Femoral Fracture Surgery

Airway: GA/LMA. Neuraxial appropriate. Access: 14-16G Pain: ++/+++ Position: Generally supine Time: 1-3 hours Blood loss: 1-3 units. Consider cell salvage. Special: High perioperative risk. Early operation → early mobilisation

Femoral fractures:

• Common in :
  • Elderly due to falls
  • Young patients from trauma
• May be:
  Generally blood loss and operative time ↑ the more distal
  • Subcapital
    Through the femoral neck.
    • Significantly less blood loss
    • Easier operative approaches (particularly if non-displaced)
    • Generally:
      • Require hip replacement if displaced
      • Pins if nondisplaced
  • Intertrochanteric
    Around the trochanters.
    • Generally dynamic hip screw
  • Subtrochanteric
    Distal to the lesser trochanter.
    • Generally ORIF with plate/screws
  • Mid/shaft or distal femur
    • Generally:
      • Intramedullary nail for non-displaced/tranverse fractures, or fractures with large fragments
        May be placed anterograde (proximal to distal) or retrograde depending on the nature of the fracture.
      • ORIF for displaced/heavily comminuted fractures Substantial blood loss and ↑ operative time.

Considerations

• B
  • Respiratory comorbidities
  • Fat embolus
    Up to 15%.
• C
  • Cardiac comorbidities
  • Prior blood loss into thigh may lead to haemodynamic instability
  • Consider arterial line
• E
  • Presence of other traumatic injuries
  • Frailty
• H
  • Potential for blood loss/transfusion requirement

Preparation

Induction

Anaesthetic options include:

• Spinal
• Epidural
• GA

Intraoperative

Key surgical stages include:

• Reaming of femoral medullary bone prior to IM nail placement
  Embolises medullary contents into the pulmonary vasculature.
  • May lead to acute right heart failure or respiratory failure

Postoperative

Complications include:

• 10% fat embolism
• 5-10% malunion
• Up to 10% infection
  Higher with open fixation.

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References