ambulatory method of treating femoral shaft fractures, utilizing fracture table for reduction

$: Ambulatory method of treating femoral shaft fractures, utilizing fracture table for reduction$
AMBULATORY METHOD OF TREATING FEMORAL SHAFT FRACTURES, UTILIZING FRACTURE

TABLE FOR REDUCTION* ROGER ANDERSON, M.D., P.A.C.S.

Orthopedic Surgeon, King County HospitaI

SEATTLE, WASHINGTON

S UCCESSFUL reduction of femoral ment. Such approximation and fixation in

shaft fractures can be more quickly al1 types of fractures of the shaft of the and effrcientIy achieved when direct femur can be accomplished when a speciaI-

FIG. I. Cornminuted fracture of the middle third. Demonstrates advantages of this physiotogic method of immobilization.

control of the recaIcitrant upper fragment ized form of skeIeta1 countertraction is is obtained, whiIe for early and complete restoration of function, it is imperative to

empIoyed. Transfixion of the upper femoraI frag-

perfect an immediate reduction sustained ment may not, at first thought, seem by positive immobiIization of each frag- feasibIe. But, since the sore means of

* Read before British Columbia MedicaI Society, Vancouver, British Columbia, September, 1935.

538

NEW SERIES VOL. XXXIX, No. 3 Anderson-Fractures of Femur American Journal of Surgery 539

proximal insertion is a pair of short haIf- incorporated in plaster, thereby actuaIIy pins put into the IateraI aspect of the naiIing the fragments to a short cast, superficiaIIy pIaced greater trochanter, it extending onIy from hip to knee.

FIG. 2. Diagrammatic sketch showing anatomic practicality of transfixing upper fragment. A, shortening aIone would not result in apposition of parts. This spira1 fracture is referred to as a Iocked fracture. See text for technique of reduction. B, cross section of Ieft upper thigh of female at the IeveI of the lesser trochanter, demonstrating relationship between haIf-pins and femoral vesseIs.

is apparent that the procedure is practica1 as weI1 as safe. (Fig. 2~.) For anatomic reasons, these haIf-pins, as the name im- plies, transfix but haIf of the thigh, aI- though they compIeteIy transfix the upper femora1 shaft. (Fig. 2~.) As the half-pins are inserted into the superior fragment at an angIe to each other, with their protrud- ing ends connected to an adjoining bar, the fragment can consequentIy be manipu- Iated as if grasped with forceps.

Technical Advantages. Transfixion of the superior fragment with haIf-pins and dual transfixion of the distal fragment by Steinmann pins or Kirschner wires serve a triple function: (I) they suppIy skeIeta1 traction and skeIeta1 countertraction; (2) they furnish the means for direct manipuIation of each fragment; and (3) they provide absoIute immobiIization when

Immediate movements at knee and hip, without disturbing apposition, are made possibIe by incorporating both sets of transfixions in the pIaster cast. (Fig. I.)

With complete immobiIization so attained, there can obviousIy be no Ioss of reduction. With minimum encasement of the thigh, which immobiIizes neither hip nor knee joint, benefits from ambulation accrue. It is evident that on drying of the plaster, immediate crutch ambulation is provided for. Patients may be fuIIy dressed through- out convaIescence, and the Iatter is prac- ticaIIy pain-free. There is, therefore, added economy in a few days’ hospita1 stay.

Traction force for reduction may be obtained through various agencies: the fracture tabIe; the anatomic femur spIint;l by means of weights and puIIey; or by manua1 traction.

