Femur and Tibial Shaft Open and Closed Fractures

Daniel J. Stinner, MD

Alicia Faye White, PT, ATC, DPT

Dr. Stinner or an immediate family member serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the Orthopaedic Trauma Association, and the Society of Military Orthopaedic Surgeons. Neither Mrs. White nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.

Introduction

The management of femur and tibial shaft fractures has made significant advances in recent decades, allowing safe, early postoperative mobilization of patients. These injuries can occur in isolation, but are also common in the polytrauma patient. Early stabilization of long-bone fractures is paramount to minimize the morbidity associated with these injuries, such as deep vein thrombosis (DVT) and pneumonia, as it allows patient mobilization. Modern techniques allow for early mobilization with rapid progression to full weight bearing in most circumstances. Comminuted, segmental, and severe open fractures can be exceptions to this rule. In addition, variations in surgical technique or time to definitive stabilization can alter a patient’s rehabilitation. The common methods of surgical stabilization of diaphyseal femur and tibia fractures are discussed in this chapter with an explanation of the typical postoperative physical therapy regimen.

Femur Fractures

The overwhelming majority of femoral shaft fractures are stabilized with intramedullary (IM) nail fixation. As such, this section will focus primarily on femur fractures treated with an IM nail, but will offer a brief explanation of the indications, as well as variations in the surgical technique and postoperative rehabilitation for diaphyseal femur fractures managed with external fixation or plate fixation. It is important to note that in high-energy femoral shaft fractures, up to 6% of patients can have an ipsilateral femoral neck fracture, which would alter the postoperative rehabilitation. Some of these neck fractures are not visible on initial radiographs.

Surgical Procedure

Operative Treatment of Diaphyseal Femur Fractures: Intramedullary Nailing of the Femur (Antegrade or Retrograde)

Indications

Nonoperative management for a diaphyseal femur fracture is virtually nonexistent, and limited to nonambulators with limited function or those who cannot tolerate a surgical procedure, secondary to the morbidity associated with such treatment and the successful outcomes that can be achieved with operative management. As such, a diaphyseal femur fracture in an adult is an indication for operative management. Standard antegrade or retrograde IM nail fixation is indicated for the majority of diaphyseal femur fractures that occur more than 5 cm below the lesser trochanter and approximately 9 cm proximal to the knee joint. Refer to Chapters 71 and 73 for a more detailed explanation of the management of proximal and distal femur fractures.

Contraindications

Contraindications are limited to patients in extremis (life-threatening injuries) or who are medically unfit for anesthesia. Typically, these patients will undergo placement of temporary skeletal traction or external fixation, which can be performed safely at the bedside in the patient who is unfit for the operating room.

Procedure

Relevant anatomy: Knowledge of the anatomy of the hip, thigh, and knee are important when managing femur fractures. When performing antegrade IM nail fixation of a femur fracture, the hip abductors (gluteus medius and minimus), which insert on the greater trochanter, can be damaged during surgical dissection, reaming, and nail insertion. Damage to the abductors
can lead to a Trendelenburg gait during the early postoperative period, but this rarely leads to a long-term functional deficit. Perhaps more important, if the starting point for the nail is too posterior, especially when using a piriformis starting point, the blood supply to the femoral head can be injured, increasing the risk of subsequent avascular necrosis. While rare occurrences of avascular necrosis have been reported in adults with the use of a piriformis starting point, cadaveric studies have demonstrated no difference in damage to the deep medial femoral circumflex artery when the piriformis starting point was compared to a trochanteric one. Distally, it is important to recognize the trapezoidal shape of the femur when placing interlocking bolts to ensure that they are not too long, which could lead to irritation of the soft tissues postoperatively. Finally, should the percutaneous placement of external fixator pins or reduction aids be needed, the anterolateral border of the thigh is a relatively safe zone for placement, as the significant neurovascular structures at risk when operating on the femur course medially and posterior in the thigh.

Techniques

Antegrade Nailing

There are a variety of surgical techniques associated with intramedullary nailing of the femur. It is often helpful to obtain rotational profiles of the well leg prior to positioning, especially if femoral rotation is going to be a concern based on the fracture type. The authors prefer the use of a fracture table for diaphyseal femur fractures; however, there are variations of this technique to include supine or lateral positioning on a radiolucent table with or without skeletal traction.

