1 Classification: In the AO Classification system the femoral shaft is defined as in effect stretching between the inferior margin of the lesser trochanter (proximal segment) (1) and the upper border (2) of a square containing the distal end of the femur (the distal segment). For descriptive purposes the shaft (or diaphyseal segment) may in turn be divided into proximal (3), middle (4), and distal thirds (5). The proximal third is sometimes referred to as the subtrochanteric zone.

2 Causes of fracture: Considerable violence is usually required to fracture the femur – e.g. in road traffic accidents, falls from a height, and crushing injuries. Pathological fractures may occur in osteoporosis, at metastatic deposits, and in association with hip prostheses. The diagnosis is usually obvious clinically and confirmed with plain films (Illus.). It is most important to exclude fracture of the patella, dislocation of the hip, fracture of the neck of the femur, and acetabular fracture.

3 Fluid loss: In a simple fracture, loss of half to one litre of blood into the tissues with accompanying shock is common. Fractures open from within out occur classically in the proximal third. Blood replacement is often required in closed fractures, and normally essential in open ones; grouping, cross-matching and setting up of an intravenous line should be done routinely (except in children). In the transport of patients to hospital, temporary splintage will help reduce local bleeding and shock.

5 I-M nailing techniques (a): Positioning: Careful positioning is required to give proximal access and to allow two-plane visualisation of the fracture with an image intensifier: (a) Traction may be applied through foot pieces or a traction pin, on an orthopaedic table with a perineal post. The affected leg is adducted, while the good leg is flexed and abducted at the hip. (b) Alternatively the operation is performed on a radiolucent table, with a pillow under the buttock (and with or without a perineal post). The leg is positioned by an assistant.

6 I-M nailing (b): Positioning ctd: Again, an orthopaedic table may be used with the patient in the lateral position. A horizontal perineal post is employed and used to permit effective skeletal or foot support traction. The good leg is extended at the hip while the affected leg is flexed at the hip to allow access for the C-arm and the head of the image intensifier.

7 I-M nailing (c): Positioning ctd: Alternatively, using an orthopaedic table, the good leg may be flexed at the hip and externally rotated, to give access for the image intensifier. Traction may be applied on the affected side in the line of the limb through a Steinman pin (1) through the tibial tuberosity (some prefer the femoral condyles), with the perineal post offering counter-traction (2). The affected side is adducted at the hip.

8 I-M nailing (d): The trochanter is exposed through a 6–8 cm lateral incision; the piriform fossa (1) is identified with a finger, and the medullary canal entered using an awl (2). The position is confirmed with the intensifier before enlarging the opening. Alternatively a guide wire (3) held in the chuck of an introducer may be used and the opening may be enlarged with a cannulated cutter (4). (An easier entry point at the tip of the trochanter may be used with angled nails – see p. 313.)

9 I-M nailing (e): Initially the aim is to reduce the fracture and pass a guide wire (1) across the fracture (2) into the distal segment. To gain purchase on the proximal fragment, a small diameter nail (3) may be slipped over the guide wire. If one angled at its tip is used, this may if rotated facilitate the reduction (4).

10 I-M nailing (f): Reaming is frequently, but not always undertaken before insertion of the nail. This may be merely to remove any tight spots, or it may aim to remove sufficient bone to ensure that ultimately there will be good contact between the nail and bone over a reasonable length of the shaft. Techniques vary, but often a reaming rod is substituted for the guide wire; cannulated flexible reamers of increasing diameter are then fed over the reaming rod until the desired bore has been achieved.

11 I-M nailing (g): The nail is then inserted. (The choice of nail length and diameter is preferably made with X-ray studies prior to surgery.) Instrumentation varies with the devices employed, but generally an insertion handle (1) is attached to the chosen nail (2) and the nail threaded down the guide wire (3). A so-called slap hammer (4) is then usually employed to drive the nail home.

