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Fractures of the femoral shaft
Orthopaedic V: injuries to the spine, pelvis and lower limbs
Fractures of the femoral shaft
Epidemiology The worldwide annual incidence is 1–1.33 fractures per 10,000 population. The annual incidence is 3 fractures per 10,000 population in individuals aged <25 years, and in those aged >65 years. These injuries are commonest in males aged <30 years.
S J Fogerty P V Giannoudis
Aetiology The cause of fracture of the femoral shaft may be traumatic or atraumatic (Table 1).
Abstract
Presentation and assessment
Fractures of the femoral shaft are associated with high-energy, multi system trauma. Management must be methodical, initially excluding lifethreatening injuries. Patients surviving for the first 24 hours after major injury as a result of effective resuscitation remain at risk of progressive organ failure and death from a local and general inflammatory response. The involvement of senior clinicians is vital to ensure there is not a delayed decline in condition after initial injury. Femoral fractures are usually managed surgically, though traction should be considered in certain circumstances. Ninety-five percent of post-traumatic diaphyseal femoral fractures heal with antegrade femoral nailing. Minimal-invasive devices stabilize these fractures without extensive dissection of soft tissue. Flexible intramedullary rods may be used in children to achieve fracture stability, but immature bones, open physes, parental care available, and growth potential must be considered when forming the management plan. Early complications include haemorrhage, fat embolism, pneumonia, multiorgan failure, neurovascular injury and compartment syndrome. Later complications include infection, non-union, delayed union, metalwork failure and heterotopic ossification. The goal of the physiotherapy programme should be weightbearing to tolerance provided surgical stability allows. The fracture should progress to union by four months.
Traumatic fracture A high-velocity injury is usually involved; significant pain and the inability to bear weight are present. There may be shortening of one leg, swelling and gross deformity. They are often associated with multisystem trauma because of the energy involved to cause the fracture. Life-threatening associated injuries must be addressed first. An organized and methodical approach to the multiply injured patient must follow ATLS™ guidelines (see Hassan, CROSS REFERENCES). Fractures can result in significant blood loss (up to 5 l) due to the vascularity of the femur.1 Blood transfusion may be required in up to 40% of isolated fractures. The pelvis, hips and knees should be examined as part of the secondary survey. A distal neurovascular examination should be done, and traction may be necessary for initial stabilization to maintain leg length and reduce pain before further management. Common injuries associated with femoral shaft fractures are listed in Table 2. Atraumatic fracture Patients with atraumatic fractures may present with few physical findings. The thigh may be swollen, the range of motion limited by pain, and they not be able to bear weight. History and examination should be done as appropriate depending on the suspected cause (e.g. examination of the abdomen and breast if a metastatic cause is suspected).
Keywords femur; fixation; traction; multisystem trauma
Anatomy
The response of the body to trauma
The femur is the strongest, longest and heaviest bone in the body and is essential for ambulation. It consists of a shaft (diaphysis), a proximal metaphysis and a distal metaphysis. The femur has excellent soft tissue coverage, accounting for its high vascularity. The blood supply enters the femur through the metaphyseal arteries and branches of the profunda femoris artery, penetrating the diaphysis and forming medullary arteries extending proximally and distally.
Phases: there is enormous interest surrounding the metabolic and immune response of the multiply injured patient in the early and intermediate phases (see Kumar, CROSS REFERENCES).
Causes of fracture of the femoral shaft
S J Fogerty MRCS is a Clinical Fellow in Orthopaedics and Trauma at Leeds General Infirmary, Leeds, UK. Conflicts of interest: none declared. P V Giannoudis EEC(Ortho) is a Professor of Trauma and Orthopaedic Surgery at the School of Medicine, Leeds University, Leeds, UK. Conflicts of interest: none declared.
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Traumatic
Atraumatic
Road traffic accidents Sports (particularly skiing and football) Falls Gunshot wounds
Repetitive stress (e.g. jogging) Metabolic disease of bone Metastatic disease Primary tumours of bone
Table 1
430
© 2007 Published by Elsevier Ltd.
