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We're gonna cover. Um, so femoral shaft, humeral shaft and tibial shaft in this session. Uh The non union stuff will be rearranged because we had to cancel it because of the strikes last week. So, unfortunately, you've got me going through femoral antiviral shaft because we had to rejig the faculty. Um But hopefully it'll be a useful session for you. So, um if there are any questions, just put them in the chat and we can talk through stuff. If anyone has any questions, just fire away, it's just relaxed and informal. Uh Well, then switch off the recordings and then go through some cases in an informal way. Um And answer any questions you might have. All right. So formal sharp fractures, uh pretty common, uh comes up in the exam usually in the trauma station, you might get it in an adult path station if you've got one that's gone wrong where there's a deformity where there, there is a non union or there is an infection. So that's when you might come across it in the exam, you might get some questions in the M C Q s uh on the topic. And so we'll try and cover everything uh in the next hour or so. So we're gonna cover the anatomy management options, tips and tricks for nailing, uh special considerations and uh we'll do some cases. So, uh the incident is 37 per 100,002, femoral shaft fractures. You think about how many nails you do most of the nails you'll do probably for neck of femur fractures, but femoral shaft fractures aren't as common, uh as neck infamous. The most common diaphyseal fracture is uh tibial shaft fractures. Uh So there were 22 ways that you're going to end up seeing a human, a femoral shaft fracture. It's either a high energy mechanism uh in the young patient and usually associated with polytrauma or a low energy mechanism in the elderly. Uh And that's usually a fragility fracture more than anything else. So, in your exam, uh you're gonna need to know a bit of the of the anatomy for the basic science part of the exam, you're going to need to know how to manage it for the trauma of iver and you're going to need some of this information for part one. So, anatomy, um one of the things in the basic science exam is in the Bible, you've got to be able to draw diagrams. And one of the things that you might be asked to draw is cross sexual anatomy and it's usually common cross sexual anatomy. So a cross section of a femur cross section of the tibia of a humorous of the forearm, um or uh anatomy of the talus or things like that. Okay. So, learning the cross sectional anatomy of the femur is worth doing when you're coming up to the exam that's worth doing. Anyway, um then when thinking about how you're going to treat these fractures or how they're going to behave or what challenges you might have in the reduction. You need to know your anatomy because you need to know your deforming forces. Okay. So the proximal fragment attached to the GTs, gluteus, medius and minimus and they abduct the fracture and then you get a flexed approximal fragment due to the effect of uh iliopsoas on the lesser try canto in the distal section. Uh You get the adductors pulling the distal fragment into various and you get extension due to the effect of gastrocnemius on the posterior aspect of the femur. So the blood supply, you all know the proximal blood supply to the hip. You got asked that registrar interviews. Um So we're not going to cover that. Um We, when you cover the anatomy of the bone in the basic science section, um you talk about the blood supply and the majority of the femoral blood supplies, endosteal. So two thirds um is endosteal. One third is periosteal and uh the diabetes supplied by a nutrient artery. Uh And that supplies the industrial supply. It's what's called the centrifugal force. A centrifugal circulation So the blood flows from high pressure inside the femur, too low pressure outside of the femur. Um And that's completely disrupted during a fracture. Uh And the worry people have about intramedullary nailing is that would it would disrupt the endosteal blood supply. But multiple studies have shown that the fracture has already done that. Um And that the industrial supply is restored even with the femoral naming whether you reme or whether you don't read. So uh you might get asked about the Winquist classification. It's pretty simple. Zero is no combination. Uh One is there's a small butterfly fragment to there's a larger butterfly fragment, but it's less than 50% of the circumference and 3 m pretty much a segmental or a large butterfly fragment. That's almost segmental. Four is a segmental fracture and five is there's a big chunk of bone missing that's been left at the roadside. That's usually an open fracture. Um That classification is important in some respects because it guides whether you're going to let them weightbear. So if you've got a lot of cortical contact and you got bone on bone and then you're not putting all the work through your fixation and it will encourage some bone healing. So you'd be more aggressive and allow them to bone heal. So uh weight bear. So transverse fractures definitely weightbear them and get them going. So your initial management um with all long bone fractures, uh you're either going to have low energy or