12 I-M nailing (h): Interlocking screws may then be inserted (1,6), but first confirm the absence of any rotational deformity (the second toe, patella and anterior superior iliac spine should be in alignment). The insertion handle usually doubles up as a jig (2) to allow easy placement of the screws. The corresponding holes in the nail may be circular (3) or slotted (4) giving static or dynamic locking (where some telescoping is possible (5)). Distal locking screws may be inserted using the intensifier for location purposes.

13 Retrograde I-M nailing (a): This can be of value in obese patients, in cases of multiple injury, and where there are additional fractures round the femoral or tibial condyles which have to be dealt with at the same time. The knee is flexed over a pillow to about 45°. The intercondylar notch is exposed either through a patellar tendon splitting incision or through a medial parapatellar incision, with lateral displacement of the patella.

14 Retrograde I-M nailing (b): A guide wire is then inserted and its position checked in two planes with the image intensifier. A reamer is threaded over the guide wire, and this is used to prepare the bone to accept the intramedullary nail which may be expanded over a short length at its hilt.

15 Retrograde I-M nailing (c): After the nail has been introduced static or dynamic locking screws may be inserted at the distal end; proximal static locking may also be carried out. Short nails are available for supracondylar fractures (including after some knee replacements) and for some distal femoral fractures after hip replacements. (Illus.: femoral mid-shaft fracture with cerclage wiring and an I-M nail with interlocking screws, plus fractures of the proximal tibia treated by open reduction and interlocking screwing.)

16 Retrograde I-M nailing (d): In the case of ipsilateral fracture of the tibial shaft it may be possible to treat both injuries by intramedullary nailing. In the case illustrated there has been a transverse fracture of the femur in the distal third treated by retrograde nailing and interlocking screwing. In the same session a fracture of the tibial shaft (anatomically reduced and not showing clearly on the film) has been secured with an angled tibial nail, with locking interlocking screws. A vacuum dressing was used to treat a thigh compartment syndrome (note circular ring of staples).

17 Retrograde I-M nailing from the fracture site: Plain, clover-leaf and some other pattern intramedullary nails may be inserted by a retrograde technique after exposure of the fracture. This can be of value where image intensification is not available. The fracture is exposed (1) and the selected nail driven up the proximal fragment (2) until it presents at the buttock where it is delivered through a small incision (3). The fracture is reduced (4), and the nail driven back down (5) across the fracture site into the distal fragment.

18 I-M nailing in children: While conservative treatment is generally advocated for shaft fractures in children, stable fractures of the femur may be treated with Nancy nails (mobilising in 7–10 days) using the principle of 3-point fixation. They range from 2–4 mm in diameter and are flexible. They are bent to fit, and have flattened ends to engage in cancellous bone and control rotation; the other, protruding ends are atraumatic. They are inserted through small 2 cm incisions (medial and lateral supracondylar for mid-shaft fractures), lateral for distal shaft fractures.

19 Other methods of fixation: External fixators: Fractures of the femur are less easy to control with external fixators than those of the tibia, owing to the magnitude of the stresses at the fracture site from the weight of the limb. Nevertheless the technique is often useful in the management of highly contaminated open fractures, and can be replaced under suitable circumstances by an I-M nail at up to 10 days post trauma. Some cases of open fracture are suitable for treatment by thin wire methods (e.g. Ilizarov p. 79).

20 Other methods of fixation: Plating: This is useful for rapid, rigid fixation in an ischaemic limb requiring vascular repair. Plating has a slightly increased risk of infection and non-union. Compression plating (but see p. 77 for alternatives) is best carried out engaging 8 cortices above and 8 below the fracture, and if possible an interfragmentary screw should be inserted. Compression plating with bone grafting is sometimes used in the treatment of non-union after intramedullary nailing.

22 Conservative treatment: Femoral shaft fractures may also be treated conservatively, especially in children. If this method is being employed, the first principle to appreciate is that the large muscle masses of the quadriceps (1) and hamstrings (2) tend to produce displacement and shortening (3). Traction can overcome this, and is the basis of most conservative methods of treatment.

