questions
37

Femoral Shaft Fractures

Topic updated on 06/11/16 4:32pm
Introduction
  • High energy injuries frequently associated with life-threatening conditions
  • Epidemiology
    • incidence
      • 37.1 per 100,000 person-years
  • Mechanism
    • traumatic
      • high-energy
        • most common in younger population
        • often a result of high-speed motor vehicle accidents
      • low-energy
        • more common in elderly
        • often a result of a fall from standing
        • gunshot 
  • Associated conditions
    • orthopaedic
      • ipsilateral femoral neck fracture
        • 2-6% incidence 
        • often basicervical, vertical, and nondisplaced
        • missed 19-31% of time
      • bilateral femur fractures q
        • significant risk of pulmonary complications
        • increased rate of mortality as compared to unilateral fractures
Anatomy
  • Osteology
    • largest and strongest bone in the body
    • femur has an anterior bow
    • linea aspera 
      • rough crest of bone running down middle third of posterior femur
      • attachment site for various muscles and fascia
      • acts as a compressive strut to accommodate anterior bow to femur
  • Muscles
    • 3 compartments of the thigh
      • anterior
        • sartorius
        • quadriceps
      • posterior
        • biceps femoris
        • semitendinosus
        • semimembranosus
      • adductor
        • gracilis
        • adductor longus
        • adductor brevis
        • adductor magnus 
  • Biomechanics
    • musculature acts as a deforming force after fracture
      • proximal fragment
        • abducted
          • gluteus medius and minimus abduct as they insert on greater trochanter
        • flexed
          • iliopsoas flexes fragment as it inserts on lesser trochanter
      • distal segment
        • varus
          • adductors inserting on medial aspect of distal femur
        • extension
          • gastrocnemius attaches on distal aspect of posterior femur
Classification
 
 Winquist and Hansen Classification
Type 0  • No comminution
Type I  • Insignificant amount of comminution

Type II  • Greater than 50% cortical contact
Type III  • Less than 50% cortical contact  
Type IV  • Segmental fracture with no contact between proximal and distal fragment
 
OTA Classification
32A - Simple  • A1 - Spiral
 • A2 - Oblique, angle > 30 degrees
 • A3 - Transverse, angle < 30 degrees
 