high energy setting in the exam, you're probably going to get a high energy setting and so you can easily get muddled talking about how you're going to check for airway breathing circulation. It's an orthopedic exam at the end of the day, they might want you to speak about resuscitation because that's part of A T L s. But what you don't want to do is waste a load of time talking about stuff that isn't gonna score your points. So what you need to do is have a practiced or rehearsed line where you're going to say, um this is a high energy mechanism of uh mechanism. I'm going to manage the patient according to A T L S protocol to exclude life threatening injuries. And I'll assume that this is a closed in neurovascular intact injury. You've then taken out all of the, all of the ambiguity about being whether you're safe or not. And now you can concentrate on fixing the femur, working out what the challenges to the fixation are going to be okay. Um And that, that's the kind of approach you need to take for the exam. Uh If they don't want you to do that and they want you to dial back and talk to you about resuscitation, they will just, they'll, they'll call you back and just go with what the examiner says. Um So in the, in the, in the management, you've all done, this patient arrived in a Kendrick splint. So Kendrick Splint is pretty good at just pain relief, holding the leg out to length and reducing muscle spasm. Uh ideally, they should have a femoral uh fascia iliac a block. Um And in an ideal world, you want to get them to theater sooner rather than later. Uh really for pain relief and stabilize the skeletal stabilization. Um But if you're not doing that, then I would recommend taking the Kendrick splint off and setting up appropriate skin traction because the Kendrick splint can cause pressure sores in the groin where that groin strap is and where the bar in dense on the skin, which may affect what your surgical incisions. Um and uh put you put your surgery at risk of wind breakdown and win complications. Um You need an A P and A lateral X ray as a minimum minimum. Uh some patient's will have a polytrauma setting. So you're going to put them through a CT scan. Er, if there's any doubt about the uh the circulation, just ask for distal run offs and get, get CT scans of the lower limb as well. Um in terms of, if there is any concern about articular extension, then get a CT at a later date once you're stabilized. Um But if you're worried about uh blood supply, make that a Ct Andrew. So now we're on to the management bit and this is going to be the main part of your exam answer. Um So briefly mention conservative management and say that there's very little role in the femoral shaft fracture. You're not going to leave someone with the femoral shaft fracture in bed, set up on traction for three months. Um That's not what we do anymore and the complications of being bedbound uh significant. Um So really the only indication for conservative management is severe frailty. If they're frail, you're going to fix them more aggressively to get them up and get the mobilizing and maintain some independence. Um But if they're very frail and cannot essentially be anesthetized and they're not fit enough to have an operation, then you can manage them conservatively, but the majority of patient's will be getting an operation. Um So surgical management, what does that entail? So there's different ways of doing things pretty much every female wants a nail, okay. And there's different ways of nailing. So, rather than tell you how to do a nail on traction, which you've all done since you're S H O s, um we'll talk to you about the different ways and approaches and strategies to deal with nailing a femur. Uh So freehand nailing you may have seen in Cambridge or a knowledge um or in other places. Um It's a good technique to learn and you should have it in your toolbox for certain criteria. So in the really big high B M, my patient's, if you set them up on a traction table, usually the apron over their abdomen will just flop into your surgical field. You won't get good x rays. Um You will not be able to feel any landmarks. It is miserable and you can't get medial enough to get your nail physically down and the you physically will not be able to do the operation. And if you are, you're, you're, the soft tissues will be tipping you into a various mail alignment. And so you'll end up with a mall, reduced and miserable operation. Um It's uh also a good indication to do free hand nailing. If the patient has bilateral femurs, uh or if they're a polytrauma patient with spinal injuries with pelvic fracture, you can't really put them up against the perennial post if they've got a vertical shear pelvic fracture because you will just be distracting that and causing bleeding. Um So then when you're doing freehand nailing, there's different ways of doing it. You can do it on a radio lucent table with a patient supine or in the bigger patient's, you do them lateral. Um and the advance you're doing it lateral is just like when you do a hip replacement, the fat drapes either side and you can actually feel the tree can to most patient's and you can get medial enough to get your entry point and get your nail down. Um So if you haven't seen this, it's