SHAFT OF FEMUR FRACTURE

A

Dissertation on

MANAGEMENT OF IPSILATERAL PROXIMAL FEMUR FRACTURE WITH

SHAFT OF FEMUR FRACTURE

Dissertation submitted in

Partial fulfilment of the regulations required for the award of M.S. DEGREE in

ORTHOPAEDIC SURGERY

THE TAMILNADU DR.M.G.R.MEDICAL UNIVERSITY COIMBATORE-TAMILNADU

APRIL 2020

CERTIFICATE - I

This is to certify that this dissertation titled MANAGEMENT OF IPSILATERAL PROXIMAL FEMUR FRACTURE WITH SHAFT OF FEMUR FRACTURE is a bonafied record of work done by Dr.A.Navaneethan , during the period of his post graduate study from May 2017 to September 2019 under guidance and supervision in the INSTITUTE OF ORTHOPAEDICS AND TRAUMATOLOGY, Coimbatore Medical College and Hospital, Coimbtore-641018, in partial fulfillment of the requirement for M.S.ORTHOPAEDIC SURGERY degree examination of The Tamilnadu Dr. M.G.R. Medical University to be held in April 2020.

Dr. B.Asokan, M.S, Mch., Prof.Dr.S.Vetrivel Chezian,

Dean M.S.Ortho., D.Ortho., FRCS., PhD.

Coimbatore Medical College& Hospital Director & Professor

Coimbatore- 641018 Institute of Orthopaedics and Traumatology Coimbatore Medical College &Hospital Coimbatore- 641018 .

CERTIFICATE – II

This is to certify that this dissertation work titled MANAGEMENT OF IPSILATERAL PROXIMAL FEMUR FRACTURE WITH SHAFT OF FEMUR FRACTURE of the candidate Dr.A.Navaneethan with Registration Number 221712256 for the award of MASTER OF SURGERY in the branch of ORTHOPAEDICS . I personally verified the urkund.com website for the purpose of plagiarism Check. I found that the uploaded thesis file contains from introduction to conclusion 88 pages and result shows 3% percentage of plagiarism in the dissertation.

Signature of the Guide

Prof.S.Vetrivel Chezian, M.S.Ortho.,D.Ortho., FRCS, PhD.

Director and Professor

Institute of Orthopaedics and Traumatology, Coimbatore Medical College, Coimbatore.

\

DECLARATION

I declare that the dissertation entitled “MANAGEMENT OF IPSILATERAL PROXIMAL FEMUR FRACTURE WITH SHAFT OF FEMUR FRACTURE” submitted by me for the degree of M.S is the record work carried out by me during the period of May 2017 to September 2019 under the guidance of Prof..S.Vetrivel Chezian, M.S.Ortho.,D.Ortho.,FRCS, PhD,

Director, Institute of Orthopaedics and Traumatology, Coimbatore Medical College& Hospital, Coimbatore. This dissertation is submitted to The Tamilnadu Dr.M.G.R. Medical University, Coimbatore, in partial fulfillment of the University regulations for the award of degree of M.S.ORTHOPAEDICS examination to be held in April 2020.

Place: Coimbatore Signature of the Candidate

Date:

( Dr.A.Navaneethan )

Signature of the Guide

Prof.S.Vetrivel Chezian, M.S.Ortho.,D.Ortho., FRCS, PhD, Director

Institute of Orthopaedics and Traumatology, Coimbatore Medical College , Coimbatore.

ACKNOWLEDGEMENT

I express my thanks and gratitude to our respected Dean Dr. B.Asokan, M.S,

Mch,Coimbatore Medical College, Coimbatore. for having given permission for conducting this study and utilize the clinical materials of this hospital.

I have great pleasure in thanking Prof. Dr.S.VetrivelChezian, M.S.Ortho.,

D.Ortho., PhD., Director, Institute of Orthopaedics and Traumatology, for his guidance and constant advice provided throughout this study.

I sincerely thank Dr.D.R.Ramprasath, M.S.Ortho.,Associateprofessor , Institute of Orthopaedics and Traumatologyfor his advice, guidance and unrelenting support during the study.

My sincere thanks and gratitude to Dr.T.Karikalan, M.S.Ortho, Associate professor , Institute of Orthopaedics and Traumatologyfor his constant advice and guidance.

My sincere thanks to Dr.K.S. Maheswaran, M.S,Ortho.,Associate Professor, Institute of Orthopaedics and Traumatology for constant inspiration, guidance and advice.

I sincerely thank Dr.S.Marimuthu, Dr.M.S.Mugundhan, Dr.P.Balamurugan, Dr.R.Vivekanandhan, Dr.M. Ravi Kumar, Dr.S.ArunKumar, Assistant Professors of this institute for their valuable suggestions and help during this study.

I thank all anesthesiologists and staff members of the theatre and wards for

their endurance during this study.

I am grateful to all my post graduate colleagues for helping in this study. Last

but not least, my sincere thanks to all our patients, without whom this study would not

have been possible.

Dr.A.Navaneethan

TABLE OF CONTENTS

SL.NO TITLE PAGE.NO

1. INTRODUCTION ¹

2. AIMS OF THE STUDY ³

3. REVIEW OF LITERATURE ⁴

4. FEMUR – APLLIED ANATOMY ⁹

5. MECHANISM OF INJURY ¹⁷

6. FRACTURE CLASSIFICATION ¹⁸ 7. RADIOLOGICAL AND CLINICAL

ASSESMENT

25

8. INTRA OPERATIVE DIFFICULTIES ²⁶ 9. MATERIALS AND METHODS

SURGICAL TECHNIQUES

27

10. RESULTS ⁴⁶

11. CASE DATA ⁴⁸

12. DISCUSSION ⁶⁸

13. CONCLUSION ⁸¹

14. BIBLIOGRAPHY ⁸²

15. MASTER CHART ⁸⁶

1

INTRODUCTION

Concurrent proximal femur fractures with shaft of femur fracture is a rare entity . In 1%–9% of all femoral shaft fractures, an additional proximal fracture of the femur is noted .Ipsilateral neck of femur fracture is seen in 2- 6% of femoral shaft fractures . The combination of ipsilateralproximal femoral fracture with shaft of femur fractures are usually high energy injuries associated with multisystem involvement.

