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Fractures of the femur and tibial shaft
ORTHOPAEDICS IV: LOWER LIMB
Fractures of the femur and tibial shaft
road traffic incidents or sporting injuries in the younger age range, whilst low-energy injuries (e.g. falling from a standing height) usually occur due to pre-existing bone weakness, that is, osteoporosis, in the elderly. The high-energy fractures may be associated soft tissue injury, open wound injury, and polytrauma.
Jonathan B Yates Fracture classifications
James R Fountain
Femoral and tibial fractures and subsequent patterns are classified by the Arbeitsgemeinschaft fὕr Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) group. This system assigns an alphanumeric code to each fracture, which allows for a classification based on anatomical location, fracture morphology and complexity. There is a free internet-based resource entitled ‘AO surgery reference’.3 The authors commend this to anyone treating these fractures, for use as a training tool as well as a quick means of classifying the fracture in question. Other classifications do exist, but this is by far the most accessible. For open tibial fractures, the most commonly used classification remains the Gustillo and Anderson system (Table 1).
Abstract Fractures of the femoral and tibial shaft are common injuries. They exhibit a bimodal age distribution and are frequently associated with other injuries. Their fracture patterns vary, and so are managed using a range of treatment options. The first priority is to check that there are no life-threatening injuries or acute complications associated with the injuries sustained. Once these are ruled out, the orthopaedic team can begin planning the treatment option best suited to the fracture and patient. For femoral fractures this usually involves intramedullary nailing, or plating, across the fracture site. Conservative and mono-lateral external fixation of the femur is now considered inadvisable because of the higher risk of complications and decreased rehabilitation potential. For tibial fractures the options are either conservative management, in a nonweight-bearing cast, or intramedullary nailing or plating. External fixation remains a useful modality in severe deformity or open fractures of the tibia. Complications commonly associated with both these fractures include venous thromboembolism, infection, compartment syndrome, fat embolism, vascular injury and mal- or non-union of bone.
Diagnosis and management All patients admitted following high-energy trauma require initial management following advanced trauma life support (ATLS) guidelines. Once life-threatening injuries have been addressed, or ruled out, lower limb injuries can then be assessed. It is critical to examine the soft tissues overlying any bony injury and the neurovascular status of the distal limb. On satisfactory assessment, the limb should be aligned and held in position using either a cast or traction. Open injuries will require full assessment in the accident and emergency department. Intravenous antibiotics should be administered, as soon as possible in the presence of any open fracture. Tetanus risk will also need to be addressed, based on the level of contamination and local guidelines. Open wounds should be handled minimally (e.g. to remove gross contamination or to photograph) and should then be dressed in saline-soaked gauze. These patients should be managed jointly by orthopaedic and plastic teams to address the bony and soft tissue elements of the injury. We suggest adherence to the British Orthopaedic Association Standard for Trauma (BOAST) guideline 4.4 Any vascular deficit to the distal limb needs immediate attention and any active haemorrhage should be controlled by direct pressure or tourniquet. Any deformity or dislocation in a pulseless limb should be addressed urgently, splinted and reassessed for neurovascular deficit.5 Any further concerns should involve discussion with the vascular surgeons. This is discussed later in this review. Assessment must include monitoring for the possibility of an evolving compartment syndrome in the injured limb. The alertness of the patient, neurovascular status and pain response to passive movement of the muscles within the affected compartment, as well to analgesia, must be documented on admission, and hourly, until the limb is deemed at low risk of developing compartment syndrome, as recommended in BOAST guideline 10.6 Nerve blocks for pain following a limb fracture have, historically, been deprecated to avoid masking the syndrome. Monitoring of compartment pressures is undertaken in some centres, however it should be noted that this can only assist with a
Keywords Complications; conservative; femoral fracture; intramedullary nailing; management; plating; tibial fracture
Introduction Fractures in the shafts of both the femur and tibia are common injuries. In the femoral shaft, this refers to a fracture in any part of the bone from the lesser trochanter to the metaphyseal flare of the condylar region of the knee. In the tibia, this can be any extra-articular fracture in the bone between the knee and ankle. Such fractures can occur in association with prostheses already in situ (i.e. total hip or knee joint replacements). However, the management of these injuries is beyond the scope of this review. Equally, lower energy fractures can occur secondary to poor quality bone or through lesions (benign and malignant). In assessing patients where this is suspected, it should be noted that the management of these patients can vary greatly from that of the trauma patient. The tibia is the most commonly fractured long bone with an incidence of approximately 14 per 100,000 per year1 whilst femoral fracture incidence is 10 per 100,000 per year.2 Both have a bimodal age distribution. Many high-energy injuries result from
Jonathan B Yates MBChB MRCS is a locally appointed Specialist Registrar in Trauma and Orthopaedics at Aintree University Hospital, Liverpool, UK. Conflict of interests: none declared. James R Fountain MBChB FRCS (Tr & Orth) is a Consultant Orthopaedic Surgeon at Aintree University Hospital, Liverpool, UK. Conflict of interests: none declared.
