Femoral Shaft Fractures

Bony Structures

The femur is the largest and strongest bone in the body ( Fig. 58.1 ). The proximal part of the femur is formed by the head, the neck and both trochanters (greater and lesser). The diaphysis (shaft) represents the middle third of the femur. It is almost cylindrical in form and has a smooth anterior-posterior (AP) bow with an average radius of curvature of 6 degrees. The anterior bow of the femur varies according to gender, age, and ethnic origin, with an average radius of 97 ± 27 cm (the smaller the radius, the more significant is the femoral bow). The implications of these anatomic variations are very important when considering intramedullary implants and also extramedullary devices. On the posterior middle third of the femur, the linea aspera represents an attachment site for various muscles and fascia and also acts as a compressive strut to accommodate the anterior bow to the femur.

The head of the femur is located eccentrically, resulting in a diversion of the mechanical and anatomic axes. The anteversion of the neck related to the shaft can vary from individual to individual, ranging from a retroversion to more than 30 degrees of anteversion. The median difference has been reported to be 4 degrees, whereas 5% of patients are reported to have an anteversion difference of more than 11 degrees. Even though the outer surface of the femur looks cylindrical in form, the thickness of the cortex on consecutive cross sections varies ( Fig. 58.2 ). Therefore a potential cortical step after an injury can serve as a sign of rotational deformity.

The proximal area of the diaphysis up to 5 cm distally to the lesser trochanter represents the subtrochanteric area. Because of the unique biomechanical features of the subtrochanteric region and the high concentration of stresses, the management of fractures in this area can be perplexing. The psoas and abductors muscles may retract the short proximal fragment into flexion, external rotation, and abduction, making reduction difficult.

The distal third of the femur consists of the metaphysis and distal femur, which represents an expanded metaphyseal block formed by the medial and lateral femoral condyles. This is separated by the intercondylar notch and forms the support of the knee joint. Injuries to the supracondylar area and the condyles themselves are described separately from diaphyseal fractures because of their distinct anatomic and biomechanical features (see Chapter 59 ). Supracondylar fractures are typically flexed by the unopposed force of the gastrocnemius.

Musculature of the Femur Region

Any surgical approach to the thigh requires a comprehensive understanding of the surrounding muscle groups, their internervous planes, and the position of major neurovascular bundles. The muscles that insert at the femur are strong and act either at the hip joint, the knee, or both joints ( Box 58.1 ).

After a femoral shaft fracture, the strong musculature around the femur acts as a deforming force, which exacerbates the deformity and makes closed reduction more challenging. More specifically, the proximal fragment is abducted (act of gluteus medius and minimus through their insertion on the greater trochanter [GT]) and flexed (act of iliopsoas through its insertion on the lesser trochanter). The distal segment of the femur, on the other hand, goes into varus (act of adductors through insertion on the medial aspect of distal femur) and extension (act of gastrocnemius through attachment on distal aspect of posterior femur). Any attempt for a successful reduction of these injuries should first address all deforming forces.

Fig. 58.3 documents the classic deformities evident after femoral fractures as a result of the unbalanced muscle pulls.

The blood supply of the femur is provided by three main systems of vessels :

• 1.

  The nutrient system: one or two arteries deriving from the perforating branches of the deep femoral artery (DFA) or directly from the DFA in some cases. After entering the bone, the nutrient artery branches into ascending and descending vessels in different ways depending on their number. The nutrient system is the principal system supplying the bone marrow and the inner two-thirds of the diaphyseal cortex and anastomoses both with the metaphyseal system at the end of the diaphysis and with the periosteal system.

• 2.

  The metaphyseal–epiphyseal system: provides blood supply to the distal part of the bone and anastomoses with the nutrient system.

• 3.

  The periosteal system: composed of many small branches that pierce the cortex with a transversal type of orientation and supplies the outer third of the bone, anastomosing with the nutrient vessels. The periosteal system derives from branches of the DFA but also of branches of the lateral femoral circumflex artery in some cases.

