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Femur fracture: causes, symptoms, diagnosis, treatment
Last reviewed: 23.04.2024
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[Fractures of the proximal femur
ICD-10 code
- S72.0. Fracture of the neck of the thigh.
- S72.1. A violent fracture.
- S72.2. The vertebral fracture.
Classification
There are medial (intraarticular) and lateral (extraarticular) fractures. The first include fractures of the head and neck of the femur, the second - interverting, overturning and isolated fractures of large and small skewers.
Medial fractures of hip
Epidemiology
Fractures of the femoral head are rare. Violations of the integrity of his neck account for 25% of all hip fractures.
Classification
Depending on the passage of the fracture line, subheading (subcapital), transhepatic (transcervical) and fracture of the base of the neck (basal) are distinguished.
By the position of the limb at the time of injury, fractures of the femoral neck are divided into abduction and adduction ones.
Causes
Abduction fractures occur when falling on the leg in the hip joint. At the same time, the cervico-diaphyseal angle, which is at the norm of 125-127 °, increases, so these fractures are also called valgus fractures.
When falling on the reduced leg, there is a decrease in the neck-diaphyseal angle (adduction, or varus, fractures). Varus fractures are found 4-5 times more often.
Symptoms
Medial fractures of the femoral neck often occur in the elderly with a fall on the reduced or withdrawn leg. After a trauma, there are pains in the hip joint and loss of the limb's limb.
Diagnostics
Anamnesis
In the history - a characteristic trauma.
Examination and physical examination
The damaged limb is rotated outward, moderately shortened. The region of the hip joint has not been changed. At palpation, the increase in pulsation of the femoral vessels under the puapartic ligament (SY Girgolava symptom) and soreness are noted. Positive symptoms of axial load and "stitched heel": patients can not lift the leg that has been unbent at the knee joint. The limb is shortened due to the functional length.
Laboratory and instrumental research
The location of the fracture and the size of the neck-diaphysial angle are determined from the roentgenogram.
Treatment
Patients with fractures of the femoral neck are treated promptly, except for punctured valgus fractures and injuries against the background of general contraindications to surgical intervention.
Conservative treatment
Conservative treatment in young people consists in the imposition of a large hip bandage in Whitman with the removal of the limb by 30 ° and rotation inwards for a period of 3 months. Then, walking on crutches is allowed without stress on the injured limb. The load is allowed no earlier than 6 months after the injury. The ability to work is restored after 7-8 months.
In elderly people, the large hip bandage gives various complications, so it is more reasonable to apply a skeletal traction for the hip condyle for 8-10 weeks with a weight of 3-6 kg. The limb is withdrawn by 20-30 ° and moderately rotated to the inside. Assign early therapeutic gymnastics. From the 710th day, patients are allowed to rise on their elbows, gradually teaching them to sit in bed, and after 2 months - to stand on crutches without load on the limb. Further tactics are the same as after removal of gypsum.
Surgery
Bone callus, as already mentioned above, develops from the endostasis, periosteum, intermediarily, parasomally from the adjacent muscles and the primary blood clot, and for a full-fledged reparative regeneration, a good blood supply is necessary. With a fracture of the femoral neck, the central fragment is almost completely deprived of food, since the blood supply comes from the metaphysis from the place where the capsule is attached. The artery of the round ligament of the thigh is obliterated at the age of 5-6 years. The pectoral neck of the femur is not covered, the fistula of the joint is fenced off from the nearest mice and the primary blood clot is blurred by the synovial fluid, so the source of regeneration is only the endosteum. All this becomes the main cause of posttraumatic aseptic necrosis of the head and neck of the femur in 25% of the affected and more.
Thus, in order to consolidate the fracture of the femoral neck in such unprofitable conditions, a good comparison and rigid fixation of fragments is necessary, which can only be achieved surgically.
In surgical treatment, there are two types of osteosynthesis of the femoral neck: open and closed.
When the method is open, an arthrotomy of the hip joint is produced, and fragments are uncovered and repopulated. Then, from the susceptible region, a pin is punched, which under the vision control and secures the fragments. The wound is sutured. An open, or intraarticular, method is rarely used, because after it often develops severe coxarthrosis. The method is traumatic.