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1
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Yates JB, Fountain JR, Fractures of the femur and tibial shaft, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.07.001
ORTHOPAEDICS IV: LOWER LIMB
The Gustillo and Anderson System for open fractures Classification
Description
Type 1
Minimal soft tissue injury, simple fracture and wound no more than 1 cm Soft tissue coverage is adequate, minimal comminution but wound is greater than 1 cm High-energy injury, extensive soft tissue damage, contaminated and comminuted fracture, but bone remains adequately covered High-energy injury, extensive soft tissue damage and periosteal stripping with bone exposure As above but injury is also associated with an arterial deficit requiring repair
Type II Type IIIA
Type IIIB
Type IIIC
Table 1
clinical diagnosis. If direct measurement is used, the compartment pressure should not be less than 30 mmHg below the diastolic blood pressure measurement. An absolute measurement of 40 mmHg with clinical symptoms is an indicator for urgent surgical decompression. In high-energy trauma, it is important to remain alert to the possibility of other coexisting injuries. Careful assessment of the joints above and below the fracture site is essential as well as a full assessment of the contralateral limb. Low-level trauma, resulting in fracture of the femur or tibia must be treated with caution in case of metabolic bone disease or malignancy, as mentioned earlier. Careful review of the mechanism of injury and assessment of the medical co-morbidities of the patient, will help to guide the management process. All suspected lower limb fractures should have an anteroposterior (AP) and lateral image of the injury site. In the case of a femoral fracture an AP view of the pelvis as well as an AP and lateral view at the knee are required (Figure 1). For tibial fractures an AP and lateral view of both the knee and ankle should be sought (Figure 2). Further imaging is not usually required unless an intra-articular extension is suspected.
Figure 1 Example of a femoral shaft fracture.
Anatomical considerations The femur has several anatomical features to consider when planning fracture reduction and fixation. When viewed axially it is roughly circular and has the roughened linea aspera posteriorly providing muscle attachments. In the sagittal plane, it has an anterior bow and in the coronal plane curves towards the midline. Numerous muscle attachments on the femur account for the deformity forces observed when assessing these fractures (Figure 3A and B). The tibia in the axial plane is more triangular than the femur and its subcutaneous anteromedial surface renders it more susceptible to an open injury when a fracture occurs. This feature also accounts for its lower blood supply compared to the femur.
Figure 2 Example of a tibia shaft fracture.
remains an option. Low-energy tibial shaft fractures can be managed non-operatively dependent on their stability and level of displacement. A long leg cast can be applied and the fracture site observed in clinic to ensure the position is maintained. Converting this cast to a below knee cast or functional brace, at around 6 weeks, allows knee movement. Surgical options include intra-medullary nailing or applying either a plate or external fixation device to the femur or tibia.
Surgical decision-making In the UK, there is a trend towards operative management of femoral shaft fractures. Conservative treatment is rare but
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Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Yates JB, Fountain JR, Fractures of the femur and tibial shaft, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.07.001
ORTHOPAEDICS IV: LOWER LIMB
Figure 3 (a) A subtrochanteric fracture showing the deforming forces acting on it. Here, we can see the effect of the abductors and external rotators on the proximal fragment. The iliopsoas tendon will also be flexing the proximal fragment anteriorly. (b) A distal femoral fracture showing the deforming forces acting on it. Here, we see the adductors pulling the distal fragment medially and the gastrocnemius and knee ligaments pulling the distal fragment posteriorly.
presence of a hip prosthesis, ipsilateral tibial fracture, deformity or obesity. As the nail is introduced through the intercondylar notch of the knee, fracture reduction is achieved through moving the limb and so traction is not required. With displaced tibial fractures the antegrade nail is much preferred (Figure 5). This is placed behind the patella tendon into the tibia (either supra or infrapatellar, as current evidence has not found a difference in functional outcome between the two). The principles are then the same for femoral nailing. It should be
Intramedullary nailing (IMN) Most femoral shaft fractures will be fixed with IMN (Figure 4). Current evidence indicates that this should be performed within 24 hours of injury. The nail itself can be inserted antegrade (from proximal to distal) or retrograde (distal to proximal) with the usual preference being antegrade. There are many different types of nail design. They each require slightly different surgical techniques but the principles are the same. A femoral retrograde nail can be used dependent on the position of the fracture, the
Figure 4 Femoral shaft fracture and intraoperative images showing treatment with a locked anterograde intramedullary nail. Postoperative images are at 1 year showing union of bone.
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Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Yates JB, Fountain JR, Fractures of the femur and tibial shaft, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.07.001
ORTHOPAEDICS IV: LOWER LIMB
Figure 5 Example of a tibial fracture treated with intramedullary nailing. Postoperative images are at 1 year.
Subtrochanteric fractures warrant proximal locking screws that traverse the femoral neck and sit in the head to improve stability. Other diaphyseal fractures have proximal locking which is targeted towards the femoral shaft (Figure 6) Whilst in many nailing systems, proximal locking can be achieved through a jig which is attached to the femoral nail, distal locking is usually freehand. Please see instructions for our preferred method of achieving this (Figure 7) The image intensifier is positioned so that the beam is perpendicular to the distal locking screw holes through the nail (this is confirmed when the holes are completely circular). The skin knife and image intensifier are used to determine where to make the skin incision. Blunt forceps can be used to make a track down to bone. The drill for the distal locking screws can then be placed onto the bone through this hole and checked (in two planes) on the image intensifier. Once satisfied that the drill is over the locking hole you can drill through the near cortex, nail and far cortex. Confirmation can be obtained by disengaging the drill from the bit and obtaining further images (the drill bit can be seen in the proximal locking hole in Figure 7). After measuring the depth, place the screw as per AO technique. Anteroposterior and lateral images confirm the screw has traversed bone and nail. Once the screws are locked distally you can observe the fracture site. If the fracture gap is large then you can gently back the nail out. This will close the fracture gap now that the nail is locked distally.
noted that, initially, some nails were unreamed to allow better contact between nail and endosteal surface of the bone. Support has grown for the use of reamed nails due to the current evidence that they actually improve periosteal blood flow without increasing the risk of infection or non-union, even in open fractures.
