Femoral Fracture Patterns Research Articles

Factors Associated with Development of Thigh Compartment Syndrome Following Subtrochanteric and Diaphyseal Femoral Fractures.

Acute compartment syndrome of the thigh (CST) is an ongoing challenge for orthopaedic surgeons as the diagnosis is often difficult to establish. Currently, there is a shortage of studies investigating risk factors for the development of thigh compartment syndrome following subtrochanteric and diaphyseal femoral fractures. This study aimed to identify risk factors associated with the development of CST following femoral fractures. Retrospective review performed in a level one trauma center from January 2011 to December 2020 for all patients with non-pathological acute subtrochanteric or diaphyseal femoral fractures. Variables collected included demographics, injury severity score (ISS) scores, mechanism of injury, classification of femoral fracture, open versus closed injuries, development of compartment syndrome, time to compartment syndrome diagnosis, number of subsequent surgeries, and primary wound closure versus split-thickness skin graft. The statistical analysis of this study included descriptive analysis, simple logistic regression, paired T-test, and Wilcoxon Signed Rank. Thirty-one (7.7%) patients developed thigh compartment syndrome following 403 subtrochanteric or diaphyseal femoral fractures. The mean (SD) age for those who developed CST was 27.35 (8.42). For every unit increase in age, the probability of developing CST decreased. Furthermore, male gender had 18.52 times greater probability of developing CST (P <0.001). AO/OTA 32-C3 and subtrochanteric femoral fracture patterns demonstrated 15.42 (P = 0.011) and 3.15 (P <0.001) greater probability of developing CST, respectively. Patients who presented to the hospital following a motor vehicle accident (MVA) or gunshot wound (GSW) had 5.90 (P= 0.006) and 14.87 (P < 0.001) greater probability of developing CST, respectively. Patients who were male, younger in age, and had a 32-C3 and subtrochanteric femoral fractures were at increased probability of developing CST. High energy trauma also increased the risk of developing CST. A high index of suspicion should be expressed in patients with these risk factors.

Pediatric floating knee injuries: Clinical modifiers affecting sports and transfer outcomes

AimThis study assessed the functional outcome, and the clinical modifiers that influence them with the aim to assist the clinician plan a better management strategy in Paediatric Floating Knee (PFK) injuries. MethodsA quasi-prospective, single-center observational study was designed to determine the functional and radiological outcomes in children (</= 16 years), with minimum 1 year follow-up after treatment for PFK from 01–01–2014 to 01–08–2019. A retrospective audit was conducted, and a prospective patient/parent reported outcome score was determined with the Pediatric Outcome Data Collection Instrument (PODCI) questionnaire for ‘transfer and mobility’ and ‘sports and physical function’. ResultsOf 32 patients with PFK injury, twenty-five patients with a mean follow-up of 43 months (SD = 18) who completed the PODCI questionnaire were analysed. Fourteen (56%) children had open fractures (Lett's D or E types) with 6 open femur and 12 open tibia fractures. Majority underwent surgical fixation, 8 children required staged reconstruction and 11 children required soft tissue procedure in the ipsilateral limb. The mean time to union for femur and tibia fractures was 3.86 months (SD = 5.3) and 3.5 months (SD = 2.9), respectively with delayed union/non-unions in 3 femoral and 4 tibial fractures. The mean knee range of movement (RoM) was 102° (SD = 34.1) with limb shortening in 6 children, and overgrowth in 3 children. The mean normative PODCI (transfer) score was 35.6 (normal range: -74 to 52) and mean PODCI (sports) score was 37.6 (normal range: -33 to 56). Both the PODCI scores demonstrated strong inverse correlation with higher ISS(p < 0.01) and > 4 cm of bone loss (p < 0.01) but poor correlation with age at injury (p = 0.5), open fracture (p = 0.17), comminuted femoral and/or tibial fracture patterns (p > 0.05) and loss of soft tissue cover (p = 0.08). ConclusionsEarly recognition of clinical modifiers such as high ISS and bone loss > 4 cm warrants targeted limb reconstruction strategy and can help to prognosticate outcome.

