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The femur

image of The femur
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Abstract

Femoral fractures occur with high frequency in dogs and cats, representing 45% of all long bone fractures. Fracture typically occurs following substantial trauma such as road traffic accident and, as such, individual fracture configuration can vary dramatically. The chapter looks at fractures of the proximal femur, fractures of the diaphysis, fractures of the distal femur. Epiphyseal fractures of the femoral head; Physeal, subcapital and intertrochanteric fractures; Fractures of the greater trochanter; Intramedullary pinning of spiral/long oblique diaphyseal fractures; Open bone plating of the diaphysis; Pin-plate stabilization of comminuted diaphyseal fractures; External skeletal fixation of the femur; Distal femoral physeal fracture stabilization in immature patients; Supracondylar fracture stabilization in mature patients; Articular fractures of the femoral condyle.

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Figures

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23.1 Fractures of the femoral head, neck and trochanteric region. Physeal fractures occur through the growth plate (blue) and subcapital fractures occur distal to the growth plate but proximal to the insertion of the joint capsule (green). Intertrochanteric fractures occur distal to the joint capsule insertion. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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23.2 A slipped capital epiphysis in an 11-month-old Toy Poodle with a 5-week history of left pelvic limb lameness and pain localizing to the left hip joint. (a) Craniocaudal and (b) frog-legged radiographic views showing widening of the coxofemoral joint space and remodelling of the femoral neck and acetabulum. The frog-legged view reveals a step to the epiphysis cranially not evident on the other view, consistent with a slipped capital epiphysis. The slipped physis can be seen on the excised (c) femoral head and (d) neck.
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23.3 Femoral neck fracture in 3-year-old Maine Coon. (a) An ill-defined radiolucent line can be seen crossing the right femoral neck on the ventrodorsal radiographic view. Postoperative (b) ventrodorsal and (c) lateromedial radiographic views following stabilization of the fracture with a lag screw and anti-rotational K-wire. A trochanteric osteotomy, performed to aid exposure and reduction of the fracture, was stabilized with a pin and figure-of-eight tension-band wire. Note, the anti-rotational K-wire is not ideally positioned in the femoral head and neck, with limited bone stock on its lateral aspect, and ideally two pins would have been placed to stabilize the trochanteric osteotomy. Fracture healing proceeded uneventfully.
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23.4 A comminuted mid-diaphyseal left femoral fracture in a 4-year-old German Shepherd Dog, repaired with an IM pin and cerclage wire 4 weeks previously. (a) Notice marked muscle wastage of the limb and protrusion of the IM pin through the skin. (b) Craniocaudal and (c) mediolateral radiographs at the time of presentation show axial collapse of the fracture and loss of reduction. (d) Intraoperative appearance of the fracture site at the time of revision with distraction of the fracture fragments being performed to restore limb length. (e–f) Postoperative radiographic appearance of the fracture following placement of a lateral 3.5 mm broad dynamic compression plate.
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23.5 (a) Mid-diaphyseal oblique left femoral fracture in a 6-month-old Cairn Terrier. The fracture was stabilized with a modified type 1/2 linear external skeletal fixator with a tied-in IM pin. (b) Follow-up radiographs revealed the fracture to have healed after 6 weeks, at which time the fixator was removed. Note: the distal two femoral pins traverse the physis. The dog was presented 12 months later with medial patellar luxation, at which point (c) radiographs revealed multiple abnormalities including coxa vara, an elongated femoral neck, femoral shortening and distal femoral varus. The medial patellar luxation can also be appreciated.
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23.6 (a) I-LOC ILN. The nail has an hourglass-shaped profile. A morse taper fit between the bolts and the nail gives angle stable fixation. (b) Craniocaudal radiograph of a 12-month-old female neutered Labradoodle with a closed comminuted fracture of the femoral diaphysis. Postoperative radiographic appearance (c) immediately and (d) 1 year following stabilization with a 7 x 160 mm I-LOC. (a, Courtesy of BioMedtrix; b–d, Courtesy of L Déjardin)
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23.7 (a) Procurvatum is normally present in the canine femur. (b) Therefore, a straight bone plate cannot readily be applied to the lateral aspect of the femur as this will cause the plate to be malaligned proximally, compromising screw purchase. (c) Alignment of the femur along the straight bone plate can result in an iatrogenic recurvatum deformity and malreduction of the fracture. (d) To remedy this, the proximal extent of the plate can be twisted to lie on the craniolateral aspect of the femur; this is known as helical plating. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 23.8
23.8 Preoperative (a) ventrodorsal and (b) mediolateral radiographs of an 18-month-old Jack Russell Terrier with a closed comminuted fracture of the femur with concurrent femoral neck fracture. Postoperative (c) cradiocaudal and (d) mediolateral radiographs. The diaphysis was stabilized with an IM pin and 3.5 mm SOP plate, and the femoral neck fracture with a lag screw and anti-rotational K-wire. Note how six-point bending of the SOP plate facilitates contouring of the plate distally to follow the normal procurvatum of the femur. Ideally, a larger IM pin should have been used.