32B - Wedge  • B1 - Spiral wedge
 • B2 - Bending wedge
 • B3 - Fragmented wedge

32C - Complex  • C1 - Spiral
 • C2 - Segmental
 • C3 - Irregular

 
Presentation
  • Initial evaluation
    • Advanced Trauma Life Support (ATLS) should be initiated
  • Symptoms
    • pain in thigh
  • Physical exam
    • inspection
      • tense, swollen thigh
        • blood loss in closed femoral shaft fractures is 1000-1500ml 
          • for closed tibial shaft fractures, 500-1000ml
        • blood loss in open fractures may be double that of closed fractures
      • affected leg often shortened
      • tenderness about thigh
    • motion
      • examination for ipsilateral femoral neck fracture often difficult secondary to pain from fracture
    • neurovascular
      • must record and document distal neurovascular status
Imaging
  • Radiographs
    • recommended views
      • AP and lateral views of entire femur
      • AP and lateral views of ipsilateral hip
        • important to rule-out coexisting femoral neck fracture
      • AP and lateral views of ipsilateral knee
  • CT
    • indications
      • may be considered in midshaft femur fractures to rule-out associated femoral neck fracture
Treatment
  • Nonoperative
    • long leg cast
      • indications
        • nondisplaced femoral shaft fractures in patients with multiple medical comorbidities
  • Operative
    • antegrade intramedullary nail with reamed technique 
      • indications
        • gold standard for treatment of diaphyseal femur fractures
      • outcomes
        • stabilization within 24 hours is associated with
          • decreased pulmonary complications (ARDS)
          • decreased thromboembolic events
          • improved rehabilitation
          • decreased length of stay and cost of hospitalization
        • exception is a patient with a closed head injury
          • critical to avoid hypotension and hypoxemia  
          • consider provisional fixation (damage control)
    • retrograde intramedullary nail with reamed technique
      • indications
        • ipsilateral femoral neck fracture 
        • floating knee (ipsilateral tibial shaft fracture) 
          • use same incision for tibial nail
        • ipsilateral acetabular fracture
          • does not compromise surgical approach to acetabulum
        • multiple system trauma
        • bilateral femur fractures
          • avoids repositioning
        • morbid obesity
      • outcomes
        • results are comparable to antegrade femoral nails
        • immediate retrograde or antegrade nailing is safe for early treatment of gunshot femur fractures 
    • external fixation with conversion to intramedullary nail within 2-3 weeks
      • indications
        • unstable polytrauma victim 
        • vascular injury
        • severe open fracture
    • ORIF with plate
      • indications
        • ipsilateral neck fracture requiring screw fixation
        • fracture at distal metaphyseal-diaphyseal junction
        • inability to access medullary canal
      • outcomes
        • inferior when compared to IM nailing due to increased rates of:
          • infection 
          • nonunion 
          • hardware failure
Surgical Techniques
  • Antegrade intramedullary nailing    
    • approach
      • 3 cm incision proximal to the greater trochanter in line with the femoral canal
    • technique
      • starting points
        • piriformis entry  
          • pros
            • colinear trajectory with long axis of femoral shaft
          • cons
            • starting point more difficult to access, especially in obese patients
            • causes the most significant damage to
              • abductor muscles and tendons
                • may result in abductor limp
              • blood supply to the femoral head
                • may result in AVN in pediatric patients
        • trochanteric entry
          • pros
            • minimizes soft tissue injury to abductors
            • easier starting point than piriformis entry nail
          • cons
            • not colinear with the long axis of femoral shaft
            • must use nail specifically designed for trochanteric entry
              • use of a straight nail may lead to varus malalignment
      • reaming
        • reamed nailing superior to unreamed nailing, with:
          • increased union rates
          • decreased time to union
          • no increase in pulmonary complications
        • indications for unreamed nail
          • consider for patient with bilateral pulmonary injuries
      • interlocking screws
        • technique
          • computer-assisted navigation for screw placement decreases radiation exposure
          • widening/overlap of the interlocking hole in the proximal-distal direction
            • correct with adjustment in the abduction/adduction plane
          • widening/overlap of the interlocking hole in the anterior-posterior plane
            • correct with adjustment in the internal/external rotation plane
    • postoperative care
      • weight-bearing as tolerated 
      • range of motion of knee and hip is encouraged
    • pros
      • 98-99% union rate
      • low complication rate
        • infection risk 2%
    • cons
      • not indicated for use with ipsilateral femoral neck fracture
      • increased rate of HO in hip abductors with antegrade nailing
      • increased rate of hip pain compared with retrograde nailing
      • mismatch of the radius of curvature of the femoral shaft and intramedullary nails can lead to anterior perforation of the distal femur
  • Retrograde intramedullary nailing  
    • approach
      • 2 cm incision starting at distal pole of patella
      • medial parapatellar versus transtendinous approaches
      • nail inserted with knee flexed to 30-50 degrees
    • technique
      • entry point
        • center of intercondylar notch on AP view
        • extension of Blumensaat's line on lateral
          • posterior to Blumensaat's line risks damage to cruciate ligaments
    • postoperative care
      • weight-bearing as tolerated
      • range of motion of knee and hip is encouraged
    • pros
      • technically easier
      • union rates comparable to those of antegrade nailing
      • no increased rate of septic knee with retrograde nailing of open femur fractures
    • cons
      • knee pain
      • increased rate of interlocking screw irritation
      • cartilage injury
      • cruciate ligament injury with improper starting point
  • External fixation with conversion to intramedullary nail within 2-3 weeks
    • technique
      • safest pin location sites are anterolateral and direct lateral regions of the femur
      • 2 pins should be used on each side of the fracture line
    • pros
      • prevents further pulmonary insult without exposing patient to risk of major surgery
      • may be converted to IM fixation within 2-3 weeks as a single stage procedure
    • cons
      • pin tract infection
      • knee stiffness
        • due to binding/scarring of quadriceps mechanism
  • Special considerations
    • ipsilateral femoral neck fracture
      • priority goes to fixing femoral neck because anatomic reduction is necessary to avoid complications of AVN and nonunion
      • technique
        • preferred methods
          • screws for neck with retrograde nail for shaft
          • screws for neck and plate for shaft
          • compression hip screw for neck with retrograde nail for shaft
        • less preferred methods
          • antegrade nail with screws anterior to nail
            • technically challenging
Complications
  • Heterotopic ossification
    • incidence
      • 25%
    • treatment
      • rarely clinically significant
  • Pudendal nerve injury
    • incidence
      • 10% when using fracture table with traction
  • Femoral artery or nerve injury
    • incidence
      • rare
    • cause
      • can occur when inserting proximal interlocking screws during a retrograde nail
  • Malunion
    • incidence
      • proximal fractures
        • 30%
      • distal fractures
        • 10%
    • risk factors
      • use of a fracture table increases risk of internal rotation deformities when compared to manual traction
      • fracture comminution   
      • night-time surgery
    • treatment
      • rotational malalignment
        • if noticed intraoperatively, remove distal interlocking screws and manually correct rotation
        • if noticed after union, osteotomy is required
  • Delayed union
    • treatment
      • dynamization of nail with or without bone grafting
  • Nonunion
    • incidence
      • <10%
    • risk factors
      • postoperative use of nonsteroidal anti-inflammatory drugs
      • smoking is known to decrease bone healing in reamed antegrade exchange nailing for atrophic non-unions 
    • treatment
      • reamed exchange nailing
  • Infection
    • incidence
      • < 1%
    • treatment
      • removal of nail and reaming of canal
      • external fixation used if fracture not healed
  • Weakness
    • quadriceps and hip abductors are expected to be weaker than contralateral side
  • Iatrogenic fracture etiologies 
    • risk factors
      • antegrade starting point 6mm or more anterior to the intramedullary axis
        • however, anterior starting point improves position of screws into femoral head
      • failure to overream canal by at least .5mm
  • Mechanical axis deviation (MAD)  
    • lengthening along the anatomical axis of the femur leads to lateral MAD
    • shortening along the anatomical axis of the femur leads to medial MAD
  • Rotational malalignment   
    • most accurately determined by the Jeanmart method 
      • using the angle between a line drawn tangential to the femoral condyles and a line drawn through the axis of the femoral neck