Fig. 58.4 describes the major vascular anatomy of the thigh. The femoral artery enters the thigh at the mid-inguinal region, medial to the femoral neck and shaft, and divides into the superficial femoral artery (SFA) and the profunda femoris artery. The SFA is essentially an artery of transit, passing through the thigh to supply all the tissues below the knee. The profunda femoris artery, however, is the artery that supplies the thigh structures, with the latter giving off a number of deep circumflex branches that encircle the femur. The most proximal of these circumflex arteries provide the arterial blood supply to the femoral head, running proximally in the posterior aspect of the hip capsule close to the piriformis fossa (PF). The more distal circumflex branches are often important during the lateral approach to the femur (usually for conventional plating of the femur) because when cut, they can retract and cause troublesome bleeding. The SFA, on the other hand, travels medially to the femur in Hunter's canal before passing through the adductor hiatus. It is then renamed as the popliteal artery and lies in the midline behind the knee within the popliteal fossa. The obturator artery enters the thigh through the obturator foramen and usually supplies a small area in the thigh but is rarely of any clinical importance in this region.

All vascular structures in the thigh can be damaged during trauma. However, because of anatomic and functional differences, they produce distinct clinical pathologies. Because of its nature and the rich muscular collateral circulation in the thigh, injuries to the profunda femoris artery are commonly associated with hemorrhage rather than ischemia. In contrast, complete injuries to the superficial femoral artery are often associated with distal ischemia, which represents a limb-threatening condition that can lead to amputation if not promptly addressed.

The nerve supply to the thigh consists of three major nerves: the sciatic nerve that lies within the posterior flexor compartment, the femoral nerve that lies within the anterior extensor compartment, and the obturator nerve that lies in the adductor compartment of the thigh. The hip abductors, which act against the adductor compartment muscles, lie in the gluteal region and are supplied by the gluteal nerves (superior and inferior). The femoral nerve enters the thigh under the inguinal ligament, lateral to the femoral artery and anteriorly to the iliopsoas muscle. It rapidly divides into its terminal muscular and cutaneous branches, supplying the anterior thigh and the extensor muscles (quadriceps femoris). The sciatic nerve enters the thigh through the greater sciatic notch and lies between the hamstring muscles (which it supplies), directly behind the femur. It then enters the popliteal fossa, where it separates into the common peroneal and the tibial nerves, passing on to supply the lower leg. The site of separation is variable and is often located high in the thigh. Clinically, the sciatic nerve is at risk in high-energy trauma. On the contrary, the peroneal division is damaged either after a direct force or from an indirect injury and tethering of the nerve due to stretching forces at the area of the hip or the fibular neck.

History of Surgical Treatment

Before the 19th century, in the era of limited hospital resources and nonexistent fracture fixation techniques, femoral fractures were associated with an increased mortality rate. It took some time for the medical profession to appreciate the amount of blood that could be lost from one femoral shaft fracture (> 1.5 L ) and the sequelae of fat embolism syndrome. Hugh Owen Thomas, a British surgeon, devised the Thomas splint to stabilize femoral fractures. His work was never fully appreciated in his own lifetime, but when his nephew, Sir Robert Jones, applied his splint during World War I, this reduced mortality from 87% to less than 20%. This approach of nonoperative management spread rapidly across the world, and different traction designs were developed and became the mainstay of treatment of femoral shaft fractures.

Surgical Strategies and Timing

Subsequently, the invention of intramedullary nailing by Küntscher and the introduction of standardized fracture fixation techniques by the Arbeitsgemeinschaft für Osteosynthesefragen ( AO) group in Switzerland paved the way for the establishment of modern fixation techniques of long bone fractures. Moreover, the publication of observational studies in the early 1980s about the benefits of early versus delayed stabilization of fractures, particularly in the polytrauma setting, provided the foundation of our current philosophy of fracture management, the so-called early total care (ETC).