Orthopaedic V: injuries to the spine, pelvis and lower limbs
patients who can benefit from this treatment can be identified rapidly.3,4
Injuries associated with fractures of the femoral shaft Soft tissue injuries of the knee (ligament, meniscal) Ipsilateral femoral neck fracture Tibial fracture (floating knee) Hip dislocation Spine fractures
Types of femoral shaft fractures The spectrum of femoral shaft fractures is broad, and ranges from undisplaced stress fractures to fractures associated with severe comminution and significant injury to soft tissue. The three femoral fracture patterns vary according to the direction of the force applied and the quantity of force absorbed: • a perpendicular force results in a transverse fracture pattern • an axial force may injure the hip or knee and cause comminution (dashboard injury) • rotational forces may cause spiral or oblique fracture patterns. The amount of comminution present increases with the amount of energy absorbed by the femur at the time of fracture.
Table 2
Stress (e.g. injury, surgery) initiates a local inflammatory and general response that is protective, and which conserves fluid and provides energy for repair. Resuscitation may attenuate the response but does not abolish it. The response is characterized by an acute catabolic reaction that precedes the metabolic process of recovery and repair. This metabolic response to trauma was divided into an ‘ebb and flow phase’ by Cuthbertson.2 The ebb phase corresponds to the period of severe shock characterized by depression of enzymatic activity and oxygen consumption. Cardiac output is below normal, core temperature may be subnormal, and a lactic acidosis is present. In the flow phase, the body is hypermetabolic, cardiac output and oxygen consumption are increased, and glucose production is increased (see Maughan, CROSS REFERENCES). Lactic acid may be normal.
Management Conservative Treatment of fractures of the femoral shaft has evolved over the past century. Until the recent past, the definitive method for treating femoral shaft fractures was traction or splinting. Before the advent of modern aggressive techniques and treatments, these injuries were often disabling or fatal. Traction has many disadvantages (Table 3). Conservative options are used infrequently (excluding fractures in young children), but traction is used in the management of fractures in very osteoporotic bone or certain periprosthetic fractures.
Organ failure: patients surviving for the first 24 hours after major injury as a result of effective resuscitation remain at risk of progressive organ failure and death from what appears to be this uncontrolled inflammatory process. A septic cause usually cannot be identified, yet the response is as if infection is present. While organ-supportive measures such as mechanical ventilation, oxygenation, renal support and total parenteral nutrition help to maintain substrate delivery and metabolite removal in the tissues, these therapies eventually fail if the microvasculature ceases to function.
Surgical Haemodynamics: the patient should be haemodynamically stable and fully resuscitated before definitive surgical management of a femoral shaft fracture. In general, the goal time to definitive surgical stabilization is 24 hours. If the patient is haemodynamically unstable and has not been adequately resuscitated, femoral fixation should be delayed and temporized with an external fixator (Figure 1) or skeletal traction until cardiovascular stability is achieved (damage-control surgery).
Interventions designed to attenuate selected elements of the inflammatory pathways are being developed: • antioxidants • enzyme inhibitors • pharmacological agents • antibodies (to soluble mediators and cell-surface receptor antagonists). Most of these interventions are experimental and have met with only limited clinical success. A major problem with attenuation of the inflammatory response is the overlap of inflammatory pathways; modulation of one or two is unlikely to be beneficial in a patient with major injuries. The speed of these responses, once initiated, requires that therapies must be given very soon after injury to be effective. The tremendous increase in knowledge of the inflammatory response, and the increasing sophistication of laboratory science that can provide assessment of mediators of inflammation and the patient’s response to the inflammatory process, allows early identification of patients at risk of post-trauma organ failure. Treatment can be tailored to an individual response to injury and
SURGERY 25:10
Locked intramedullary nailing (Figure 2a) is the first-line treatment for most adult fractures of the femoral shaft. It can be carried out with the patient in the supine or lateral position ± fracture table.
Disadvantages of traction Poor control of the length and alignment of the fractured bone Development of pulmonary insufficiency Deep vein thrombosis Decubitus ulcers Joint stiffness due to supine positioning Table 3
431
© 2007 Published by Elsevier Ltd.
