- Discussion:
- in the report by PJ. Nowotarski MD et al, the authors examined the role of external fixation of femoral shaft fractures in multipling injured patients;
- out of 1507 fractures of the shaft of the femur were treated with IM nailing 59 (4 %) of those fractures were treated with early external fixation
followed by planned conversion to IM nail fixation;
- 2-stage stabilization protocol was selected for patients who were critically ill and poor candidates for an immediate intramedullary procedure or
who required expedient femoral fixation followed by repair of an ipsilateral vascular injury;
- IM nailing was delayed secondary to medical instability in forty-six patients and secondary to vascular injury in eight.
- all fractures of the shaft of the femur were stabilized with a unilateral external fixator within the first twenty-four hours after the injury;
- duration of external fixation averaged 7 days before the fixation with the static interlocked IM nail.
- infection rate was 1.7 percent;
- conclusions: immediate external fixation followed by early closed IM nailing is a safe treatment method for fractures of the shaft
of the femur in selected multiply injured patients;
- Work Up:
-
Head Injury
- some authors have expressed concern that intraoperative hypoxia and hypotension may commonly occur w/ early
IM nail stabilization;
- both hypoxia and hypotension may lead to aggravated brain injury;
- w/ significant brain injury, there will often be enhanced frx healing and therefore, there may be increased efficacy of external fixation;
- in addition, IM nailing in head injured patients may lead to hip
heterotopic ossification;
- as noted by Starr et al (Jan 1998), early femoral shaft stabilization did not increase prevalence of CNS complications in head injured patients;
- references:
- Treatment of Femur Fracture with Associated Head Injury. AJ Starr et al. J. Orthop Trauma. Vol 12. No 1. Jan 1998. p 38-45.
- Early fracture fixation may be deleterious after head injury. RR Jacks et al. J. Trauma. Vol 42. 1997. p 1-5.
-
Lower Extremity Fracture Fixation in Head-Injured Patients.
-
Head injuries coexistent with pelvic or lower extremity fractures--early or delayed osteosynthesis.
- Treatment of major skeletal injuries in patients with a severe head injury. British Medical Journal - Clinical Research. 288(6433):1822-3, 1984 Jun 16.
-
Year Book: Timing of Osteosynthesis of Major Fractures in Patients With Severe Brain Injury.
-
Evidence for a humoral mechanism for enhanced osteogenesis after head injury.
- PreOperative Surgical Considerations:
- if the procedure is to be performed supine on a flourotable, ensure that the flouro can image the entire femur before the patient is prepped;
- patient can be positioned supine w/ folded towels underneath the sacrum and the knee inorder to raise the injured side off the table;
- the non injured leg is allowed to remain on the table (below the level of the injured side);
- or consider using a GYN leg holder for the uninjured leg which make it easier to obtain a lateral of the femur;
- initial reduction:
- note the anteversion of the uninjured leg using the rider test;
- it is important to have the best reduction possible (especially rotational) prior to inserting the pins;
- if the fracture is not initially reduced prior to pins insertion, then the skin will bunch up over the half pins (when the fracture is reduced later on);
- fixator length:
- confirm that the fixator length is optimal using flourosopy;
- Operative Technique:
- half pin insertion sites:
- pins are inserted along the lateral femoral cortex;
- it may be useful to slightly raise or lower the plane of the half pins so that the fixator does not obstruct lateral radiographs;
- final reduction:
- use of the half pins to help toggle the fracture segments into opposition;
External fixation of pediatric femoral fractures.
External fixation of femoral fractures. Indications and limitations.
Effects of changing strategies of frx fixation on immunologic changes and systemic complications after multiple trauma: Damage control orthopedic surgery.