Principles of intramedullary nailing The patient is positioned on the operating or traction table according to the proposed method of reduction Once in theatre, space must be provided for equipment trays and the image intensifier Reduce fracture For femoral fractures, reduction is usually achieved in traction on a traction table For tibial fractures, reduction can be achieved by either freely suspending the lower limb over a bolster on the table or through the use of specialist reduction devices If unable to reduce in traction then the fracture site is opened and reduced using bone clamps The entry point for the guide wire is first found under image intensifier control The wire is inserted and passed through the canal across the fracture site under fluoroscopy When the wire is correctly placed it is measured for the nail length The canal is reamed, keeping the wire in situ, to 1.5 mm greater than the intended nail diameter A nail of the correct size is selected to match the length and diameter of reamed canal The nail can now be inserted with a proximally locking jig attached The nail is locked proximally and distally with screws into bone, through the nail
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Plating Plating of the femur has fallen out of use in many places because of its relatively higher rates of implant failure compared to IMNs. Where the fracture configuration is either too proximal or distal, preventing stable and secure locking of the IMN, plating remains an alternative. More modern femoral plates are usually
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Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Yates JB, Fountain JR, Fractures of the femur and tibial shaft, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.07.001
ORTHOPAEDICS IV: LOWER LIMB
Figure 6 Example of a subtrochanteric fracture treated with recon intramedullary nail and cabling. Postoperative images show union of bone at 1 year.
Figure 7 Freehand distal locking of an intramedullary nail.
associated with soft tissue loss and coverage of bone cannot be achieved, or where the patient is unstable, or secondary to polytrauma, external fixation is the only stabilizing intervention, as part of damage control surgery. Once the patient becomes more stable, a return to theatre for conversion of the external device to an internal device is usually required. The use of an external device as definitive treatment can lead to issues with pin site infection, malunion and if the device bridges the knee e stiffness.
precontoured to the proximal or distal end of the femoral shaft and some are specifically designed to be minimally invasive. Plating is the treatment of choice in certain peri-prosthetic fractures. In tibial plating systems the screws are placed to preserve the knee or ankle joints whilst controlling the fracture (Figure 8A and B).
External fixation When other methods of fixation are contraindicated or unavailable, external fixation is the alternative. Where the fracture is
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Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Yates JB, Fountain JR, Fractures of the femur and tibial shaft, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.07.001
ORTHOPAEDICS IV: LOWER LIMB
Figure 8 (a) Examples of a femoral shaft fracture treated with plating and cabling. (b) Example of a tibial shaft fracture treated with plating.
For tibial fractures, fine wire external fixators are an option for definitive treatment and may be used as first-line treatments (e.g. Taylor spatial or Ilizarov frames). These can correct shortening and complex deformity. Whilst they are particularly useful in managing tibial malunion, associated bone loss, deformity or infection, they also play a significant role in the management of high energy open fractures (Figure 9A and B).
Venous thromboembolism (VTE) The patient’s risk is assessed on admission, based on regional and national guidelines.7 If treated early, femoral and tibial shaft fractures carry a low risk of VTE. Nevertheless, the presence of a fracture will increase the patient’s risk, particularly until mobility is restored. Generally, the decision on whether to give VTE prophylaxis out of hospital lies with the surgical team. For IMN patients or those with external devices, the lead author recommends VTE prophylaxis as inpatient treatment only. Patients treated in non-weight bearing casts should be treated with more caution, lowering the threshold for VTE prophylaxis, in accordance with the National Institute for Care Excellence (NICE) recommendations.
Postoperative care Once treatment plans are agreed, it is essential to ensure that patients are absolutely clear about their weight-bearing status for the affected limb, taking account of any other injuries incurred. They will need to be assessed for venous thromboembolism (VTE) prophylaxis and the treatment period. Follow-up for the patient is essential. We normally see patients within 2 weeks of surgery to obtain radiographs, perform wound checks, suture removal and review their progress.
Infection If the fracture is closed then infection risk is lowered. Worsening soft tissue injury increases the risk of infection. Open fractures of the lower limb carry risks in the region of 1e10%. All patients with open fractures should be given intravenous antibiotics within an hour in the accident and emergency department, be assessed for tetanus prophylaxis and have the wound cleaned from gross contamination, photographed and dressed in
Complications of tibial and femoral shaft fractures The following are the most commonly associated complications occurring with operatively managed fractures of the femur and tibia and will need to be discussed with patients offered surgery.
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Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Yates JB, Fountain JR, Fractures of the femur and tibial shaft, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.07.001
ORTHOPAEDICS IV: LOWER LIMB
Figure 9 (a) Temporary external fixation of a compound femoral fracture, a retrograde femoral nail has been used as the definitive treatment, and of a tibia fracture, plating was ultimately used as definitive treatment. Postoperative imaging is at 1 year. (b) Low tibial fracture treated definitively with a fine wire frame.
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Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Yates JB, Fountain JR, Fractures of the femur and tibial shaft, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.07.001
ORTHOPAEDICS IV: LOWER LIMB
patient requires urgent revascularisation of limb in theatre, pending the treatment of other life threatening injuries. No further imaging must delay this process. Once in theatre, temporary revascularisation should happen first with assessment of viability of the lower limb. Limb viability does not only depend on the vascular flow but also the level of soft tissue loss and neurological status, a decision to amputate should involve two consultants. Following temporary revascularisation, skeletal stabilisation is achieved followed by definitive vascular reconstruction. The lead author recommends adherence to BOAST guideline 6 on management of arterial injuries in association with fractures and dislocations.5
saline-soaked dressings. This will prevent the unnecessary exposure of the wound, prior to definitive treatment in theatre. Antibiotics are maintained until the point of closure of the wound.