worth making an effort to try and see it because it's not difficult but if you, you need to know how to set up the patient and the main thing is getting your X ray views. Once you get your X ray views and once you re orientate yourself, it's just like doing any other now. And the reduction is much easier because the leg is free. You're not fighting the soft tissues so often if you try and reduce the femoral shaft and you jack them out on as much traction as possible. You're fighting against that Fascia lata. It's like a bow string and you, it's really difficult to reduce. Um Whereas actually you put a bit of gentle traction, you can rotate and you can put a clamp on the, on the femur and it will, it will do, it will reduce beautifully. Um It's a free hand nailing. It's, it's a good skill to learn. Um Next, if you've got posterior sag. So the a proximal femoral fragment is there and you've got sub truck and the femur has dropped like that. You need to bring it back up and that's either getting an S H O with a hammer lifting things up, but they don't always exist depending on where you work. Uh So an alternative option is to use this and this is essentially a broom handle with part of a hip support, uh cushion taped to the broom handle, um as a bit of padding and then jammed against the floor. And what under the femur and what that does just lifted the femur up for this. Uh the HS I was doing during um during COVID um where there were no assistance. Uh So it just brings that femur up and you can hold it in that reduced uh position and just fix it in situ. Then we talk about getting the entry point, right? And some of you may have heard of Troche for MS entry nails. Um So that's using a truck and Terek entry nail and going a bit more medial than it was designed to go. And the entry point for the uh for the truck and terror country now is the tip of the G T. And that's usually where the fracture exits. And if you go at that position, you can fall into the fracture and end up in a various Malory deustche uh proximal femur. So one of the ways you can get around that is go a lot more medial of a little bit more medial. So you just passed the tip of the duty just medial to it almost at the Piriform fossil, which is why it's been given the nickname Troche form a sentry and you make your entry point there as the nail goes down, it's got a little six degree bend. It will kick the proximal fragment into six degrees of six more degrees of valgus and it will close down the gap in the lateral cortex that you can see here. Um and reduce the fracture and hold it in a slightly more valgus position and prevent various. Um Now you've got to use it carefully in the right fashion because it can go wrong. If you go crazy medial, you can just get it completely wrong and just go into a crazy amount of valgus and that's not any good either. So if you get that wrong, so this is um we'll talk about how to correct entry point in a second. Um This is what happens when you go to lateral or you can't medialize your entry point enough and you, you're rima, it's an, instead of taking away that medial bit of bone, it slips into the fracture site and pushes that proximal fragment immediately and tips it into various. And when it does that, that's not, you know, this, this person would have had a perfect reduction and as the nails gone down, it's both translated and tipped into varies. And if you're gonna fix in that position, it's not ideal. Um you might get away with it. Um But it is likely to fail because you fixed it in various. It's mechanically unfavorable and the implant will likely fatigue fail. Uh and uh best you'll get a malunion. So to avoid this, there are certain ways to medialize your entry point and I'll show you pictures of those in a second. So there's different ways of doing it. Uh So you can use an all uh to get a bit more medial and manually take out a bit more medial bone. You can get a nibbler or a run draw and take out a bit more medial bone or as I've done before, you can put a ring handle bone spike into what the lateral side of the entry point that you put in. And as you do that, you pull on the, the ring handle spike and what that does is take the various proximal femur and jacket out into a bit of valgus. But it also as the rema goes down, it bounces off the spike goes medial and creates a medialize is your entry point in order to allow the nail to hold it in that correct position. Um So it's quite a nice trick uh to bail out a misplaced entry point. The next thing is getting your rotation right in femoral shaft fractures. Um It's really important to try and get the rotation. Absolutely perfect. And there are different ways of doing that. And so this is patient. I saw an award round and uh nail was done by a colleague. Um It was a high energy injury. Uh And I went to check his pulse is put his feet together, so his feet are equally externally rotated. And then I looked up and that on the normal side, you can see his patellas pointing up as you'd expect when you do. When we do A D H S, we do ephemeral nail, but his patella on the operated side is completely internally rotated by significant amount. And so actually the rotation is um is completely off here. Um And if you turned the kneecaps, it pointed outwards, the