Femoral Shaft Fracture: Winquist Classification, IM Nailing & Rehab MCQs

Fracture Shaft of Femur

The Femur is the strongest bone in the body. Fractures here usually require high-energy trauma (e.g., MVA). It is a major injury associated with life-threatening blood loss and fat embolism.

1. Deforming Forces

Muscles pull the fragments into specific deformities:

• Proximal 1/3 Fracture: Proximal fragment is Flexed (Psoas), Abducted (Gluteus Medius), and Externally Rotated.
• Middle 1/3 Fracture: Distal fragment is pulled upward (Quadriceps/Hamstrings) causing shortening.
• Distal 1/3 Fracture: Distal fragment is pulled into Extension/Posterior tilt (Gastrocnemius).

2. Winquist & Hansen Classification

Based on the degree of comminution (fragmentation):

• Type I: Minimal/No comminution.
• Type II: < 50% comminution (at least 50% cortical contact remains).
• Type III: > 50% comminution.
• Type IV: Segmental comminution (No contact between proximal and distal fragments).

3. Management

• First Aid: Thomas Splint (traction splint) to reduce pain and bleeding.
• Adults (Gold Standard): Interlocking Intramedullary (IM) Nail. Allows early mobilization.
• Children (< 5 years): Gallows Traction or Spica Cast.
• Children (5-11 years): Titanium Elastic Nails (TENS).

Warning: Fat Embolism Syndrome (FES)
Common in long bone fractures (24-72 hrs post-injury).
Triad: Hypoxia (Respiratory distress), Confusion (Cerebral), Petechial Rash (Chest/Axilla).

25 Practice MCQs

Q1. The Gold Standard treatment for adult femoral shaft fracture is:

Answer: A). Biomechanically superior (load-sharing) and allows early weight bearing.

Q2. Typical blood loss in a closed femur fracture is:

Answer: A). Significant hemorrhage can occur into the thigh compartment.

Q3. In proximal third fractures, the proximal fragment is:

Answer: A). Pulled by Iliopsoas (Flexion) and Gluteus Medius (Abduction).

Q4. Which muscle pulls the distal fragment posteriorly in lower 1/3 fractures?

Answer: A). Risks injury to the popliteal artery.

Q5. Winquist Type IV fracture is characterized by:

Answer: A). Highly unstable.

Q6. Fat Embolism Syndrome typically presents within:

Answer: A). Classic triad: Hypoxia, Confusion, Petechiae.

Q7. Gallows Traction is used for:

Answer: A). Legs are suspended vertically; buttocks must be off the bed.

Q8. Thomas Splint is primarily used for:

Answer: A). Reduces muscle spasm and blood loss during transport.

Q9. TENS (Titanium Elastic Nail System) is indicated for:

Answer: A). Flexible nails inserted retrograde.

Q10. Early mobilization (weight bearing) is possible with IM nailing because:

Answer: A). Stimulates callus formation.

Q11. Dynamization of the nail involves:

Answer: A). Done if union is delayed (typically after 12 weeks).

Q12. External Fixation is the choice for:

Answer: A). Avoids putting metal into a contaminated wound.

Q13. Myositis Ossificans usually affects which muscle after femur trauma?

Answer: A). Bone formation within the muscle hematoma.

Q14. A major risk of reaming the medullary canal is:

Answer: A). Reaming increases intramedullary pressure, pushing fat into venous system.

Q15. Average healing time for adult femoral shaft fracture is:

Answer: A). Weight bearing progresses as callus forms.

Q16. Knee stiffness is common after femur fracture because:

Answer: A). The gliding mechanism of the quads gets scarred down.

Q17. Quadriceps lag refers to:

Answer: A). Indicates extensor mechanism weakness.

Q18. Perkins traction allows:

Answer: A). Skeletal traction without a splint.

Q19. Malunion in rotation causes:

Answer: A). Check rotation by comparing to the normal leg during surgery.

Q20. The entry point for Antegrade femoral nailing is:

Answer: A). Piriformis fossa (straight nail) or Tip (curved nail).

Q21. Retrograde nailing is inserted through the:

Answer: A). Used for distal fractures or ipsilateral hip implants.

Q22. Delayed union is defined if no healing by:

Answer: B). Non-union is usually > 6-9 months.

Q23. Is compartment syndrome common in the thigh?

Answer: B). More common in the lower leg (tibia).

Q24. Which nerve can be injured by traction against the fibular neck?

Answer: A). Causes foot drop.

Q25. Continuous Passive Motion (CPM) is used to:

Answer: A). Especially useful if fracture fixation is stable.