Compartment syndrome As mentioned previously, this syndrome is serious and must be treated as an emergency. This is most frequently encountered with tibial shaft fractures, but can occur anywhere else in the body. It can occur in the presence of an open fracture if the compartments are intact. Patients should be observed closely, pre- and postoperatively, for disproportionate pain and pain on passive flexion and extension of the foot. Monitoring compartments is useful, but not adopted by every orthopaedic unit in the UK and much depends on good clinical judgement. Failure to detect this syndrome can lead to muscle necrosis, renal failure (through acute tubular necrosis secondary to circulatory myoglobin released from muscle tissue), long-term disability and amputation of the limb. If at the time of surgery it is felt that the compartments are tight or that the patient is at high risk of developing the syndrome, it is recommended that prophylactic fasciotomies should be carried out. The potential need to perform intraoperative fasciotomies must be remembered pre-operatively at the consenting process. The lead author prefers the two-incision approach, to perform a four-compartment fasciotomy in the lower leg, as advised by BOAST guideline 4.
Malunion and non-union Where fractures have been treated non-operatively, patients need to be warned about the slightly increased risk of mal or nonunion when compared to operative fixation. Tibial diaphyseal fractures which have failed to generate enough bridging callus to achieve clinical stability by 16 weeks are considered delayed union fractures, for the femoral shaft this time scale is 26 weeks. However as the femur has a richer blood supply than the tibia, the overall non-union rates in tibial fractures tend to be higher. Non-union of fractures in operative patients may be secondary to failure to achieve adequate stability or failure of an environment adequate to allow bony healing (biological failure). In this article these failure processes are highly simplified, however failure to achieve adequate stability with subsequent increased sheer stresses across the fracture promotes fibrous tissue formation at the expense of osseous tissue. A biological failure may be secondary to the extensive soft tissue injury and relative avascularity of the fracture. The soft tissue disruption is often greater in open fracture and hence they have a greater non-union rate. In addition, there are also a number of patient-specific factors which lead to an increased risk non-union of bone. These include the use of tobacco or nicotine in any form, diabetes, poor nutritional health, vitamin D deficiency, use of anti-inflammatories or steroids during healing, infection and old age. Their impact needs to be minimized wherever possible. If there is no radiological evidence of union by 6 months, operative interventions should be explored. Additional therapy to facilitate bone healing, especially for patients who have had previous surgery for non-union, is extracorporeal shockwave therapy (ESWT). An external device is fitted outside the body overlying the fracture and the pulsed ‘shockwaves’ (mechanical energy similar to soundwaves) is used to stimulate bone healing. This treatment may be used as a first-line treatment if the risk of non-union is high and the patient is not fit for surgical intervention. Multiple interventions and adjuvant treatments are available for the treatment of non-union, however they remain outside the scope of this paper.
Fat embolism syndrome This syndrome commonly occurs in severe long bone fractures or in poly-trauma, but is often not symptomatic. The classical presentation occurs around 24e72 hours post injury, with respiratory deficit, agitation and a petechial rash. This is thought to be caused by toxic fatty acids leading to endothelial injury and mechanical obstruction by fat globules. This mainly occurs in the lung but can occur elsewhere, leading to multi-organ failure. It may trigger disseminated intravascular coagulopathy and cause a systemic inflammatory response. Any suspicion of this syndrome requires close patient observation, ideally in a critical care environment. Treatment remains supportive only hence early stabilisation of fractures in adequately resuscitated patients, reduces the risk of this syndrome developing.
Vascular injury As with any limb injury, it is critical to check whether the blood vessels are intact. Whilst for closed, isolated fractures the incidence of vascular injury is low, for open injuries this increases. Vascular injury requires urgent assessment by the vascular team and skeletal stabilisation in theatre by the orthopaedic team. Revascularisation must occur within 3e4 hours to prevent tissue damage and decrease the risk of amputation. Restoration of blood flow following an ischaemic time in excess of 6 hours increases the risk of revascularisation injury through release of myoglobin. The generally accepted chain of events should be to control external haemorrhage with direct pressure or tourniquet; document any coexisting neurological injury; realign limb under sedation; splint and reassess vascular status and reimage fracture with radiographs. This should all occur in the Accident and Emergency department. If there remains a vascular deficit the
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Anterior knee pain Anterior knee pain is the most common postoperative complaint displayed by patients who have had a tibial IMN. This must be explained to all patients undergoing such procedures. If the pain persists, beyond the time when the fracture has achieved union, removal of the nail can be offered in an attempt to reduce symptoms.
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Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Yates JB, Fountain JR, Fractures of the femur and tibial shaft, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.07.001
ORTHOPAEDICS IV: LOWER LIMB
Summary
2 Weiss RJ, Montgomery SM, Al Dabbagh Z, Jansson KA. National data of 6409 Swedish inpatients with femoral shaft fractures: stable incidence between 1998 and 2004. Injury 2009; 40: 304. 3 www.aosurgery.org. Last accessed March 2016. Hosted by AO foundation. 4 The British Orthopaedic Association Standard for Trauma 4: the management of severe open lower limb fractures. The British Orthopaedic Association, 2009. 5 The British Orthopaedic Association Standard for Trauma 6: management of arterial injuries associated with fractures and dislocations. The British Orthopaedic Association, 2014. 6 The British Orthopaedic Association Standard for Trauma 10: diagnosis and management of compartment syndrome of the limbs. The British Orthopaedic Association, 2014. 7 Venous thromboembolism: reducing the risk for patients in hospital. NICE guideline CG92. National Institute for Health and Care Excellence, January 2010.