 

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Qbank (43 Questions)

TAG
(SBQ12.2) A 25-year-old male presents following a motor vehicle collision with a Glasgow Coma Scale of 7. Subsequent imaging in the trauma bay demonstrates a bifrontal cerebral contusion, an L4 burst fracture, multiple rib fractures, an LC-1 type pelvic ring injury, a femoral shaft fracture, and an open ipsilateral tibial shaft fracture. He is intubated and an intracranial pressure monitor is placed which consistently measures 30mm Hg. He is normotensive with a lactate of 1.5 after 2 liters of crystalloid and 1 unit of packed red blood cells. Which of his injuries would most dictate a temporizing approach with external fixation of his femoral shaft fracture instead of reamed intramedullary nailing? Topic Review Topic

1. L4 burst fracture
2. Bifrontal cerebral contusion
3. Open ipsilateral tibia fracture
4. LC1 pelvic ring injury
5. Rib fractures

PREFERRED RESPONSE ▶
TAG
(SBQ12.10) A 24-year-old male sustains the isolated injuries shown in Figures A and B during a high-speed motor vehicle accident. On physical examination, the overlying skin is intact and there is no evidence of a Morel-Lavallée lesion. Which of the following surgical techniques is considered to have the highest rate of fracture malreduction with this combined injury? Topic Review Topic
FIGURES: A   B        

1. Antegrade cephalomedullary nail
2. Retrograde intramedullary nail and 3 cannulated screws
3. Retrograde intramedullary nail and sliding hip screw
4. Antegrade intramedullary nail and 3 cannulated screws
5. Plate fixation of the diaphyseal fracture and 3 cancellous screws

PREFERRED RESPONSE ▶
TAG
(OBQ13.144) A 23-year-old man undergoes intramedullary nailing for a comminuted right femur fracture. Three weeks after surgery, CT scans are performed to assess for rotational malalignment. In Figure A, the angular rotation of the right femoral neck is internal rotation of 13° while the angular rotation of the left femoral neck is external rotation of 13°. In Figure B, the angular rotation of the right and left femoral condyles is external rotation of 17° and 3°, respectively. At revision surgery, in order to correct the rotational malalignment, the right distal femur must be rotated which of the following? Topic Review Topic
FIGURES: A   B        

1. Internally by 20°
2. Externally by 20°
3. Internally by 14°
4. Externally by 14°
5. Internally by 40°

PREFERRED RESPONSE ▶
TAG
(OBQ12.51) A 34-year-old male presents after falling off a roof at his job. He has an obvious deformity of his left lower extremity, and injury radiographs are shown in Figures A and B. He has no other injuries. Which of the following definitive treatment algorithms will most likely lead to the best outcomes in this patient? Topic Review Topic
FIGURES: A   B        

1. Closed reduction and percutaneous screw fixation of the femoral neck, followed by reamed antegrade nailing of the femur fracture
2. Reamed antegrade nailing of the femoral shaft fracture, followed by open reduction and percutaneous screw fixation of the femoral neck fracture
3. Reamed retrograde nailing of the femoral shaft fracture, followed by closed reduction and percutaneous screw fixation of the femoral neck
4. Open reduction and screw fixation of the femoral neck, followed by reamed retrograde nailing of the femoral shaft fracture
5. Open reduction and screw fixation of the femoral neck, followed by plating of the femoral shaft fracture

PREFERRED RESPONSE ▶
TAG
(OBQ12.232) A 22-year-old male sustains the injury seen in Figures A and B as the result of a motor vehicle collision. He subsequently undergoes the procedure shown in Figures C and D with a 12 millimeter nail. When would full weight-bearing be allowed after surgery? Topic Review Topic
FIGURES: A   B   C   D    

1. Immediately
2. 4-6 weeks
3. 8 weeks
4. 12 weeks
5. After consolidation is seen

PREFERRED RESPONSE ▶
TAG
(OBQ11.91) A 25-year-old male sustained a closed midshaft femur fracture following a motor vehicle collision. He is taken to the operating room for intramedullary nail fixation of the fracture. Figure A is a lateral flouroscopic view of the distal femur taken just prior to distal interlocking screw placement. What change in position (with the C-arm stationary) would be expected to produce a perfect lateral view of the interlocking hole? Topic Review Topic
FIGURES: A          

