. >> Okay. Everything OK? >> Yes. >> Can you lift your foot? Oh, excuse me. Does that hurt? >> Yes. >> OK, now we’ll have a look at the pulses. Let's see. Yes, that’s strong. So’s that one. Okay. Excuse me. That is still there then. It certainly is We now need to check as to whether anything is open there. No, it is really just bruised and containing a lot of haematoma. >> The energy behind the impact exerts a very significant influence on additional concomitant injuries, such as muscular bruising, skin defects, vascular and nerve injuries or the formation of bone defects and infections. Femoral shaft fractures are classified with the number 32 according to the AO scheme. Within this, simple shaft fractures are awarded the letter A, complex shaft fractures with wedge fragments the letter B and comminuted fractures or multiple stage fractures the letter C. >> Did you get to see the images already when you were in Schneizlreuth? >> No, but they told me I had to undergo an operation at all costs as a fairly complex fracture is involved. >> Precisely, thigh fractures have to be stabilised otherwise it will not be possible to walk well again. I’ll now show you the images we have taken of your injury. They were sent over from Schneizlereuth. You can see here that it is completely broken. >> Mmhhmmhh. >> That is the hip, that is the knee and precisely here is where the carrier probably hit you from the side and then the bone broke. >> Yes. >> And that will wiggle about and will not heal well without an operation. The best way to stabilise that is with a nail, with a nail being inserted in practical terms via small incisions from the hip into the medullary cavity. This allows it to be repositioned and the nail can then be locked in place with screws. It is therefore possible for it to be locked in place top and bottom with screws. >> Ok. And that means the nail will remain in place in my leg for the rest of my life, does it? >> No, it can be removed again after one or two years. >> Ok. >> Treatment is usually of a surgical nature as femoral fractures are usually unstable, dislocated or at least subject to the threat of being dislocated. Any exceptions represent an unacceptable perioperative risk. The implants available for the surgical treatment of femoral shafts are fixateur externe, intramedullary rods or plate osteosynthesis. These slides show examples of a series of surgical treatments of femoral shaft fractures. A DCS (dynamic condylar) screw is shown on the left side. A femoral nail is shown in image No. 2 from the left. A condylar plate can be seen in the centre. The second image from the right shows an undrilled femoral nail and on the far right, an internal fixation with a locking-compression plate. Intramedullary rods are the standard form of surgical treatment employed. The patient is placed on an extension table for this and the entry point for the antegrade nailing is at the tip of the greater trochanter. These x-ray images show examples of the treatment of a femoral shaft fracture by means of a distal femoral nail. In this procedure, the nail is driven forward into the femoral medullary cavity through the knee joint. This method is currently somewhat in decline as what is basically a healthy knee joint has to be penetrated and the risk of an infection stemming from this is not inconsiderable. Furthermore, cases of not inconsiderable rotation malalignment have been observed following femoral nailing. These x-ray images show examples of the treatment of femoral fractures by means of fixateur externe. What can be clearly recognised is the transient stabilisation which has been achieved in a cross-joint manner. The application of polyaxial fixed-angle plate systems has recently proven to be an optimum system for treating periprosthetic fractures or distal femoral fractures. You can see on the left side of these x-ray images a corresponding fracture image and the postoperative treatment on the right side. >> I have already got the answers here as well. Everything is shown precisely in this. >> Mmhhmmhh. >> We would like to do this already today, as soon as possible, probably this afternoon, and the various methods are shown here once again, with the most favoured still being a nail and as I said, we would do this today. >> Mmhhmmhh. >> We now need to inform the anaesthetist and tell him to book a room for you and then we are all set. Any further questions? >> I would like to eat something. >> Not possible, unfortunately. You need you to have an empty stomach when we operate >> Ok. >> Can you survive that? >> Mmhhmmh. >> On the right, Ok. And to finish things off, I need a signature, giving your consent for us to do this and now I’ll fetch the anaesthetist. >> OK. >> OK? OK, then we’ll meet up again later for the operation. >> Thank you. >> See you later. In summary, it can be stated that femoral shaft fractures are injuries which are now much less feared due to modern osteosynthesis procedures. [MUSIC]