23 Traction methods: (a) Skin traction: Adhesive strapping is used in children and young adults. There are occasional difficulties with skin sensitivity and pustular infections under the strapping, and if this becomes a problem alternative methods may have to be used, e.g. skeletal traction after the infection subsides. (Non-adhesive tapes may sometimes be used for short periods of light traction.)

24 Traction methods: (b) Skeletal traction: The site generally chosen is in the region of the tibial tuberosity. (Some, however, prefer the femoral condyles to avoid stressing the ligaments of the knee, albeit this being seldom a problem.) Skeletal traction is preferred in the older patient with inelastic skin and where heavy traction is required. There are occasional problems with pin track infections.

25 Applying skin traction (a): With the exercise of care and gentleness this can usually be done without an anaesthetic. (1) Begin by shaving the skin. (2) It is then traditional to swab or spray the skin with a mildly antiseptic solution of balsam of Peru in alcohol. This may facilitate the adhesion of the strapping.

26 Applying skin traction (b): Commercial traction sets use adhesive tapes which can stretch from side to side but not longitudinally. They come supplied with traction cords (1) and a spreader bar (2) with foam protection for the malleoli (3). Begin by applying the tape to the medial side of leg – do this by peeling off the protective backing with one hand (4) while pressing the tape down and advancing the other (5).

27 Applying skin traction (c): The leg is internally rotated and the tape applied to the outside of the leg, preferably a little more posterior than on the medial side. The tapes should extend up the leg as far as possible, irrespective of the site of the fracture. Now apply traction to the leg (6) and finally secure the tapes throughout their length with encircling crepe bandages (7).

28 Applying skeletal traction (a): The preferred site is the upper tibia a little under 2 cm (1″) posterior to the prominence of the tibial tuberosity (1). It is important to avoid the knee joint, and the growth plate in children so begin by carefully identifying it by flexing the knee (2), noting its relationship to the tuberosity (3). If a general anaesthetic is not employed, infiltrate the skin and tissue down to periosteum with local anaesthetic (e.g. 2–3 mL of 1% lidocaine) (4).

29 Skeletal traction (b): Now make a small incision in the skin (1) enough to take the traction pin only; inset it until the point strikes bone. Drive the pin through the lateral tibial cortex by applying firm pressure and twisting the chuck handle (2). You should feel it penetrate the outer cortex and pass quickly with little resistance till it meets the medial cortex. Stop at this stage.

30 Skeletal traction (c): Infiltrate the skin down to periosteum on the medial side, using the lie of the pin to guide you to the expected exit area (3). Drive the pin through the medial cortex, and make a small incision over the tenting skin to allow it to come through. Protect the openings with gauze strips soaked in Nobecutane^™ or a similar sealant (4). Try to inset the pin at right angles to the leg.

31 Traction systems: Skin traction in a Thomas splint (a): The most important decision in selecting a Thomas splint is the ring size. To save time (e.g. before anaesthesia) the uninjured leg may be measured, and an allowance of 5 cm made for swelling, present and anticipated. It is nevertheless wise to have readily available a size above and below the estimate in case of inaccuracies.

32 Thomas splint (b): Anaesthesia will be required in the adult. Applying traction with one hand on the spreader bar (2) the selected splint is pushed up the leg (3). It should reach the ischial tuberosity (or more likely the perineum) and it should be possible to pass one finger beneath the ring round its complete circumference. If the ring is too large or too small, maintain traction while the next size is tried.

33 Thomas splint (c): The choice of soft furnishings and their method of application is often made with a fanaticism that may amaze the uncommitted. Slings to bridge the side irons may be formed from strips of 15 cm (6″) wide calico bandage (1). It is traditional to secure these with large safety pins inserted from below, close to the outer iron (2). Sometimes spring clips are used. A double bandage thickness ensures greater rigidity (3).

34 Thomas splint (d): The sling placed directly beneath the fracture (5) should preferably be unyielding, and one of canvas with web and buckle fastenings (4) is often favoured in this situation. It is customary to apply the splint with the master sling in position; the other slings are then attached and adjusted to the contours of the limb. Less satisfactorily perhaps the splint is applied with all the slings already in position.