540 American Journal of Surgery Anderson-Fractures of Femur MARCH, 1938

eIectric motor driI1. When x-rays are taken to check position and depth of insertion of the haIf-pin, this assembIy shouId be

Fracture Table Reduction Technique. After a preIiminary hypodermic and skiagrams in two views, the patient is pIaced

FIG. 3. Placement of proximal haIf-pins and aIso distal dua1 transfixions. A, the trochanteric half- pin, a, is driIIed by the right hand into the center of the greater trochanter, whiIe the Ieft hand holds the clamping bar, b, paraIIe1 to the thigh. ES, the locking haIf-pin, c, after passing through the obIique hoIe in the cIamping bar, is driIIed com- pIeteIy through the shaft and Iocked in position by tightening the nut, d. The haIf-pin units are made in three sizes: Iarge, medium and chiId. c, the most dista1 transfixion, f, either pin or wire, or a pair of haIf-pins If preferred, is inserted at the superior edge of condyIes while the other transfixion, e, is passed through at a point about 2 inches superior to the condyles. D, after reduction the transtixions are securely incorporated in the short cast, which extends only from the hip to the knee joint.

on the fracture tabIe with the feet secureIy covered with a steriIe towe1. A good ruIe bandaged to the foot pIates, and after some is to have the ends of the haIf-pins pass traction has been exerted and the tabIe top we11 beyond the media1 cortex of the bone; dropped, the upper thigh and the knee are therefore, shouId the radiographs demon- surgicaIIy prepared for the transfixions. strate that penetration is inadequate, the

Superior transfixion is demonstrated in *haIf-pins require no preparation for deeper Figure 3. Because the Iower haIf-pin pene- insertion. trates the dense cortica1 bone of the shaft, Two dista1 transfixion pins or wires are it is best to empIoy a carpenter’s driI1 or an routineIy empIoyed, in order that the knee

NEW Smms VOL. XxX1X. No. 3 Anderson-Fractures of Femur American ~~~~~~~ ,,fsurgery 541

joint be Ieft mobiIe. If, however, onIy one that the dual distal transfixions are not dista1 transfixion is desired, the cast must parallel to each other. of necessity be extended down to the IeveI Correction of the Iower fragment is now

FIG. 4. Demonstration of sreps in reduction on a Hawley fracture table. (See aIs: Fig. 6.) A, first stage, the pIacement of half-pins in the superior fragment and two transfixions, or haIf-pins if desired, into distal fragment. B, second stage, the attachment of the mechanica hand or clamp to the half-pins, the cIamp being universaIIy adjustable and operable equally we11 for child or large adult, as well as for either Ieg. Here a Hawley table is used, but the cIamp may be fastened to any standard type of orthopedic tabIe. If clamp is not avaiIabIe, a reliable, steady assistant can manipuIate and manuaIIy hold the half-pin unit while the pIaster is applied. c, third stage, the appIication of a padded or unpadded cast is not made until a perfect reduction with direct end-to-end contact, radiographically proved, has been achieved. AI1 transfixions must be securely incorporated in the cast.

of the mid-caIf, and the dista1 transfixion should be put in at an obIique angIe to the transverse axis of the knee joint. Such obIiquity provides better immobiIization and prevents any sidewise. sIiding of the dista1 fragment on the transfixion. WhiIe awaiting Roentgen findings on the Iocation of the haIf-pins, the most dista1 transfixion is inserted into the superior edge of the IateraI condyIe (Fig. 3c), the uppermost dista1 pin or wire being pIaced about two inches above the condyIe at an angIe so

made by adjusting the traction nut, and by rotating the foot pIate of the fracture tabIe. ManipuIation of the upper dista1 transfixion, either manuaIIy or by tying this pin with bandage to the overhead bar of the fracture tabIe, corrects anteroposterior dispIacements.

