Fractures of the femur and tibial shaft

Fracture classifications

Femoral and tibial fractures and subsequent patterns are classified by the Arbeitsgemeinschaft f?r 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

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

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

Surgical decision-making

In the UK, there is a trend towards operative management of femoral shaft fractures. Conservative treatment is rare but 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

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

Principles of intramedullary nailing

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  The patient is positioned on the operating or traction table according to the proposed method of reduction

  
  

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  Once in theatre, space must be provided for equipment trays and the image intensifier

  
  

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  Reduce fracture

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    For femoral fractures, reduction is usually achieved in traction on a traction table

    
    

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    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

    
    

  
  

  
  

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  If unable to reduce in traction then the

  
  

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 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

External fixation

When other methods of fixation are contraindicated or unavailable, external fixation is the alternative. Where the fracture is 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

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.

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.

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

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 1–10%.

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 saline-soaked dressings. This will prevent the unnecessary

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

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 24–72 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

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 3–4 hours to prevent tissue damage and decrease the risk of amputation. Restoration of blood flow following an ischaemic time in excess

Malunion and non-union

Where fractures have been treated non-operatively, patients need to be warned about the slightly increased risk of mal or non-union 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

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.

Summary

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