35 Thomas splint (e): Calico and canvas slings can drift, separate, or ruck, and many prefer the smoothness of an unbroken circular bandage, stretched in double thickness over the splint (e.g. Tubigrip^™) (1). This has the disadvantage of ‘waisting’ the splint (2), being less than firm under the fracture and tending to drift distally (3). The last may be prevented by anchoring it to the ring with ribbon gauze or bandage (4).

36 Thomas splint (f): If multiple slings are used, any tendency for them to separate may be minimised by pinning each to its neighbour (1); any tendency to distal drift may be prevented by attaching the top sling to the posterior half of the ring. A layer of wool should be placed between the slings and the limb to smooth out any unevenness (2) (not necessary with circular woven bandage). In all cases, a large pad (e.g. of gamgee) should be placed directly beneath the fracture to act as a fulcrum.

37 Thomas splint (g): In long oblique fractures and those with apposition no manipulation will be needed and the traction system may be completed by, for example, tying the cords to the end of the splint (1). The convention of passing the medial cord under the corresponding iron helps to control the tendency to lateral rotation (2). A Chinese windlass (of spatulae or a metal rod) may be used to take up slack (3).

38 Thomas splint (h): Where skeletal traction is being used a metal loop (4) (Tulloch–Brown loop) allows a direct pull to be made in the line of the limb. The loop may be tied to the end of the Thomas splint (5) and tensioned with a windlass as previously described (6). A stirrup (7) may be employed to prevent springing of the loop. Protect the sharp ends of the pin with caps (8).

39 Thomas splint (i): Manipulation: With the exception of the young child, manipulation is advisable if there is loss of bony apposition. With the splint in position, but unattached, an assistant applies strong traction (1) while pressure is applied in the directions deduced from the radiographs (2). When the traction is eased off, the limb remains the same length if a hitch has been obtained (3) but telescopes if not (4).

40 Thomas splint (j): After the traction cords have been attached, the end of the splint can be raised temporarily on a pillow (1) while the limb is bandaged to the splint using, for example, 15 cm (6″) crepe bandages (2). Note, gamgee or wool padding behind the fracture to act as a fulcrum (3), behind the knee to keep it in slight flexion (4), and along the shin to avoid sores (5).

41 Thomas splint (k): The system described is normally referred to as fixed traction in a Thomas splint. The basic principles are straightforward, but it is important that they are thoroughly understood. Muscle tension (mainly quads and hams) tends to produce shortening (1); this can be overcome by traction, for example, through a Steinman pin (2) aided by a loop and traction cord (3). If the traction cord is tied to a ringless Thomas splint, the reduction is maintained so long as a pull is kept on the cord (4); redisplacement occurs if the cord is released (5). This proximal migration is normally prevented by the ring (6) so that the reduction is maintained even when the traction cord is released (7). Note that muscle tone = tension in traction cord = ring pressure.

42 Thomas splint (l): The pressure of the ring of the Thomas splint tends to produce sores (1) (especially in the perineal, groin and ischial tuberosity regions) and must be relieved (3). This is done by applying traction (c. 3 kg/8 lb) to the anchored cords (2). If ring pressure is unrelieved, increase the traction weights.

43 Thomas splint (m): The traction weights have a tendency to pull the patient down towards the foot of the bed (4). This may continue till the splint comes to rest on the traction pulley (5). This may be countered if it becomes a problem by raising the foot of the bed (6), when the traction weight is balanced by the upward component of the patient’s body weight (7).

44 Thomas splint (n): Supporting the limb and the splint (i): To allow the patient to move about the bed and prevent pressure on the heel, it is desirable to support the splint; this may be done most simply by tying a cord from the end of the splint to an overhead bar of the Balkan beam bed. The position of the suspension cord may be adjusted from near the midline to either side. (Illus.: lateral attachment to control external rotation.)

45 Thomas splint (o): Supporting the splint (ii): Some prefer a lively system which can be achieved in various ways, e.g. by weights and a system of pulleys (1). The suspension cord may be arranged in Y-fashion to straddle both irons of the Thomas splint (2). Support for the proximal end of the splint (3) is less clearly an advantage; although often pursued – it may cause extra pressure beneath the ring (4).

