Femoral Fractures

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Definition/ Description

A femoral fractures is a fracture in thigh bone. The femur is the largest and strongest bone in our body so it requires a large or high impact force to break this bone. Most femur fractures are the result of a high energy trauma, such as a motor accident, gunshot wounds and jumps and falls from a height. A femoral fracture is a very serious injury and needs 3-6 months to heal.
Femur fractures can be classified in 3 types: Femoral head fracture, femoral shaft fracture and femoral condyles fracture.

Clinically relevant anatomy

Osteology:
The femur consists of a head, greater and lesser trochantor, Shaft, Lateral and medial condyles with in between the patellar surface.

Musculature:

The femur is surrounded by different muscles: the quadriceps, the adductors, abductors and the hamstrings. 1. Quadriceps: M rectus femoris, M vastus lateralis, M vastus medialis, M vastus intermedius 2. Adductors: M adductor longus, M adductor brevis, M adductor longus, M pectineus, M gracilis 3. Abductors: M tensor fasciae latae 4. Hamstrings: M biceps femoris, M semimembranosus, M semitendinosus

After a femoral fracture, the most of this muscles are much weaker than before so a physiotherapy is very important.

Several large muscles attach to the femur. Proximally, the gluteus medius and minimus attach to the greater trochanter, resulting in abduction of the femur with fracture. The iliopsoas attaches to the lesser trochanter, resulting in internal rotation and external rotation with fractures. The linea aspera (rough line on the posterior shaft of the femur) reinforces the strength and is an attachment for the gluteus maximus, adductor magnus, adductor brevis, vastus lateralis, vastus medialis, vastus intermedius, and short head of the biceps. Distally, the large adductor muscle mass attaches medially, resulting in an apex lateral deformity with fractures. The medial and lateral heads of the gastrocnemius attach over the posterior femoral condyles, resulting in Flexion deformity in distal-third fractures.

Epidemiology/ Etiology

A femoral fracture is related to different reasons: first of all, the age: older persons (over the 70) have a bigger chance to break the femur. Another reason is Osteoporosis. Persons with osteoporosis has also a higher chance to break their femur. Morbidity and mortality rates have been reduced in femoral shaft fractures, mainly as the result of changes in methods of fracture immobilization. Current therapies allow for early mobilization, thus reducing the risk of complications associated with prolonged bed rest. The incidence of femoral fractures is reported as 1-1.33 fractures per 10,000 population per year in the USA. In individuals younger than 25 years and those older than 65 years, the rate of femoral fractures is 3 fractures per 10,000 population annually.

Characteristics/ clinical presentation

A broken thigh bone is almost always very obvious. A few signs include severe pain, inability to move the leg or stand on it and swelling. There’s also an inability to bear weight and possibly a shortening of the affected leg is common when the fracture is displaced. It also may result in a loss of blood in the femur and a haematoma can be present in the surrounding soft tissue.

Examination

Ante posterior and lateral x-rays (used to look for a break in the bone) views of the femur are obtained to confirm the fracture. It’s better to use the x-rays views also for the hip, the lower leg and the knee to detect any associated injuries, because a femur fracture is almost associated with other traumatic injuries. For that reason a general physical examination can be practice.

Outcome Measures

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Examination

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Medical Management

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Physical Therapy Management

A femur fracture is a very serious injury. Surgery is sometimes but not always needed. The surgeon will align the fractured parts of the bone. The long immobilization is followed by an extensive physical therapy. After a femoral fracture, most of the muscles are much weaker than before so physiotherapy is very important.
The physiotherapist has to begin with range of motion exercises for the hip, knee and ankle because the mobility is decreased after the immobilization. Mobilization is a very important treatment in the recover process. The patient can also start with strengthening exercises.

Mobilization exercises : Knee: flexion and extension, abduction and adduction Hip: flexion and extension, abduction and adduction, rotation
Quadriceps exercises need to start as soon as possible after the surgery because the quadriceps help for a good stability in the knee. Flexion exercises also need to start as soon as possible, provided the means can be devised to support the fracture fully. Physiotherapy should be continued until an acceptable functional range has been achieved or until a static position has been reached. It is necessary to record the range of movements in the knee with accuracy: first this should be done at weekly and then at monthly intervals.

Key Research

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

Greenberg MT. Greenberg’s text-atlas of emergency medicine. Philadelphia: Lippincott Williams & Wilkins, 2005. 

Cartwright LA, Pitney WA. Fundamentals of athletic training, 2nd ed, Champaign, IL: Human Kinetics, 2005. 

Walker B, Anatomy of sports injuries, Chichester: Lotus Publishing and North Atlantic Books, 2007.

Mcrae R, Esser M, Practical fracture treatment, 5th ed, Elsevier Churchill Livingstone, 2008.

Iwata K, Mashiba D. Surgical treatment of proximal femur fracture. Clin Calcium 2010; 20(9):1386-92. http://www.ncbi.nlm.nih.gov/pubmed/20808047)

Partanen J. Etiopathology and treatment-related aspects of hip fracture [dissertation]. Oulu: University of Oulu. 2003. http://herkules.oulu.fi/isbn9514270959/html/c228.html