Orthopaedic V: injuries to the spine, pelvis and lower limbs
Recent studies suggest results of retrograde femoral nailing approaches success rates found with antegrade techniques. Retro grade nailing may be preferred if the fracture involves the distal femur or is associated with an ipsilateral femoral neck fracture. A floating knee (i.e. an ipsilateral femoral shaft and tibial shaft fracture) is also a relative indication for a retrograde technique. The retrograde technique is beneficial in the obese, the pregnant and in patients with total hip or total knee prostheses. Of posttraumatic diaphyseal femoral fractures, 95% heal with antegrade femoral nailing.5 Plate fixation may be used if femoral fractures are associated with vascular injury requiring repair, with ipsilateral fem oral neck fractures, or non-unions requiring bone grafting (see Marsh, CROSS REFERENCES). Plate fixation has the disadvantage that extensive dissection of soft tissue may interfere with the blood supply of comminuted fragments, decrease the periosteal osteogenesis and lead to complications (e.g. non-union).
Figure 1 Radiograph showing an external fixator applied for initial stability.
a Postoperative radiograph showing femoral nailing. b Radiograph three months after nailing showing considerable formation of callus. Figure 2
SURGERY 25:10
432
© 2007 Published by Elsevier Ltd.
Orthopaedic V: injuries to the spine, pelvis and lower limbs
Limited-incision techniques (e.g. minimally invasive plate osteosynthesis) and locked plating systems (e.g. less invasive stabil ization system) have recently been introduced.
training programme/phase is completed. The progression can include cycling, swimming, and running in chest-deep water before resuming more intensive weightbearing training. Patients must maintain upper-extremity and cardiovascular fitness and avoid lower-extremity exercise early in the healing process. Physiotherapy should be started to improve the range of motion for the hip and knee, and for muscle strengthening. Weightbearing is permitted after stability of bone healing has been achieved. Crutch-assisted touch-weightbearing may be permitted depending on the fracture pattern. Greater weightbearing can be initiated in simple fracture patterns because they are axially stable postoperatively.
Children: flexible rods (Nancy nails) may be used as an altern ative to the adult options discussed above. Immature bones, open physes, parental care available, and growth potential must be considered when forming the management plan.
Complications Complications (early and late) are listed in Table 4.
Traumatic fractures A visit to the follow-up clinic at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year should be arranged. The fracture should be healed by 4 months (Figure 2b). The athlete should be back to pre-injury status at one year post-injury. Long-term symptoms may include hamstring weakness, limited standing and walking, intermittent pain and inability to return to pre-injury work. ◆
Rehabilitation Trauma-related fractures Physiotherapy: the goal of physiotherapy is weightbearing to tolerance provided surgical stability allows. Progression to full weightbearing can gradually start once pain has resolved. Running must be avoided for 8–16 weeks while the low-impact
Complications of surgery for fractures of the femoral shaft Early
Late
Haemorrhage Exaggerated systemic inflammatory Response Fat embolism Pulmonary embolism Deep venous thrombosis Pneumonia Multiorgan failure Long stay in the ICU Infection (if the fracture is open) Neurovascular injury Compartment syndrome (rare, due to compartment size)
Infection Non-union (>6 months) rate of 1% Delayed union (>3 months) Malunion Refracture Metalwork failure Prominent metalwork Neurovascular injury (injury-related or iatrogenic) Heterotopic ossification Peroneal nerve palsy (usually due to traction) Injury to pudendal nerve Injury to sciatic nerve False aneursym Atrioventricular fistula (angiogram needed)
References 1 Advanced Trauma Life Support™. www.facs.org/trauma/atls 2 Cuthbertson DP. Post-shock metabolic response. Lancet 1942; 1: 433–6. 3 Pape HC, Giannoudis PV, Krettek C, Trentz O. Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical decision making. J Orthop Trauma 2005; 19: 551–62. 4 Giannoudis PV, Smith RM, Bellamy MC, Morrison JF, Dickson RA, Guillou PJ. Stimulation of the inflammatory system by reamed and unreamed nailing of femoral fractures. An analysis of the second hit. J Bone Joint Surg Br 1999; 81: 356–61. 5 Tigani D, Fravisini M, Stagni C, Pascarella R, Boriani S. Interlocking nail for femoral shaft fractures: is dynamization always necessary? Int Orthop 2005; 29: 101–4.
Cross references Hassan A, Tesfayohannes B. Clinical assessment of major injuries. Surgery 2006; 24(6): 185–9. Kumar S, Leaper DJ. Basic science of sepsis. Surgery 2005; 23(8): 272–7. Marsh JL. Principles of bone grafting: non-union, delayed union. Surgery 2006; 24(6): 207–10. Maughan R. Basic metabolism II: carbohydrate. Surgery 2005; 23(5): 154–8.
