Rosen & Barkin's 5-Minute Emergency Medicine Consult (268 page)

• 536.40 Gastrostomy complication, unspecified
  
• 536.49 Other gastrostomy complications
  
• 996.79 Other complications due to other internal prosthetic device, implant, and graft
  

BASICS

Fractures classified according to:

• Location:
  
  • Proximal 3rd (subtrochanteric region)
    
  • Middle 3rd
    
  • Distal 3rd (distal metaphyseal–diaphyseal junction)
    
• Geometry:
  
  • Spiral
    
  • Transverse
    
  • Oblique
    
  • Segmental
    
• Extent of soft tissue injury:
  
  • Open
    
  • Closed
    
• There are 2 commonly accepted classification systems of femoral fractures: The AO/OTA and the Winquist and Hansen.
  
• Degree of comminution: Winquist and Hansen classification:
  
  • Grade I: Fracture with small fragment <25% width of femoral shaft; stable lengthwise and rotationally
    
  • Grade II: Fracture with 25–50% width of femoral shaft; stable lengthwise; may or may not have rotational stability
    
  • Grade III: Fracture with >50% width of femoral shaft; unstable lengthwise and rotationally
    
  • Grade IV: Circumferential loss of cortex; unstable lengthwise and rotationally
    

• Usually requires major, high-energy trauma
  
• Patients are mostly young adults with high-energy injuries (motor vehicle accidents [MVAs], gunshot wounds [GSWs], falls):
  
  • Spiral fractures with falls from height
    
• Consider pathologic fracture if minor mechanism
  
• Can occasionally be due to stress fracture from repetitive activity
  
• Complications include compartment syndrome, fat embolism, adult respiratory distress syndrome (ARDS), hemorrhage.
  

• Atypical femur fractures have been associated with use of bisphosphonate medications.
  

• 70% of femoral fractures in children <3 yr old are the result of nonaccidental trauma (NAT).
  
• Spiral fractures of the femur strongly suggest NAT.
  

DIAGNOSIS

• Thigh pain, deformity, swelling, shortening
  
• Patient unable to move hip or knee
  
• Commonly presents as multitrauma:
  
  • Chest, abdominal, pelvic, hip, knee injury, including dislocation
    

• Rarely open fracture, unless injury is due to penetrating trauma
  
• Patient may be hypotensive due to hemorrhage into the thigh.
  
• Patient may have impaired circulation in the distal leg due to vascular compromise, compartment syndrome.
  

• Radiographs (see Imaging)
  
• Assess distal pulses, palpate compartments, evaluate sensation and motor function.
  
• If pulses are not equal or palpable, bedside Doppler or angiography may be necessary.
  
• Search for associated injuries with multisystem trauma.
  
• In suspected NAT, obtain skeletal survey or bone scan.
  

CBC, type and cross-match

• AP pelvis, true lateral of the hip, AP and lateral views of the femur, complete knee series
  
• Baseline CXR, other films as indicated by trauma protocols
  

• Hip fracture or dislocation
  
• Knee fracture or dislocation
  
• Thigh contusion or hematoma
  

TREATMENT

• Immobilization of the extremity and application of a traction splint can be important for tamponade of further blood loss into the thigh:
  
  • Backboard immobilization, rigid splinting, support of extremity for position of comfort
    
• Contraindications to traction:
  
  • Fractures close to the knee
    
  • Fracture or dislocation of the ipsilateral hip
    
  • Fractures of the pelvis
    
  • Fractures of the lower leg
    
• Do not attempt to reduce open fractures in the field; cover open wounds with sterile dressings.
  
• Monitor closely for development of hemorrhagic shock, as thigh can contain 4–6 U of blood.
  

• Airway, chest, abdominal injuries take precedence.
  
• Monitor BP continuously for signs of hemorrhagic shock.
  

• Maintain lower extremity stability.
  
• Remove splint and clothing.
  
• Pain control:
  
  • Isolated femur injuries: Parenteral analgesia
    
  • Multitrauma or pediatric patients: Femoral nerve block
    
• Orthopedic consultation necessary for all femur fractures:
  
  • Emergent if neurovascular compromise
    
  • Open fractures must go directly to the OR for irrigation and débridement.
    