The Patterns and Trends in the Surgical Fixation Modalities of Intertrochanteric Femoral Fractures

Objectives: To study the Intertrochanteric fractures patterns, distributions, and fixations modalities. In addition to assessing orthopedic surgeons’ tendencies toward implant choices according to the fracture morphology. Methods: This descriptive study reviewed the clinical and radiological records of 574 admitted with intertrochanteric femoral fractures in two hospitals of Jordanian Royal Medical Services from January - 2017 to December – 2020. Utilizing Picture Archiving and Communication System (PACS), patients’ radiographs were evaluated regarding the fracture patterns, surgical fixation technique, and indications. Results: Females accounted for 59.1% of patients. The mean age was equal to 76.40 ± 11.65 years, with an age range of 82 years (20 – 102 years). Comorbidities were found in 65.3% of patients. The majority of the fractures (54.5%) were of a simple fracture pattern, and the Dynamic Hip Screw (DHS) was the most commonly used surgical implant (51.9%). Preoperative mortality accounted for 2.3%. Conclusions: Understanding intertrochanteric femoral fracture patterns and proper implant choice improves outcomes and avoids complications. We found that DHS use was the first choice in stable fracture patterns. However, there is an increasing tendency to use PFN over other modalities in both stable and unstable intertrochanteric fractures. The use of other modalities to treat unstable fracture may be explained by the occasional non-availability of the superior PFN.

Defining length stability in paediatric femoral shaft fractures treated with titanium elastic nails.

IntroductionOptimal paediatric femoral shaft fracture patterns or lengths amenable to titanium elastic nail stabilization have not been well defined. The purpose of this study is to identify radiographic parameters predictive of treatment failure with flexible intramedullary nails based upon fracture morphology.MethodsA retrospective review was performed of all femoral shaft fractures treated with flexible intramedullary nails over a five-year period. All patients with at least six weeks of postoperative radiographic imaging were included. Fracture characteristics included location, pattern, length, obliquity, angulation, translation and shortening. Postoperative radiographs were reviewed to determine shortening and angulation.ResultsThere were 58 patients with 60 femoral shaft fractures stabilized with titanium nails, with 46 healing within acceptable parameters and 14 considered malunions. Six of the 14 malunions developed complications requiring early unplanned intervention. No patients in the treatment success group had a complication. Between the treatment success and failure groups, fracture pattern, location, length, obliquity, angulation, translation or shortening were not statistically different. Mean nail canal fill was significantly lower in the failure group (0.72 versus 0.81; p = 0.0146), with a receiver operating characteristic curve identifying canal fill 76% as the optimal threshold.ConclusionThis is the first study to measure the length and obliquity of paediatric femoral shaft fractures and to determine their relationship to radiographic alignment after healing. None of the preoperative fracture characteristics were predictive of malalignment or shortening. We recommend the use of larger nail sizes in the treatment of paediatric femoral shaft fractures, especially if there is concern for residual instability.Level of evidenceIV

A review of pediatric femoral fracture patterns, surgical managements, and outcomes

&lt;p class="abstract"&gt;&lt;strong&gt;Background: &lt;/strong&gt;Femoral fractures are the most common pediatric orthopedic fractures that require hospitalization. The non-accidental injury should be suspected in early infancy and non-ambulatory children. Treatment of pediatric femoral fractures is widely variable and depends on intrinsic and extrinsic factors. This study presents pediatric femoral fracture epidemiology and outcomes and reviews the literature regarding best practices in pediatric femoral fractures.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This retrospective study reviewed the clinical and radiological records of forty-sevens femur fractures in the pediatric age group from September 2020 until June 2021 in Prince Rashid bin AL Hassan Military Hospital in Jordan.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Males form 80.9% of patients. The mean age for the patients was equal to 6.70 years (±3.91). Falling is responsible for the majority of the injury. The middle femur shaft was fractured in 46.8%, and the pathological fracture was found in 17% of patients. Non-operative treatment by cast represents 42.6%. All fractures were healed at 7.90 weeks (±2.37).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Pediatric femur fracture lacks standardized treatment. Nevertheless, most fractures healed with satisfactory results. Younger age groups are more likely to be treated non-operatively. Non-surgical treatment is more prone to shortening, angulation, and later return to weight-bearing and activity. Children older than eight years treated by plating demonstrated faster healing, return to full weight-bearing, and lower complication rate. &lt;/p&gt;

New versus old: 95 degree angled blade plate versus distal femoral locking plate. A randomized clinical trial.