46 Thomas splint (p): Supporting the splint (iii): Another form of lively splint support (‘the octopus’) consists of elastic Bunjee cord (1), which can be adjusted with tensioners (2). The cords are attached to the splint with G-cramps (3) and to cross members of the Balkan beam (4) by means of a bar (5) along which a pulley (6) is free to move, allowing easy movement up and down the bed (7).

47 Thomas splint (q): Check radiographs should be taken after the application of a Thomas splint, after any major adjustment, and thereafter at fortnightly intervals till union.

Corrections:

(i) If there is persistent shortening (1) tighten the windlass in a fixed traction system (2). This will inevitably increase ring pressure, and must be compensated by increasing the traction weight (3). (Soft tissue between the bone ends may nevertheless thwart reduction.)

48 Thomas splint (r): Corrections: (ii) Where the proximal fragment is abducted (4) the position may be improved by increasing the traction (5) and abducting the leg (6). The position of the ring traction pulley and the splint supports will require corresponding adjustment. (iii) If the proximal fragment is adducted (7) increase of traction alone (8a) may lead to an improvement in the position. It may be helpful to apply side thrust with a pad (8b) between the leg and the medial side iron. (iv) Flexion and/or abduction of the proximal fragment (9) due to unresisted psoas and gluteal action is frequently a very painful complication. In the young patient, raising the splint (10) and/or abducting the leg and bandaging a local pad in position (11) may bring the fragments into alignment, but this manoeuvre is less certain in the older patient where internal fixation is frequently advisable for femoral fractures at this level and of this type. In any patient in whom this conservative technique is practised, care must be taken to avoid pressure in the region of the anterior superior iliac spine (12).

49 Thomas splint (s): Corrections: (e) Perhaps the commonest residual deformity requiring and amenable to correction is backward sag at the fracture site (13). If a continuous posterior support is used, the padding behind the fracture should be increased in thickness. If separate slings are used, the sling behind the fracture should be tightened and/or the padding behind the fracture increased (14).

50 Thomas splint (t): Aftercare (i): During the first 72 hours following fracture, swelling of the thigh from haematoma and oedema may render the ring tight round its circumference. (Normally it should be easy to put a finger under the ring at any point.) To avoid changing the splint, split the ring with a hacksaw, ease the ends apart, and protect them with adhesive strapping.

51 Thomas splint (u): Aftercare (ii): The following items should be checked daily. Look for impending pressure sores (and take appropriate action). In the Achilles tendon region if the slings stop at this level (1); Under the heel, if the heel is included (2); If a circular woven support is used, a cruciate incision in it at heel level is prophylactic (3); Over the malleoli (4).

52 Thomas splint (v): Aftercare (iii): The ring area: Good nursing care is vital to avoid skin breakdown. In addition, for: circumferential tightness, split the ring; perineal pressure, increase the ring traction weight; anterior spine pressure (a), lower the splint (b); pressure below the ring (c), decrease or remove any support weight (d) and place a pillow above the ring (e); pad the edge of the sling if needed (f).

53 Thomas splint (w): Aftercare (iv): Check daily for weakness of ankle dorsiflexion (1) indicative of common peroneal nerve palsy and necessitating careful inspection of the neck of the fibula where the cause is generally felting of the wool padding which then transmits pressure from the side iron (2). Repad, and fit a Sinclair foot support or similar if the palsy is complete: expect recovery in 6 weeks.

55 Early mobilisation techniques (a): Where there is abundant callus and the fracture cannot be sprung, splintage may be discarded and the knee mobilised till there is sufficient mature callus to allow weight bearing.

(b): The Pearson knee-flexion piece: this may be used as soon as some stabilising callus appears at the fracture site.