Femoral and tibial shaft fractures are common injuries. Nevertheless, they require careful assessment and management to achieve successful outcomes and minimize complications. If good practice is lacking or if commonly associated features are not looked for, this can have severe treatment consequences. This review therefore aims to equip the reader with a sound knowledge of these key features for assessing these injuries, providing a safe algorithm and a strong foundation from which to develop surgical knowledge in this area. A
REFERENCES 1 Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury 2006; 37: 691e7.
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Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Yates JB, Fountain JR, Fractures of the femur and tibial shaft, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.07.001
Fractures of the femur and tibial shaft
road traffic incidents or sporting injuries in the younger age range, whilst low-energy injuries (e.g. falling from a standing height) usually occur due to pre-existing bone weakness, that is, osteoporosis, in the elderly. The high-energy fractures may be associated soft tissue injury, open wound injury, and polytrauma.
Jonathan B Yates Fracture classifications
James R Fountain
Femoral and tibial fractures and subsequent patterns are classified by the Arbeitsgemeinschaft fὕr Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) group. This system assigns an alphanumeric code to each fracture, which allows for a classification based on anatomical location, fracture morphology and complexity. There is a free internet-based resource entitled ‘AO surgery reference’.3 The authors commend this to anyone treating these fractures, for use as a training tool as well as a quick means of classifying the fracture in question. Other classifications do exist, but this is by far the most accessible. For open tibial fractures, the most commonly used classification remains the Gustillo and Anderson system (Table 1).
Abstract Fractures of the femoral and tibial shaft are common injuries. They exhibit a bimodal age distribution and are frequently associated with other injuries. Their fracture patterns vary, and so are managed using a range of treatment options. The first priority is to check that there are no life-threatening injuries or acute complications associated with the injuries sustained. Once these are ruled out, the orthopaedic team can begin planning the treatment option best suited to the fracture and patient. For femoral fractures this usually involves intramedullary nailing, or plating, across the fracture site. Conservative and mono-lateral external fixation of the femur is now considered inadvisable because of the higher risk of complications and decreased rehabilitation potential. For tibial fractures the options are either conservative management, in a nonweight-bearing cast, or intramedullary nailing or plating. External fixation remains a useful modality in severe deformity or open fractures of the tibia. Complications commonly associated with both these fractures include venous thromboembolism, infection, compartment syndrome, fat embolism, vascular injury and mal- or non-union of bone.
Diagnosis and management All patients admitted following high-energy trauma require initial management following advanced trauma life support (ATLS) guidelines. Once life-threatening injuries have been addressed, or ruled out, lower limb injuries can then be assessed. It is critical to examine the soft tissues overlying any bony injury and the neurovascular status of the distal limb. On satisfactory assessment, the limb should be aligned and held in position using either a cast or traction. Open injuries will require full assessment in the accident and emergency department. Intravenous antibiotics should be administered, as soon as possible in the presence of any open fracture. Tetanus risk will also need to be addressed, based on the level of contamination and local guidelines. Open wounds should be handled minimally (e.g. to remove gross contamination or to photograph) and should then be dressed in saline-soaked gauze. These patients should be managed jointly by orthopaedic and plastic teams to address the bony and soft tissue elements of the injury. We suggest adherence to the British Orthopaedic Association Standard for Trauma (BOAST) guideline 4.4 Any vascular deficit to the distal limb needs immediate attention and any active haemorrhage should be controlled by direct pressure or tourniquet. Any deformity or dislocation in a pulseless limb should be addressed urgently, splinted and reassessed for neurovascular deficit.5 Any further concerns should involve discussion with the vascular surgeons. This is discussed later in this review. Assessment must include monitoring for the possibility of an evolving compartment syndrome in the injured limb. The alertness of the patient, neurovascular status and pain response to passive movement of the muscles within the affected compartment, as well to analgesia, must be documented on admission, and hourly, until the limb is deemed at low risk of developing compartment syndrome, as recommended in BOAST guideline 10.6 Nerve blocks for pain following a limb fracture have, historically, been deprecated to avoid masking the syndrome. Monitoring of compartment pressures is undertaken in some centres, however it should be noted that this can only assist with a
Keywords Complications; conservative; femoral fracture; intramedullary nailing; management; plating; tibial fracture
Introduction Fractures in the shafts of both the femur and tibia are common injuries. In the femoral shaft, this refers to a fracture in any part of the bone from the lesser trochanter to the metaphyseal flare of the condylar region of the knee. In the tibia, this can be any extra-articular fracture in the bone between the knee and ankle. Such fractures can occur in association with prostheses already in situ (i.e. total hip or knee joint replacements). However, the management of these injuries is beyond the scope of this review. Equally, lower energy fractures can occur secondary to poor quality bone or through lesions (benign and malignant). In assessing patients where this is suspected, it should be noted that the management of these patients can vary greatly from that of the trauma patient. The tibia is the most commonly fractured long bone with an incidence of approximately 14 per 100,000 per year1 whilst femoral fracture incidence is 10 per 100,000 per year.2 Both have a bimodal age distribution. Many high-energy injuries result from
Jonathan B Yates MBChB MRCS is a locally appointed Specialist Registrar in Trauma and Orthopaedics at Aintree University Hospital, Liverpool, UK. Conflict of interests: none declared. James R Fountain MBChB FRCS (Tr & Orth) is a Consultant Orthopaedic Surgeon at Aintree University Hospital, Liverpool, UK. Conflict of interests: none declared.