However, this surgical dogma was challenged in the early 1990s because some selected groups of patients with femoral fractures (with chest, head, and/or severe abdominal/pelvic injuries) were noted to have an increased incidence of perioperative complications that was attributed to the early-fixation approach and the instrumentation of the femoral canal with reamed intramedullary (IM) nailing. It was then thought that the type of fixation, the excessive activation of the immunoinflammatory system, and the genetic constitution of the patient were all responsible for the adverse outcome. Changing the surgical tactics by doing as little as possible from the surgical point of view but at the same time providing adequate temporary skeletal stability to control shock and painful stimuli, provide resuscitation of soft tissues, and minimize the phenomenon of fat embolism (an extreme form of this being adult respiratory distress syndrome [ARDS]) led to the concept of damage-control orthopaedics (DCO). These two strategies somehow created some dichotomy in the scientific community, particularly among orthopaedists in North America and Europe. It became clear that the reason behind this conflict was the failure to define clearly the profile of the patient that each strategy should be applied to for maximum benefit. In addition, it did not help the fact that DCO appeared to be overprescribed in patients who could be managed with ETC.

Nowadays, with the knowledge acquired and the stricter criteria developed, only a small number of patients (10% to 15%) are being managed with DCO. The criteria for DCO include a patient profile that is in an extremis physiologic state. Usually, this patient with multiple injuries suffers from the lethal triad (acidosis, hypothermia, coagulopathy). Other specific features include multiple fractures in the elderly; bilateral femoral shaft fractures; and severe chest, brain, and/or abdominal injuries.

Lately, Vallier and colleagues introduced the early appropriate care (EAC) concept of fracture fixation in the multiple injury patient. According to the authors, three physiologic parameters should be assessed: lactate, acid–base excess, and pH. Consequently, if improvement in acidosis is noted (lactate is <4, pH is 7.25, or base excess is 5.5), then definitive fixation of femoral, pelvic, acetabulum, and thoracolumbar spine fractures can take place within 36 hours (application of ETC). DCO is only recommended for patients in whom resuscitation has not been successful in the first 8 hours from presentation. The authors advocated that such an approach could be applied easily, is cost-effective, and can assist surgeons to evaluate the physiologic condition of the patient in a standardized manner and make appropriate decisions at the right time. The application of this protocol has been associated with a reduction in complications, a reduced length of hospital stay, and good overall outcomes. Of interest, Pape et al. expressed concerns about EAC and its appropriateness for specific subsets of polytrauma patients, highlighting that the three parameters proposed by Vallier et al. (lactate, pH, and base excess) can be problematic in elderly patients, patients with diabetes, and patients who suffer from renal failure. Pape et al. also expressed concerns that even the type of fluid during resuscitation can affect lactate levels and cautioned that the EAC protocol does not refer to the type of fluids that should be used. Moreover, they questioned the originality of the data available in Vallier's research group because parameters assessing coagulopathy, clotting factors, and circulatory and pulmonary function were missing. Pape et al. proposed the so-called safe definitive surgery (SDS) approach. Based on this concept, borderline, unstable, and extremis polytrauma patients would be subjected to ongoing physiologic assessment in the resuscitation room at “multiple end points.” When the patient is declared physiologically stable and safe, definitive treatment can be executed. If the patient continues to be in an unstable or extremis physiologic state, then DCO surgery is suggested. Ongoing reevaluation is mandatory, examining the coagulatory, respiratory system, and vasopressor requirements. If the patient remains unwell and the end points of resuscitation have not been established, the patient remains in the intensive care unit until improvement is made. When the patient is declared stable, then the surgeon can proceed with SDS.