Inspite of taking pelvis radiographs for all polytrauma patients with shaft of femur fractures , still the neck of femur fractures is often missed which is significant which is reported to be about 20-30%. Of all the hip fractures associated with femoral shaft fracture, only one-fourth are trochanteric with the remaining being neck fractures. Appropriate diagnosis of this injury is the need of hour to prevent the dreaded complications like avascular necrosis of femoral head or non union.

Over the past few years various treatment modalities haven been proposed and variable implants have been designed for these complex femoral fractures . The choices of fixation has been broadly divided into use of single or double implants for both fracture fixation . Single-implant options include: 1)reconstruction-type nail with locking screws passing through neck fracture into head through the nail 2) hip screw with long side plate for proximal shaft fracture, 3) Long Proximal femoral nail.

Double -implant options include: (1) shaft fixation with antegrade nail and cancellous screws placed in neck by passing anterior and posterior to nail as well as miss-a-nail technique, 2) retrograde intramedullary nailing for shaft fixation with cancellous lag screw placed superior to the tip of the nail for neck stabilization, 3) hip screw with short side plate for neck fracture and separate plate for shaft, 4) plate for shaft and

2

cancellous screw for neck fracture. But still the best method of managing femoral polytrauma remains a controversy .

This is a prospective study done to analyse the Management of Ipsilateral proximal femur fracture with shaft of femur fracture .

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AIM OF THE STUDY

To analyse the MANAGEMENT OF IPSILATERAL PROXIMAL FEMUR FRACTURES WITH SHAFT OF FEMUR FRACTURE done in our Institute of Orthopaedics and Traumatology , Coimbatore Medical College Hospital .

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REVIEW OF LITERATURE

Ipsilateral bifocal femoral fractures was an Rare injury in past . But these femoral polytrauma`s are increasing day by day . The severity of these bifocal injuries was detailed by the fact that early description of ipsilateral shaft of femur fracture associated with femoral neck fractures are the results of autopsy findings of paptients who sustained significant polytrauma , which was reported by Ravalgia et al .

In 1965 ,Denkernotted 8 bifocal fracture in a continued series of 1003 femoral shaft fractures spanned over a period of 8 year reported from Swedish hospital , giving 0.8% rate of detection. a study in Taiwan in 1991 with 1425 consecutive femoral shaft fractures , 42 ipsilateral hip fractures were identified by Wu and Shih giving a rate of 3%. The median age of case in a meta-analysis of 659 case of concurrent ipsilateralfractures of proximal femur and shaft of femur spanned over 30 years was reported as 34 yeras (8-76) by AnttiAlho et al in 1996. vonRüden et al 1n 2015 reported that the cause was found to be polytrauma in 57 cases and mono- trauma in 8 cases from study period of 2004 to 2013 among 65 cases.

FRACTURE PATTERN

According to Dencker 1965 and wolfgang 1976, the trochantric fractures were transverse and intertrochantric .The femoral neck fractures were divided into Subcapital, mid cervical and basicervical based on the fracture location and commonest was found to be Basicervical occurring in 62% of all femoral neck fracture cases. Alho also reported that trochantric fractures had an frequency of 28%

of all combined ipsilateral proximal femur and shaft of femur fractures.

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MISSED PROXIMAL FEMUR FRACTURE

Delayed diagnosis of proximal femur fractures in bifocal femoral fractures was reported to be 30% and the delay was found to be between days to month. The proximal femur fracture was not missed when the polytraumatised patients were analysed with hip radiographs. Missed diagnosis of neck of femur fracture in primary survey of patients resulted in some non unions. These missed fractures warrents a second surgery which resulted in economic burden for the patients . Another major complication in delayed diagnosis of proximal femur fractures was osteonecrosis of femoral head which was not associated with delay in diagnosis or the timing of surgery.

TREATMENT OPTIONS ENDERS NAIL

Casey and chapman in 1979 used enders nail as multiple intramedullary fixation with supplementary pins in neck to treat these complex fractures which resulted in malunions and nonunions .

SCREW FIXATION OF PROXIMAL FEMUR FRACTURES COMBINED WITH PLATE FIXATION OF THE SH FT

In 1984 Scintowsky used AO/ASIF techniques of screw fixation for proximal femur fractures and plate fixation for shaft of femur fractures .This technique resulted in 82 proximal femur fractures cases without any complication . There was reported case of one osteonecrosis of femoral head in 61 neck of femur cases and one malunion in 21 trocahntric fractures. Bennetalso reported similar results in management of proximal femur fractures with shaft of femur fracture with unlocked Kuntscher nailing of shaft of femur combined with screw fixation for proximal femur fractures.

6 MISSING THE NAIL TECHNIQUE

Combined nailing and pinning was reported by Bucholz and Rathjen in 2001 and stated that either screws should be inserted anterior or posterior to nail and in more or less parallel fashion.

LONG PROXIMAL FEMORAL NAILING

Dousa et al reported good results of ipsilateral proximal femur fracture with shaft femur frscture being treated with long PFN .In their case series they reported 20% with bad results probably due to associated knee injuries and 80% with good and average results . Pavleka et al also observed 63.9% good and 30.6% fair and 5.5%

poor results . There are lot of studies which has documented that results of function assent are qualitative and usage of valid tools is less.

HIP SCREW WITH SHORT SIDE PLATE FOR NECK FRACTURE AND SEPARATE PLATE FOR SHAFT

Kashayi – chowdojirao S et al reported that use of various of comination of plate and screws resukted in 76.9% good and 15.3% fair and 7.6% poor results .They also reported two cases of delayed union and one case of non union at shaft level and need for revision surgery – bone grafting alone in two cases and redo platting with bone grafting in one case. They also reported that no cases of osteonecrosis of femoral head nor the proximal fracture non unions .

RETROGRADE INTRAMEDULLARY NAILING FOR SHAFT FIXATION WITH CANCELLOUS LAG SCREW PLACED SUPERIOR TO THE TIP OF THE NAIL FOR NECK STABILIZATION

Von ruden et al reported that use of retrograde intramedullary nailing for shaft fixation with cancellous lag screw placed superior to the tip of the nail for neck

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stabilization resulted in good clinical out comes 75% using Friedman Wyman assessment system.