Table 4
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433
© 2007 Published by Elsevier Ltd.
Fractures of the femoral shaft
Epidemiology The worldwide annual incidence is 1–1.33 fractures per 10,000 population. The annual incidence is 3 fractures per 10,000 population in individuals aged <25 years, and in those aged >65 years. These injuries are commonest in males aged <30 years.
S J Fogerty P V Giannoudis
Aetiology The cause of fracture of the femoral shaft may be traumatic or atraumatic (Table 1).
Abstract
Presentation and assessment
Fractures of the femoral shaft are associated with high-energy, multi system trauma. Management must be methodical, initially excluding lifethreatening injuries. Patients surviving for the first 24 hours after major injury as a result of effective resuscitation remain at risk of progressive organ failure and death from a local and general inflammatory response. The involvement of senior clinicians is vital to ensure there is not a delayed decline in condition after initial injury. Femoral fractures are usually managed surgically, though traction should be considered in certain circumstances. Ninety-five percent of post-traumatic diaphyseal femoral fractures heal with antegrade femoral nailing. Minimal-invasive devices stabilize these fractures without extensive dissection of soft tissue. Flexible intramedullary rods may be used in children to achieve fracture stability, but immature bones, open physes, parental care available, and growth potential must be considered when forming the management plan. Early complications include haemorrhage, fat embolism, pneumonia, multiorgan failure, neurovascular injury and compartment syndrome. Later complications include infection, non-union, delayed union, metalwork failure and heterotopic ossification. The goal of the physiotherapy programme should be weightbearing to tolerance provided surgical stability allows. The fracture should progress to union by four months.
Traumatic fracture A high-velocity injury is usually involved; significant pain and the inability to bear weight are present. There may be shortening of one leg, swelling and gross deformity. They are often associated with multisystem trauma because of the energy involved to cause the fracture. Life-threatening associated injuries must be addressed first. An organized and methodical approach to the multiply injured patient must follow ATLS™ guidelines (see Hassan, CROSS REFERENCES). Fractures can result in significant blood loss (up to 5 l) due to the vascularity of the femur.1 Blood transfusion may be required in up to 40% of isolated fractures. The pelvis, hips and knees should be examined as part of the secondary survey. A distal neurovascular examination should be done, and traction may be necessary for initial stabilization to maintain leg length and reduce pain before further management. Common injuries associated with femoral shaft fractures are listed in Table 2. Atraumatic fracture Patients with atraumatic fractures may present with few physical findings. The thigh may be swollen, the range of motion limited by pain, and they not be able to bear weight. History and examination should be done as appropriate depending on the suspected cause (e.g. examination of the abdomen and breast if a metastatic cause is suspected).
Keywords femur; fixation; traction; multisystem trauma
Anatomy
The response of the body to trauma
The femur is the strongest, longest and heaviest bone in the body and is essential for ambulation. It consists of a shaft (diaphysis), a proximal metaphysis and a distal metaphysis. The femur has excellent soft tissue coverage, accounting for its high vascularity. The blood supply enters the femur through the metaphyseal arteries and branches of the profunda femoris artery, penetrating the diaphysis and forming medullary arteries extending proximally and distally.
Phases: there is enormous interest surrounding the metabolic and immune response of the multiply injured patient in the early and intermediate phases (see Kumar, CROSS REFERENCES).
Causes of fracture of the femoral shaft
S J Fogerty MRCS is a Clinical Fellow in Orthopaedics and Trauma at Leeds General Infirmary, Leeds, UK. Conflicts of interest: none declared. P V Giannoudis EEC(Ortho) is a Professor of Trauma and Orthopaedic Surgery at the School of Medicine, Leeds University, Leeds, UK. Conflicts of interest: none declared.
SURGERY 25:10
Traumatic
Atraumatic
Road traffic accidents Sports (particularly skiing and football) Falls Gunshot wounds
Repetitive stress (e.g. jogging) Metabolic disease of bone Metastatic disease Primary tumours of bone
Table 1
430
© 2007 Published by Elsevier Ltd.
