Thigh contusions, resulting from a direct blow, can be a very disabling injury. Contusions of the anterior portion of the thigh muscle are usually more serious than those involving the lateral portion of the quadriceps muscle, because of the differences in muscle mass percent in the two areas. As with other regions of the body, contusions are graded according to the severity of the injury.
Growth Disorder of Thigh BoneFractures involving the shaft of femur are commonly seen in young adults involved in high velocity, high-energy trauma as occurs in a road traffic accident (RTA). Therefore it is usually associated with other skeletal injuries or injuries to the visceral organs.
Applied Anatomy of Femur
• Femur is the strongest bone in the body, being involved in transmission of weight.
• Weight transmission occurs through the medial cortex hence the medial cortex bears compressive stresses.
• Blood supply to the femur comes from one or two nutrient vessels arising from the cruciate anastomosis.
• End steal blood supply is the prominent source supplying the inner 3/4 th of the cortex. And this is disrupted during fractures.
• The femur is acted upon by strong muscles as follows:
Gluteus medius =>abduction
Iliopsoas — flexion, external rotation- proximally
Adductors —Adduction
Gastrocnemius — Posterior
Angulation—distally.
FRACTURE OF SHAFT OF FEMUR
Shaft of the femur is defined as part of the femur from the lower border of the lesser trochanter till the upper border of a square fitting the femoral condyles. Fractures involving the shaft of femur are usually caused by high-energy injuries, usually in young adult individuals. This is often associated with multiple bone fractures and multiple system injuries. Fracture femur is associated with significant morbidity and hospital stay.
Pathology
Fracture may occur at any site along the entire shaft, i.e. in the upper, middle or lower third region. The fracture may be transverse, oblique, spiral or comminuted. The femur gives attachment to bulky powerful muscles; therefore displacement of the fractured ends is very common. The glutei and Iliopsoas attached on to the proximal femur produce abduction, flexion and external rotation of the proximal fragment. The adductor muscles produce adduction of the distal fragment. The bulky muscles may interpose between fracture ends and interfere with the union of the fracture.
Clinical Features
Clinical features in a patient having fracture shaft of femur are always prominent. There will be pain, swelling, abnormal mobility and an obvious angular deformity of the thigh following an accident of trauma. Bony crepitus is also present.The examination must include looking for abnormalities in the hip and knee joints which may be missed. Systematic examination of all the long bones and visceral systems must be carried out to rute out other major injuries.
Injury to the popliteal vessels and sciatic nerve must also be ruled out.
Investigations
Radiograph of the femur should be taken both in AP and lateral view. This should also include radiographs of the hip and knee joint, so that injuries to these joints are not missed.
Management
Fractures involving the shaft of femur usually unite, but Malunion is quite common. Since femur involved in the weight bearing axis, the aim of the treatment is:
1. Proper alignment of the bone to avoid limb length discrepancies.
2. Early and adequate bony union to allow for early mobilization.
Immediate treatment
Fractures of the shaft of femur are usually associated with a blood loss to the amount of 1500 ml into the neighboring tissues without appreciable swelling. Therefore immediate treatment for these fractures involves:
• Adequate replacement of the lost blood volume.
• Proper immobilization and reduction with traction, A patient with fracture shaft of the femur should be splinted immediately in the casualty room. Splinting reduces the pain and prevents injury to the surrounding muscles and neurovascular bundles by the sharp edge of the fractured bone ends,
• Treatment of systemic and visceral injuries.
Definitive treatment
Definitive treatment for fractures of the shaft of femur can be done by conservative methods or by surgical interventions.
Conservative treatment: This can be achieved by the following means:
• Skin traction and immobilization of the limb in abduction and external rotation.
• Skeletal traction using upper tibial pin traction and immobilization.
This mode of treatment most often results in union but it is commonly associated with:
• Shortening and angular deformities of femur
• The prolonged period of recumbency resulting in complications like bed sore, pneumonia, contractures of knee joint etc.
Surgical intervention: Internal fixation is the best method of treatment for fracture shaft of the femur. Internal fixation can be achieved by following techniques: .
1. Standard intramedullary nails-Kuntscher’s nails: The Kuntscher’s nails (commonly called K-nails) have a clover leaf cross-section with a slot on one side with an eye at both ends. This is ideal for fracture at the level of the isthmus. The isthmus is located at the junction of the upper and middle thirds of the shaft where the medullary canal is the narrowest. In this technique after open reduction, the nail is inserted in a retrograde manner. If the facilities of radiographic control or image intensifier exist, then closed nailing can also be done in antegrade manner without opening the fracture site. The principle of fixation of the nail is three point fixation achieved at
• Pyriform fossa,
• Isthmus
• Medial cortex at the lower end of the nail.
The advantages of Kuntscher’s nailing are that it can be done without the image intensifier, and it is less expensive. The disadvantage, however, is that it cannot be performed in comminuted fractures and in fractures of the distal third of the femur.
2. Inter locking nails: Interlocking nails are an improvement over the conventional (Kuntscher’s) in tramedullary nails. These are provided with interlocking screws with slots for these screws at the proximal and distal end. The interlocking screws can be applied at both proximal and distal ends; they provide rotational stability at the fracture site. The screws pass through both the cortices and through the intervening nail. They are inserted under the control of image intensifier, without opening the fracture site. Thus they prevent the loss of fracture haernatoma as well as avoid stripping of the periosteum. They have expanded the indications of intramedullary nailing to involve the:
i. Comminuted fractures, and
ii. Segmental fractures.
iii. Further advancement in interlocking techniques have resulted in newer system Gamma nails, reconstructions nails etc.
3. Plating: Dynamic compression plates are used for fixation of oblique fractures. These plates are applied on the lateral cortex of femur producing compressive force at the fracture site. The disadvantages of plate fixation are that it involves
• Extensive stripping of the periosteum which may delay the fracture union.
• Delayed weight bearing and therefore problems of recumbency.
• Extensive implant with high chances of infection.
Complications
Complications of fracture of femur can be divided into immediate and late complications.
Immediate complications
1. Shock: In patients with closed fracture of shaft of femur upto 1500 ml of blood can be lost into soft tissue without much swelling. Hence replacement of the lost blood volume is very important. An IV line should be started in every patient of fracture shaft of femur: and the pulse and blood pressure should be monitored.
2. Fat embolism: This is seen after 1-2 days following fracture shaft of femur.
3. Injury to the surrounding neurovascular structure is a very rare complication due to a bone spike causing damage to the neurovascular bundles. Injury to the blood vessels requires emergency exploration.
Late complications
1. Malunion: When the reduction is not satisfactory or if the fracture redisplaces, the fracture may go in for Malunion. This is the most common complication associated with fracture of femur. This occurs in a position of external and lateral angulation. A shortening of less than 3 cm can be treated with heel and sole raise in the shoes.
2. Knee stiffness: Follows prolonged immobilization. This is due to:
• Adhesions within the joint across the articular surfaces.
• Patello femoral adhesions.
• Quadriceps contracture.
3. Nonunion: This is diagnosed if there is no evidence of callus after 6 months following fracture.
• This is caused by soft tissue interposition at the fracture site.
• There is frank abnormal mobility, pain on stressing at the fracture site.
• Treatment is by open reduction and internal fixation with bone grafting.
Experiencing an injury to the inner thigh or groin can make each step more painful than the next. While you are rehabilitating a sports hernia, groin pull or groin strain, your physician may recommend physical therapy exercises to allow your inner thigh and groin muscles to strengthen properly without re-injuring the area. Always speak with your physician, however, before beginning any exercise or physical therapy program.