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Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Yates JB, Fountain JR, Fractures of the femur and tibial shaft, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.07.001
ORTHOPAEDICS IV: LOWER LIMB
The Gustillo and Anderson System for open fractures Classification
Description
Type 1
Minimal soft tissue injury, simple fracture and wound no more than 1 cm Soft tissue coverage is adequate, minimal comminution but wound is greater than 1 cm High-energy injury, extensive soft tissue damage, contaminated and comminuted fracture, but bone remains adequately covered High-energy injury, extensive soft tissue damage and periosteal stripping with bone exposure As above but injury is also associated with an arterial deficit requiring repair
Type II Type IIIA
Type IIIB
Type IIIC
Table 1
clinical diagnosis. If direct measurement is used, the compartment pressure should not be less than 30 mmHg below the diastolic blood pressure measurement. An absolute measurement of 40 mmHg with clinical symptoms is an indicator for urgent surgical decompression. In high-energy trauma, it is important to remain alert to the possibility of other coexisting injuries. Careful assessment of the joints above and below the fracture site is essential as well as a full assessment of the contralateral limb. Low-level trauma, resulting in fracture of the femur or tibia must be treated with caution in case of metabolic bone disease or malignancy, as mentioned earlier. Careful review of the mechanism of injury and assessment of the medical co-morbidities of the patient, will help to guide the management process. All suspected lower limb fractures should have an anteroposterior (AP) and lateral image of the injury site. In the case of a femoral fracture an AP view of the pelvis as well as an AP and lateral view at the knee are required (Figure 1). For tibial fractures an AP and lateral view of both the knee and ankle should be sought (Figure 2). Further imaging is not usually required unless an intra-articular extension is suspected.
Figure 1 Example of a femoral shaft fracture.
Anatomical considerations The femur has several anatomical features to consider when planning fracture reduction and fixation. When viewed axially it is roughly circular and has the roughened linea aspera posteriorly providing muscle attachments. In the sagittal plane, it has an anterior bow and in the coronal plane curves towards the midline. Numerous muscle attachments on the femur account for the deformity forces observed when assessing these fractures (Figure 3A and B). The tibia in the axial plane is more triangular than the femur and its subcutaneous anteromedial surface renders it more susceptible to an open injury when a fracture occurs. This feature also accounts for its lower blood supply compared to the femur.
Figure 2 Example of a tibia shaft fracture.
remains an option. Low-energy tibial shaft fractures can be managed non-operatively dependent on their stability and level of displacement. A long leg cast can be applied and the fracture site observed in clinic to ensure the position is maintained. Converting this cast to a below knee cast or functional brace, at around 6 weeks, allows knee movement. Surgical options include intra-medullary nailing or applying either a plate or external fixation device to the femur or tibia.
Surgical decision-making In the UK, there is a trend towards operative management of femoral shaft fractures. Conservative treatment is rare but
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ORTHOPAEDICS IV: LOWER LIMB
Figure 3 (a) A subtrochanteric fracture showing the deforming forces acting on it. Here, we can see the effect of the abductors and external rotators on the proximal fragment. The iliopsoas tendon will also be flexing the proximal fragment anteriorly. (b) A distal femoral fracture showing the deforming forces acting on it. Here, we see the adductors pulling the distal fragment medially and the gastrocnemius and knee ligaments pulling the distal fragment posteriorly.
presence of a hip prosthesis, ipsilateral tibial fracture, deformity or obesity. As the nail is introduced through the intercondylar notch of the knee, fracture reduction is achieved through moving the limb and so traction is not required. With displaced tibial fractures the antegrade nail is much preferred (Figure 5). This is placed behind the patella tendon into the tibia (either supra or infrapatellar, as current evidence has not found a difference in functional outcome between the two). The principles are then the same for femoral nailing. It should be
Intramedullary nailing (IMN) Most femoral shaft fractures will be fixed with IMN (Figure 4). Current evidence indicates that this should be performed within 24 hours of injury. The nail itself can be inserted antegrade (from proximal to distal) or retrograde (distal to proximal) with the usual preference being antegrade. There are many different types of nail design. They each require slightly different surgical techniques but the principles are the same. A femoral retrograde nail can be used dependent on the position of the fracture, the
Figure 4 Femoral shaft fracture and intraoperative images showing treatment with a locked anterograde intramedullary nail. Postoperative images are at 1 year showing union of bone.
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Figure 5 Example of a tibial fracture treated with intramedullary nailing. Postoperative images are at 1 year.
Subtrochanteric fractures warrant proximal locking screws that traverse the femoral neck and sit in the head to improve stability. Other diaphyseal fractures have proximal locking which is targeted towards the femoral shaft (Figure 6) Whilst in many nailing systems, proximal locking can be achieved through a jig which is attached to the femoral nail, distal locking is usually freehand. Please see instructions for our preferred method of achieving this (Figure 7) The image intensifier is positioned so that the beam is perpendicular to the distal locking screw holes through the nail (this is confirmed when the holes are completely circular). The skin knife and image intensifier are used to determine where to make the skin incision. Blunt forceps can be used to make a track down to bone. The drill for the distal locking screws can then be placed onto the bone through this hole and checked (in two planes) on the image intensifier. Once satisfied that the drill is over the locking hole you can drill through the near cortex, nail and far cortex. Confirmation can be obtained by disengaging the drill from the bit and obtaining further images (the drill bit can be seen in the proximal locking hole in Figure 7). After measuring the depth, place the screw as per AO technique. Anteroposterior and lateral images confirm the screw has traversed bone and nail. Once the screws are locked distally you can observe the fracture site. If the fracture gap is large then you can gently back the nail out. This will close the fracture gap now that the nail is locked distally.
noted that, initially, some nails were unreamed to allow better contact between nail and endosteal surface of the bone. Support has grown for the use of reamed nails due to the current evidence that they actually improve periosteal blood flow without increasing the risk of infection or non-union, even in open fractures.