RENDEVOUS TECHNIQUE

Von ruden et al used Rendevous Technique by using the combination of retrograde intramedullary nailing and dynamic hip screw (DHS) osteosynthesis.This technique offers the possibility to proceed with a two-step strategy and thereby following the principle of damage control orthopedics (DCO). On the day of injury, primary treatment of the shaft fracture is performed using external fixator stabilization, whereas the proximal fracture is stabilized using definitive DHS internal osteosynthesis. The second step, which is performed following stabilization of the general conditions of the patient after several days, included removal of external fixator and the conversion to stable fixation of the shaft fracture with retrograde i.m.

nailing. This technique resulted in 77.7% of patients had good clinical outcomes.

RECONSTRUCTION NAIL

Rusell and Taylor designed Reconstruction Nail which is very much useful to treat these complex fractures .Shetty et al used reconstruction nails to treat ipsilateral neck femur fracture with shaft of femur Fracture from period of 1995 to 2005 which had 27 cases and stated that 76% had good outcomes and 9% had poor outcomes using Friedman and Wyman score .they also stated that use of this implant needs long term learning curve and surgical procedure is technically demanding which had less blood loss and biological fixation of both fractures as an added advantage.

Kao et al reported that median operating time was 280 minutes (range 125- 430 minutes ) and median blood loss was 300 ml (range 100- 600ml) of 15 cases of ipsilateral neck femur fracture with shaft of femur Fracture treated from period of

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1999 to 2005 with reconstruction nail. They repoted that average union time was 3 months for neck of femur fracture and 8.5 months for shaft fracture .

However Tsai et al in 2009 reported several disadvantages using reconstruction nails . This includes technically demanding procedure and displacement of un displaced neck fracture while inserting the nail and difficulties in obtaining rotational alignment of fracture and improper placement of proximal locking screws .

ROLE OF PROSTHETIC REPLACEMENT:

Yip KM et al used a customized long stem AM prosthesis with half sawed GK nail for these fractures with good results in old patients . Indicated in 1) Pathological fractures 2) Long stem prosthesis with cable fixation may be used in case of elderly patients with upper shaft fracture 3) Prosthetic replacement for the neck fracture combined with retrograde nailing may also be indicated for lower levels of shaft fracture in old patients 4) Revision of femoral neck non unions in elderly patients.

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FEMUR APPLIED ANATOMY

Hip joint is congruous only in the weight bearing position which accommodates a non spherical femoral head . The internal trabecular system of head of femur was illustrated by Ward in 1839. The orientation is along lines of stress; thicker lines come from the calcar; they rise superiorly into weight-bearing dome of the femoral head.

Forces acting in this arcade are largely compressive. Singh’s index is used for the diagnosis and grading of osteoporosis is based on trabecular pattern on x-rays of the upper end of the because the weakened bone has less ablity to hold the internal fixation devices .

10 VASCULAR ANATOMY

The arterial supply of the proximal end of the femur was decribed by Crock in three groups:

(1) An extracapsular arterial ring - at the base of the femoral neck.

(2) Ascending cervical branches of the extracapsular arterial ring-located on the surface of the femoral neck.

(3) The arteries of the round ligament.

Lateral femoral circumflex artery branches form the ring anteriorly and extracapsular arterial ring posteriorly is formed by a large branch of medial femoral circumflex artery.superior and inferior gluteal arteries contribute a minor percentage to this anastomotic ring Retinacular arteries arise form the ascending cervical branches of extracapsular ring. Which was described by Weitbrecht which is potentially at risk of getting injured in neck of femur fracture. As there is excellent vasculkar supply to femur metaphysis there are no osteonecrotic changes in femoral neck when compared to femoral head.

The ascending cervical arteries can be divided into four groups, anterior, medial, posterior, and lateral based on their relationship to the femoral neck of which major blood supply is from lateral group.

Chung described thesubsynovial intra articular arterial ring which is formed on the surface of neck of femur at the articular cartilage margin as asecond ring.

Subsynovial intra articular ring gives rise to Epiphyseal arterial branches which supplies the head of femur.The osteonecrosis occurs in all femoral neck fractures that communicate with the point of entry of the lateral epiphyseal vessels as stated by Claffey.Sevitt and Thompson also demonstrated that most femoral head circulation is from the superior retinacular and lateral epiphyseal vessels.

11

SIGNIFICANCE OF VASCULAR ANATOMY

(a) Intraosseous cervical vessels which cross the marrow spaces from below . (b) The artery of the ligamentumteres (medial epiphyseal vessels).

(c) The retinacular vessels, which are branches of the extracapsular arterial ring.

They run along the femoral neck beneath the synovium.

In femoral neck fractures intraosseous vessels are disrupted and the femoral head receives nutrition from the remaining retinacularvessels which necessitates appropriate fixation of neck of femur fractures

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FEMORAL SHAFT ANATOMY

The femur is the longest bone in the body. It is cylindrical in shape in most of its length and bowed with forward convexity. The radius of curvature is approximately 120 cm. The upper extremity has aarticular head, projecting medially formed by the medial inclination of the upper part of the shaft. The distal femur has condyle which articulates with tibia. Most of he muscles have attachment to bone itself. The anatomy these musculature is indeed essential to perform atraumatic surgical intervention and also describes the commonly observed patterns of deformity

Attachments on the femur:

Ligamenumteres is attached to the fovea on the head of femur.

Greater trochanter attachements

- Apex of greater trochanter provides attachment to piriformis

- The lateral part of the anterior surface gives attachment to Gluteus minimus .

- Medial surface provides attachment to Obturatorinternus and two gemelli .

- The trochanteric fossa attaches Obturatorexternus

- The ridge on the lateral surface provides insertion to Gluteus medius.

Lesser trochanter attachments

- The apex and medial part of lesser trochanter attaches psoas muscle - The iliacus muscle is inserted on the base of trochanter

Intertrochanteric line attachments : - The capsular ligament of hip joint

- Upper part attaches Iliofemoral ligaments

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- From upper end highest fibres of the vastuslateralis originates - From lower end highest fibres of the vastusmedialisorginates Shaft of femur attachemts:

- Medial head of gastrocnemius muscle orginates from medial part of popliteal surface

- Vastusintermedius arise from the upper three fourth of anterior and lateral surface

- Vastus lateralis arise from the upper part of intertrochanteric line, anterior and inferior aspect of greater trochanter.