To address the concerns that surfaced and the arguments made among clinicians between ETC, DCO, and EAC, Giannoudis et al. proposed that clinicians should be less opinionated, leave behind any disagreements and conflicts, and try to think “outside the box.” They went on to state that the epicenter of our decisions should be of doing no “further harm to the patient,” intervening promptly, and utilizing the concept of individualized/personalized medicine. They proposed the dogma of prompt, individualized, safe management (PRISM; Fig. 58.5 ). This dogma is based on the foundation that (1) every patient reacts in a different way to the same degree of trauma; (2) every patient has a different genetic constitution; and (3) the trauma service provision and resources, including manpower, are dissimilar from country to country. Consequently, trying to stratify polytrauma patients into specific pathways could lead to overlooking the importance and need of patient-specific/personalized treatment. Our goal should be to apply the type of treatment that fits best, based on the physiologic parameters that the patient presents with, while maintaining flexibility in a continuous manner. In regard to what markers should be used for the physiologic assessment of the patient, each trauma center should utilize whatever means of investigations is available and should apply the in-house trauma protocol that has been developed. Although not every unit is expected to measure interleukin-6 (IL-6) levels, other parameters have been proposed that can be assessed (e.g., lactate, acid–base balance, pH, lung function, blood pressure, pulse rate, hemoglobin, etc.). The presence of injury patterns, comorbidities, and the age of the patient should also be taken into consideration to obtain an accurate picture of the physiologic state of the patient. Such a strategy will provide the clinician with the required ammunition to make a decision in a personalized, safe manner. Because the condition of the patient is very dynamic (can change rapidly and frequently unexpectedly) the in-house protocol of physiologic assessment should be activated frequently, particularly during prolonged surgery, and the surgeon should be ready to revert to DCO from an ETC initial decision. Giannoudis et al. concluded that clinicians should stop arguing about ETC, DCO, and EAC. Instead, the philosophy of PRISM should be implemented and become the new “conceptual framework” for treating polytrauma patients.

Diagnostic and Preoperative Treatment

Since its introduction in the 1980s, the Advanced Trauma Life Support (ATLS) protocol has become the standard of care for the assessment of patients with multiple injuries. The A, B, C, D, E algorithm of ongoing evaluation of the patient's vital functions allows early identification of life-threatening injuries and the initiation of lifesaving procedures. It is important to remember that primary assessment, along with simultaneous resuscitation maneuvers, is essential for obtaining control of the situation. Describing the different existing protocols of resuscitation is beyond the scope of this chapter. As previously stated, every unit should have developed its own protocol of clinical assessment, which clinical and biochemical parameters to measure for monitoring resuscitation and vital organ function, and when and how to activate a massive transfusion protocol.

The availability of modern computed tomography (CT) scanners and the introduction of the so-called pan CT have significantly shortened the time to diagnosis of injuries sustained, allowing initiation of treatment modalities without any unnecessary delays.

The diagnosis of a femoral fracture can be made clinically from the scene of the accident by assessing the presence of swelling, bruising, deformity, pain, and instability. In polytrauma cases, this pain can be masked by other, more significant injuries, whereas if the patient is unconscious or intubated, other signs and symptoms must be looked for. On inspection, the thigh is usually tense and swollen, whereas the affected leg is often shortened.

A splint should be applied promptly, facilitating resuscitation of the surrounding soft tissues, reduction of the painful stimuli, and the formation of hematoma to support control of hemorrhage. It has been reported that the average blood loss after isolated femoral fractures can be as high as 1500 mL, which may result in hypovolemic shock.

A thorough clinical examination is mandatory to identify other concomitant injuries that may adversely affect the short- and long-term outcomes. Ipsilateral injuries of the knee and hip joint should always be suspected until proven otherwise. Injuries to the knee joint might be more difficult to diagnose initially due to the floating femoral shaft. For this reason, the knee should always be examined for stability at the end of any primary and secondary stabilization. A magnetic resonance imaging (MRI) scan could be obtained after definitive stabilization of the femoral fracture and when the condition of the patient has improved. Noteworthy is that arthroscopy of the knee joint in patients with femoral shaft fracture revealed pathologic findings in more than 50% of the patients (anterior cruciate ligament [ACL] ruptures, incidence of 5%; posterior cruciate ligament [PCL] ruptures, incidence of 2.5%). In another, more recent study, out of 42 patients studied, arthroscopy revealed medial meniscus injury in 12 knees, 3 lateral meniscus injuries, 18 ACL injuries, and 2 PCL injuries. In varus and valgus stress tests, 15 medial collateral ligament (MCL) and 4 lateral collateral ligament (LCL) laxities were noticed.

The presence of distal pulses and neurologic function must be clearly documented pre- and postoperatively. The presence of a vascular injury with persisting major hemorrhage or distal limb ischemia is an important parameter in determining the survival of the patient and limb. The most common artery involved is the profundal femoris artery. The incidence of vascular injury after femoral fractures has been estimated to be 1.6%. The principles of assessment and management of fractures with vascular injuries are considered elsewhere (see Chapter 16 ).