1. Raising the leg
2. Lowering the leg
3. Internal (or external) rotation of the leg
4. Abduction (or adduction) of the leg
5. Fluoroscopic magnification

PREFERRED RESPONSE ▶
TAG
(OBQ11.110) Which of the following is an advantage of computer-assisted navigation used to place medullary nail interlocking screws compared to a freehand techinque? Topic Review Topic

1. Reduced fluoroscopy time
2. More reliable placement of interlocking screws through the nail
3. Reduced procedure time
4. Increased quality of fluoroscopic images
5. Improved accuracy of screw length

PREFERRED RESPONSE ▶
TAG
(OBQ11.245) A 22-year-old male undergoes retrograde intramedullary nailing for the injury seen in Figure A. Which of the following would place branches of the femoral nerve and deep femoral artery at greatest risk during placement of the interlocking screw seen in Figure B? Topic Review Topic
FIGURES: A   B        

1. Anterior to posterior placement above the lesser trochanter
2. Anterior to posterior placement below the lesser trochanter
3. Lateral to medial placement above the lesser trochanter
4. Lateral to medial placement below the lesser trochanter
5. Open placement with blunt dissection down to bone

PREFERRED RESPONSE ▶
TAG
(OBQ10.12) A 34-year-old male is involved in a motor vehicle collision and sustains several orthopaedic injuries. Figure A shows a red line representating a fracture of the proximal femur. This fracture orientation is often present when found concomitantly with which of the following orthopaedic injuries? Topic Review Topic
FIGURES: A          

1. Ipsilateral acetabular fracture
2. lumbar spine burst fracture
3. Ipsilateral femoral shaft fracture
4. Anterior-posterior compression pelvic injury
5. Ipsilateral calcaneus fracture

PREFERRED RESPONSE ▶
TAG
(OBQ10.256) Which of the following factors is most associated with malrotation during antegrade or retrograde femoral nailing? Topic Review Topic

1. Surgeon experience
2. Level of primary fracture line
3. Use of a piriformis starting portal
4. Fracture comminution
5. Closed reduction technique

PREFERRED RESPONSE ▶
TAG
(OBQ09.28) A 29-year-old male sustained a mid-shaft femur fracture in a motorcycle accident. Which of the following is associated with approximately 5% of patients sustaining this injury? Topic Review Topic

1. Heterotopic ossification
2. Ipsilateral femoral neck fracture
3. Ipsilateral posterolateral corner injury
4. Pudendal nerve injury
5. Ipsilateral superficial femoral artery injury

PREFERRED RESPONSE ▶
TAG
(OBQ09.102) A 26-year-old male sustains a femoral shaft fracture treated with the implant shown in Figure A. Postoperatively, what muscular deficits can be expected at medium and long-term follow-up? Topic Review Topic
FIGURES: A          

1. Weakness with hip abduction and knee flexion
2. Weakness with hip abduction and knee extension
3. Weakness with knee flexion and knee extension
4. Weakness with hip external rotation and hip abduction
5. Weakness with hip external rotation and hip flexion

PREFERRED RESPONSE ▶
TAG
(OBQ09.195) Antegrade femoral nailing has an increased rate of which of the following when compared to retrograde femoral nailing? Topic Review Topic

1. Varus malalignment
2. Union rate
3. Operative time
4. Subsequent operative procedures
5. Hip pain

PREFERRED RESPONSE ▶
TAG
(OBQ08.105) A 38-year-old male was struck by a truck and sustained the injury seen in figure A. Treating this injury with an intramedullary nail with a larger radius of curvature can lead to what complication? Topic Review Topic
FIGURES: A          

1. Posterior perforation of the distal femur
2. Varus malreduction
3. Comminution of the fracture site
4. Iatrogenic femoral neck fracture
5. Anterior perforation of the distal femur

PREFERRED RESPONSE ▶
TAG
(OBQ08.220) Reamed femoral intramedullary nailing is associated with a higher rate of which of the following, as compared to nonreamed nailing for distal femoral shaft fractures? Topic Review Topic

1. Malalignment
2. Pulmonary complications
3. Need for transfusion
4. Iatrogenic fracture
5. Union

PREFERRED RESPONSE ▶
TAG
(OBQ07.19) Your 25-year-old patient complains of anterior knee pain after retrograde femoral nailing for a diaphyseal fracture and asks you why you didn’t perform antegrade nailing as he has seen on the internet. You tell him that retrograde nailing is your preferred technique over antergrade nailing for diaphyseal femoral fractures because it has been shown to have which of the following? Topic Review Topic

1. Increased rate of union
2. Decreased rate of infection
3. Shorter operative time
4. Lower rates of hip pain
5. Lower rates of knee pain

