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THIGH BONE FRACTURES (FEMUR FRACTURES)

Thigh Bone Fractures (Broken thigh bone): Femur fractures

Femur is otherwise called as thigh bone. Thigh bone is the longest and strongest bone human body. Being the strongest bone it usually gets fractured following a high energy trauma or injury. In this section we will be discussing about the fractures of thigh bone.

Causes:

- Thigh bone fractures in young are frequently due to high energy injury, usually following a motor vehicle accidents, fall from height and gunshot injuries.
- In case of elderly, thigh bone fractures can occur following low energy injuries like slip and fall. This could be due to weak bones (osteoporosis)

Types of thigh bone fractures:

Depending on the severity of injury thigh bone fracture could be

- Simple with two pieces or

- Comminuted with multiple bits, or

- Closed with intact skin or

- Open with bone protruding out of the skin.

Open fracture. If a bone, breaks in such a way that bone fragments stick out through the skin or a wound is exposed down to the broken bone, the fracture is called an open or compound fracture. In case of open fractures there is damage to the surrounding muscles, tendons, nerves and blood vessels. They have a higher risk for complications like infections, delayed wound healing, infection spreading to the bone, delayed healing of fracture..

Complaints / Symptoms

- Pain,

- Swelling,

- Deformity,

- Inability to bear weight

Examination by doctor:

- Thigh bone fractures are caused by high energy trauma, examination by doctor is must to rule out other associated injuries.

- Enquiry of mode of injury

- Other associated fractures and injuries

Tests: X –rays:

- X-ray of injured limb covering full length of thigh bone can show us level, type of fracture.

- Computed tomography (CT) scan: may be rarely necessary to asses any complex fractures.

- Special CT scans – CT Angiogram is done in cases of thigh bone fractures with associated blood vessel injuryto know the level of vascular injury.

Management:

Fractures of the thigh bone are usually following high velocity road traffic accidents or following a bad fall. Initially after the injury the injured limb must be splinted and patient needs to be shifted accident and emergency department in the hospital.

Primary management:

Emergency physicians initially examine the patient for any associated injuries asses vital parameters like pulse, blood pressure. Patient is first stabilized and further plan regarding surgery is made.

Surgical Treatment

Timing of surgery: Depends on the type of fracture

Open fractures:

In case of open fracture, the fractured ends of the bone are exposed to the external environment and they are to be operated immediately to prevent infection.

In case of fractures associated with blood vessel injury fracture should be fixed and the blood vessel injury should be repaired.

Closed fractures:

In case of closed fractures where the skin and softtisue around the fracture is intact surgery can be planned after the patient is stabilized. In the meantime while the surgery is planned the injured limb is placed in splint or traction to maintain the length of the leg and also to reduce pain.

Different types of fracture fixation:

Interlocking nails:Intramedullary nails

- This is the most preferred implant by most of the surgeons for fixing the fractures of thigh bone. Intramedullary nails are specially designed titanium or medical grade steel nails which are introduced into the marrow cavity of femur. They come in different diameters and lengths to suit length of femur in different patients.

During the surgery, the patient is positioned on the table and fracture is aligned. Surgeons at the time of surgery take help of intraoperative X- ray machine (C – Arm) to guide the entry of the nail into the femur bone. Through a small incision at the hip joint, Intrameddulary nails are introduced into the marrow cavity and passed across the fracture site to stabilize the fracture. The nail is locked at upper and lower end of thigh bone with screws using a separate small incision.

Plates and screws:

Use of plates and screws are limited to those fractures of thigh bone that are extending near to the hip or knee joints.During the surgery, the surgeon exposes fracture site to align the fracture ends and fix with plate and screws

External fixation:

Use of external fixator is very limited in the treatment of fractures of the femur. It is usually used as temporary method of stabilizing the fractured bone in patients who had open fractures, multiple injuries and not fit for surgery. It provides stability until patient is fit to undergo definitive surgery. In case where there extensive soft tissue damage around the thigh along with the fracture, external fixation aids in stabilizing the fracture and also helps plastic surgeon to provide soft tissue cover to the bone. In some cases, external fixator is continued till the fracture is fully healed.