- Vastusmedialis arise from the lower part of intertrochanteric line , medial lip of lineaaspera.

- The medial lip of lineaaspera provides attachment to Adductor longus - The medial margin of gluteal tuberosity attaches Adductor magnus.

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Anterior aspect Posterior aspect

aspect

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PATTERN OF DEFORMITIES

MIDDLE THIRD FRACTURES PROXIMAL THIRD

FRACTURES

DISTAL THIRD FRACTURES

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BLOOD SUPPLY OF THIGH

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MODE OF INJURY

High velocity injuries such as fall from height , road traffic accidents are the leading cause of ipsilateral proximal femur with shaft of femur fractures . The mechanism of this type of fractures is found to br high energy axial or longitudinal compression with with hip being abducted . in this majority of force is transmitted to shaft whuch lead sto fracture communition and less severe proximal femur fractures .Lliterature suggest that the femoral neck fractures are found to be minimally displaced which can be missed .

As the proximal femur receives less amount of energy in trauma , the incidence of neck non-union and osteonecrosis is on the lower side .Most of ghe energy is transmitted to shaft region which leads to communition and which takes more time for union which primarily decides the disability period . Range of ipsilateral knee injuries include 20-40% which can cause significant morbidity.

As the bifocal femoral fractures results from high velocity trauma, chest injuries , abdominal injuries , head injuries knee injuries can be seen as an associated injuries.

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FRACTURE CLASSIFICATION 1) NECK OF FEMUR FRACTURE

ANATOMIC CLASSIFICATION

INTRACAPSULAR EXTRACAPSULAR

PAUWELS CLASSIFICATION

Type I - fracture 30 degrees from the horizontal Type II- 50 degrees from the horizontal

Type III- 70 degrees from the horizontal

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GARDENS CLASSIFICATION

( Based on degree of displacement on pre reduction anteroposterior radiograph) TYPE I - Valgus impacted incomplete fracture, disruption of the lateral cortex

while the medial cortex is preserved TYPE II- Complete fracture

TYPE III- Complete fracture, partial displacement indicated by change in angle of the trabeculae

TYPE IV- Complete fracture, complete displacement leading to parallel orientation of the trabeculae.

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2) INTERTROCHANTRIC FRACTURE CLASSIFICATION

TYPE I and II- posterior medial cortex is intact or with less comminution ; stable fracture.

TYPE III, IVand V- posteromedial cortex is severlycomminutted ; unstable f ractures .

TYPE I AND II

TYPE III, IV and V

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BOYD AND GRIFFIN CLASSIFICATION

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3)

SUBTROCHANTRIC FRACTURE CALSSIFICATION

SEINSHEIMER CLASSIFICATION

Type II = two-part, (A) transverse, (B) spiral with lesser trochanter attached to proximal fragment, (C) spiral with lesser trochanter attached to the distal fragment;

Type III = three-part, (A) spiral with lesser trochanter part of the third fragment, (B) spiral with the third part a butterfly fragment;

Type IV = four or more parts,

Type V = subtrochanteric–intertrochanteric fractures.

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4)

SHAFT OF FEMUR CLASSIFICATION

FRACTURE GEOMETRY- Transverse, Oblique, Spiral, Comminuted . WINQUEST – HANSEN CLASSIFICATION OF DIAPHYSEAL FEMUR FRACTIRES ( Based on communition)

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SWIONTKOWSKI ET AL CLASSIFICATION OF COMPLEX FEMORAL FRACTURES

Type 1- Fracture of the shaft with neck

Type 2 - Fracture of the shaft with trochanteric fracture Type 3-Fracture of the shaft with sub trochanteric fracture Type 4 - Segmental fractures of the femoral shaft

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CLINICAL AND RADIOLOGICAL ASSESMENT

After stabilising the general condition of the patient , primary survey is done to asses the bony injuries and other system injuries .

RADIOLOGICAL INVESTIGATIONS X- RAYS

1. X-ray pelvis with both hips-Anteroposterior.

2. X-ray of ipsilateral hip in 15 degrees of internal rotation.

3. X-ray full length femur –antero-posterior and lateral . 4. X-ray knee joint-antero-posterior and lateral.

CT SCAN

CT scan of abdomen and pelvis to rule out any intra abdominal and intra pelvic injuries

CT pelvis with bilateral hips helps to rule out the occult neck of femur fractures .

By using Tornetta et al best practice protocol , in the year 2007 he showed better results in diagnosing occult neck of femur fractures in patient with shaft of femur fracture .

Tornetta et al best practice protocol includes

1. Dedicated internal rotation plain x-ray.

2. A 2-mm ct scan through the femoral neck.

3. A fluoroscopic lateral of the femoral neck before fixation.

4. Postoperative orthogonal hip x-rays in the operative room.

COMPLICATIONS

26 INTRA OPERATIVE

1. Displacement of undisplaced femoral neck fractures 2. Medial or lateral entry point

3. Femoral shaft fracture site gets distracted while inserting the nail 4. Improper reduction in closed manner leading to opening of fracture site

POST OPERATIVE

1. Femoral neck non union( 6 month post operatively) or delayed union ( 3 months post operatively)

2. Rotational malalignment – considered if it is more than 15 degrees.

3. Malunion – considered if more than 5 degrees of angulation in eith coronal or sagittal plane

4. Shortening and limb length discrepancy 5. Implant failure ( screw cut out )

6. Iatrogenic sciatic , pudendal nerve injury 7. Infection

8. Abductor weakness in hip 9. Heterotrophic ossification 10. Knee stiffness

11. Osteonecrosis of femoral head

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MATERIALS AND METHODS

It is a prospective study done among 25 patients to assess the management of ipsilateral proximal femur fracture with shaft of femur fracture in Institute of Orthopaedics and Traumatology, Coimbatore medical college from May 2017 to September 2019 .

Patients who had ipsilateral proximal femur fractures ( Neck, Intertrochanter, Subtrochanter) with shaft of femur fracture were included in the study .