Radiographic assessment of the injury should follow a repeat of the original clinical examination done during the primary survey. Radiographs in two planes should be obtained (AP and lateral), and the joints above and below should be included ( Fig. 58.6 ). Typical ipsilateral injuries include the patella, femoral condyles, femoral head/neck, and acetabulum. Fractures of the tibia, the so-called floating-knee injuries, should also be excluded. Not infrequently, associated fractures can be minimally displaced and therefore not visible in plain radiographs. With the introduction of pan CTs, the early diagnosis of these injuries is increasing. An associated neck of femur fracture would have implications for the management and choice of surgical procedure (see following discussion) in the polytrauma patient.

Management of Soft Tissue Injuries

Open fractures of the femur are secondary to significant energy ( Fig. 58.7 ), and their management follows standard protocols. Although the infection risk in open injuries can be significantly higher, major closed injuries can be equally severe and can be underestimated, as could be the significant associated hemorrhage.

Closed soft tissue injuries range from minor contusions to major closed degloving injuries and compartment syndrome, as described by Tscherne and Oestern. The management of severe soft tissue injury is described in extent in Chapter 19 .

With regard to compartment syndrome, the anterior compartment has been found to be the most commonly affected. A retrospective study reporting on 21 cases of compartment syndrome of the thigh revealed that only in 10 patients was a femoral fracture evident, and 5 of those fractures were open. It is obvious that an open fracture cannot preclude the presence of compartment syndrome.

Additional risk factors associated with the development of this complication include hypotension, compression, military antishock trousers, coagulopathy, and vascular injuries. In a recent systematic review focusing on the incidence and outcomes of thigh compartment syndrome, 90% of cases of thigh compartment syndrome were attributed to blunt trauma. Forty-four percent of cases had associated femoral fractures, of which 22% were open fractures.

Primary nerve injuries in the presence of femoral shaft fractures are rare. Only a few cases are reported in the literature, with a predominance of sciatic nerve injuries.

General Aspects

Nowadays, the vast majority of femoral shaft fractures are treated operatively. This philosophy has evolved over the years as the benefits of operative treatment were clearly demonstrated in a number of studies reporting a reduction of painful stimuli, thromboembolic events, and respiratory insufficiency; early patient ambulation; and a decrease in muscular atrophy, joint stiffness, and malunion.

Research has also highlighted the benefits of early fracture fixation within 24 to 36 hours of admission. The standard of care in terms of the choice of fixation remains reamed IMN. In patients with multiple injuries and in situations where the principle of damage control has been applied due to the unstable physiologic condition of the patient, temporary stabilization of the femoral shaft with external fixation is an acceptable option. Conversion of the external fixation to IMN (see Videos 58.1 through 58.5 ) usually takes place as soon as the patient's condition has improved, within a week from the original incident. However, it is not uncommon for the external fixator to become the definitive stabilization tool, particularly in poor countries where implants might not be available or in cases where the patient has been unwell for weeks in the intensive care unit due to a severe head injury (HI). Open femoral fractures are managed like any other open long bone fracture, following the principles of débridement, irrigation, temporary (external fixation) or definitive stabilization (IMN), and appropriate soft tissue cover.

During admission to the hospital, the femoral fracture is stabilized with a Thomas splint or skin traction. When delays are anticipated, skeletal traction can be considered a method of temporary stabilization. Usually, supracondylar transosseous pin traction is used. Cast splinting is rarely effective.

Other options for operative treatment include conventional and/or locking plates, particularly when the fracture lines extend from the distal one-third of the femoral shaft to the articular surface of the femoral condyles (see Videos 58.5 through 58.7 ).

Nonoperative Treatment

Nonoperative treatment is particularly popular in underdeveloped countries. Due to the lack of well-trained surgeons, affordable equipment, and a clean surgical environment, nonoperative treatment of femoral shaft fractures remains the best and often the only option. On the contrary, in developed countries, nonoperative treatment is used very rarely and only for patients who are not fit for surgery.

It is noteworthy that this difference in practice between underdeveloped and developed countries may be associated with the big difference in the average age of the two populations of patients.

A systematic review of the management of femoral shaft fractures in low- and middle-income countries reported that the average age of those with femoral shaft fractures was 32.9 years, whereas the national epidemiologic study in Sweden reported that the average age was 67 years.