A widespread , or extraarticular, method of osteosynthesis of the femoral neck has become widespread . The patient is placed on the orthopedic table. Under local or general anesthesia, a reposition of fragments is made by removing the limb by 15-25 °, traction along the axis and internal rotation is 30-40 ° compared to the normal position of the foot. The achieved reposition is confirmed by an X-ray.
Dissect soft tissues in the susceptible region to the bone, from this point a pin is pierced, which must fasten the fragments, without deviating from the axis of the neck of the thigh. This is not an easy task, because the surgeon does not see the fragments. In order not to miss, they resort to the help of various guides. Many surgeons do not use directors, but do the following. Parallel to the lumpy bunch, a metal bar with holes is sewn onto the skin of the patient's stomach. From the susceptible region, two spokes are carried out, guided by the projected projection of the femoral neck. Carry out X-ray inspection. If the spokes stand well, a three-bladed nail is punched through them. If not, then the position of the nail is corrected, focusing on the spokes and a plate with holes. After the fragments are fixed, the traction along the limb axis is eliminated, the fragments are knocked together by a special instrument (impactor), and the diaphyseal pad is screwed onto the trichlasp nail, which is fastened to the femur with screws. The wound is sutured. Apply a posterior gypsum lingette from the angle of the scapula to the ends of the fingers for 7-10 days. From the first day after the operation, they begin respiratory gymnastics. After elimination of the immobilization of the limb, the decontamination position is imparted. The patient is allowed to climb on his elbows, and then sit on the bed. After 4 weeks, the victim can walk on crutches with no load on the operated limb. The load is allowed no earlier than 6 months after the operation. Workability is restored after 8-12 months.
Optimal simplification of the technique of closed osteosynthesis of the femoral neck teleradiology control. It helps to significantly reduce the time of intervention, which is extremely necessary for operations in older patients burdened with concomitant diseases. After reposition, a cut is made to the bone in the area of the pitting fossa 2-3 cm long. The fragments are fastened with two or three long spongy screws. Apply seams to the skin.
A more reliable and durable form of osteosynthesis of cervical and vertebral fractures is the fixation with a dynamic crocheted DHS screw, as will be discussed in the section "Lateral fractures".
If a patient refuses surgery or concomitant diseases is considered a contraindication to surgery, treatment should be aimed at activating the patient. The refusal of the operation does not mean refusal of treatment. It begins with the prevention of thromboembolic complications (bandage of limbs, anticoagulants). The patient should sit in bed, starting from the 2nd day after the injury, on the third day - sit, dangling his legs from the bed. The patient should learn as early as possible to stand and move on crutches with a limb suspended on his own neck with the help of a cloth strap.
Currently, in the treatment of medial head fractures in elderly people with a high degree of prospects for the development of aseptic necrosis, joint replacement is increasingly recognized. It can be unipolar (with the replacement of only the head of the femur) or bipolar (with replacement of the head and acetabulum). For this purpose, prostheses Sivash, Shercher, Moore, etc. Are used. The advantage is given to total endoprosthetics.
Lateral fractures of femur
Epidemiology
Lateral fractures account for 20% of all hip fractures.
Interverting and overt fractures of the hip
Clinical picture and diagnosis. Pain in the area of trauma, limb function impairment. When examined, a swelling in the area of a large trochanter is revealed, palpation is painful. Positive symptom of the axial load. On the roentgenogram, a fracture is revealed, the line of which passes extraarticularly lateral to the attachment of the joint capsule.
The leg. A large area of the fracture, and, accordingly, the contact area of the fragments, as well as good blood supply, can successfully heal the fracture fractures conservatively.
They impose a skeletal traction for the epicondyle of the thigh, the weight of the load is 4-6 kg. The limb is laid on the functional tire and retracted by 20-30 °. The duration of the traction is 6 weeks, then the leg is fixed with a gypsum hip bandage for another 4-6 weeks. The total period of immobilization is not less than 12 weeks. Work allowed after 4-5 months.