The purpose was to compare the locking condylar plate (LCP) with the 95° angled blade plate (ABP) for distal femoral fracture patterns amenable to either device. Our hypothesis was that LCP would outperform ABP with primary outcome of nonunion and secondary outcomes of reoperation and malunion. 78 adult patients with 79 eligible fractures and mean age of 60 years were prospectively randomized to LCP (n=45) or ABP (n=34). Mean ISS was 16. 22% fractures were open. Patient-reported functional outcomes were assessed with the Musculoskeletal Function Assessment (MFA). All patients were followed to union, and mean follow-up was 25 months. There were no differences in age, sex, fracture pattern, co-morbidities or mechanism for the two groups. Three patients had infections, one superficial after LCP and one deep infection each after ABP and LCP. Three patients developed nonunion after LCP versus none after ABP (p=0.06). Nine patients healed with minor deformity after LCP versus 5 following ABP. One fracture had major deformity after ABP versus two after LCP. Eight patients had a secondary procedure following LCP versus two after ABP (p=0.05). The investigation failed to support newer technology being better. Evidence did not indicate the LCP was superior to the ABP. Trends for primary union and fewer secondary procedures suggest that ABP may have superior performance to LCP for fracture patterns which may be treated with either implant.

Relationship between the AB0 Blood System and Proximal Femoral Fracture Patterns in the Turkish Population.

Objective AB0 blood groups have shown to be associated with increased risk of several orthopedic disorders such as Achilles tendon rupture and hip osteoarthritis. The objective of this study was to investigate relationships between the AB0 blood system and hip fracture patterns, duration of hospitalization, and amount of blood transfusion. Methods Data of 308 patients treated due to hip fractures in our hospital between 2017 and 2019 were evaluated. Epicrisis reports and X-rays of the patients included in this study were retrospectively screened, and hip fractures were classified as intracapsular and extracapsular fractures. Patients were divided into A, B, 0, and AB groups according to blood groups. Results The mean age of the patients was 75.54 ± 13.5 years. Of all patients, 103 had an intracapsular fracture and 205 had an extracapsular fracture. No statistically significant correlation was found between blood groups and fracture patterns. No statistically significant difference was found between the amounts of transfusion according to the blood groups, and no significant difference between the durations of hospitalizations according to the blood groups. Conclusion In our study population, we could not find a significant relationship between the AB0 blood system and fracture patterns. We think that these potential relationships could be explained with further comprehensive studies with larger populations.

Outcomes for Elderly Patients With Atypical Femoral Fractures Compared to Typical Femoral Fractures for Length of Stay, Discharge Destination, and 30-Day Mortality Rate.

Introduction:Despite increasing recognition of atypical femoral fractures (AFFs), there’s conflicting evidence about incidence, aetiology, and short-term outcomes of these injuries. This study reports the incidence of AFFs at our center and compares the early postoperative outcomes against typical femoral fractures (TFFs).Methods:A retrospective observational cohort study of patients presenting to our trauma unit between November 2015 and July 2016 was undertaken. Inclusion criteria required radiologically confirmed proximal femoral fracture, which was then categorized as AFF or TFF. Primary outcome measures included length of stay, discharge destination, and 30-day mortality.Results:Two hundred thirty-nine patients presented to our trauma unit over 9 months with either a fractured neck of femur or proximal femoral fracture. A total of 122 were identified as pertrochanteric, subtrochanteric, or proximal femoral shaft fractures of which 25 (20.5%) displayed atypical radiographic features consistent with AFF. The 2 groups were similar for average age (TFF 85.3 years vs AFF 85.0 years), gender (19% vs 16% male gender), American Society of Anaesthesiology grade (3.0 vs 3.0), cognitive score (abbreviated mental test score = 7.03 vs 7.08), and preinjury place of residence (88.9% vs 92.0% lived in own home). Typical fractures were fixed with either dynamic hip screw or intramedullary nailing, all atypical fractures were fixed with intramedullary nailing. There was no statistical difference between the 2 groups for length of stay (12.8 days vs 14.3 days; P > .05), discharge to preinjury residence (45.1% vs 36%; P > .05), or 30-day mortality (8.1% vs 12%; P > .05).Discussion:In our predominantly geriatric population atypical radiographic features were observed in around 10% of patients presenting with proximal femoral fractures or fractured neck of femur. Previous studies have reported poor outcomes for pain, mobility, and length of stay after AFF. However, we observed no difference in short-term outcome measures when compared to patients with typical proximal femoral fracture patterns at our trauma unit.Conclusion:With modern principles of trauma care outcomes achieved following AFFs may be equivalent to typical femoral fractures in the geriatric population.