INCLUSION CRITERIA

• Age group 18 to 70 years of either sexes.

• Fractures duration less than 21 days after haemo dynamic stabilization.

• Ipsilateral proximal femur fracture with shaft of femur fracture -Confirmed by clinical examination, x rays and if required CT scan.

• Patients who give informed consent and willing for follow up.

EXCLUSION CRITERIA

• Compound fractures of pelvis.

• Patients less than 18 years of age.

 Patients unfit for surgery.

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 Associated comorbid conditions history of suffering from Myocardial Infarction(MI) less than 1year, psychiatric illness, head injury.

 Pathological fracture.

 Associated major visceral injury .

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TREATMENT MODALITIES

TRAUMA CARE

In our study , after resuscitation of patients and clearing other life

threatening injuries the patients were taken up for radiological assessment. Initially the limb was stabilised using Thomas splint .Distal neuro vascular structures of injured limb is assessed systematically.

Radiographs taken includes :

1. Pelvis with both hips-anteroposterior view ,

2. Affected hip with femur –traction internal rotation view, 3. Femur full length-anteroposterior and lateral

4. Ipsilateral knee joint-anteroposterior and lateral.

No patient were taken up for CT since the proximal femur fractures were well diagnosed with xraysitself . After initial diagnosis patients were put on upper tibial pin traction till undergoing definitive surgery.

MODE OF INJURY

All patients were suffered high velocity injury in the form of Road Traffic Accidents

GENDER

22-male and 3- female

TIME OF SURGERY

Mean time delay was 20 days ( Range – 08 to 42 days ) from the time of trauma .

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AGE DISTRIBUTION

The mean age was 30 years ( Range – 19 to 78 years )

Age No. Of patients Percentage

Less than 25 years 4 16%

26-50 years 15 60%

51- 75 years 5 20%

76 years and above 1 4%

ACCORDING TO FRACTURE PATTERN PROXIMAL FEMUR FRACTURE PATTERN

AGE DISTRIBUTION

less than 25 years 26-50 years 51-75 years 76 years and above

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Proximal femur fracture pattern

Proximal femur fracture pattern

No. Of patients Percentage

Neck of femur fracture 16 64%

Intertrochantric fracture 4 16%

Subtrochantric fracture 5 20%

Proximal femur fracture pattern

Neck of femur intertrochantric Subtrochantric

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SHAFT OF FEMUR FRACTURE( Based on Winquest and Hansen classification) Shaft femur fracture

Winquest and Hansen type

No. of patients Percentage

Type- 0 2 8%

Type- 1 5 20%

Type- 2 4 16%

Type- 3 0 -

Type- 4 14 56%

SWIONTKOWSKI ET AL CLASSIFICATION OF COMPLEX FEMORAL FRACTURES

Winquest and Hansen type

Type- 0 Type- 1 Type- 2 Type- 3 Type- 4

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Swiontkowski et al classification

TYPE NUMBER OF CASES PERCENTAGE

Type 1 16 64%

Type 2 4 16%

Type 3 5 20%

Type 4 - Nil

ASSOCIATED POLYTRAUMA`S

Swiontkowski et al classification

Type 1 Type 2 Type 3 Type 4

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In our study 10 patients had associated soft tissue and bony injuries such as intestinal perforation, Scrotal Injury, Head injury, metatarsal fracture, patella fracture , roximal tibia fracture, contralateral shaft of femur fracture, ipsilateral both bone leg

fracture,humerus fracture, Pubic Diastasis and Brachial plexus injury

S.NO ASSOCIATED INJURIES NO. OF CASES

1. Scrotal injury 1

2. Abdominal injury necessating emergency Laparotomy

1

3. Head injury ( managed conservatively) 1

4. Floating knee (ipsilateral limb injury)

Proximal Tibia Fracture 1

Fracture Both bone leg 1

5. Contralateral shaft of femur fracture 2

6. Patella fracture 2

7. Humerus shaft fracture 1

8. Pubic Diastasis 1

9. Brachial plexus injury 1

SURGICAL PROCEDURES DONE 1) PROXIMAL FEMORAL NAILING - 22

2) IMIL FEMUR NAILING WITH AO CANCELLOUS FIXIATION BY MISSING THE NAIL FOR NECK OF FEMUR FRACTURE - 2

3) RECONSTRUCTION NAIL – 1

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OPERATIVE PROCEDURES

a) Operating limb was cleansed using soap and water a day before surgery after clipping the hair .

b) Test dose of injection Tetanus toxoid and Xylocaine were given.

2) PRE OPERATIVE PLANNING

a) Nail length - appropriate measurement of contralateral limb or by using a radiographic ruler under image intensifier and diameter of medullar canal ( at the level of isthumus )

Radiographic ruler in proximal and distal aspect of femur under c arm guidance

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Measurement of Nail Diameter using radiographic ruler under image intensifier 3) PATIENT POSITIONING WITH IMAGE INTENSIFIER CONTROL

Patient usually positioned in supine on traction table with good access of c- arm to Femoral head and Neck for anteroposterior and lateral images

.

37 4) SKIN INCISION

Made 1 cm proximal to tip of greater trochanter and extending proximally in line with gluteus maximus which are retracted to acesses the pyriform fossa and tip of the trochanter based on the implants used.

5) ENTRY POINT

Correct entry point was made under c arm guidance .

PFN AND FEMUR IMIL ENTRY POINT

a) FEMUR IMIL NAIL – Pyriformis fossa b) PFN – Tip of greater trochanter

( RED LINE – IMIL NAIL; GREEN LINE – PFN )

RED LINE – IMIL NAIL GREEN LINE – PFN

38 c) RECONSTRUCTION NAIL ENTERY

Usually taken 5mm anterior to standard nail entry to facilitate central screw placement in neck

Postion of awl is checked under AP and Lateral C- Arm Views

Red – standard IMIL entry, Green – Recon nail entry

39 6) REAMING AND NAIL INSERTION

Medullary canal was opened using a reamer and reaming done 1mm larger than the measured nail diameter

Nail insertion

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7) Lower limb abducted and proximal and distal locking done after confirming neck shaft angle under image intensifier .