In older people, treatment with skeletal traction can be continued up to 8 weeks. Then, during 4 weeks, cuff stretching with a weight of 1-2 kg is applied or the limb's limb position is applied with the help of a retortion boot. To exclude the rotation of the limb, it is possible using sandbags or a retorting boot, cuffs AP. Chernov.
Surgical treatment of vertebral fractures is performed with the aim of activating the victim, reducing the time spent in bed, the fastest training in walking on crutches and self-service.
The operation consists in carrying a two-bladed or three-bladed nail into the femoral neck, which is fastened with fragments, and a large diaphyseal patch is used to impart rigidity to the construction. Instead of nails, you can use a L-shaped plate. The terms of treatment and rehabilitation are the same as for conservative treatment.
In weakened patients, the operation is simplified by replacing the three-bladeed nail with three long spongy screws.
One of the optimal fixatives for vertebral fractures is a dynamic DHS screw. Some stages of the technique of its superposition are shown in Fig. 8-6.
After the intervention, external immobilization is not needed. The patient walks on crutches with a dosed load on the limb, starting from the 3-4th week.
With simultaneous fractures of the femoral neck and skewers, a gamma nail with locking screws (GN-gamma nail) is used. The Gamma-nail is distinguished by the strength of the structure and is qualitatively higher than the nail of DHS. It is also good that in the case of having a susceptible fracture of the femur, its lengthened version (LGN) can also be used. The main advantage of the nail is that the patient is allowed a dosed load on crutches already on the 6th day after the operation.
Isolated fractures of skewers
Fracture of a large trochanter often occurs as a result of a direct mechanism of injury and is characterized by local pain, edema, restriction of limb functions. Palpation can reveal crepitation and a mobile bone fragment. Then the radiography is performed.
20 ml of 1% solution of procaine is injected into the fracture site. The limb is placed on a functional tire with a 20 ° lead and a moderate external rotation.
Fracture of a small trochanter is the result of a sharp contraction of the iliac-lumbar muscle. At the same time, swelling and tenderness are found on the inner surface of the thigh, a violation of the hip flexion - "a symptom of a stitched heel". The reliability of the diagnosis is confirmed by the radiograph.
After anesthetizing the fracture site, the limb is placed on the tire in the flexion position in the knee and hip joints to a 90 ° angle and moderate internal rotation. In both cases, disciplinary cuff traction is applied with a weight of up to 2 kg.
Terms of immobilization in isolated fractures of skewers - 3-4 weeks.
Recovery of disability occurs after 4-5 weeks.
Diaphyseal Fractures of the Thigh
ICD-10 code
S72.3. Fracture of the body [diaphysis] of the femur.
Epidemiology
About 40% of all fractures of the femur are made up.
Causes
Arise from direct and indirect injury mechanism.
Symptoms and Diagnosis
Diagnosis of a typical diaphyseal fracture is characterized by all its characteristic features. A traumatic feature is the frequent development of shock and bleeding into soft tissues, reaching a loss of 0.5-1.5 liters.
Depending on the level of damage, the fractures of the upper, middle and lower thirds are distinguished, and the displacement of the fragments, and accordingly the tactics in case of violation of the integrity of each of the segments will be different.
- With fractures in the upper third under the effect of muscle traction, the central fragment is displaced anteriorly, outward and rotated outwards. Peripheral fragment is brought and pulled up.
- With a fracture in the middle third, the central fragment is somewhat inclined anteriorly and outwardly, the peripheral fragment is biased upward and slightly reduced. Deformity of the limb is due to the predominant displacement along the length and moderate angular curvature.
- Fracture in the lower third of the femur is characterized by the displacement of the central fragment anteriorly and internally due to the flexion of the flexors and powerful adductor muscles. A short peripheral fragment as a result of the contraction of the gastrocnemius muscles deviates posteriorly. It is possible to damage the neuromuscular bundle with a bone fragment.
Where does it hurt?
Complications of a hip fracture
After hip fractures, especially those treated with old methods, in many cases, persistent extensor contractures of the knee joint develop. The cause of their occurrence is a prolonged immobilization, joint damage or myofasciosis. The latter consists in the fusion of the heads of the quadriceps femoris with the bone, and also various layers of soft tissues between each other, which leads to the shutting down of the functions of the knee joint. Sometimes myofasciothhenodez is combined with patellodez - the increment of the patella to the hip condyles.