In this technique, metal pins are inserted through small incisions into the bone above and below the fracture site. These metal pins in turn are attached to bar outside to stabilize the construct.

External fixation is often used to hold the bones together temporarily when the skin and muscles have been injured.

(Left) This x-ray shows a healed femur fracture treated with intramedullary nailing. (Right) In this x-ray, the femur fracture has been treated with plates and screws.

Postoperative Management:

  1. Patient is initially managed in postoperative ward or ICU depending the recovery from anesthesia.
  2. Patient is admitted for 3 to 4 days in hospital.
  3. Intravenous Antibiotics, pain medications and drugs to prevent blood clots in legs are given during your stay at hospital.
Day 1:

- Gentle movement in bed.

- knee range of motion and ankle pump exercises.

- Walking with help of walker without weight bearing on the operated leg with in pain limits.

Day 2:

- Increasing the duration and repetitions of the exercises.

Day 3:

- Dressing is changed and plans are made for discharge.

Discharge advice and follow up protocol:

  1. Discharge medications include simple analgesics, blood thinning drugs for two weeks, Calcium, vitamin D and multivitamin supplements for period of 3 months.
  2. Patients are advised to continue the exercises and walking with the help of walker with in pain limits.
  3. Patients are reviewed in OPD after 2 weeks for suture removal.
  4. Next visit is scheduled approximately 6 weeks after the date of surgery.
  5. During the 6 weeks period patients are encouraged to continue exercises.
  6. Majority of the thigh bone fractures take 4 to 6 months to completely heal.
  7. Patients are advised to follow up every 6 weeks for initial 6 months and later on every 3 months.
  8. During every visit, X rays are taken to see the progress of fracture healing.
Dynamization:

In certain cases during initial follow up after 6 weeks or 2 months, X- rays may reveal delay in fracture healing. In these cases, a small procedure of screw removal from the nail can be done to enhance fracture healing. This procedure is called as Dynamization. The nails are designed in such a way that one of the holes in nail is oblong and allows nail to slide after removal of one screw in the other hole.

Complications following thigh bone fractures

.

·The ends of broken bones are often sharp and can cut or tear surrounding blood vessels or nerves.

·

·Closed thigh bone fractures can some time causes acute compartment syndrome. In this scenario, pressure build up in closed compartment of thigh resulting in compression of muscles, nerves, and blood vessels. If this pressure is not relieved permanent, damage to the soft tissue structures may result. This is a surgical emergency. In this procedure surgeon makes incisions over the skin and muscles to relive the pressure in the thigh.

·Blood vessels and nerve injuries : Ends of the broken bore are often sharp and can cut or injure surrounding blood vessels or nerves. The repair of blood vessels and nerves should be done immediately.

·Open fractures: In this type of injuries, ends of bone are exposed to outside environment. Even with good surgical aseptic precautions, muscles and bone can get infected. Treatment of bone infection is difficult and may require multiple surgeries and long term use of antibiotics..

Complications from Surgery

Other complications besides general risks from surgery and anesthesia include

·Infection

·Injury to nerves and blood vessels

·Clotting of blood vessels of the Leg also called as Deep vein thrombosis.

·Fat embolism: It is a condition in which bone marrow enters blood stream and reaches lungs causing difficulty in breathing and life threatening complications. This can happen from the fracture itself or during surgery.

·Malunioun : when the fracture end of the bone heal in angulated or rotated position

·Delayed union: Fracture healing is slower than usual period.

·Nonunioun: In some cases, fracture fails to unite. These fractures need to be revised with exchange of implant with new one and bone grafting

·Limb shortening: In some cases there could be shortening of 0.5 cm to 1 cm in the limb length. This is because some amount of bone gets resorbed at the fracture site during healing.

·Hardware irritation (sometimes the end of the nail or the screw can irritate the overlying muscles and tendons)

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