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23.9 (a) Mediolateral and (b) craniocaudal radiographs of a closed, comminuted bicondylar fracture of the distal femur in a 6-year-old Dobermann. Postoperative (c) mediolateral and (d) craniocaudal radiographs. The fracture was stabilized with a transcondylar lag screw and bilateral 3.5 mm SOP locking plates.
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23.10 Fractures of the distal femur. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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23.11 Views of the (a) medial and (b) caudocranial aspects of the canine distal femoral physis. Note the morphology of the metaphyseal pitons that interdigitate with the physis. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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23.12 Exposure of the hip region via a craniolateral approach. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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23.13 Exposure and fixation of a proximal femoral epiphyseal fracture (capital fracture in adults). (a) The femur is externally rotated and Hohmann retractors are used to elevate the distal segment to allow inspection of the fracture site. (b) Pointed reduction forceps are used to maintain reduction. (c) Lag screw and K-wire fixation. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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23.14 Retrograde drilling of the glide hole for lag screw fixation of femoral neck fractures. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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23.15 The centre insert sleeve is placed in the glide hole and the fracture reduced. An adjustable stop is attached to the drill bit a distance ( corresponding to just less than the measured depth of the femoral head, such that articular penetration does not occur. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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23.16 Femoral neck fracture repaired with a lag screw and anti-rotational K-wire. Pointed reduction forceps can be used to maintain reduction of a femoral neck fracture following the drilling of the screw glide hole (see text for details). Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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23.17 Femoral neck fracture repaired with three K-wires. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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23.18 (a) Cranial and (b) lateral views of a fracture of the greater trochanter repaired with two K-wires and a figure-of-eight tension-band wire. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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23.19 Cranial view of a fracture of the greater trochanter in a mature patient repaired with a single lag screw. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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23.20 Proximal aspect of a disarticulated left femur showing the optimum entry/exit point for an IM pin in the trochanteric fossa.
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23.21 Lateral exposure of a femoral diaphyseal fracture. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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23.22 Normograde pin placement. (See text for details.). Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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23.23 Retrograde pin placement. The pin should be purposely oblique within the bone during placement, touching the medial cortex distally so that the trochar tip tracks laterally away from the joint and the sciatic nerve. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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23.24 Pin–plate construct used to stabilize a comminuted mid-diaphyseal femoral fracture. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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23.25 Application of a modified type 2 linear external skeletal fixator to the femur. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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23.26 Exposure of a distal femoral fracture. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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23.27 (a) Position of reduction forceps to hold distal epiphyseal separation of femur reduced with insertion points for Rush pins or K-wires. (b) Reduced epiphyseal separation in a cat showing position of Rush pins before they are seated completely. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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23.28 (a) Correct K-wire placement for distal femoral repair. (b) The pins are bent axially towards the femoral trochlea and then cut off. Wire twisters are used to straighten the tip of the pin away from the trochlea. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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23.29 Epiphyseal separation repaired with two Rush pins. Their hooks are above and clear of the bearing surface of the condyles. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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23.30 Intraoperative image of a right supracondylar short oblique fracture stabilized with a 2.7 mm supracondylar plate applied to the lateral aspect of the femur. Note helical contouring of the plate proximally to account for natural procurvatum of the bone.
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23.31 (a) Mediolateral view of a transverse supracondylar femoral fracture in a 2-year-old Lhasa Apso. Postoperative (b) mediolateral and (c) craniocaudal views. The fracture was stabilized with a 2.4 mm supracondylar plate. (Courtesy of D Clements)
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23.32 (a) Caudocranial radiograph of a medial femoral condylar fracture in an 11-month-old cat. (b) The fracture has been reduced and stabilized with three lag screws. (Courtesy of T Gemmill)

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