Principles of intramedullary nailing The patient is positioned on the operating or traction table according to the proposed method of reduction Once in theatre, space must be provided for equipment trays and the image intensifier Reduce fracture For femoral fractures, reduction is usually achieved in traction on a traction table For tibial fractures, reduction can be achieved by either freely suspending the lower limb over a bolster on the table or through the use of specialist reduction devices If unable to reduce in traction then the fracture site is opened and reduced using bone clamps The entry point for the guide wire is first found under image intensifier control The wire is inserted and passed through the canal across the fracture site under fluoroscopy When the wire is correctly placed it is measured for the nail length The canal is reamed, keeping the wire in situ, to 1.5 mm greater than the intended nail diameter A nail of the correct size is selected to match the length and diameter of reamed canal The nail can now be inserted with a proximally locking jig attached The nail is locked proximally and distally with screws into bone, through the nail
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Plating Plating of the femur has fallen out of use in many places because of its relatively higher rates of implant failure compared to IMNs. Where the fracture configuration is either too proximal or distal, preventing stable and secure locking of the IMN, plating remains an alternative. More modern femoral plates are usually
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Figure 6 Example of a subtrochanteric fracture treated with recon intramedullary nail and cabling. Postoperative images show union of bone at 1 year.
Figure 7 Freehand distal locking of an intramedullary nail.
associated with soft tissue loss and coverage of bone cannot be achieved, or where the patient is unstable, or secondary to polytrauma, external fixation is the only stabilizing intervention, as part of damage control surgery. Once the patient becomes more stable, a return to theatre for conversion of the external device to an internal device is usually required. The use of an external device as definitive treatment can lead to issues with pin site infection, malunion and if the device bridges the knee e stiffness.
precontoured to the proximal or distal end of the femoral shaft and some are specifically designed to be minimally invasive. Plating is the treatment of choice in certain peri-prosthetic fractures. In tibial plating systems the screws are placed to preserve the knee or ankle joints whilst controlling the fracture (Figure 8A and B).
External fixation When other methods of fixation are contraindicated or unavailable, external fixation is the alternative. Where the fracture is
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Figure 8 (a) Examples of a femoral shaft fracture treated with plating and cabling. (b) Example of a tibial shaft fracture treated with plating.
For tibial fractures, fine wire external fixators are an option for definitive treatment and may be used as first-line treatments (e.g. Taylor spatial or Ilizarov frames). These can correct shortening and complex deformity. Whilst they are particularly useful in managing tibial malunion, associated bone loss, deformity or infection, they also play a significant role in the management of high energy open fractures (Figure 9A and B).
Venous thromboembolism (VTE) The patient’s risk is assessed on admission, based on regional and national guidelines.7 If treated early, femoral and tibial shaft fractures carry a low risk of VTE. Nevertheless, the presence of a fracture will increase the patient’s risk, particularly until mobility is restored. Generally, the decision on whether to give VTE prophylaxis out of hospital lies with the surgical team. For IMN patients or those with external devices, the lead author recommends VTE prophylaxis as inpatient treatment only. Patients treated in non-weight bearing casts should be treated with more caution, lowering the threshold for VTE prophylaxis, in accordance with the National Institute for Care Excellence (NICE) recommendations.
Postoperative care Once treatment plans are agreed, it is essential to ensure that patients are absolutely clear about their weight-bearing status for the affected limb, taking account of any other injuries incurred. They will need to be assessed for venous thromboembolism (VTE) prophylaxis and the treatment period. Follow-up for the patient is essential. We normally see patients within 2 weeks of surgery to obtain radiographs, perform wound checks, suture removal and review their progress.
Infection If the fracture is closed then infection risk is lowered. Worsening soft tissue injury increases the risk of infection. Open fractures of the lower limb carry risks in the region of 1e10%. All patients with open fractures should be given intravenous antibiotics within an hour in the accident and emergency department, be assessed for tetanus prophylaxis and have the wound cleaned from gross contamination, photographed and dressed in
Complications of tibial and femoral shaft fractures The following are the most commonly associated complications occurring with operatively managed fractures of the femur and tibia and will need to be discussed with patients offered surgery.
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Figure 9 (a) Temporary external fixation of a compound femoral fracture, a retrograde femoral nail has been used as the definitive treatment, and of a tibia fracture, plating was ultimately used as definitive treatment. Postoperative imaging is at 1 year. (b) Low tibial fracture treated definitively with a fine wire frame.
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patient requires urgent revascularisation of limb in theatre, pending the treatment of other life threatening injuries. No further imaging must delay this process. Once in theatre, temporary revascularisation should happen first with assessment of viability of the lower limb. Limb viability does not only depend on the vascular flow but also the level of soft tissue loss and neurological status, a decision to amputate should involve two consultants. Following temporary revascularisation, skeletal stabilisation is achieved followed by definitive vascular reconstruction. The lead author recommends adherence to BOAST guideline 6 on management of arterial injuries in association with fractures and dislocations.5
saline-soaked dressings. This will prevent the unnecessary exposure of the wound, prior to definitive treatment in theatre. Antibiotics are maintained until the point of closure of the wound.
