Femur, shaft: wedge fracture, spiral wedge—32-B1

10.1055/b-0034-87640

Femur, shaft: wedge fracture, spiral wedge—32-B1

Theerachai Apivatthakakul, Suthorn Bavonratanavech

Case description

A 25-year-old man was involved in a motorcycle accident and sustained an isolated closed fracture of the distal third of his left femur. The fracture extended from midshaft to distal third with a spiral wedge. The patient underwent emergency laparotomy for abdominal pain and distension shortly after admission.

Indication for MIPO

Treatment by relative stability with indirect reduction is suitable for this fracture. Fixation may be achieved either by intramedullary nailing or MIPO. Intramedullary nailing would necessitate transfer of the patient to a fracture table.

a–b X-rays in AP and lateral views show a fracture of the midshaft of the femur that extends distally with a long spiral fragmented wedge.

Preoperative planning

Once a decision has been made for MIPO, a good preoperative plan helps to facilitate the subsequent execution of the surgical procedure. The plan should include the surgical approach, a graphic representation of the fracture fragments, the reduction technique, the most appropriate implant, and the sequential steps required in its application.

The fracture configuration is segmental comminution. The correct length of the femur can be determined by comparing the length with the uninjured femur using the cable technique or fragment apposition of the cortex.

A template of the fracture fragments is drawn. The fracture must be realigned. The reduction and fixation steps and sequence of the screws are planned as shown in Fig 17.3-2 . First, the plate is precontoured distally, then the screws are inserted.

a–b Preoperative planning. The plate is fixed to the distal fragment in the center of the lateral cortex (1, 2). Manual traction is performed to reduce the fracture:

Length control—cortex apposition, cable cord test then screw insertion (3)
After preliminary fixation, both internal and external hip rotation is performed and should be the same as preoperative hip rotation of the uninjured side.
AP angulation is checked by C-arm in the lateral position followed by screw fixation (4)

Additional fixation proximally (5), then distally (6). There is percutaneous reduction of the butterfly fragment to close the gap (7).