CHAPTER I

INTRODUCTION

The femur is the strongest, longest, and heaviest bone in the body and is essential for
normal ambulation. The femoral shaft is tubular with a slight anterior bow, extending from
the lesser trochanter to the flare of the femoral condyles. The femur is subject to many forces
during ambulation including axial loading, bending, and torsional forces.
The spectrum of femur fractures is wide and ranges from non-displaced femoral
stress fractures to fractures associated with severe comminution and significant soft-tissue
injury. Femur fractures are typically described by location (proximal, shaft, distal). These
fractures may then be categorized into three major groups; high-energy traumatic fractures,
low energy traumatic fractures through pathologic bone (pathologic fractures) and stress
fractures due to repetitive overload.
Traumatic femur fractures in the young individual are generally caused by highenergy forces and are often associated with multisystem trauma. In the elderly population,
femur fractures are typically caused by a low energy mechanism such as a fall from standing
height. Isolated injuries can occur with repetitive stress and in the presence of metabolic bone
diseases, metastatic disease or primary bone tumors.
The femur is very vascular, and fractures can result in significant blood loss into the
thigh. Up to 40% of isolated fractures may require transfusion as such injuries can result in
loss of up to three units of blood. This factor is significant, especially in elderly patients who
have less cardiac reserve.
Femur fracture patterns vary according to the direction of the force applied and the
quantity of force absorbed. A perpendicular force results in a transverse fracture pattern, an
axial force may injure the hip or knee, and rotational forces may cause spiral or oblique
fracture patterns. The amount of comminution present increases with increasing amounts of
force.

Most femur fractures are treated surgically. The goal of early surgical treatment is
stable, anatomic fixation, allowing mobilization as soon as possible. Surgical stabilization is
also important for early extremity function, allowing both hip and knee motion and
strengthening. Injuries and fractures of the femur may have significant short and long-term
effects on gait kinematics and function if alignment is not restored.CHAPTER II
CONTENS REVIEW

I.

ANATOMY OF FEMUR
The femur is the only bone located within the human thigh. It is both the
longest and the strongest bone in the human body, extending from the hip to the
knee. It is classed as a long bone, and is in fact the longest bone in the body. The
main function of the femur is to transmit forces from the tibia to the hip joint. It acts
as the place of origin and attachment of many muscles and ligaments so we shall
split it into three areas; proximal, shaft and distal.

Picture 1. Femur; anterior and posterior view

Proximal
The proximal area of the femur forms the hip joint with the pelvis. It consists
of a head and neck, and two bony processes called trochanters. There are also two
bony ridges connecting the two trochanters

Head Has a smooth surface with a depression on the medial surface this is for
the attachment of the ligament of the head. At the hip joint, it articulates with the
acetabulum of the pelvis.
Neck Connects the head of the femur with the shaft. It is cylindrical, projecting in
a superior and medial direction this angle of projection allows for an increased
range of movement at the hip joint.
Greater trochanter this is a projection of bone that originates from the anterior
shaft, just lateral to where the neck joins. It is angled superiorly and posteriorly, and
can be found on both the anterior and posterior sides of the femur. It is the site of
attachment of the abductor and lateral rotator muscles of the leg.
Lesser trochanter much smaller than the greater trochanter. It projects from the
posteromedial side of the side, just inferior to the neck-shaft junction. The psoas
major and iliacus muscles attach here.
Intertrochanteric line a ridge of bone that runs in a inferomedial direction on the
anterior surface of the femur, connecting the two trochanters together. The
iliofemoral ligament attaches here a very strong ligament of the hip joint. After it
passes the lesser trochanter on the posterior surface, it is known as the pectineal line.
Intertrochanteric crest similar to the intertrochanteric line, this is a ridge of bone
that connects the two trochanters together. It is located on the posterior surface of the
femur. There is a rounded tubercle on its superior half, this is called the quadrate
tubercle, which is where the quadratus femoris attaches.