Compartment syndrome As mentioned previously, this syndrome is serious and must be treated as an emergency. This is most frequently encountered with tibial shaft fractures, but can occur anywhere else in the body. It can occur in the presence of an open fracture if the compartments are intact. Patients should be observed closely, pre- and postoperatively, for disproportionate pain and pain on passive flexion and extension of the foot. Monitoring compartments is useful, but not adopted by every orthopaedic unit in the UK and much depends on good clinical judgement. Failure to detect this syndrome can lead to muscle necrosis, renal failure (through acute tubular necrosis secondary to circulatory myoglobin released from muscle tissue), long-term disability and amputation of the limb. If at the time of surgery it is felt that the compartments are tight or that the patient is at high risk of developing the syndrome, it is recommended that prophylactic fasciotomies should be carried out. The potential need to perform intraoperative fasciotomies must be remembered pre-operatively at the consenting process. The lead author prefers the two-incision approach, to perform a four-compartment fasciotomy in the lower leg, as advised by BOAST guideline 4.
Malunion and non-union Where fractures have been treated non-operatively, patients need to be warned about the slightly increased risk of mal or nonunion when compared to operative fixation. Tibial diaphyseal fractures which have failed to generate enough bridging callus to achieve clinical stability by 16 weeks are considered delayed union fractures, for the femoral shaft this time scale is 26 weeks. However as the femur has a richer blood supply than the tibia, the overall non-union rates in tibial fractures tend to be higher. Non-union of fractures in operative patients may be secondary to failure to achieve adequate stability or failure of an environment adequate to allow bony healing (biological failure). In this article these failure processes are highly simplified, however failure to achieve adequate stability with subsequent increased sheer stresses across the fracture promotes fibrous tissue formation at the expense of osseous tissue. A biological failure may be secondary to the extensive soft tissue injury and relative avascularity of the fracture. The soft tissue disruption is often greater in open fracture and hence they have a greater non-union rate. In addition, there are also a number of patient-specific factors which lead to an increased risk non-union of bone. These include the use of tobacco or nicotine in any form, diabetes, poor nutritional health, vitamin D deficiency, use of anti-inflammatories or steroids during healing, infection and old age. Their impact needs to be minimized wherever possible. If there is no radiological evidence of union by 6 months, operative interventions should be explored. Additional therapy to facilitate bone healing, especially for patients who have had previous surgery for non-union, is extracorporeal shockwave therapy (ESWT). An external device is fitted outside the body overlying the fracture and the pulsed ‘shockwaves’ (mechanical energy similar to soundwaves) is used to stimulate bone healing. This treatment may be used as a first-line treatment if the risk of non-union is high and the patient is not fit for surgical intervention. Multiple interventions and adjuvant treatments are available for the treatment of non-union, however they remain outside the scope of this paper.
Fat embolism syndrome This syndrome commonly occurs in severe long bone fractures or in poly-trauma, but is often not symptomatic. The classical presentation occurs around 24e72 hours post injury, with respiratory deficit, agitation and a petechial rash. This is thought to be caused by toxic fatty acids leading to endothelial injury and mechanical obstruction by fat globules. This mainly occurs in the lung but can occur elsewhere, leading to multi-organ failure. It may trigger disseminated intravascular coagulopathy and cause a systemic inflammatory response. Any suspicion of this syndrome requires close patient observation, ideally in a critical care environment. Treatment remains supportive only hence early stabilisation of fractures in adequately resuscitated patients, reduces the risk of this syndrome developing.
Vascular injury As with any limb injury, it is critical to check whether the blood vessels are intact. Whilst for closed, isolated fractures the incidence of vascular injury is low, for open injuries this increases. Vascular injury requires urgent assessment by the vascular team and skeletal stabilisation in theatre by the orthopaedic team. Revascularisation must occur within 3e4 hours to prevent tissue damage and decrease the risk of amputation. Restoration of blood flow following an ischaemic time in excess of 6 hours increases the risk of revascularisation injury through release of myoglobin. The generally accepted chain of events should be to control external haemorrhage with direct pressure or tourniquet; document any coexisting neurological injury; realign limb under sedation; splint and reassess vascular status and reimage fracture with radiographs. This should all occur in the Accident and Emergency department. If there remains a vascular deficit the
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Anterior knee pain Anterior knee pain is the most common postoperative complaint displayed by patients who have had a tibial IMN. This must be explained to all patients undergoing such procedures. If the pain persists, beyond the time when the fracture has achieved union, removal of the nail can be offered in an attempt to reduce symptoms.
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Summary
2 Weiss RJ, Montgomery SM, Al Dabbagh Z, Jansson KA. National data of 6409 Swedish inpatients with femoral shaft fractures: stable incidence between 1998 and 2004. Injury 2009; 40: 304. 3 www.aosurgery.org. Last accessed March 2016. Hosted by AO foundation. 4 The British Orthopaedic Association Standard for Trauma 4: the management of severe open lower limb fractures. The British Orthopaedic Association, 2009. 5 The British Orthopaedic Association Standard for Trauma 6: management of arterial injuries associated with fractures and dislocations. The British Orthopaedic Association, 2014. 6 The British Orthopaedic Association Standard for Trauma 10: diagnosis and management of compartment syndrome of the limbs. The British Orthopaedic Association, 2014. 7 Venous thromboembolism: reducing the risk for patients in hospital. NICE guideline CG92. National Institute for Health and Care Excellence, January 2010.
Femoral and tibial shaft fractures are common injuries. Nevertheless, they require careful assessment and management to achieve successful outcomes and minimize complications. If good practice is lacking or if commonly associated features are not looked for, this can have severe treatment consequences. This review therefore aims to equip the reader with a sound knowledge of these key features for assessing these injuries, providing a safe algorithm and a strong foundation from which to develop surgical knowledge in this area. A
REFERENCES 1 Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury 2006; 37: 691e7.
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Please cite this article in press as: Yates JB, Fountain JR, Fractures of the femur and tibial shaft, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.07.001