From the immobilization and artrogenic contractures, myofasciosis is distinguished by the fact that it occurs after a short (2-3 months) fixation of the limb and with an intact knee joint.
Diagnosis is characterized by a sense of obstruction in the site of adhesion, lack of pain in the development, atrophy of the hip muscles, mainly in the middle third, a violation of the mobility of the cutaneous-fascial thigh case. Check mobility by moving soft tissues up, down, and around the longitudinal axis. The existing scars after the operations are retracted and are even more retracted when trying to move in the knee joint. Note the shift of the patella to the top and the outside, as well as the limitation of its mobility.
With long-term contractures, valgus deviation of the lower leg and recurvation of the knee joint develop.
Characterized by symptoms of tension and uneven muscle tone. In the first case, passive flexion of the tibia leads to a well-expressed tension of the muscles to the site of adhesion. The tension does not extend to the proximal parts. In the second case, with active flexion of the tibia, there is a muscle tension above the fusion and its absence in the distal sections.
X-ray finds excessive bone callosity with spiny outgrowths, soft tissue entrainment, muscle atrophy and an increase in the subcutaneous fat layer.
In the zone of the knee joint - regional osteoporosis, the condyles of the thigh are deformed: reduced and stretched in the anteroposterior direction (symptom of the "boot"). Especially the outer condyle suffers.
Changing the angle of the patella. If the angle between the posterior surface of the patella and the axis of the femur is 27.1 °, then with myofasciosis, the angle decreases to 11.1 °. The patella itself changes its structure and shape. The cortical layer becomes thinner, the body becomes porous and rounded - a "lens" symptom. On the electromyogram above the fusion site, the changes are minimal, but below the fusion of the oscillations are sharply reduced, uneven in height and frequency, and sometimes the curve approaches a straight line.
All the revealed symptoms of knee joint disorders are grouped into a differential diagnostic table, which is necessary to distinguish the three most common contractures: immobilization, arthrogenic and myofasciosis.
It should be noted that the myofasciosis of the knee joint in most cases does not lend itself to conservative treatment and requires surgical intervention. The operation consists of tenomiolysis, separation of the heads of the four-headed muscle and subsequent plastic surgery. In the postoperative period, early functional treatment is mandatory.
In the clinic SamGMU operative treatment of myofasciosis of the knee joint has been conducted since 1961 by various methods: Payra, Judet, Thompson-Kaplan. In recent years, the operations are carried out according to the procedure developed by A.F. Krasnov and V.F. Miroshnichenko.
Longitudinally the straight and intermediate heads are separated from the broad hamstrings and mobilized as much as possible beyond the adhesive process. After this, the tendon of the straight and intermediate thigh muscles is divided in the frontal plane and cut off from the patella. By traction along the length and flexion of the lower leg, these muscles are stretched and the crus is bent to the maximum possible angle, more often to the norm (30-40 °). The tendon of the intermediate thigh muscle is dissected along, and the ends are removed to the right and left of the rectus femoris muscle. The leg is bent at an angle of 90-100 ° and produces the plasty of the quadriceps femoris muscles, using the tendons of the tendon of the intermediate muscle not only to restore the functions, but also to plastic the defects that arise when bending at the knee joint. Then layer-by-layer tissue is sewn on a semi-bent knee joint, a plaster bandage is applied for 2-3 weeks, then removable for another 10-12 days. In the wound for 1-2 days leave two drainage tubes, preferably with active aspiration. From the 2nd to the 3rd day physiotherapy and LFK passive type are shown. On the 4th-5th day, exercise therapy is performed for the knee joint: active flexion and passive extension of the shin. From the 7th-8th day the patient unbends his lower leg, lying on his side, and from the 10th to the 12th day - in a sitting position. After removing the cast, mechanotherapy, swimming pool and exercise therapy in the water, exercises on the simulators, crutches during walking are shown. The load on the limb is allowed after 2-3 weeks from the moment of surgery, but it should be remembered that in the first months after the operative intervention, there is a deficit of active extension at 10-15 °.
What do need to examine?