It seems that femoral shaft fractures affect younger people in low- and middle-income countries who are able to tolerate long periods of immobilization, whereas elderly people in high-income countries are known to have worse outcomes with no or delayed surgery and are therefore treated operatively.

In general terms, traction is only used as a temporary measure to restore leg length and alignment, as well as to provide pain relief and limit blood loss before surgical stabilization. Closed management by traction is, however, both complex to manage and time consuming, often requiring months of bed rest. It does not offer the early return to function provided by modern fracture stabilization techniques.

Traction can either be applied via the skin or the skeleton. Skin traction, with padded adhesive tapes secured with a bandage to the leg, can only be used with a light weight (5 to 7 pounds). It is poorly tolerated by patients because it may result in local skin problems or losing hold and thus control. For adults, it only acts as a temporary measure until definitive treatment. Skin traction applied through an ankle strap on a splint designed for emergency transportation (e.g., Hare traction) is useful in the immediate prehospital environment.

In contrast, skeletal traction permits the use of greater traction force and can be tolerated for long-term treatment (months). A traction pin may be placed in either the distal femur or the proximal tibia. A 5-mm pin, threaded in the central portion to prevent backing out, is preferred. In a study at a university hospital setting in Africa, 69 femoral shaft fractures were managed by traction. The mean hospital stay was 45 days, and the average time of traction was between 30 and 40 days. At the end of the traction period, 8 patients (11.8%) showed a decrease in the quadriceps mass, and 7 patients (10.3%) showed stiffness of the knee with a range of motion limited to 0 to 90 degrees. Most patients were discharged after about 8 months of treatment. One patient suffered a nonunion, and one was malunited. The authors concluded that such an approach to the management of femoral shaft fractures should be encouraged in countries like theirs where it is a luxury to have a C-arm in the operating room and where the hardware often is not available to perform stabilization of long bone fractures.

Technical Aspects of Femoral Traction

Longitudinal traction for femoral fractures has been used since the time of Hippocrates (460 to 370 BC). The aim of using traction is to realign the bony fragments by applying traction in line with the long axis of the limb. As previously discussed, nowadays, it is used as a temporary measure to control pain and bleeding at the fracture site in the early stages after injury (i.e., prehospital care). It is rarely used as a definitive treatment for femoral shaft fractures. The management of a patient on femoral traction requires skill and paying daily attention to details over the required healing period. Each traction system has its proponents, with emphasis on the relevant application of balanced forces and early knee motion whenever possible. Problems associated with traction include bed and traction ring sores; skeletal pin infection and pin migration; the ability to control position that can lead to shortening and/or malunion (overriding of the fracture parts may occur); and the need for prolonged bed rest and immobility that often leads to knee stiffness, muscle wasting, and the development of deep vein thrombosis.

Compared with proximal tibia pins, distal femoral pins allow more direct control of the femur and have a limited effect on knee function. They are normally placed at the level of the superior pole of the patella and outside the knee capsule to avoid joint infection. Ideally, a femoral pin should be inserted with the patient's knee flexed to 90 degrees to avoid tethering of the iliotibial band, but this is not practical in the awake patient. Proximal tibial pins are placed just behind and below the tibial tubercle. They cannot be used in the presence of an ipsilateral knee injury, and an additional disadvantage is that they restrict knee motion during rehabilitation.

Several traction systems exist, each designed to apply a traction force along the femoral axis and balance against an opposite force. If the traction force is unbalanced, it will result in the patient being pulled down the bed, which can subsequently cause buttock and sacral skin problems from friction. A common problem is that eventually, the traction weights come to rest on the floor, rendering the whole traction system ineffective.

A simple method of applying traction consists of attaching a rope to the clamp holding the traction pin or wire, then passing it over a pulley, and finally attaching its free end to a weight hanging free at the foot of the bed. The leg is then supported by pillows arranged to minimize deformity and prevent the heel from resting on the bed (which can often result in pressure sores). Depending on the patient's size and thigh musculature, 15 to 25 pounds of traction is usually sufficient to restore femoral length during the first few days after injury, when muscle spasm can be intense. Repeat radiographs are required to adjust the weight and therefore traction force. This simple technique provides only limited support for the fractured femur and restricts mobility.