Picture 2. (A) Proximal femur in anterior view and (B) posterior view
The Shaft

The shaft descends in a slight medial direction. This brings the knees closer to
the bodys center of gravity, increasing stability. On the posterior surface of the
femoral shaft, there are roughened ridges of bone, these are called the linea
aspera (Latin for rough line)
Proximally, the medial border of the linea aspera becomes the pectineal
line. The lateral border becomes the gluteal tuberosity, where the gluteus maximus
attaches. Distally, the linea aspera widens and forms the floor of the popliteal fossa,
the medial and lateral borders form the the medial and lateral supracondylar lines.
The medial supracondyle line stops at the adductor tubercle, where the adductor
magnus attaches.
Distal
The distal end is characterised by the presence of the medial and lateral
condyles, which articulate with the tibia and patella, forming the knee joint.
Medial and lateral condyles rounded areas at the end of the femur. The
posterior and inferior surfaces articulate with the tibia and menisci of the knee, while
the anterior surface articulates with the patella.
Medial and lateral epicondyles bony elevations on the non articular areas
of the condyles. They are the area of attachment of some muscles and the collateral
ligaments of the knee joint.
Intercondylar fossa A depression found on the posterior surface of the
femur, it lies in between the two condyles. It contains two facets for attachment of
internal knee ligaments.
Facet for attachment of the posterior cruciate ligament found on the
medial wall of the intercondylar fossa, it is a large rounded flat face, where the
posterior crucitate ligament of the knee attaches.
Facet for attachment of anterior cruciate ligament found on the lateral
wall of the intercondylar fossa, it is smaller than the facet on the medial wall, and is
where the anterior cruciate ligament of the knee attaches.

Picture 3. C. Posterior Surface of the Shaft , (D) Anterior and (E) Posterior Surface
of the Distal Portion of the Femur
Arteries of Femur
The main artery of the femur is femoral artery. It is a continuation of the external
iliac artery (terminal branch of the abdominal aorta). The external iliac becomes the
femoral artery when it crosses under the inguinal ligament and enters the femoral
triangle.
In the femoral triangle, the profunda femoris artery arises from the posterolateral
aspect of the femoral artery. It travels posteriorly and distally, giving off three main
branches:

Perforating branches Consists of three or four arteries that perforate the

adductor magnus, contributing to the supply of the muscles in the medial and

posterior thigh.
Lateral femoral circumflex artery Wraps round the anterior, lateral side

of the femur, supplying some of the muscles in the lateral side of the thigh.
Medial femoral circumflex artery Wraps round the posterior side of the
femur, supplying the neck and head of the femur. In a fracture of the femoral
neck, this artery can easily be damaged, and avascular necrosis of the femur
head can occur.

Picture 4. Arteries of femur

II.

FEMUR FRACTURE

FRACTURES
Definition:A fracture is any break in a bone, including chips, cracks,
splintering, and complete breaks.

Two Basic Types Of Fracture:

1. Closed Fracture (Simple fracture):Occurs when a bone is broken but there is no penetration
extending from thefracture through the skin.
2. Open Fracture: (Compound fracture)Is a fracture in which there is a wound over the
fracture site, with or withoutbone protruding through it.This type of fracture is more serious
than closed fractures because the risks ofcontamination and infection are greater.

Fractures are further classified according to their appearance on x-ray:

Types of fracture
A. Green stick fracture
o Usually occurs in children whose bones are still pliable (like green sticks)
o A break occurs straight across part of the width of the bone, perpendicular tothe long
axis
B. Transverse Fracture
o Cuts across the bone at right angles to its long axis
o often caused by direct injury
C. Oblique Fracture
o The fracture line crosses the bone at an oblique angle

D. Comminuted Fracture:
o The bone is fragmented into more than two pieces
E. Impacted Fracture:
o The broken ends of the bone are jammed together
F. Spiral Fracture:
o Usually results from twisting injuries
o The fracture line has the appearance of a spring2

3.2 Procces of Fracture

a. Direct
fracture occurs at the site of trauma. Direct pressure on the bone and fracture in the
area of pressure. Ex : direct hit over the bone
b. Indirect
Trauma occurs when trauma doesnt directly delivered to areas farther from the
fracture. Usually the soft tissue remains intact. Ex: after falling on outside stretched
hands
c. Force of Powerful Muscle Actions
For example, violent cough may cause rib fracture
d. Aging and bone disease
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Can increase the risk of fractures (pathologic fractures), with bones breaking even
minor accidents
e. Twisting Forces
Such injuries are often seen in football and skiing accidents where a person's foot is
caught and twisted with enough forces to fracture a leg bone

Causes Of Fractures:

1. Direct Force :The bone breaks at the spot of application of the force e.g., direct hit over a
bone,bullet injury.
2. Indirect Force :The bone breaks away from the application of force somewhere else, e.g.
after fallingon outside stretched hands.
3. Force of Powerful Muscle Actions :For example, violent cough may cause rib fracture
4. Aging and bone disease :Can increase the risk of fractures (pathologic fractures), with
bones breaking evenminor accidents
5. Twisting Forces :Such injuries are often seen in football and skiing accidents where a
person's foot iscaught and twisted with enough forces to fracture a leg bone.