Orthopaedic V: injuries to the spine, pelvis and lower limbs
patients who can benefit from this treatment can be identified rapidly.3,4
Injuries associated with fractures of the femoral shaft Soft tissue injuries of the knee (ligament, meniscal) Ipsilateral femoral neck fracture Tibial fracture (floating knee) Hip dislocation Spine fractures
Types of femoral shaft fractures The spectrum of femoral shaft fractures is broad, and ranges from undisplaced stress fractures to fractures associated with severe comminution and significant injury to soft tissue. The three femoral fracture patterns vary according to the direction of the force applied and the quantity of force absorbed: • a perpendicular force results in a transverse fracture pattern • an axial force may injure the hip or knee and cause comminution (dashboard injury) • rotational forces may cause spiral or oblique fracture patterns. The amount of comminution present increases with the amount of energy absorbed by the femur at the time of fracture.
Table 2
Stress (e.g. injury, surgery) initiates a local inflammatory and general response that is protective, and which conserves fluid and provides energy for repair. Resuscitation may attenuate the response but does not abolish it. The response is characterized by an acute catabolic reaction that precedes the metabolic process of recovery and repair. This metabolic response to trauma was divided into an ‘ebb and flow phase’ by Cuthbertson.2 The ebb phase corresponds to the period of severe shock characterized by depression of enzymatic activity and oxygen consumption. Cardiac output is below normal, core temperature may be subnormal, and a lactic acidosis is present. In the flow phase, the body is hypermetabolic, cardiac output and oxygen consumption are increased, and glucose production is increased (see Maughan, CROSS REFERENCES). Lactic acid may be normal.
Management Conservative Treatment of fractures of the femoral shaft has evolved over the past century. Until the recent past, the definitive method for treating femoral shaft fractures was traction or splinting. Before the advent of modern aggressive techniques and treatments, these injuries were often disabling or fatal. Traction has many disadvantages (Table 3). Conservative options are used infrequently (excluding fractures in young children), but traction is used in the management of fractures in very osteoporotic bone or certain periprosthetic fractures.
Organ failure: patients surviving for the first 24 hours after major injury as a result of effective resuscitation remain at risk of progressive organ failure and death from what appears to be this uncontrolled inflammatory process. A septic cause usually cannot be identified, yet the response is as if infection is present. While organ-supportive measures such as mechanical ventilation, oxygenation, renal support and total parenteral nutrition help to maintain substrate delivery and metabolite removal in the tissues, these therapies eventually fail if the microvasculature ceases to function.
Surgical Haemodynamics: the patient should be haemodynamically stable and fully resuscitated before definitive surgical management of a femoral shaft fracture. In general, the goal time to definitive surgical stabilization is 24 hours. If the patient is haemodynamically unstable and has not been adequately resuscitated, femoral fixation should be delayed and temporized with an external fixator (Figure 1) or skeletal traction until cardiovascular stability is achieved (damage-control surgery).
Interventions designed to attenuate selected elements of the inflammatory pathways are being developed: • antioxidants • enzyme inhibitors • pharmacological agents • antibodies (to soluble mediators and cell-surface receptor antagonists). Most of these interventions are experimental and have met with only limited clinical success. A major problem with attenuation of the inflammatory response is the overlap of inflammatory pathways; modulation of one or two is unlikely to be beneficial in a patient with major injuries. The speed of these responses, once initiated, requires that therapies must be given very soon after injury to be effective. The tremendous increase in knowledge of the inflammatory response, and the increasing sophistication of laboratory science that can provide assessment of mediators of inflammation and the patient’s response to the inflammatory process, allows early identification of patients at risk of post-trauma organ failure. Treatment can be tailored to an individual response to injury and
SURGERY 25:10
Locked intramedullary nailing (Figure 2a) is the first-line treatment for most adult fractures of the femoral shaft. It can be carried out with the patient in the supine or lateral position ± fracture table.
Disadvantages of traction Poor control of the length and alignment of the fractured bone Development of pulmonary insufficiency Deep vein thrombosis Decubitus ulcers Joint stiffness due to supine positioning Table 3
431
© 2007 Published by Elsevier Ltd.
Orthopaedic V: injuries to the spine, pelvis and lower limbs
Recent studies suggest results of retrograde femoral nailing approaches success rates found with antegrade techniques. Retro grade nailing may be preferred if the fracture involves the distal femur or is associated with an ipsilateral femoral neck fracture. A floating knee (i.e. an ipsilateral femoral shaft and tibial shaft fracture) is also a relative indication for a retrograde technique. The retrograde technique is beneficial in the obese, the pregnant and in patients with total hip or total knee prostheses. Of posttraumatic diaphyseal femoral fractures, 95% heal with antegrade femoral nailing.5 Plate fixation may be used if femoral fractures are associated with vascular injury requiring repair, with ipsilateral fem oral neck fractures, or non-unions requiring bone grafting (see Marsh, CROSS REFERENCES). Plate fixation has the disadvantage that extensive dissection of soft tissue may interfere with the blood supply of comminuted fragments, decrease the periosteal osteogenesis and lead to complications (e.g. non-union).