Better fracture control and bed-bound mobility can be obtained by the use of a supportive splint, such as the Thomas splint. This consists of a padded ring that goes around the proximal thigh and is attached to a long steel loop that must be selected to be slightly wider and somewhat longer than the leg. Traction is then applied between the ring and the end of the splint. Fabric slings and pads are placed posterior to the thigh to support the femur directly and re-create the femoral bow. A small windlass is commonly used to tighten the traction and pulls against the leather ring, which is pushed into the groin. Suspending the splint on and applying weights to pull the whole splint out of the groin prevent ring sores. Typically, the foot of the bed must be raised slightly to balance the traction.

In many North American hospitals, a balanced suspension is made for the injured leg, using a modified Thomas splint, with a semicircular proximal ring. A hinged Pearson attachment is typically added to support the lower leg with the knee slightly flexed. Either both ends or just the proximal end of the Thomas splint is supported with a rope-pulley-weight combination, with the weights chosen to balance the splint so that it supports the patient's leg and helps with fracture control while permitting some adjustment and mobility by the patient, within the limits set by the separately applied skeletal traction rope.

Another traction system is the Perkins traction, often associated with the care of tibial plateau fractures. It also offers an effective and simple means of managing traction for femoral shaft fractures. It adds the benefit of knee mobilization, which may begin as soon as the patient's comfort permits. Perkins traction is longitudinal traction applied with the patient on a split bed, arranged so that the lower half of the mattress can be removed or dropped to permit knee flexion while traction is maintained ( Fig. 58.12 ). Longitudinal traction is applied from a distal femoral pin and out over pulleys off the end of the bed. The split bed allows the end of the mattress to be removed so that the patient can start early knee motion while remaining on traction.

When traction is used as definitive treatment, it is usually maintained for several weeks (typically 5 to 6 weeks in adults) until adequate fracture healing has occurred and the fracture is without tenderness or movement on clinical examination. At this time, continued protection is necessary to avoid potential gradual angulation. For more distal femoral shaft fractures, this can be effectively provided with a hinged-knee cast brace, but such support may not be sufficient for proximal femoral shaft fractures, particularly in the subtrochanteric region.

Alternative options are to use a spica cast (either recumbent or ambulatory) or to continue skeletal traction until mature fracture healing is present, clinically and radiographically—often as long as 12 weeks after injury. According to a systematic review, the average traction time was found to be 52.8 days (range, 19.8 to 122.5 days), the average length of stay was 55.4 days (range, 45 to 140 days), and the average time to partial weight bearing was 52.2 days (range, 42 to 60 days).

Clearly, paying attention to detail and expert nursing care are required to achieve a well-aligned femur and to prevent local complications. In addition to the previously mentioned problems of malunion, nonunion, stiffness, and pressure sores, other complications that have been reported include a higher risk of thromboembolic events and the development of osteoporosis and muscle atrophy. The overall morbidity and mortality are significantly higher when compared with early operative stabilization.

Contraindications for nonoperative treatment include the presence of compartment syndrome, vascular injuries, traction injury to any of the lower limb nerves, nonunion (late complication), and irreducible fractures with impending soft tissue perforation.

Pearls and Pitfalls

Skeletal Traction With Pins

• Compared with proximal tibia pins, distal femoral pins allow more direct control of the femur and have a limited effect on knee function.

• Femoral pins should be inserted with the patient's knee flexed to 90 degrees to avoid tethering of the iliotibial band.

• Proximal tibial pins are placed just behind and below the tibial tubercle.

• A traction weight of 15 to 25 pounds is usually sufficient to restore femoral length during the first few days after injury.

• Complications include bed and traction ring sores; skeletal pin infection; pin migration; shortening and/or malunion; and prolonged bed rest and immobility that can lead to knee stiffness, muscle wasting, and deep vein thrombosis.

• Contraindications for nonoperative treatment include compartment syndrome, vascular injuries, traction injury to any of the lower limb nerves, nonunion (late complication), and irreducible fractures with impending soft tissue perforation.