right leg would be completely externally rotated, which is not what the patient uh had before. And it doesn't match the other side. And so when you don't have a cortical read, when the female, when the female femoral shaft is pretty smashed and you can't judge your reduction, but it's roughly about right and roughly lined up, don't forget to check rotation and there's different ways of doing that. Okay. Um The problem with rotation, you can get malrotation in is as high as 56% of cases of femoral shaft fractures. Um The thought is that if you get it off, if you're off by 15 degrees, that's significant to the patient and they will notice a difference. So this case was way more than 15 degrees and actually went on to have it revised. Um If it's less than 15 degrees is generally quite well tolerated and your normal anti version is between six and 24 degrees. Um which is important if you're going to use the nail as your guide, which I'll explain in a second. So one way is to match the other side. So you can use your rotation on the intact femur uh to check radiologically beforehand and you can't, you can only do that if you doing freehand technique or if you thought about it before you put the patient up on traction. So you get X rays with the kneecap pointing up and the foot in a certain position. And then you kind of memorize roughly what the leg looks like. And you get an A P X ray of the lesser trochanter and you get an A P X ray of the knee and you save those X rays and you compare your final fixation on the other side to those x rays to make sure that it matches. So that your rotation is about right. You check both clinically radio and radiologically, okay. But then what do you do? You don't have a good side to reference off. Um So one option is to use the anti version of the nail. Okay. And so we were saying that your normal anti version is between six and 24 degrees and you can tolerate plus minus 15. So uh depending on the nail that you have. The nail itself has built in anti version. OK. What I mean by that is from this picture, this is the Smith and nephew into town nail. And uh this the distal locking bolt is the gold bolt here, okay. And the blue bolt that is the uh a fellow medullary uh recon fixation, okay. The difference between the distal locking and the fellow Medullary locking is 12 degrees. So the nail itself has 12 degrees of anti version. The significance of that is if you want to give the patient 12 degrees of anti version that's within the normal limits. Um And so it is likely that it will be well tolerated. Um So the way you do that is that you put your nail down, you get the correct entry point, you put your nail down and you can't tell from your fracture because of the middle bit is just completely mush. And you're trying to just bridge that fragment. And the way you check your rotation is you get a perfect uh circle for your distal locking. So you can see perfect circles. So you know that you're orthogonal to the nail and then you bring the femur round to match it, okay. And so you get a perfect circle, a perfect lateral of the femur like we can see here where both condors are superimposed on each other. So when you have perfect circles in the nail and a perfect lateral, the distal femur, you know that you're anti version is 12 degrees depending on your nails. So if it was using this now would be 12 degrees. Other nails are 15 to 20 degrees, okay. Um But you know that that is within the acceptable limit and if you have nothing to reference off, it's a really good way to get close enough. Um And it's a useful trick to, to have especially in bilateral females. So the other option is you could externally fixate. But in terms of uh femoral fractures, external fixation is really only reserved for the damage control setting or you can use an L R S frame for limb salvage. For example, um the majority of the treatment is going to be um intramedullary nailing. Uh you can uh plate fractures, uh the femur. So you can use a proximal femoral locking plate or a distal femoral locking plate to treat shaft fractures. Um But uh often it's an off access uh fixation uh and it's prone to fatigue failing. Okay. Uh It's really only reserved for difficult metaphyseal injuries uh that harder to control using an intranet gallery now. And actually, the vogue now is to, if you have difficult fractures to augment your fixation, we'll talk a little bit about that later. So, um if you're gonna do uh plating, you have to respect the biology, you can't strip it off completely. So you've got perfect ivory sawbones and you just put it, you plate it rigidly, you shouldn't do that. So if you've got some combination, you've got to think about what you're doing with the plate, you're bridging. So you don't need to open that fracture site up. You can Bridget with using um IPO technique and that preserves the blood supply and preserves the biology. Okay. Um Lateral locking plates in distal femurs. If you used alone in a complex fracture, the failure rate in some modern series is as high as 22% between 18 and 22%. So lateral locking plate alone is not the answer all the time. Okay. Um And so this stuff um is a separate talk. We'll talk about a later stage in the teaching program. Um But they would, they overlap a