Figure 1 Radiograph showing an external fixator applied for initial stability.
a Postoperative radiograph showing femoral nailing. b Radiograph three months after nailing showing considerable formation of callus. Figure 2
SURGERY 25:10
432
© 2007 Published by Elsevier Ltd.
Orthopaedic V: injuries to the spine, pelvis and lower limbs
Limited-incision techniques (e.g. minimally invasive plate osteosynthesis) and locked plating systems (e.g. less invasive stabil ization system) have recently been introduced.
training programme/phase is completed. The progression can include cycling, swimming, and running in chest-deep water before resuming more intensive weightbearing training. Patients must maintain upper-extremity and cardiovascular fitness and avoid lower-extremity exercise early in the healing process. Physiotherapy should be started to improve the range of motion for the hip and knee, and for muscle strengthening. Weightbearing is permitted after stability of bone healing has been achieved. Crutch-assisted touch-weightbearing may be permitted depending on the fracture pattern. Greater weightbearing can be initiated in simple fracture patterns because they are axially stable postoperatively.
Children: flexible rods (Nancy nails) may be used as an altern ative to the adult options discussed above. Immature bones, open physes, parental care available, and growth potential must be considered when forming the management plan.
Complications Complications (early and late) are listed in Table 4.
Traumatic fractures A visit to the follow-up clinic at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year should be arranged. The fracture should be healed by 4 months (Figure 2b). The athlete should be back to pre-injury status at one year post-injury. Long-term symptoms may include hamstring weakness, limited standing and walking, intermittent pain and inability to return to pre-injury work. ◆
Rehabilitation Trauma-related fractures Physiotherapy: the goal of physiotherapy is weightbearing to tolerance provided surgical stability allows. Progression to full weightbearing can gradually start once pain has resolved. Running must be avoided for 8–16 weeks while the low-impact
Complications of surgery for fractures of the femoral shaft Early
Late
Haemorrhage Exaggerated systemic inflammatory Response Fat embolism Pulmonary embolism Deep venous thrombosis Pneumonia Multiorgan failure Long stay in the ICU Infection (if the fracture is open) Neurovascular injury Compartment syndrome (rare, due to compartment size)
Infection Non-union (>6 months) rate of 1% Delayed union (>3 months) Malunion Refracture Metalwork failure Prominent metalwork Neurovascular injury (injury-related or iatrogenic) Heterotopic ossification Peroneal nerve palsy (usually due to traction) Injury to pudendal nerve Injury to sciatic nerve False aneursym Atrioventricular fistula (angiogram needed)
References 1 Advanced Trauma Life Support™. www.facs.org/trauma/atls 2 Cuthbertson DP. Post-shock metabolic response. Lancet 1942; 1: 433–6. 3 Pape HC, Giannoudis PV, Krettek C, Trentz O. Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical decision making. J Orthop Trauma 2005; 19: 551–62. 4 Giannoudis PV, Smith RM, Bellamy MC, Morrison JF, Dickson RA, Guillou PJ. Stimulation of the inflammatory system by reamed and unreamed nailing of femoral fractures. An analysis of the second hit. J Bone Joint Surg Br 1999; 81: 356–61. 5 Tigani D, Fravisini M, Stagni C, Pascarella R, Boriani S. Interlocking nail for femoral shaft fractures: is dynamization always necessary? Int Orthop 2005; 29: 101–4.
Cross references Hassan A, Tesfayohannes B. Clinical assessment of major injuries. Surgery 2006; 24(6): 185–9. Kumar S, Leaper DJ. Basic science of sepsis. Surgery 2005; 23(8): 272–7. Marsh JL. Principles of bone grafting: non-union, delayed union. Surgery 2006; 24(6): 207–10. Maughan R. Basic metabolism II: carbohydrate. Surgery 2005; 23(5): 154–8.
Table 4
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433
© 2007 Published by Elsevier Ltd.