PREFERRED RESPONSE ▶
TAG
(OBQ07.74) A 26-year-old male presents after a motor vehicle accident. Work-up reveals a closed left femoral shaft fracture, and an ipsilateral posterior wall fracture. He undergoes intramedullary nailing of the femur, and open reduction internal fixation of the posterior wall. He is treated with 25 mg of indomethacin three times daily for 6 weeks following an initial dose on the evening of surgery for heterotopic ossification prophylaxis. Which of the following is true regarding this post-operative treatment protocol? Topic Review Topic

1. It is associated with an increased rate of femoral shaft nonunion
2. It has no affect on the healing time of the posterior wall fracture
3. It is associated with a faster time to union
4. Indomethacin is superior to radiation treatment in the prevention of heterotopic ossification
5. There is a decreased rate of revision surgery needed when indomethacin is administered post-operatively

PREFERRED RESPONSE ▶
TAG
(OBQ07.194) Postoperative varus alignment of a subtrochanteric femur fracture treated with an intramedullary nail has been shown to be related to which of the following factors? Topic Review Topic

1. Use of a piriformis entry nail through a greater trochanteric entry portal
2. Use of a greater trochanteric entry nail through a piriformis entry portal
3. Use of a lateral entry nail through a piriformis entry portal
4. Use of a femoral distractor device to obtain reduction
5. Use of a fracture table to obtain reduction

PREFERRED RESPONSE ▶
TAG
(OBQ06.33) The greatest amount of iatrogenic injury to the piriformis tendon is associated with which of the following? Topic Review Topic

1. Antegrade piriformis entry femoral nailing
2. Antegrade greater trochanteric entry femoral nailing
3. Retrograde femoral nailing
4. External fixation of a femoral shaft fracture
5. Open reduction and internal fixation of an intertrochanteric fracture

PREFERRED RESPONSE ▶
TAG
(OBQ06.39) In patients with ipsilateral femoral neck and shaft fractures, what percent of femoral neck fractures are diagnosed on a delayed basis if fine cut CT is not utilized? Topic Review Topic

1. 1%
2. 10%
3. 30%
4. 60%
5. 75%

PREFERRED RESPONSE ▶
TAG
(OBQ06.41) A 22-year-old male sustains the injury shown in Figure A. When placing an antegrade intramedullary nail with manual traction in a supine position, which of the following is true when compared to placement of a nail using a fracture table? Topic Review Topic
FIGURES: A          

1. Increased operative time
2. Decreased internal malrotation deformities
3. Increased external malrotation deformities
4. Increased pudendal nerve injury
5. Increased need for revision

PREFERRED RESPONSE ▶
TAG
(OBQ06.57) A trauma patient presents with a major head injury and femoral shaft fracture. He undergoes early fixation of the femur fracture with a prolonged period of intraoperative hypotension. What is the most likely outcome to be expected post-operatively in this patient? Topic Review Topic

1. Increased risk of post-operative bleeding
2. Increased risk of pneumonia
3. Decreased IV fluid administration
4. Lower Glasgow Coma Scale scores at the time of discharge from hospital
5. Improved central nervous system outcomes at the time of discharge from hospital

PREFERRED RESPONSE ▶
TAG
(OBQ06.163) A 33-year-old female sustains the injury shown in Figure A. Compared to antegrade nailing of this injury, retrograde nailing has been shown to have an increased amount of which of the following? Topic Review Topic
FIGURES: A          

1. Operative time
2. Symptomatic distal interlocking screws
3. Hip pain
4. Union rate
5. Final knee range of motion

PREFERRED RESPONSE ▶
TAG
(OBQ05.57) A 32-year-old male sustains a closed head injury, a closed pelvic ring injury, as well as the bilateral open femoral fractures shown in Figures A-C. He remains borderline hypotensive with a base deficit of 4.9 after an exploratory laparatomy and splenectomy. After irrigation and debridement of his open fractures, what is the most appropriate treatment for this patient at this time? Topic Review Topic
FIGURES: A   B   C      

1. Bilateral retrograde femoral nailing and pelvic binder application
2. Bilateral retrograde femoral nailing and anterior pelvic external fixation
3. Bilateral antegrade femoral nailing and pelvic binder application
4. Bilateral femoral external fixation and anterior pelvic external fixation
5. Bilateral femoral plating and anterior pelvic external fixation

PREFERRED RESPONSE ▶
TAG
(OBQ05.132) Which of the following has been shown to have similar biochemical and clinical characteristics as iliac crest autograft? Topic Review Topic

1. BMP-2
2. BMP-7 with collagen matrix carrier
3. Hydroxyapatite cement
4. Platelet rich plasma with allograft cancellous bone carrier
5. Femoral intramedullary reaming contents

PREFERRED RESPONSE ▶
TAG
(OBQ05.189) A patient undergoes the treatment seen in Figure A for a displaced intertrochanteric femoral fracture. With use of this construct, a starting point 3 mm anterior to the center of the piriformis fossa has which of the following benefits? Topic Review Topic
FIGURES: A          