What is the ideal working length for bridge plating osteosynthesis of a femoral shaft fracture? A multinational online survey evaluation.

to evaluate how orthopedic surgeons in Latin America define the working length for distinct patterns of femoral shaft fracture. a survey was developed presenting different options of working length in four femoral fracture patterns. The survey was submitted to the participants using Google Forms tool. The association between professional characteristics and medical management options according to each type of fracture was analyzed by Chi-square test, with 5% significance level. seven hundred and seven professionals from all Latin America answered the survey. The majority prefered a smaller working length for all situations presented in the study. There was a significant association between the main interest area and the medical preference for the management in fracture types AO 32-B3 and 32-C2 (p<0.05). Other professional characteristics had no significant association at the level of 5%. most of the study participants preferred constructions with smaller working length, representing approximately one-third of the total length of the plate, regardless of fracture pattern. There was a significant association between the main interest area (orthopedic trauma) and medical management options for fracture type AO 32-B3 and 32-C2. This can be attributed in part to the fact that these two types of fractures are considered, in the view of the authors, intermediate patterns in terms of strain. This study reinforces the importance of understanding the concept of working length, showing that its calculation remains more based on the surgeons' experience than grounded by strong biomechanical concepts governing the fracture healing process.

Efficacy of Surgical-Site, Multimodal Drug Injection Following Operative Management of Femoral Fractures: A Randomized Controlled Trial.

Multimodal analgesia inclusive of periarticular injection with a local anesthetic agent has been rapidly assimilated, with demonstrated safety and efficacy, into the care of patients undergoing elective lower-extremity arthroplasty. The present study was performed to evaluate the efficacy and safety of a surgical-site, multimodal drug injection for postoperative pain control following operative management of femoral fractures. There were 102 patients undergoing operative intervention (plate fixation, intramedullary device, or arthroplasty) for a broad range of femoral fracture patterns who were prospectively randomized either to receive an intraoperative, surgical-site injection into the superficial and deep tissues containing ropivacaine, epinephrine, and morphine or to receive no injection. Visual analog scale (VAS) scores were recorded at regular intervals as the primary outcome measure. Narcotic consumption and medication-related side effects were also monitored. The injection group demonstrated significantly lower VAS scores (p < 0.05) than the control cohort in the recovery room and at the 4, 8, and 12-hour postoperative time points. The median score (and interquartile range) was 1.6 (0 to 4.0) for the injection group and 3.2 (1.3 to 5.7) for the control group immediately postoperatively, 1.0 (0 to 3.0) for the injection group and 5.0 (2.0 to 7.0) for the control group at 4 hours, 2.0 (0 to 4.0) for the injection group and 5.0 (2.0 to 6.8) for the control group at 8 hours, and 3.5 (0 to 5.0) for the injection group and 5.0 (2.0 to 8.0) for the control group at 12 hours. Additionally, narcotic consumption was significantly lower (p = 0.007) in the injection group (5.0 mg [1.3 to 8.0 mg]) compared with the control group (9.7 mg [3.9 to 15.6 mg]) over the first 8 hours following the surgical procedure. No cardiac or central nervous system toxicity was observed secondary to infiltration of the local anesthetic. Surgical-site injection with a multimodal analgesic cocktail provides improved pain control and reduces narcotic utilization over the first postoperative day, with no observed adverse effects attributable to the local injection, across a diverse orthopaedic trauma population undergoing operative intervention for femoral fractures. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Intraobserver and Interobserver Reliability and the Role of Fracture Morphology in Classifying Femoral Shaft Fractures in Young Children