Treatment of hip fracture
Conservative treatment of hip fracture
Treatment can be conservative and operative. Fractures without displacement are treated by fixing the extremity with a large hip bandage, observing the rule: "The higher the fracture, the greater the hip extraction".
In oblique and spiral fractures, it is advisable to use skeletal traction. The spokes are guided through the epicondyle of the thigh, using a weight of 8-12 kg. The limb is placed on the tire. Taking into account the displacement of the central fragment and to avoid angular deformation of the "riding breeches" with high fractures of the femur, the limb is withdrawn no less than 30 ° from the axis of the trunk. With fractures in the middle third, the lead does not exceed 15-20 °. In both cases, flexion in the knee and hip joints corresponds to 140 °, in the ankle - 90 °.
For fractures of the femur in the lower third, to avoid damage to the neuromuscular bundle and to obtain a comparison of the fragments, it is necessary to lay the reduced limb on the functional tire and bend it at an angle of 90-100 ° in the knee and hip joints. A soft roller is placed under the peripheral patch. The state of the neurovascular bundle is monitored.
Terms of immobilization with conservative methods of treatment 10-12 weeks.
Surgical treatment of hip fracture
The open reposition is terminated by fastening the fragments one way. The most frequently used intramedullary metalloesteosynthesis, less often - extramedullary. Complete the operation by suturing the wound with catgut and applying a gypsum hip bandage.
In operated patients, limb fixation continues for 12 weeks.
Currently, the possibilities of traumatologists in the treatment of fractures of the femur have significantly increased. Restrained attitude of doctors to the use of spokes on the thigh due to frequent suppuration of soft tissues was replaced by active application of external fixation rods, both as an independent method of treatment, and for the preparation of future interventions. A series of powerful and large-sized plates appeared, which allows successfully treating multifuncular fractures of the femur. Particular attention should be paid to the modern, most promising method of intramedullary osteosynthesis with locking pins.
There are four ways of intramedullary osteosynthesis of the body of the femur: reconstructive, compression, dynamic and static.
The insertion of the pin into the femur can be performed antegrade (through the proximal part) or retrograde (through the distal section).
Antegrade method
The operation is performed on the extensional operating table under X-ray control. The patient is placed on his back.
A cut is made over the top of a large trochanter 8-10 cm long. The apex of the large trochanter is released. Slightly medial and anteriorly there is a depression through which Kirschner's needle is passed into the medullary canal.
On the spoke with a cannulated awl widen the hole, and then deepen it by 8 cm. The diameter of the hole should be 2 mm larger than the diameter of the pin. Measure the depth of the medullary canal to the distal part. The intraosseous rod is connected to the proximal and distal guides and, replicating the fragments, is carried into the medullary canal.
Reconstructive nails are used for intraosseous osteosynthesis of the proximal femur with cervical fractures and vertebral fractures. Thanks to the angled installation of reconstructive screws, the head and the area of the trochanter are in anatomical position with respect to the bone body. First the proximal and then the distal part is blocked.
Compression rods are used for intraosseous osteosynthesis of the femur, and the fracture should be at least 3 cm from the blocking screw.
The design of the bar allows the use of compression, dynamic and static methods, and the locking screws with these methods are first placed in the distal and then in the proximal bone. Target-makers clean. With the compression method, the compression screw is screwed into the threaded hole inside the rod, with dynamic and other methods, a blind screw is screwed into it.
Retrograde method
Applied with low diaphyseal fractures of the femur or when it is impossible to work on the proximal part - the presence of metal structures, endoprosthesis, etc.
Before the operation on the radiographs determine the nature of the fractures and the size of the implant rod. The patient lies on a table with a knee joint bent at 30 °. With a small cut, Payra from the medial side opens the knee joint. Expose the intercondylar fossa, through it form a channel in the femur, which becomes a continuation of the medullary canal. Its depth should be 6 cm, width - 1.5-2 cm more than the diameter of the rod. The latter is connected with the target and injected into the medullary cavity. Blocking of the stem begins with the most distal opening, and then - in the proximal part. The operation is completed by inserting a blind screw into the distal end of the intraosseous stem and suturing the knee joint injury. External immobilization is not needed.