Method: The traction cord (1) is transferred to the Pearson attachment (2) which is fixed to the Thomas splint (3) and hinges at the level of the knee axis (4). An adjustable cord (5) may be used to gradually advance the range of permissible knee flexion. The end of the Thomas splint is raised (6) and supported (7) while a cord (8) may allow the patient to assist his knee extension manually.

56 Early mobilisation techniques (c): Cast bracing (i): After 4–8 weeks in a Thomas splint, cast bracing may be considered, especially in fractures of the distal half. Many techniques are practised. In a typical procedure the patient is sedated with diazepam, a sandbag placed under the buttocks, and a cast sock drawn over the knee (1). Circular woven bandages (stockingette) encase the limb in two sections (2) and are taped in position (3).

57 Cast bracing (ii): A layer of wool roll is used to protect the bony prominences below the knee (4) and as a single layer of padding in the thigh (5). A below-knee plaster is then applied (6) and completed by turning back and incorporating the circular woven bandage (7). An appropriately sized bucket top of polythene is selected (8), trimmed as required and taped in position (9).

58 Cast bracing (iii): Traction is applied to the leg (10), the bucket is pulled well into the groin (11), a plaster thigh piece applied, moulded in a quadrilateral fashion (to prevent rotation) (12) and completed (13). Maintaining traction in 10° flexion, polycentric hinges (14) are carefully positioned with a jig which is centred on the patella (15). The side-stays (16) are adjusted until the fixation plates (17) lie snugly against the upper and lower plaster components. Large encircling jubilee clips (18) may be used to hold the hinges in position while the jig is removed and flexion function checked. The hinges are plastered in position (19) and a rocker or boot applied (20). The hinges can be unlocked by removal of two set screws (21).

60 Other methods of treating fractures of the femur: Hamilton-Russell traction: This is particularly applicable in the conservative treatment of bilateral fractures; it is a form of balanced traction where the pull on the limb (1) is countered by the body weight (2) through the bed being raised (3). The fracture and distal fragment are supported by a padded canvas sling (4), angled slightly towards the head (5) to counter a tendency to distal drift. The theory behind the classical arrangement is that the line of pull on the femur is the resultant (6) of a parallelogram of forces, where the horizontal component (7) is doubled because of the pulley arrangement (8). Friction losses spoil the theory, and many prefer direct control of all forces (9). This method of treatment, although often useful, gives restricted support to the fracture. Note that balanced traction can be carried out using a Thomas splint bandaged to the limb, but unattached to any of the traction cords.

61 Gallows traction: Children up to the age of 3 years (or 4 if very small and light) are ideally treated by this method, which may sometimes be used at home if the circumstances are suitable. Traction tapes are applied to both legs and fixed to an overhead beam (1) so that the child’s buttocks are just clear of the bed (2), making nursing easy. The body weight is responsible for the traction. Gallows traction should not be used in the older child as there is the risk of vascular spasm and peripheral gangrene.

62 Hip spica: Stable femoral shaft fractures may be supported by a plaster hip spica (3); this must include the injured leg to the toes, the other leg to above the knee, and extend to above the nipple line (‘one and a half hip spica’). A hip spica may be used for the fretful child where good nursing care is available at home (with fortnightly out-patient reviews) or for the badly infected open injury in the adult (see Ch. 11 for application details).

63 Conservative treatment of ipsilateral fracture of the femur and tibia: The complication rate for these combined injuries is high, irrespective of treatment. To allow early mobilisation, internal fixation (e.g. by intramedullary nailing) of both fractures is often preferred. Where conservative treatment is indicated (e.g. in children) a Steinman pin is inserted proximally (1), the tibia manipulated, and a below-knee cast applied incorporating the pin (2). A Thomas splint (3) with traction through the pin (4) controls the femoral fracture.

65 Fractures of the femur after hip replacement (a): The Vancouver Classification of these fractures (Duncan and Masri) is well established. Three Groups, some with subdivisions, are recognised: Type A: These are the trochanteric fractures (incidence 4%), and are subdivided into A_G and A_L, depending on which trochanter is involved. Type B: These occur round or just distal to the stem of the prosthesis. In B1 the prosthesis is stable (incidence 16%).