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Distal locking was done using free hand technique under image intensifier

Missing Nail the technique

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INTRAOPERATIVE ASSESMENT OF FRACTURE REDUCTION GARDENS ALIGNMENT INDEX ( Neck of femur fracture)

Angle of 160° to 180° on both anteroposterior and lateral radiographs considered satisfactory

The black arrows indicate anatomical reduction, with the red arrows representing unacceptable reduction positions

LESSER TROCHANTER SHAPE SIGN

Used to assess the rotation of distal fragment of femur intra operatively

1 2 3 4

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1) The shape of the lesser trochanter on the opposite side is obtained and stored in image intensifier screen.

2) The shape of lesser trochanter on both sides are matched so that the proximal segment rotation before distal locking

3) If proximal segment is internally rotated means , lesser trochanter will appear as small in shape.

4) If proximal segment is externally rotated means , lesser trochanter will appear larger in shape.

LOWELL INDEX

A- Anatomically aligned femoral neck ; on both AP and Lateral xrays projected as shallow S or reverse S pattern.

B- Flattening of one curve and a sharp apex on the opposite side demonstrates Malalignment.

44 POSTOPERATIVE PROTOCOL

1. On the day of surgery after spinal anaesthesia wares of , chest physiotherapy was given.

2. Antibiotics was administered until 5^thpost operative day.

3. Knee and ankle mobilisation ,static quadriceps exercises was started on postoperative day 2.

4. Drain removal was done done on day 2.

5. Alternate day sterile dressing was done till suture removal . 6. Suture removal was done on 14 ^thpost operative day.

7. Advised non weight bearing for 6 week .

8. Gradual partial assisted tip toe weight bearing was advised for another 6 weeks.

9. Radiological and functional examination was done 4 week once for first 6 months and 12 weekly after that.

POST OPERATIVE ANALYSIS

Friedman and Weiman assessment system was used for assessing the range of motion, functional status at each follow up .

Friedman and Weiman assessment system

Results Activities of daily living Pain Range Of Motion

Good No Limitation Nil < 20% loss of hip or knee motion

Fair Mild Limitation Mild to

moderate

20 – 50% loss of hip or knee motion

Poor Moderate Limitaion Severe > 50% loss of hip and knee motion

45 Radiological assessment (post operative)

Union- Radiographical union was defined as bridging trabeculae across the fracture site or solid callus with cortical density connecting both fracture fragments.

Angular malalignment- more than 5 degrees of angular deformity in coronal or sagittal plane

Rotational mal alingnment- more than 15 degrees of rotational Delayed union – if no signs of union by 3 months

Non union- if no signs of union by 6 months .

46 Results

Twenty five cases of Ipsilateral proximal femur fracture with shaft of femur attending our institute were managed with long proximal femur nail(22 cases), Standard IMIL nail with Missing the nail technique for neck of femur fracture (2 case), reconstruction nail( 1 case ) were analysed with average follow up of 1 year ( range 8 months to 18 months).

Observations

1. Out of 25 patients 22 are male and 3 are female

2. All patients were victims of high velocity Road traffic accident

3. Among 25 patients , four patients were less than25 years (16%), Fifteen patients were between 26-50 years (60%), Five patients were among 51 to 75 years (20%), one patient was above 76 years (4%).

4. The proximal femur fractures were , 16 (64%)were neck of femur , 4 (16%)were intertrochantric and 5 (20%) were subtrochantric .

5. Among 25 shaft of femur fracture type 0 was among 2 (8%)cases , type-1 was among 5 cases (20%) , type 2 was among 4 cases (16%), and no cases of type 3 and 14(56%)cases of type 4.(Based on Winquest and Hansen type ) 6. Based on swiontkowsi et al classification complex femoral fractures , 16

(64%) cases were of type 1, 4 ( 16%) cases were of type2 and 5 ( 20%) cases of type 3.

7. Ten patients had associated injuries like one case of scrotal injury, one case of abdominal injury necessating emergency laparotomy, one case of head injury , 2 case of patella fracture, 2 cases of contralateral femur fracture .

8. No cases of proximal femur were missed initially

9. The average time delay in our study was 20 days ranging from 8 to 42 days

47

10. The average duration of surgery was 2 hours 45 minutes , ranging from 2 hours to 4 hours .

11. Of these closed reduction of fracture was in 11 cases and open reduction was done among 14 cases , cerclage was done among 2 cases for shaft of femur fracture ,bone grafting for shaft of femur was done done among one case, intra operatively there was difficulty in making entry point in 3 cases and 2 cases of shaft of femur got distracted on insertion of nail(but healed well), one case of undisplaced neck of femur got distracted on nail insertion which has to be reduced again after removal of nail in the same setting .

12. Superficial post operative infection was found among 2 cases which was managed with antibiotics .

13. Post operatively no cases developed deep venous thrombosis , 3 cases had foot drop ( which recovered fully at 3 months time)

14. The average union time for proximal femur fractures was 15 weeks( Range - 14 to 30 weeks ), shaft of femur fracture was 29 weeks ( Range -26 to 40 weeks)

15. Three cases of shaft fracture showed delayed union which went on unite well within 8 months without second intervention.

16. Functional out come was assessed Based on Friedman and Weiman assessment system and was found to be good among among 19 cases , fair among 5 cases and poor among 1 case.

