Incidence

The majority of femoral shaft fractures today are treated by internal fixation. The exception may be children and young adolescents but even in this age group, there is a growing tendency toward surgical stabilization.

Traditionally, femoral shaft fractures in adults were treated by either closed intramedullary nailing or open reduction with plate fixation. Although each method had its advantages and disadvantages, the choice of the method of fixation really depended on the experience of the surgeon, his preference and the facilities available. However, with the advent of the antegrade locked intramedullary nail inserted by closed means, conventional open plating as a method of fixing femoral shaft fractures gradually became less popular. There were several reasons for this: plating was a much larger procedure requiring extensive exposure; there was frequent need for bone grafting, greater blood loss, higher incidence of infection, significant rate of implant failure and nonunion, and a greater likelihood of loss of knee motion.

With the introduction of indirect fracture reduction and minimally invasive plate osteosynthesis (MIPO), many disadvantages of conventional plating of femoral shaft fractures were overcome. In fact, for certain fracture configurations, MIPO may have a distinct advantage over intramedullary nailing. However, it should be emphasized that this technique is not easy but attention to detail will help to avoid some difficulties associated with this method.

Current methods of treatment

The gold standard for treatment of femoral shaft fractures in adults is closed intramedullary nailing which provides relative stability regardless of the fracture morphology. However, if there are indications for plating, different types of stability should be considered. In type 32-A fractures, the standard teaching is anatomical reduction and absolute stability to achieve direct fracture healing using the principle of interfragmentary or axial compression. This may be possible using MIPO techniques, although it is necessary to make a small incision directly over the fracture site to obtain accurate reduction which is then maintained using a variety of temporary holding devices before definitive plate fixation is performed.

Wave plating for type 32-A fractures was recently reviewed in a prospective series of 57 patients [ 1]. The authors suggest that this is a safe and efficacious treatment alternative to IM nailing for simple femoral fractures in countries where IM nails are limited by availability, cost, and patient‘s physical characteristics [1]. In type 32-B and 32-C fractures the principle of bridge plating should be applied as the aim is relative stability to promote indirect fracture healing by callus formation. Standard MIPO technique without exposure of the fracture site is recommended.

Indication for MIPO

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  Type 32-B and type 32-C fractures, especially those with proximal extension into the trochanteric area or distal extension into the condylar area

  
  
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  Fractures in the pediatric population older than 8 years with open epiphyses, or when there is no possibility to use elastic nails to provide adequate stability, as in complex fractures

  
  
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  Femoral fractures with narrow or deformed intramedullary canal

  
  
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  Femoral fractures with associated spinal or pelvic fractures; further damage can be caused when using a fracture table for femoral nailing

  
  
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  Femoral fracture with ipsilateral tibial fracture that requires surgery and use of a fracture table is not appropriate

  
  
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  Femoral fracture in association with abdominal injury that requires laparotomy and can proceed for plating on a normal operating table

  
  
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  Periprosthetic fractures

  
  
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  Ipsilateral neck and shaft fractures when the neck fracture is treated using a separate implant

  
  
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  Fractures associated with lung contusion in which IM nailing may be risky

Contraindication for MIPO

MIPO should not be performed if surgery is delayed for more than 2 weeks following the injury as soft-tissue contracture renders indirect reduction of the fracture impractical.

Blood supply to the femoral shaft

The blood supply of the femoral shaft is derived from two main sources: The inner 2/3 of the cortex derives its blood supply from the nutrient artery which arises from the second perforating artery and enters the bone proximally and posteriorly along the linea aspera, while the outer 1/3 of the cortex is supplied by the periosteal arteries which are derived from the surrounding muscles supplied by the perforating arteries ( Fig 17.1-1 ). Following displaced fractures, the circulatory pattern of the femoral shaft is drastically altered due to disruption of the medullary blood supply. However, the periosteal blood vessels are seldom extensively stripped because of their perpendicular orientation to the cortical surface. Until the recovery of the endosteal circulation, the periosteal vessels are the main source of blood supply around the fracture zone; hence the importance of preserving the periosteal vessels and the perforating arteries. By placing the plate in a submuscular, extraperiosteal tunnel, MIPO minimizes the damage to these vessels and helps to improve the results of internal fixation of the femur using plates.

Shape of the femur

The antecurvature of the femoral shaft has a radius of curvature of approximately 1.5 m. There are also lateral cortical flares 2–3 cm distal to the vastus ridge and at the distal metaphyseal area. These features must be considered when long plates are used as precontouring will be required ( Fig 17.1-2, Fig 17.1-3 ).

Anesthesia

Either general or regional anesthesia may be used, depending on the condition of the patient.

Patient and image intensifier positioning

The patient is positioned supine on a radiolucent operating table. A supporting pad is placed under the knee to maintain it in 40–60° flexion with the patella pointing upward in neutral position ( Fig 17.1-5 ).

The limb is prepared and draped from the level of the iliac crest to below the knee. If desired, the opposite uninjured limb is also prepared and draped free to allow intraoperative comparison with the fractured side.

The C-arm is positioned on the opposite side of the operating table. It should be able to be tilted so that the x-ray beam is perpendicular to the axis of the femoral shaft, and must be able to be moved so that images from the hip to the knee can be taken. Its placement and range of movement should be checked before preparation and draping. The position of the C-arm should be marked on the floor to prevent unnecessary imaging to localize the fracture area.