Fractures of the femoral shaft

FRACTURES COMPARATIVE

OF THE FEMORAL SHAFT

STUDY OF THE PRESENT

DUVAL PREY,M.D.,

P.A.c.s.,

AND

JNO.

METHODS

OF TREATMENT*

M. FOSTER, JR., M.D., P.A.C.S.

DENVER, COL.

F

RACTURES of the shaft of the femur are compIex in nature and therefore demand the most intent

proper foIIow-up records, but a very exceIIent idea of the anatomica resuIt couId be procured, for the reason that

l%. I. Bryant overhead traction method of treatment for fractures of femur in infants. (From Moorhead’s Traumatic Surgery.)

and strict attention to detaiI, so that a satisfactory resuIt may be obtained. Because there are so many forms of treatment in use for this type of fracture, it is extremeIy diffrcuIt to determine justIy the vaIue of each. However, in the Denver Genera1 HospitaI, there has been a sufficient number of fractures of the femora1 shaft treated by a diversity of doctors, each with his own preferred treatment, which to furnish, when reviewed, sufficient data for a vaIuabIe comparative study. This paper, then, represents a study of a11 the fractures of the femora1 shaft which have been treated at the Denver Genera1 HospitaI since 1928, 147 in number. Each case has been anaIyzed in respect to the form of treatment it received and the resuIt that was obtained. It is hard to estimate the functiona end-result in these cases, because of the diffrcuIty of obtaining * From the Department

FIG.

2.

Infant

in suspension. (From Traumatic Surgery.)

Moorhead’s

a11 had had a fina x-ray check, -which was avaiIabIe. In reviewing these records, we were impressed with the importance of cIassifying the cases according to the patient’s age, and when this was accomplished, the most satisfactory ruIe of conduct was obvious for each group.

of Surgery,

116

Denver

General

HospitaI.

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U ndoubtedIy, the muscuIar deveIopment and the site of the fracture are of great significance, but the individual’s age is of even more importance, and unti1 we fuIIy appreciate this fact, we are doomed to have many unsatisfactory results. With this idea in mind, a11 the patients with a fracture of the femora1 shaft were arbitrariIy divided into four cIasses according to their age; nameIy, infants, chiIdren, aduIts and the eIderIy. Using this method of approach, we found the most gratifying resuIts in the first cIass, or infants, to have been obtained when the Bryant overhead traction method of care was used. This treatment consists of suspending the infant from an overhead frame by means of traction on both Iegs, sufficient to raise the peIvis sIightIy from the bed. This form of therapy for fractures of the femora1 shaft not onIy gave the best resuIts but had the further advantage of minimizing the nursing care required. The onIy unsatisfactory end-resuIts in this youngest group occurred in 3 cases: 2 which were immobiIized in pIaster, and one which was treated bv means of IongitudinaI traction. AccordingIy, unIess some very unusua1 circumstance prevents its use, the Bryant overhead traction form of treatment is by far the most satisfactory method of care for infants with a fracture at any pIace in the femora1 shaft. In the second group, which is composed of children, it was found that the greatest number of satisfactory resuIts were obtained by using the Russell traction method of treatment. RusseII, of New Zealand, contends that the Iimb need onIy be pIaced in a position of comfort and moderate traction, thereby restoring the muscIes to their norma equiIibrium, and the fragments wiI1 assume their natura1 position. This is accompIished by a comparatively simpIe system of puIIeys, using skin traction beIow the knee, with the limb suspended in sIight abduction with moderate Aexion of the knee. Eight pounds of weight wiI1 ordinariIIy furnish a sufficient puI1.

American

Journnl

01 St~rg:rry

II-

There has been some aIarm in the past that traction beIow the knee might resuIt in an injury to the knee joint. RusseII,

FIG. 3.

Russell traction apparatus.

however, contends that the weakest point in the Ieg is not at the knee, but at the site of the fracture, and hence the yieId must occur at that point. UndoubtedIy this is true, for in not a singIe case of this series has there been the sIightest sign of any damage to the knee joint as a result of this form of treatment. Further, by using so Iittfe weight, not only is the patient more comfortabIe, but there is no tendency for the moIeskin to sIip, thereby requiring re-appIication. In addition, this method permits the reguIation of the correct degree of abduction required for that individua1 fracture, because it must be remembered that the higher the site of the fracture, the greater the degree of abduction necessary for the proper alignment of the fragments. However, there are two errors of application in the RusseII form of treatment which are commonIy experienced, and must be guarded against. First, unIess the site of the fracture is supported, there wiI1 be a posterior sagging of the fragments, and second, the patient’s hee1 must not rest upon the bed. AccordingIy, these patients shouId be carefulIy examined each day by the surgeon, and must have an inteliigent and weII-informed nurse, especiaIIy qualified, so that she can make minor rearrangements of the apparatus as required.

FIG. 4. Russell

traction apparatus applied the aged this form

to eIderIy femaIe with fractured femora1 shaft. of treatment is especiaIly advantageous.

FIG. 5.

FIG. 6.

FIG. 5. OriginaI roentgenogram of fracture of femora1 shaft. FIG. 6. Same case as Figure 5, after reduction.

In c:hiIdren Emd

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& Foster-Fractures

Moreover, it must be remembered that an absoIuteIy correct anatomical approximation of the fragments in children,

FIG. FIG. 7. OriginaI FIG. 8. Anterior FIG. 9. Lateral

7.

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tion used, that we fee1 no hesitancy in advising, particuIarIy in muscular individuaIs, this type of treatment as the

FIG.