48 CASE - 1

 Chandrasekar46/male, H/O RTA

 Intertrochantric fracture With Shaft Of Femur Fracture left Side

 Boyd and griffin TYPE 2 ; WINQUEST HANSEN Type IV

 CRIF WITH LONG PFN Functional out come - good

PRE OP

49

50

51

CASE -2

• Neck Of Femur With Shaft Of Femur Fracture Right Side

• GARDENS TYPE 2 ; WINQUEST HANSEN Type IV

• ORIF WITH LONG PFN WITH CERCLAGE FOR SHAFT OF FEMUR

52

53

54 CASE – 3

 Mani 65/male

 H/O RTA

 subtrochantric fracture With Shaft Of Femur Fracture right Side

 SHEINSHEIMER TYPE 2A ; WINQUEST HANSEN Type IV

 ORIF WITH LONG PFN with cerclage with bone grafting

55

IMMEDIATE POST OP

56

57 CASE - 4

• Subramani 59/male

• H/O RTA

• Neck of femur fracture With Shaft Of Femur Fracture left Side

• Gardens type 2 ; WINQUEST HANSEN Type 0

• CRIF With IMIL Nailing With Neck Screw By Miss The Nail Technique

58

59

CASE – 5

 Anbarasu 28/male

 H/O RTA

 neck of femur fracture With Shaft Of Femur Fracture left Side( left brachial plexus injury )

 Gardens TYPE 3 ; WINQUEST HANSEN Type IV

 CRIF WITH LONG PFN

60

61 CASE - 6

 ANTONY RAJ 44/male

 H/O RTA

 Neck Of Femur fracture With Shaft Of Femur Fracture right Side

 GARDENS TYPE 4; WINQUEST HANSEN Type I

 ORIF WITH LONG PFN

INTRA OP

62

63 CASE -7

 RAJASEKARAN 29/male

 H/O RTA

 Neck Of Femur With fracture With Shaft Of Femur Fracture left Side

 GARDENS TYPE 4 ; WINQUEST HANSEN Type II

 CRIF WITH LONG PFN

PRE OP

64

65

66 CASE -8

 Santhoshkumar sani

 30/male, H/O RTA,

 Nek of femur with shaft of femur fracture left side

 ORIF WITH RECONSTRUCTION NAIL PRE OP

IMMEDIATE POST OP

67

8 MONTHS POST OP

68 DISCUSSION

Management of these complex ipsilateralproximal femur fracture with shaft of femur fracture has its own complication , as stabilisation of these fractures pose a diagnostic and treatment perplexity. The conundrum of these fracture management which needs meticulous preoperative planning has swayed from conservative management to various modalities of stabilisation .Since there is no solidarity about best available device for fixation, it has paved way for designing of newer implant and advancement of surgical techniques which posses its own pros and cons.

The contrivance of Proximal femur nail , Reconstruction nail has been a evelation in managing these bifocal fractures as these can be stabilised using a single implant .This resulted in decrease morbidity and mortality of these cases facilitating early rehabilitation .

Eighteen cases of complex bifocal fractures were included in our study of which neck with shaft fracture was found in 16 cases (64%) and intertrochanter with shaft was found in 4 cases (16%) and subtrochanter with shaft of femur was found in 5 cases (20%).

69

We compared our study with other studies by Randelli et al in 1999, Jain et al 2004,Tsai et al in 2008 , Kashayi- Chowdojirao et al in 2016 and Dahuja A et al in 2018 , which had an average follow up of 2 years but in our study average follow up was found to be 8- 18 months .

AUTHORS NUMBER OF CASES FOLLOW UP

Randelli et al 27 2 years

Jain et al 23 2.5 years

Tsai et al 32 1.9 years

Kwashayi and Chowdojirao S at al ( Group 1and 2)

25

Group 1 (n=13)

1.12 year (58.46±15.32 weeks) Group 2

(n=12)

0.99 year (52±13.88 weeks)

Dahuja A et al 25 1.2 years

Our study 25 1 year

PROXIMAL FEMUR FRACTURES

Neck of femur

Intertrochantric FRacture Subtrochantric Fracture

70

FOLLOW UP DATA`S

Comparison of means (t-test) Data of My study vs group I of Kashyi et al

Results

Mean Difference 4.46

Standard error 4.094

95% CI -3.913 to 12.833

Test statistic t 1.089

Degree of freedom (DF)

29

Significance level P = 0.2849(P>0.05)

(Not Significant) My study

Mean 54.00

Standard deviation 7.08

Number of cases 25

Kashyi et al study

Mean 58.46

Standard deviation 15.32

Number of cases 13

27

23

32

13 12

25 25

0 5 10 15 20 25 30 35

Randelli et al Jain et al Tsai et al Kashayi - Chowdojirao et al Group 1

Kashayi - Chowdojirao et al Group 2

Dahuja A et al Our study

Number of cases

71

FOLLOW UP DATA`S

Comparison of means (t-test) Data of My Study vs group II of Kashyi et al

Results

Mean Difference -2

Standard error 3.839

95% CI -9.864 to 5.864

Test statistic t -0.521

Degree of freedom (DF)

28

Significance level P = 0.6065(P>0.05) (Not Significant) My study

Mean 54.00

Standard deviation 7.08

Number of cases 25

Kashyi et al study

Mean 52.00

Standard deviation 13.88

Number of cases 12

72

The proximal femur union rate was found to 100% in our study ,similar to that of Randelli et al , Dahuja A et al and Kashayi- Chowdojirao et al ( group 1 and 2) study .Other studies such as Jain et al and Tsai et al reported 96% and 91%

respectively.

Proximal femur fracture union rate

Comparison of means (t-test) Data of my study vs I group of Kashyi et al my study

Mean 15.50

Standard deviation 2.15

Number of cases 25

Kashyi et al study

Mean 15.75

Standard deviation 0.89

Number of cases 13

100

96

91

100 100 100 100

86 88 90 92 94 96 98 100 102

Randelli et al Jain et al Tsai et al Kashayi - Chowdojirao et al Group 1

Kashayi - Chowdojirao et al Group 2

Dahuja A et al

Our study

Proximal Femur union Rate

73 Results

Mean Difference 0.25

Standard error 0.634

95% CI -1.047 to 1.547

Test statistic t 0.394

(Degree of freedom) DF

29

Significance level P = 0.6964 (P>0.05)

(Not significant)

Proximal femur fracture union rate

Comparison of means (t-test) Data of My study vs group II of Kashyi et al

My study study

Mean 15.50

Standard deviation 2.15

Number of cases 25

Kashyi et al study

Mean 16.48

Standard deviation 1.40

Number of cases 12

74 Results

Mean Difference 0.98

Standard error 0.705

95% CI -0.464 to 2.424

Test statistic t 1.390

Degree of freedom (DF)

28

Significance level P = 0.1753(P>0.05) ( Not significant)

The femur shaft fracture union rate was found to be 84% in our study which is similar to that of Randelli et al. The percentage of shaft union in other studies were Jain et al 83%, Tsai et al 78%, Dahuja A et al 92%, Chowdojirao et al group 1 - 77%and group 2- 92% .