• Antibiotics:
  
  • Fractures requiring surgery: Cefazolin if open fracture with laceration (clindamycin if allergic to cephalosporins). If extensive soft tissue damage or contamination: Consider gentamicin/tobramycin, tetanus.
    
  • If highly contaminated wound: Consider penicillin G to cover clostridial species.
    
• Femur fractures with diminished or absent distal pulses, an expanding hematoma, or a palpable pulsatile mass require immediate angiography or femoral artery exploration.
  
• Skeletal traction should be applied if the patient will not go to the OR immediately.
  

• Antibiotics:
  
  • First line:
    
    • Cefazolin: 2 g IM/IV q6–8h (peds: 50–100 mg/kg IM/IV divided q6–8h max. 1 g)
      
  • Second line:
    
    • Clindamycin: 450–900 mg IM/IV q6–8h; max. dose: 4.8 g/d (peds: 20–40 mg/kg/d IM/IV in 3–4 divided doses)
      
• Moderate sedation:
  
  • Etomidate: 0.1–0.3 mg/kg IV once (not recommended for <12 yr)
    
  • Fentanyl: 50–100 μg IV over 1–2 min once (peds: >6 mo 1–2 μg/kg IV once)
    
  • Ketamine: Caution in adults due to potential for emergence reaction (peds: 0.2–1 mg/kg IV, 0.5–4 mg/kg IM once)
    
  • Midazolam: 0.07 mg/kg IM or 1 mg slow IV q2–3min up to 5 mg max. (peds: 0.25–0.5 mg/kg PO once to a max. of20 mg PO; 6 mo–5 yr: 0.05–0.1 mg/kg IV titrate to max. of 0.6 mg/kg; 6–12 yr: 0.025–0.05 mg/kg IV titrate to max. of 0.4 mg/kg)
    
  • Propofol: 40 mg IV q10sec until induction; 5–60 μg/kg/min IV continuous infusion
    
• Pain control:
  
  • Hydromorphone: 0.5–2 mg IM/SC/slow IV q4–6h PRN; titrate for pain control (peds: 0.015 mg/kg per dose IV q4–6h PRN)
    
  • Morphine: 2–10 mg IV q4h; titrate for pain control (peds: 0.1 mg/kg IV q4h; titrate for pain control to max. 15 mg/dose)
    

• Assess markers for NAT:
  
  • Delay in presentation
    
  • History of mechanism inconsistent with the injury
    
  • Isolated trauma to the thigh, associated burns, bruises, or linear abrasions
    
• Assess for dislocation of the femoral capital epiphysis.
  
• Depending on the age of the patient and the fracture type, pediatric femoral fractures may not require operative treatment.
  

FOLLOW-UP

• All femur fractures must be admitted except as noted below in Discharge Criteria.
  
• Any suspicion of NAT in children
  

In certain rare circumstances of pathologic fracture or femur fractures in patients who are not ambulatory and would not undergo operative fixation, discharge can be considered in consultation with orthopedics if adequate pain control can be achieved and proper follow-up ensured.

Follow-up will likely be determined by operating surgeon based on clinical course.

• Due to the high-energy mechanism required to incur a femoral fracture, other associated traumatic injuries must be ruled out.
  
• Document neurovascular function on initial assessment and frequently reassess.
  
• Depending on the age of the patient and the fracture type, pediatric femoral fractures may not require operative treatment.
  

• Barnett P. Alternatives to sedation for painful procedures.
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• Hospenthal DR, Murray CK, Andersen RC, et al. Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: Endorsed by the Infectious Diseases Society of America and the Surgical Infection Society.
  J Trauma
  . 2011;71(2 suppl 2):S210–S234.
  
• Kanlic E, Cruz M. Current concepts in pediatric femur fracture treatment.
  Orthopedics
  . 2007;30(12):1015–1019.
  
• Smith RM, Giannoudis PV. Femoral shaft fractures. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C., eds.
  Skeletal trauma: Basic Science, Management, and Reconstruction.
  4thed. Philadelphia, PA: Saunders Elsevier; 2009, Chapter52.
  
• Wheeless’ Textbook of Orthopaedics. Femoral shaft fracture. Available at
  http://www.wheelessonline.com/ortho/femoral_shaft_fracture
  . Accessed on January 31, 2013.