1. Improved placement of screws through the nail into the femoral head
2. Decreased risk of varus alignment
3. Decreased risk of joint penetration
4. Decreased risk of avascular necrosis of femoral head
5. Decreased risk of iatrogenic proximal femur fracture

PREFERRED RESPONSE ▶
TAG
(OBQ05.221) A 20-year-old male is involved in a motorcycle accident and presents with the injuries shown in Figures A-F. The left ankle injury is open medially, with a clean 3cm laceration, and the right femur and tibia are closed. He has no visceral or head injury, and is hemodynamically stable. He is cleared to go to the operating room. Without taking into account order of fixation, how should his injuries be treated? Topic Review Topic
FIGURES: A   B   C   D   E   F

1. Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and casting
2. External fixation of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF
3. Antegrade nailing of the femur, external fixation of the tibia and ankle after debridement
4. Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF
5. External fixation of the tibia and femur, and ankle debridement and external fixation

PREFERRED RESPONSE ▶
TAG
(OBQ04.188) Placing the starting point for an antegrade femoral nail too anterior to the axis of the medullary canal can most commonly lead to what intraoperative complication? Topic Review Topic

1. Nail incarceration
2. Loss of locking screw trajectory into the lesser trochanter
3. Creation of a recurvatum deformity
4. Iatrogenic fracture of the proximal fragment
5. Decrease in hoop stresses

PREFERRED RESPONSE ▶
TAG
(OBQ04.204) Which of the following variables has not been shown to be increased in patients who sustain bilateral femoral shaft fractures as compared to patients with unilateral femoral shaft fractures? Topic Review Topic

1. Hypotension upon initial evaluation
2. Mortality
3. Incidence of femoral rotational deformity
4. Open skull fractures
5. Pelvic fractures