A 3- to 4-cm skin incision is made proximal to the tip of the greater trochanter following the trajectory of the femur. The gluteal fascia is split and if a piriformis entry nail is to be utilized, blunt dissection is carried down to the piriformis fossa, which is just medial to the greater trochanter. Once the guidewire is appropriately placed, an opening is made in the femur with a rigid reamer. The fracture is reduced using a variety of techniques, usually closed manipulation, but at times open reduction is required. A flexible guidewire is passed to the distal femur, and the canal is reamed, followed by insertion of an appropriately sized nail. The nail is adequately seated and appropriate rotation and restoration of length is confirmed. Interlocking bolts are placed percutaneously through the iliotibial band proximally using the insertion guide and distally using a freehand technique to control the length and rotation of the femur.

Retrograde Nailing

Retrograde nailing can be performed for diaphyseal femur fractures with advantages in several clinical scenarios. Retrograde nailing may be preferred in morbidly obese patients in whom access to the starting point for an antegrade nail may be problematic, patients with a traumatic knee arthrotomy, patients with an ipsilateral femoral neck fracture that is stabilized prior to treatment of the femoral shaft fracture, and polytrauma patients for whom supine positioning on a radiolucent “flat-top” table is advantageous, that is, allowing for bilateral procedures to proceed simultaneously.

The patient is placed supine on a radiolucent table with a bump under the operative hip. A radiolucent triangle is positioned under the operative knee for access to the appropriate starting point. An incision is made over the patellar tendon. A medial, patellar tendon split, or lateral arthrotomy can be made to gain access to the knee joint. The guidewire is then inserted to the distal femur, centered on the anteroposterior (AP) fluoroscopic view and at the tip of Blumensaat’s line on the lateral fluoroscopic view of the knee. This puts the optimal starting point just anterior to the femoral origin of the posterior cruciate ligament (PCL) and at the midpoint of the intercondylar sulcus. Once the canal is reamed and an appropriately sized femoral nail is inserted, appropriate rotation and restoration of length is confirmed and interlocking bolts are placed percutaneously in the distal femur through the iliotibial band and proximally in an anterior to posterior direction using the freehand technique through the quadriceps muscle (Figure 72.1).

Alternative treatments include plate and external fixation of the femur, which typically require variations of the physical therapy protocol. They are discussed in the next sections.

Plate Fixation of the Femur

Although commonly performed for proximal and distal femur fractures, plating of the femur is not commonly performed for diaphyseal (shaft) fractures due to the need to limit weight bearing postoperatively. Indications for plate fixation of a femoral shaft fracture include deformity or proximal or distal hardware that precludes placement of an IM nail, for example, total hip replacement. When plating of the femur is performed, an open technique may be used or a minimally invasive lateral, subvastus approach is employed. Care must be taken to ensure that adequate hemostasis is obtained, as there are a few large perforating vessels that must be ligated when elevating the vastus lateralis from the intermuscular septum. When reaching the femur, the fracture is reduced and the plate is applied to the lateral border of the femur just anterior to the intermuscular septum.

External Fixation of the Femur

External fixation of a femur fracture is commonly performed initially in the trauma patient as a bridge to IM nail fixation when the patient is too sick or unstable to undergo definitive fixation acutely (Figure 72.2). In exceptional cases, external fixation is used as definitive fixation of the femur. Skin conditions, such as severe burns, may also preclude safe placement of IM nails or plates. It may also be used in conjunction with a nail as a reconstructive tool to regain length.

External fixators are commonly placed in a uniplanar fashion and usually are not stable enough to allow weight bearing. As such, these are often not used for definitive fixation, but rather they are commonly converted to definitive internal fixation within 2 weeks, after the patient is more stable and able to tolerate such a procedure. Ringed external fixators, which provide multiplanar fixation, can be used for definitive fixation of diaphyseal fractures, but have a very specific set of indications,

as this treatment modality requires great technical skill and can be extremely burdensome on the patient. A benefit of this form of fixation is the ability to perform distraction osteogenesis to treat a large bony defect or correct angular deformities. It can also be used in the setting of infection or osteomyelitis, as the fixation can be distant to the zone of injury/infection while still providing rigid enough fixation to permit weight bearing during the postoperative period. Both forms of external fixation must contend with the entrapment of muscle by the pins or wires, which limit motion and risk infection. Additionally, patients contend with the external bulk of the frame.

Figure 72.1 Anteroposterior (A) and lateral (B) radiographs demonstrate a midshaft femur fracture that underwent retrograde intramedullary nailing (C and D) through a traumatic knee arthrotomy.

Figure 72.2 Both a radiograph (A) and a clinical photograph (B) are shown demonstrating placement of a uniplanar external fixator prior to definitive fixation.

Complications of Femur Fracture Fixation

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