8.

roentgenogram of chiId with fracture of middk of femoraI posterior view of same case as Figure 7, after reduction. view of same case as Figure 7, after reduction.

aIthough desirabIe, is not necessary for an exceIIent functiona resuIt. If the alignment of the fragments is good, despite the fact there may be some posterior displacement of the Iower fragment, an exceIIent functional resuIt may be anticipated. The third cIass consists of ad&s between sixteen and sixty years of age. In this group, the Iargest percentage of good resuIts were obtained by the use of some form of skeIeta1 traction. The percentage of men in this group was found to be much Iarger than that of women, which is probabIy due to their more numerous exposures to accidenta injuries. SkeIetal traction, however, gave the greatest number of good anatomical results. So much better were these than any obtained by the other methods of reduc-

01 Surgvr\

FIG.

0.

shaft.

method of choice. Further, it is more important that we obtain a good anatomica result in this group, because nature, aIthough kind, has her favorites, and an aduIt with a fracture of the femorai sha’ft is unfortunateIy not among the especiaIIy priviIedged. A reduction which wouId prove not onIy satisfactory but exceIIent in an infant or a child might be found to give onIy ~1 moderatery gratifying resuIt in a man or woman. AImost 90 per cent of the cases in this series requiring an open operation for reduction of the fracture were obtained from this third group, and invariabIy after some form of skin traction had faiIec1. Moreover, even when by operation the fragments were placed in their norma position, unIess some form of fixation was used, such as a wire, plates, or an externa1

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Prey & Foster-Fractures

cIamp, there often resuIted a IateraI bowing at the Iine of the fracture. The fact is not generaIIy appreciated

cause of these two conditions which must be accepted as premises to the proper treatment of fractures of the femora1

FIG. 12.

FIG. IO.

FIG. II.

that a pIaster cast, no matter how cIeverIy and carefuIIy appIied, wiI1 not maintain the fragments in their proper alignment unIess some form of fixation is used at the site of the fracture, or some form of traction is used which has been incorporated in the pIaster. FrequentIy, the fractured ends of the femur are so notched that when pIaced in apposition, there is no danger of their sIipping, and here it is the custom rather than using some form of foreign fixation, to have traction incorporated in the pIaster case by means of moIeskin appIied to the Ieg. There are two variants to be considered in these fractures; first, the muscuIar puI1, and second, the IocaIity of the fractures; so both the amount of weight required and the direction of the puI1 must necessariIv varv in each case. Be-

FIG. 13.

Original roentgenogram of fracture of femur above condytes. FIG. 13. Same case as Figure 12, after reduction.

FIG.

FIG. IO. OriginaI roentgenogram of fracture of femur, just above knee. FIG. I I. Same case as Figure IO, after reduction.

JULY. 1934

12.

shaft, we have found the foIIowing mode of care to prove most satisfactory. an ice-tong or a Under anesthesia, Steinman pin is appIied. Continuing the anesthetic, the ffuoroscope is then utiIized, not so much with the idea of reducing the fracture and Iocking the fragments, aIthough when possibIe this shouId be done, but mainIy to indicate in what position the Ieg is to be placed, so that by subsequent traction, a correct reduction of the fragments can be anticipated. By the use of the fluoroscope with this idea in mind, it is astounding with what ease a decision can be reached regarding the proper plane for the traction. In other words, the degree of abduction, adduction or ffexion required for that individua1 case becomes perfectIy obvious, and the increased percentage of good resuIts subseauentIv obtained is remarkabIe.

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some of the Figures 5-13 indicate resuhs that were obtained when the proper plane of traction was utilized. To repeat, then, it was found that the greatest number of satisfactory reductions in this third group were obtained by the empIoyment of some form of skeIeta1 traction; whether this was accomphshed by the use of a Steinman pin, ice-tongs, or a Kurschner wire seemed to make very IittIe difference in the final outcome. If this is true, then a most exceIIent approximation of the fragments can be expected and accompIished, providing the proper direction for the puI1 in each individua1 case is perceived, and by using for this purpose, we the fluoroscope simplify the treatment as we11 as improve the percentage of favorabIe end-resuIts. The fourth group is made up of individuals over sixty years of age. In this cIass it seemed to make very Iittle difference whether reduction was accompIished by means of skeIeta1 traction or by the RusseII method of care, both evidentIy giving about equally good functional resuits. We do beIieve, however, that a

SUMMARY

greater exactness of approximation of the fragments was obtained by the use of some

AI1 fractures of the femoral shaft admitted to the Denver Genera1 HospitaI, as we11 as those encountered in private practice since 1928, were reviewed and arbitrariIy divided into four classes according to the age of the patient. From this study, the most satisfactorymode of care is reported for each group; namely, infants were benefited most when the Bryant overhead form of traction was used; chiIdren responded most satisfactoriIy to the RusseII traction method of treatment; skeIeta1 traction proved most efficient in aduIts under sixty years of age; whiIe both the RusseII method and skeIeta1 traction gave equahy good resuhs in the aged. The extreme vaIue to be obtained by the more common utiIization of the Auoroscope, as an indicator of the proper pIane of traction for each individua1 case, is not generaIIy appreciated; and for this reason, it is suggested that with the more frequent empIoyment of the Auoroscope for this the resuIts with a11 forms of purpose, traction wiI1 be improved, and consequentIy the number of cases requiring a reduction wiI1 necessubsequent open

form of skeIeta1 traction.

sarily

be reduced.