PREFERRED RESPONSE ▶
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300 responses
http://upload.orthobullets.com/cases/2479/8125007b-67d0-4b5e-8066-6586a2baabb4_slav01.jpg http://upload.orthobullets.com/cases/2479/4265f59f-5d04-4f18-9c05-7872aff13137_slav.jpg http://upload.orthobullets.com/cases/2479/da91609c-764b-411b-881c-bcfbac4b3321_slav1.jpg
HPI - Traffic accident 1 year ago 1.- Left femur: Bifocal fracture (shaft and femoral...
poll
1/12/2016
379 responses
http://upload.orthobullets.com/cases/2443/2747581d-dcd9-4d72-9356-c7fbb862860a_fem_non_un.jpg http://upload.orthobullets.com/cases/2443/364bb655-3930-498d-8566-b29c9efcf8ec_fem_non_union.jpg http://upload.orthobullets.com/cases/2443/357ffbb0-472c-4225-bb33-0cc7c76f6e15_fem_non_un_15.jpg
HPI - Pain in the knee present since 2 months postop; with stiffness in the knee in mo...
poll
11/23/2015
302 responses
http://upload.orthobullets.com/cases/2424/58e6fefc-abba-4399-b6a4-f0c345073cde_11.jpg http://upload.orthobullets.com/cases/2424/160eb4ca-4838-4292-b9f3-1f63205fe79c_12.jpg
HPI - H/o fall down on LF thigh
poll
11/3/2015
233 responses
http://upload.orthobullets.com/cases/2362/open femur.jpg
HPI - 17-year-old male present to ER 10-days after gun shot wound to his left thigh. I...
poll
9/19/2015
436 responses
http://upload.orthobullets.com/cases/2355/90c91197-2fa4-46d7-8159-31a0c50b7212_fr_femur.jpg http://upload.orthobullets.com/cases/2355/1ab189a1-12da-41f8-be7e-00144fe357b0_fr_femur_knee.jpg http://upload.orthobullets.com/cases/2355/58f37075-7fa8-4f57-8861-a722f289dd3c_im_nail.jpg
HPI - RTA with severe pain and inability to bear weight on rt lower limb.
poll
9/13/2015
506 responses
http://upload.orthobullets.com/cases/2301/sa1.jpg http://upload.orthobullets.com/cases/2301/sa2.jpg http://upload.orthobullets.com/cases/2301/sa3.jpg
HPI - Trapped his right leg in wheelchair while moving to bed - deformation, came to h...
poll What type of implant would you use for 1st and 2nd operation?
7/28/2015
132 responses
http://upload.orthobullets.com/cases/2214/fx_1.jpg http://upload.orthobullets.com/cases/2214/fx_2.jpg
HPI - Level fall 2 weeks ago, because of a operating room lack we could not fix it ear...
poll Best treatment for this case
4/26/2015
327 responses
http://upload.orthobullets.com/cases/2209/10005.jpg http://upload.orthobullets.com/cases/2209/14.jpg http://upload.orthobullets.com/cases/2209/12.jpg
HPI - A 26 years old male involved in RTA , generally stable , with closed comminuted...
poll what do you think about the stability of the fixation? when and how you are...
4/25/2015
45 responses
http://upload.orthobullets.com/cases/2102/image.jpg http://upload.orthobullets.com/cases/2102/20150105_204818.jpg http://upload.orthobullets.com/cases/2102/20150105_204831.jpg
HPI - 20-year-old male with left thigh deformity , pelvic pain, splenic rupture after...
poll How would you treat this fracture?
1/5/2015
244 responses
http://upload.orthobullets.com/cases/2094/weatherford_110919_-6.jpg http://upload.orthobullets.com/cases/2094/weatherford_110919_-7.jpg http://upload.orthobullets.com/cases/2094/photo-33.jpg
HPI - 40-year-old healthy male with isolated lower extremity pain after a motorcycle c...
poll How would you treat this fracture?
12/29/2014
78 responses
http://upload.orthobullets.com/cases/2093/20141221_114446.jpg http://upload.orthobullets.com/cases/2093/20141221_114432.jpg
HPI - The patient suffered this injury after road traffic accident , the pt is otherwi...
poll How would you treat this injury?
12/29/2014
318 responses
http://upload.orthobullets.com/cases/2075/wp_20141202_005.jpg http://upload.orthobullets.com/cases/2075/wp_20141202_008.jpg http://upload.orthobullets.com/cases/2075/wp_20141202_006.jpg
HPI - Operated 2 times. 1st time non union with an intramedular nail no blocked proxi...
poll what is the best treatment? We do not have allograft
12/2/2014
655 responses
http://upload.orthobullets.com/cases/2060/photo0258_1_.jpg http://upload.orthobullets.com/cases/2060/photo0260.jpg http://upload.orthobullets.com/cases/2060/photo0261.jpg
HPI - Collided with a car while he was riding a motor bike 2 days ago.
poll How would you treat this injury?
11/13/2014
976 responses
http://upload.orthobullets.com/cases/2030/photo0302.jpg http://upload.orthobullets.com/cases/2030/photo0303.jpg http://upload.orthobullets.com/cases/2030/photo0304.jpg
HPI - He had closed fracture of R/ Femur following RTA in 2013. He was operated in a p...
poll What will you do for this patient at this stage?
9/20/2014
189 responses
http://upload.orthobullets.com/cases/2004/img_20140804_170031.jpg http://upload.orthobullets.com/cases/2004/img_20140804_170022.jpg
HPI - Patient had road side accident about 1yrs back when he sustained closed fracture...
poll What should be the treatment for femoral nonunion
8/16/2014
347 responses
http://upload.orthobullets.com/cases/1969/img_20140701_103250.jpg http://upload.orthobullets.com/cases/1969/img_20140701_103303.jpg
HPI - History of road side accident 5 months back leading to closed fracture shaft fem...
poll What should be the treatment option
7/13/2014
349 responses
http://upload.orthobullets.com/cases/1866/20140407_123841.jpg http://upload.orthobullets.com/cases/1866/femur.jpg http://upload.orthobullets.com/cases/1866/20140409_123605.jpg
HPI - A 60 year old psychiatric patient (Schizophrenia) lived in an institution and mo...
poll How would you treat this injury?
4/7/2014
129 responses
http://upload.orthobullets.com/cases/1850/1-1.jpg http://upload.orthobullets.com/cases/1850/2.jpg http://upload.orthobullets.com/cases/1850/3.jpg