Operative Treatment

Currently, in the developed world, all adult femoral shaft fractures are usually managed operatively. Reasons for nonoperative treatment, as previously stated, include medically unfit patients and patients consenting for nonoperative treatment.

External Fixation

Definitive treatment of femoral fractures with external fixation systems is still used around the globe despite the evidence surrounding the success and effectiveness of IMN. Indications for external fixation include open fractures with or without associated vascular injury, polytrauma, stabilization before patient transfer to another facility, and patients with poor medical condition who are unable to tolerate the surgical stress reaction of IMN ( Fig. 58.13 ).

The application of external fixation systems to the femur requires good knowledge of anatomy because there is extensive muscle coverage around the thigh. It can be technically demanding because there is no useful subcutaneous border that will allow safe pin placement without tethering the surrounding musculature and restricting knee motion. A standard external fixator that allows free, independent pin placement is usually used, consisting of 5- or 6-mm threaded pins. The insertion of the pins can follow an arc from true lateral to anterior, limited by the position of the femoral artery and sciatic nerve. It should be emphasized that the pins should be placed so that they will not interfere with planned later definitive fixation. Before pin insertion, any rotational deformity or fracture overlap should be addressed by the application of manual traction. Blunt dissection of the soft tissues is mandatory to avoid muscular damage. Use of small retractors will facilitate safer insertion of the pins. Care should be taken to ensure that both cortices are engaged. In that respect, feeling the pin thread itself passing into the opposite cortex will provide confirmation of the right depth of insertion.

Routinely, all pins must be checked with image-intensification control in two planes to assess optimum pin placement. Proximal pins can be directed into the femoral neck and head. The use of anterior-posteriorly placed pins should be restricted because it provides tenodesis of the rectus femoris muscle, with subsequent stiffness. The joint capsule of the knee should also not be penetrated. The femorotibial spanning is preferred in these cases. The pin and frame construct should be applied according to the fracture anatomy but planned to be as stable as possible, with the most stable construct involving near–far pin placement and the rods applied as close to the soft tissues as is practical for skin care. A pin placement too close to the fracture side might increase the risk for infection.

In practice, an emergency fixator for damage control can be applied very quickly, especially anterolaterally. The aim is to provide adequate stability during the initial critical care process. A definitive reduction at this time is not essential. If general or local difficulties predominate, a frame providing good alignment and stability will be satisfactory, and protracted attempts at a perfect reduction should be avoided. However, later definitive nailing will be facilitated by the maintenance of good tissue tension with normal length and good alignment if this is easily achievable (see secondary nailing).

In severe open fractures, most surgeons will perform immediate definitive fixation after wound débridement and lavage. If there is an indication not to proceed to definitive fixation, an external fixator should be applied after débridement, which acts as a very good temporary stabilizing device. The patient can then be considered for transfer or for definitive care. In this situation, local soft tissue conditions and the availability of an experienced surgeon will determine the timing for conversion. Definitive treatment, however, should not be delayed unless additional severe polytrauma issues are evident; indeed, current evidence supports that in severe open fractures, the sooner definitive skeletal stabilization and healthy soft tissue cover is provided, the better the outcome will be.

Noteworthy is that self-drilling, self-tapping monocortical pins reduce stability by 20% compared with classic bicortical pins but can be applied faster and save time, which might be important in critically ill patients with multiple extremity fractures. Common complications that have been reported with the use of external fixators for the definitive treatment of femoral shaft fractures include loss of reduction, malunion, frequent pin site infections, nonunion, and osteomyelitis. In a recent study evaluating the result of treatment in 87 fractures after polytrauma, all fractures united at an average of 23.60 ± 11.37 weeks (ranging from 13 to 102). The external fixator was removed after an average of 33.99 ± 14.33 weeks (ranging from 20 to 120). Overall noted complications were 9.19% of delayed union, 1.15% of septic nonunion, 5.75% of malunion, and 8.05% cases of loss of reduction. The authors concluded that external fixation of femoral shaft fractures in polytrauma is an ideal method for definitive fracture stabilization, with minimal additional operative trauma and an acceptable complication rate.

Key Points: External Fixation

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