Spiral fractures of long bones have long been cited as indications of non-accidental trauma (NAT) in children; however, fracture types are only loosely defined in the literature, and intraobserver and interobserver variability in defining femoral fracture patterns is rarely mentioned. We sought to determine reliability in classifying femoral fractures in young children using a standard series of radiographs shown to physicians with varied backgrounds and training and to determine if a quantitative approach based on objective measurements made on plain radiographs could improve definition of these fractures. On 50 radiographs, the fracture ratio--fracture length divided by bone diameter--was determined and radiographs were reviewed by 14 observers, including pediatric orthopaedic surgeons, emergency room physicians, and musculoskeletal radiologists, who classified the fractures as transverse, oblique, or spiral. A second review of the images in a different order was carried out at least 10 days after the first. Overall, intraobserver agreement was strong, whereas interobserver reliability was moderate. Experience level did not correlate with either result. Complete agreement among all observers occurred for only 5 fractures: 3 transverse and 2 spiral. An average fracture ratio near 1.0 appeared to be predictive of a transverse fracture and a ratio of >3.0, a spiral fracture; ratios between these 2 values resulted in essentially random classification. The ability to reproducibly classify femoral fractures in young children is highly variable among physicians of different specialties. These results support the belief that fracture morphology has little predictive value in NAT because of the wide variability in what observers classify as a spiral fracture of the femur. Caution should be used in the use of descriptive terms such as spiral, oblique, or transverse when classifying femoral fractures, as well as when evaluating children for possible NAT, because of the variability in classification. Level III-diagnostic study.

Treatment of Femoral Fractures in Children by Pediatric Orthopedists: Results of a 1998 Survey

This study aimed to determine treatment preference of various femoral fracture patterns in children by pediatric orthopedists and whether it is practice dependent. In September 1998, members of the Pediatric Orthopedic Society of North America were surveyed to determine their current preferences in treating each of four middle one-third femoral fracture patterns in four age groups. Forty-four percent (286/656) of those surveyed responded. For each fracture pattern, operative treatment was increasingly preferred over nonoperative as patient age increased, and the preferred treatments within the operative and nonoperative categories changed significantly as patient age increased. Fourteen specific cases of femoral head avascular necrosis were noted after rigid reamed and unreamed rodding. There is a statistically significant trend by pediatric orthopedists to treat older children's femur fractures operatively and younger children's nonoperatively. The consensus treatment is age dependent. The numerous cases of avascular necrosis after rigid rodding are a concern.

Elastic stable intramedullary nailing for unstable femoral fractures in children: preliminary results of a new method.

Many femoral fracture patterns in children cannot be stabilized sufficiently by intramedullary nailing only. Such fractures may require additional cast bracing or cerclage wiring after nailing. To overcome this problem, pediatric Ender nails that can be interlocked were designed to achieve better fracture stabilization. Seventeen children (age, 2.5 to 15 years) were treated with this method for unstable traumatic fractures of the femur. The average follow-up period was 11.8 months. All fractures healed within 4 weeks in the mean. There were no major complications. This new method prevents shortening and axial deviation of the fractured femur. Start of postoperative mobilization and increase of weight-bearing is mainly determined by the child.

First experiences with unreamed AO intramedullary nail in treatment of femoral shaft fractures

The unreamed femoral nail (UFN) system, with its numerous proximal interlocking options, allows a minimal invasive surgical procedure for the treatment of nearly all femoral fracture patterns. Sixty-six fractures, 5 cases of osteolysis or pathologic fractures, 2 limb shortenings and 1 lengthening (monorail technique) and 3 cases of pseudarthrosis were stabilised with the UFN from July 1994 to December 1996. The fractures were analysed according to the AO classification. We found 31 polytrauma patients with an mean ISS of 21.8 and a mean PTS of 25.4. Most of the multiply injured patients (n = 26) were stabilised with the UFN primarily. Follow-up of 44 patients ranged from 4 to 18 months postoperatively. According to our clinical and radiological score the results were excellent in 34% of cases, good in 36.3%, poor in 20.4% and bad in 9%. Average fracture healing time was about 9.8 weeks.