100

83 78 77

92 92

84

0 20 40 60 80 100 120

Randelli et al Jain et al Tsai et al Kashayi - Chowdojirao et al Group 1

Kashayi - Chowdojirao et al Group 2

Dahuja A et al

Our study

Femur shaft fracture union Rate(%)

75

Comparison of means (t-test) Data of My study vs group I of Kashyi et al

My study

Mean 32.44

Standard deviation 3.99

Number of cases 25

Kashyi et al study

Mean 19.27

Standard deviation 1.18

Number of cases 13

Results

Mean Difference -13.17

Standard error 1.146

95% CI -15.513 to -10.827

Test statistic t -11.495

Degree of freedom (DF)

29

Significance level P < 0.0001 (P<0.01) ( Significant)

76

Comparison of means (t-test) Data of My study vs group II of Kashyi et al My study

Mean 32.44

Standard deviation 3.99

Number of cases 25

Kashyi et al study

Mean 20.06

Standard deviation 1.16

Number of cases 12

Results

Mean Difference -12.38

Standard error 1.19

95% CI -14.817 to -9.943

Test statistic t -10.404

Degree of freedom (DF)

28

Significance level P < 0.0001 (P<0.01) ( Significant)

77

The average union time for proximal femur fracture and shaft of femur fracture in our study was found to be 15 .50±2.12 weeks and 32.44±3.99 weeks respectively which is compared with other reported studies

3.7 4 4

3.62 3.79

4.3

3.45

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

Randelli et al Jain et al Tsai et al Kashayi - Chowdojirao et al Group 1

Kashayi - Chowdojirao et al Group 2

Dahuja A et al

Our study

Time taken for proximal femur union (months)

4.8 5.5

8.8

4.43 4.61 5.4

6.67

0 1 2 3 4 5 6 7 8 9 10

Randelli et al Jain et al Tsai et al Kashayi - Chowdojirao et al Group 1

Kashayi - Chowdojirao et al Group 2

Dahuja A et al

Our study

Time taken for proximal femur union

(months)

78

The factors which favours the union in these complex femoral fractures are found to be Minimal fracture gap , sufficient vascularity and stability . Moreover these complex femoral fractures are casused high enery trauma of which most of force are transmitted to shaft which leads to comminuted fracture fragments causing delayed and non unions.

Two of our patients had superficial post operative wound infection which settled after usage of antibiotics

In our study there was difficulty in making entry point in 3 cases and 2 cases of shaft of femur got distracted on insertion of nail(but healed well), one case of undisplaced neck of femur got distracted on nail insertion which has to be reduced again after removal of nail in the same setting.

In our study no case of varusmalunion of neck was found similar to that of reported studies .

In our study no case of osteonecrosis of femoral head was notted at mean follow up of 8 months to 18 months using plain radiographs . Randelli et al and Jain et al reported a rate of 4 % osteonecrosis of femoral head using MRI studies .

This studies has limitations such as small number of cases and short follow up time . MRI was not done in our cases , as it a valuable tool in picking up early osteonecrotic femoral head changes .

79

The average duration of time delay in surgery was 20 days ( range8- 42 days ) Garg reported that even when the surgical intervention is delayed the fracture which were anatomically reduced and fixed internally unitted well which suggest that anatomical reduction is indeed the main factor influencing the union rate not the time delay for surgery and also the fact that most of the energy is transmitted in shaft fracture leading to less rate of proximal femur non union.

In our study the average duration of surgery was 2 hours 45 minutes , ranging from 2 hours to 4 hours. And the mean age was 30 years is lower when compared with other reported studies .

In our study closed reduction of fracture was done in 11 cases and open reduction was done among 14 cases in order to attain stable anatomic reduction which is the most difficult thing in these complex femoral fractures even for surgeons with vast clinical experience .

80

AUTHORS NUMBER

OF CASES

RATE OF UNION (%)

TIME TAKEN FOR UNION VARUS REDUCTIO

N OF NECK ( no. of case

)

AVN CHANGES

(%)

INFECTION (%)

FOLLOW UP NEC

K

SHAF T

NECK SHAFT

Randelli et al

27 100 100 3.7months 4.8 months 4 4 0 2 years

Jain et al 23 96 83 4 months 5.5 months 0 4 0 2.5 years

Tsai et al 32 91 78 4.0 months 8.8 months 0 0 0 1.9 years

KashayiC howdojira

o S et al ( group 1

and 2)

25

1 13 100 77 3.62 months (15.75±0.89 Weeks)

4.43months (19.27±1.18

Weeks)

0 0 0 1.12 years

(58.46±15.32 weeks) 2 12 100 92 3.79 months

(16.48±1.4 Weeks)

4.61 months (20.06±1.16

weeks)

0 0 0 0.99 year

(52±13.88 weeks) Dahuja A

et al

25 100 92 4.3 months 5.4months 1 0 4 1.2 years

81 Our study 25 100 84 3.45 months

(15±2.12 weeks)

6.67months (32.44±3.99

weeks)

0 0 11 1 year

COMPARISON OF CLINICAL OUT COMES OF MANAGEMENT OF IPSILATERAL PROXIMAL FEMUR WITH SHAFT OF FEMUR FRACTURE.

82

CONCLUSION

In our study of these 25 complex femoral fractures we were able to achieve satisfactory functional outcomes with less complications in most number of cases . With increased clinico – surgical experience we can bring down the operating time and closed anatomical reduction of these complex fractures .

In our study we experienced difficulties such as time delay in surgery , open reduction of fracture , and difficulty in gaining entry point . But we achieved good functional outcome inspiteof the initial setbacks.

Dispute still exits regarding the implants used in managing these bifocal fractures no studies have reported that these can be managed best with implants ( single or double ) avalible in the market .

Since these fractures are associated with multiple associated injuries , the functional outcome is mostly swayed by it not the surgical intervention which is being done .

The major impediment of our study were the smaller sample size and duration of follow up.

Hence we conclude that perfect anatomical reduction and stable internal fixation is the need for the these complex femoral fractures not the implant we used in achieving it .

A long term follow up of these cases is essential to find out the delayed complication such as osteonecrosis of femoral head .

83

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