HPI - fall from height traction in Thomas splint for 12 days
poll Is this position accepted ?
3/31/2014
148 responses
http://upload.orthobullets.com/cases/1761/20140124_161425.jpg
HPI - Sustained fracture 8 months back. Underwent an open interlocking nailing and pri...
poll How would you treat this patient?
1/24/2014
246 responses
http://upload.orthobullets.com/cases/1741/d282f514-8f99-476e-b063-b37fd5e0b1f8_ap_left_femur.jpg
HPI - An 83F presents to you 2 weeks after ORIF for a supracondylar left femur fractur...
poll Would you reop to get better result? Prevent psudoarthrosis ?
1/4/2014
4 responses
http://upload.orthobullets.com/cases/1690/20131116_100746.jpg http://upload.orthobullets.com/cases/1690/img-20131030-wa0000.jpg http://upload.orthobullets.com/cases/1690/img-20131030-wa0006.jpg
HPI - pain at left hip ,increases on moving the left lower limb,5 cms of shortening,
poll what is treatment of choice now?
11/16/2013
5 responses
http://upload.orthobullets.com/cases/1654/image3188 edited.jpg
HPI - two years back patient had an accident and sustained Gustillo open III fracture...
poll How can this be treated??
10/6/2013
892 responses
http://upload.orthobullets.com/cases/1622/delayed uonion of shaft femur.jpg
HPI - falling from hieght operated since 4,5 mounth no visible callus and thereis a...
poll management?
9/10/2013
45 responses
http://upload.orthobullets.com/cases/1614/manjit kaur 1.jpg http://upload.orthobullets.com/cases/1614/manjit kaur dr rajesh 2.jpg http://upload.orthobullets.com/cases/1614/manjit kaur dr rajesh.jpg
HPI - Communited/segmental subtrochanteric femur fracture, treated by by closed reduct...
poll What should be further plan of treatment
9/3/2013
365 responses
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HPI - Pain in thigh,unable to bear weight,no signs of any infection
poll Next management
8/24/2013
103 responses
http://upload.orthobullets.com/cases/1468/fem ap.jpg http://upload.orthobullets.com/cases/1468/fem lat.jpg http://upload.orthobullets.com/cases/1468/fem non union.jpg
HPI - 3 years ago had a fall and fractured his left femur which had an intramedullary...
poll what are the options surgically
4/4/2013
229 responses
http://upload.orthobullets.com/cases/1453/photo-0020.jpg http://upload.orthobullets.com/cases/1453/photo-0021.jpg http://upload.orthobullets.com/cases/1453/photo-0019.jpg
HPI - Motor bike accident. Developed compartment syndrome of R leg. Double incision Fa...
poll How to fix the femur & tibia? ( we dont have retrograde nails)
3/16/2013
218 responses
http://upload.orthobullets.com/cases/1431/preop.jpg http://upload.orthobullets.com/cases/1431/preop1.jpg http://upload.orthobullets.com/cases/1431/int1.jpg
HPI - history of road traffic accident
poll how would you have treat this patient after the first nailing?
2/27/2013
135 responses
http://upload.orthobullets.com/cases/1402/20130129_124730.jpg http://upload.orthobullets.com/cases/1402/20130129_125343.jpg http://upload.orthobullets.com/cases/1402/20130129_125348.jpg
HPI - Road side accident on 25 feb 2012. Ipsilateral fracture neck femur and shaft tre...
poll What should be the treatment plan
2/5/2013
62 responses
http://upload.orthobullets.com/cases/1387/11.jpg http://upload.orthobullets.com/cases/1387/1.jpg http://upload.orthobullets.com/cases/1387/12.jpg
HPI - 42 YEARS OLD LADY , NO CO-MORBIDITY , SUSTAIN MVA 3 DAYS BACK , HEMODYNAMICALLY...
poll WHAT WOULD BE THE BEST OPTION FOR HER femur fracture
1/14/2013
2406 responses
http://upload.orthobullets.com/cases/1323/agha fem frac3.jpg http://upload.orthobullets.com/cases/1323/agha femur frac.jpg http://upload.orthobullets.com/cases/1323/agha femur frac1.jpg
HPI - pain deformity left femur after fall at home
poll elastic nailing or spica
11/17/2012
40 responses
http://upload.orthobullets.com/cases/1294/photo5.jpg http://upload.orthobullets.com/cases/1294/photo3.jpg http://upload.orthobullets.com/cases/1294/image.jpg
HPI - Patient has Duchenne muscle dystrophy, bed ridden, severe osteoporosis. Fell dow...
poll What is the best fixation option?
10/18/2012
34 responses
http://upload.orthobullets.com/cases/1285/fati kaci^  m_cr_20050625_112853_1.jpg http://upload.orthobullets.com/cases/1285/3627e4cb-a7f1-4578-baba-6615725416ed_ft1.jpg http://upload.orthobullets.com/cases/1285/fethi kaci^ m_cr_20050704_115457_1.jpg
HPI - h/o fall from height
poll shaft of femur should we open and alighn rotated fragments
10/11/2012
28 responses
http://upload.orthobullets.com/cases/1251/subtroch ap.jpg http://upload.orthobullets.com/cases/1251/subtroch lat.jpg
HPI - patient has cushing syndrome and is on steroids
poll what is the best treatment in given circumstances
7/30/2012
79 responses
http://upload.orthobullets.com/cases/1177/ap1.jpg http://upload.orthobullets.com/cases/1177/ap2.jpg http://upload.orthobullets.com/cases/1177/lateral 1.jpg
HPI - GSW to left thigh
poll How would you treat this patient?
3/14/2012
283 responses
http://upload.orthobullets.com/cases/1141/97322841.jpg http://upload.orthobullets.com/cases/1141/97322842.jpg
HPI - 40 yrs old male with history of spina bifida and neurological deficit both lower...
poll what will be the line of management
2/5/2012
123 responses
http://upload.orthobullets.com/cases/1021/1.jpg http://upload.orthobullets.com/cases/1021/2.jpg http://upload.orthobullets.com/cases/1021/3.jpg
HPI - s/p MVC, isolated injury to RLE
poll Any other treatment ideas/preferred treatment for this pattern of injury?
2/4/2011
6 responses
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