little bit with diaphyseal fractures. And so the distal fractures um you what people are tending to do now is the, you can lateral locking plate alone, you can uh use a supracondylar nail with lots of distal locking options or you can use a combination of both and you can do it what's called a nail plate construct. And the indications really for a nail plate construct is um if you're unable to reduce uh the fracture anatomically, uh you're not going to have that cortical read that will allow you to the bone to do some of the weight bearing. So, pretty much all of the fixation, all of the forces will be going through your fixation. Um If you've got medial combination, that's a risk factor for failure. If you've got osteoporosis, that's also a risk factor for failure. So, um you might want to think about augmenting your fixation in those scenarios. The next thing with uh thermal sharp fractures is the uh the difficulty with that atypical femoral fractures. So, atypical femoral fractures uh have these key characteristics. Okay. So it was difficult to come up with a definition. But the American Society of bone and mineral research um have come up with this definition. If you've got four out of five of these criteria, it is an atypical femur fracture. Okay. So the story, the history is minimal or no trauma and these patient's usually fracture then fall rather than fall and fracture. Um And so the history is really important. Uh the fracture usually originates from the lateral cortex and is pretty transverse uh in orientation. Um Complete fractures may be associated with, with the medial spike, but they started with the transverse component of the lateral cortex. The fracture is uh not communicated or minimally commuted and uh there's localized periosteal thickening at the lateral cortex. So the risk factors for developing a typical thermal fractures is unfavorable biomechanics and various conditions, you can get a various femur and if you've got a various female, what that means is that your body weight, your the mechanical access has changed and you're putting much more force through that lateral cortex. Okay. And so, unless you uh correct the alignment, there's still going to be a lot of force going through that lateral cortex and the risk will be that they go on to a non union. Um So you have to manage these fractures carefully and make sure not to fix them in various. So that's the mechanical side of thing. The other problem with these is the biological side of things. So bisphosphonate's inhibit osteoclasts activity. Okay. Um So the osteoclasts don't work when you knock yourself or you have a little crack, you end up with a little micro fracture uh within the bone. Now, your body will automatically turn over that bone and he'll, and part of that process is the, is the uh part of that process is undertaken by the royal of osteo class. Now, if you're on bisphosphonates for a long time, your osteo class essentially and knocked out and do not work. And so you have old bone rather than new, healthy bone *** freshened up. And what happens is that old bone is weaker and you end up with a crack that then propagates because it doesn't remodel. Okay. And so when you recognize a atypical thermal fracture, remember to stop the bisphosphonates. Okay. So I've seen a few cases where it's been nailed, no one's really picked up that, that this was a atypical fracture. The patient had carried on their bisphosphonate's in a year or two later. They come in with the other side broken exactly the same story. Okay. So if you have an atypical thermal fracture, remember to check what medication they're on and to check whether they're on a bisphosphonate. So in summary, uh for the exam, you've got to exclude life threatening conditions and then focus on your fixation strategy. You need to understand the anatomy and the deforming forces and have some strategies to overcome difficult patterns. You've got to be aware of all of the approaches uh and techniques available and have a low threshold to recon lock the next. So there's an option to do that less Citrac screw. Um There's all sorts of reasons not to. Um And so my approach is I would recon everyone. Um You've got nothing to lose unless you're doing it wrong. Um Because if you've missed an ipsilateral neck of femur fracture, uh then it doesn't really matter because you've got screws in the neck, protecting the neck. If the patient falls at a later date and they get neck femur fracture, um because the neck wasn't protected, you'll be kicking yourself because it's a much more difficult situation to treat. Um If uh you've got the rotation wrong, um you could have used the rotation of the nail if you go center center in the uh in that proximal fracture. Um So there's lots of advantages of locking into the neck and I'd recommend that everyone does. Um in terms of um uh fixation, you can either go retrograde or antegrade. Uh We'll talk about retrograde nailing at the workshop next week. Um We can have a brief chat offline if you've got any questions. Now, essentially, if it's proximal go, antegrade, if it's distal go retro, if it's in the middle, go either, okay. That's pretty much it for femoral shaft fractures and then we can discuss some cases offline, stop the recording for like