Signs And Symptoms Of Fractures:

1. The primary symptom of fracture is PAIN.

o Pain is often severe and constant and is felt at or near the site of fracture
o The patient may report that he heard something snap or felt the bone break.
2. Swelling And Discoloration
o These begin shortly after injury
o Discoloration my start as reddening of the skin
3. Tenderness Or Discomfort which may lead to severe restriction or use of the
areaaffected

4. Bone may BREAK through the skin

5. DEFORMITY

Tscherne classification of closed fractures

This classifies soft tissueinjury in closed fractures and takes into account indirect versus
direct injury mechanism
Grade 0 : injury from indirect forces with negligible soft tissue damage
Grade 1 : closed fracture caused by low moderate energy mechanisms, with superficial
abrasions or contusions of soft tissues overlying the fracture
Grade 2 : closed fracture with significant muscle contusion, with possible deep, contaminated
skin abrasions associated with moderate to severe energy mechanisms and skeletal injury;
high risk for compartment syndrome
Grade 3 : extensive crushing of soft tissues , with subcutaneous degloving or avulsion, with
arterial distruption or established compartement syndrome.
1.5.
Bone Healing
Bone healing process (cortical bone on bone length) consists of five
phases, there are:

1. Hematoma phase (within 24 hours arising bleeding)

If a fracture occurs, the small blood vessels that pass through the canaliculi in system
suffered a tear in the area of the fracture and hematoma will form between the two sides of
the fracture. Large hematoma covered by the periosteum. Periosteum will be motivated and
able to experience tears hematoma that occurred as a result of pressure that can occur
extravasation of blood into soft tissue. Osteocytes with the lacuna, located one millimeter
from that area of blood loss and fractures will die, which would lead to an avascular area
dead bone on the sides of the fracture immediately after the trauma.
2. Proliferation / inflammation Phase (Occurs 1-5 days after trauma)
Soft tissue reaction occurs around the fracture as a healing reaction. Healing occurs
because of osteogenic cells which proliferate from perosteum to form callus on the external
and internal callus in endosteum areas as cellular activity in the canal medullaris. In the event
of severe laceration in the periosteum of the healing cells derived from mesenchymal cells
that are not differentiated into soft tissue. In the early stages of fracture healing by
anadditional amount of osteogenic cells which provides rapid growth of malignant tumors.
Soft tissue are not formed from freezing hematoma organization of a region of the fracture.
After a few weeks of the fracture callus will form as a mass of tissue covering the osteogenic.
On radiological examination contains bone callus yet so it is still a radiolucent area.
3. Callus formation Phase (occurring 6-10 days after trauma)
After the formation of the cellular tissue that grew from each fragment based
on derived from osteoblasts and then on chondroblasts form the cartilage. Osteoblasts
place occupied by the intercellular matrix of collagen and attachment of
polysaccharide by calcium salts formed immature bones. This bone forms called
"woven bone" (an indication of the first radiological fracture healing).
4. Consolidation phase (2-3 weeks after the fracture to heal)
Woven bone callus will form the primary andgradually transformed into a
more mature bone by the osteoblasts activity and excess callus lamellar structure can
be gradually resorbed.
5. The remodeling phase (time over 10 weeks)
Slowly happening in osteoclastic resorption and osteoblastic process persists
on external callus is slowly disappearing. Intermediates turned into a bone callus is
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compact and contains haversian systems and callus inside will experience to form a
marrow space.
Any factors that affecting bonehealing :
1. Age of patients
2. Localization and fracture configuration
3. Shifting the initial fracture
4. Vascularity in the second fragment
5. Reduction and immobilization
6. Time immobilization
7. The room between the two fragments and soft tissue interposition
8. Infection Factors
9. Synovial fluid
10. Movement of active and passive limb

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