Clinicals on Femur

1◊◊The upper end of the femur is a common site for fracture in the elderly. The neck may break immediately
beneath the head (subcapital), near its midpoint (cervical) or adjacent to the trochanters (basal), or the fracture
line may pass between, along or just below the trochanters. Fractures of the femoral neck will interrupt
completely the blood supply from the diaphysis and, should the retinacula also be torn, avascular necrosis of
the head will be inevitable. The nearer the fracture to the femoral head, the more tenuous the retinacular blood
supply and the more likely it is to be disrupted. Avascular necrosis of the femoral head in children is seen in
Perthe’s disease and in severe slipped femoral epiphysis; both resulting from thrombosis
of the artery of the ligamentum teres. In contrast, pertrochanteric fractures, being outside the joint capsule,
leave the retinacula undisturbed; avascular necrosis, therefore, never follows such injuries (Fig. 162).
There is a curious age pattern of hip injuries; children may sustain greenstick fractures of the femoral neck,
schoolboys may displace the epiphysis of the femoral head, in adult life the hip dislocates and, in old age,
fracture of the neck of the femur again becomes the usual lesion.
2◊◊Fractures of the femoral shaft are accompanied by considerable shortening due to the longitudinal
contraction of the extremely strong surrounding muscles. The proximal segment is flexed by iliacus and psoas
and abducted by gluteus medius and minimus, whereas the distal segment is pulled medially by the adductor
muscles. Reduction requires powerful traction, to overcome the shortening, and then manipulation of the
distal fragment into line with the proximal segment; the limb must therefore be abducted and also pushed
forwards by using a large pad behind the knee. Fractures of the lower end of the shaft, immediately above the
condyles, are relatively rare; fortunately so, because they may be extremely difficult
to treat since the small distal fragment is tilted backwards by gastrocnemius, the only muscle which is
attached to it. The sharp proximal edge of this distal fragment may also tear the popliteal artery, which lies
directly behind it (Fig. 163).
3◊◊The angle subtended by the femoral neck to the shaft may be decreased, producing a coxa vara deformity.
This may result from adduction fractures, slipped the femoral epiphysis or bone-softening diseases. Coxa
valga, where the angle is increased, is much rarer but occurs in impacted abduction fractures.
Note, however, that in children the normal angle between the neck and shaft is about 160°.
Clinical features
1◊◊Lateral dislocation of the patella is resisted by the prominent articular surface of the lateral femoral
condyle and by the medial pull of the
lowermost fibres of vastus medialis which insert almost horizontally along the medial margin of the patella. If
the lateral condyle of the femur is underdeveloped, or if there is a considerable genu valgum (knock-knee
deformity), recurrent dislocations of the patella may occur.
2◊◊Adirect blow on the patella may split or shatter it but the fragments are not avulsed because the quadriceps
expansion remains intact. The patella may also be fractured transversely by violent contraction
of the quadriceps — for example, in trying to stop a backward fall. In this case, the tear extends outwards into
the quadriceps expansion, allowing the upper bone fragment to be pulled proximally; there may be a gap
of over 2 in (5 cm) between the bone ends. Reduction is impossible by closed manipulation and operative
repair of the extensor expansion is imperative. Occasionally this same mechanism of sudden forcible
quadriceps contraction tears the quadriceps expansion above the patella, ruptures the ligamentum
patellae or avulses the tibial tubercle. It is interesting that following complete excision of the patella for a
comminuted fracture, knee function and movement may return to 100% efficiency;
it is difficult, then, to ascribe any particular function to this bone other than protection of the soft tissues of the
knee joint anteriorly.
Clinical features on patella
1◊◊The upper end of the tibial shaft is one of the most common sites for acute osteomyelitis. Fortunately, the
capsule of the knee joint is attached closely around the articular surfaces so that the upper extremity of the
tibial diaphysis is extracapsular; involvement of the knee joint therefore only
occurs in the late and neglected case.
2◊◊The shaft of the tibia is subcutaneous and unprotected anteromedially throughout its course and is
particularly slender in its lower third. It is not surprising that the tibia is the commonest long bone to be
fractured and to suffer compound injury.
3◊◊The extensive subcutaneous surface of the tibia makes it a delightfully accessible donor site for bone-
grafts.
Clinical features on hip joint
Trendelenburg’s test
The stability of the hip in the standing position depends on two factors, the strength of the surrounding
muscles and the integrity of the lever system of the femoral neck and head within the intact hip joint. When
standing on one leg, the abductors of the hip on this side (gluteus medius and minimus and tensor fasciae
latae) come into powerful action to maintain fixation at the hip joint, so much so that the pelvis actually rises
slightly on the opposite side. If, however, there is any defect in these muscles or lever mechanism of the hip
joint, the weight of the body in these circumstances forces the pelvis to tilt downwards on the opposite side.
This positive Trendelenburg test is seen if the hip abductors are paralysed (e.g. poliomyelitis), if there is an
old unreduced or congenital dislocation of the hip, if the head of the femur has been destroyed by disease or
removed operatively (pseudarthrosis), if there is an un-united fracture of the femoral neck or if there is a very
severe degree of coxa vara. The test may be said to indicate ‘a defect in the osseo-muscular stability of the hip
joint’. A patient with any of the conditions enumerated above walks with a characteristic ‘dipping gait’.
Dislocation of the hip
The hip is usually dislocated backwards and this is produced by a force applied along the femoral shaft with
the hip in the flexed position (e.g. the knee striking against the opposite seat when a train runs into the
buffers). If the hip is also in the adducted position, the head of the femur is unsupported posteriorly by the
acetabulum and dislocation can occur without an associated acetabular fracture. If the hip is abducted,
dislocation must be accompanied by a fracture of the posterior acetabular lip. The sciatic nerve, a close
posterior relation of the hip, is in danger of damage in these injuries, as will be appreciated by a glance at Fig.
156. Reduction of a dislocated hip is quite simple providing that a deep anaesthetic is used to relax the
surrounding muscles; the hip is flexed, rotated into the neutral position and lifted back into the acetabulum.
Occasionally, forcible abduction of the hip will dislocate the hip forwards. Violent force along the shaft (e.g. a
fall from a height) may thrust the femoral head through the floor of the acetabulum, producing a central
dislocation of the hip.