The upper fragment may be manuaIIy manipuIated through the “handk,” as it were, of the haIf-pin unit, its position heId by the assistant whiIe pIaster is appIied. However, a more reIiabIe procedure is to

542 American Journd of Surgery Anderson-Fractures of Femur MARCH, 1938

use the fracture tabIe mechanical arm. ImmobiIization is obtained through a (Fig. 4.) This bracket cIamp, devised to be short cast, either padded or unpadded, quickIy fastened to any reguIation fracture which extends onIy from the crest of the

FIG. 5. The universa1 fracture tabIe cIamp or mechan- ica1 arm is constructed so that it can be quickly fastened to any of the standard fracture tables by tightening handle, k. The universal bracket, d, is pivoted under the hip, and abduction and adduc- tion corrections made by swinging and locking this bracket at b. The rotating arc, a, through its hand-operated handIe, b, rotates the fragment into position, and as the arc is swiveIed and Iocked at c, a11 Aexion and extension deformities can be corrected. The half-pin assembly, f, is attached by tightening its nut. Construction is such that rotation and a11 manipulations, regardIess of the size of the patient, are anatomicaIIy made with the center of the hip as the axis.

table, may be adapted to the age and the size of the patient, and reguIated for either the right or the Ieft femur. (Fig. 5.) The cIamp or so-caIIed “mechanica arm” is so constructed that a11 manipuIations, me- chanicaIIy performed, are made on the norma anatomic axis with the head of the femur as the center. Reduction shouId be radiographicaIIy checked unti1 apposition is practicaIIy perfect.

iIium to the knee, and securely incorporates the transfixions, the pin-ends being covered with corks and pIaster. (Figs. I and 18.)

DirectIy upon the setting of the pIaster, the patient is removed from the fracture table.

After-Cure. This is minimaI. OnIy occa- sionaIIy is it necessary to spIit the cast; however the plaster over the groin, and back of the knee is cut away to provide mobiIity for the hip and knee joints.


A B

FIG. 6. Roentgenogram of fractured femur in same patient shown in Figure 4. A, before reduction. 6, after reduction.

FIG. 7. Same patient as shown in Figure 6. Final resuIt thirteen and one-half months after reduction. Bowing caused by unprotected weight- bearing foIIowing removaI of the transfixions.


Transfixion wounds need no care unti1 the hospita1. At first it is best to use crutches, transfixions are removed, usuaIly eight to but in the Iate convaIescence a cane usuaIIy twelve weeks Iater, depending on caIIus suffices. AmbuIation apprehension soon formation. disappears and convalescence shouId not

FIG. 8. Comminuted fracture of middIe third, reduced under spina anesthesia. Here the mechanica arm is pivotIy fastened to the upper end of this anatomic femur splint, and again all mechanica manipuIations are made with the head of the femur as the center. The sacral rest, T, an integral part of the apparatus, is adjustabIe to fit any sized patient.

The uppermost of the two distal transfixions (in this case a Kirschner wire in the Tautner t) is fastened into the horseshoe, which is pivoted for IateraI or media1 adjustments; through a gear and rack arrangement, this dista1 fragment aIso is rotated on the normaI anatomic axis. Further- more, by pressure down or up on the knee joint, anteroposterior dispIacements are overcome. Traction supplied by turning nut, n, of the traction rod. When avaiIabIe, we prefer to use the anatomic femur splint, as the correction is more easiIy obtained, while through mechanica locks, apposition is positiveIy held during the application of the pIaster. Furthermore, the construction of the splint and its adiustabIe stand, s, was devised to permit free and easy access for fluoroscopic and x-ray examination.

Skiagrams are repeated severa times. Separation of fragments, caused by over- traction at the time of reduction, unequa1 contraction in the drying of the pIaster, or Iater sIight absorption at the ends of the fragments, as a result of circuIatory trauma, caI1.s for correction in order to avoid deIayed union. Such a condition is quickIy remedied by removing a thin, transverse section of the cast.

AmbuIation is permitted as soon as the patient is out of shock and the pIaster dried, and within a few days the patient, fuIIy dressed, can generaIIy Ieave the

cause much discomfort. Pain, if present, is usuaIIy due to fauIty technique. How- ever, the continued puI1 of the skin against the transfixions in moving about may resuIt after a few weeks in some distress, accompanied by a puruIent discharge. As this secretion is steriIe, however, no attention is necessary, and dressings are Ieft undisturbed for the usua1 time Iimit. ShouId these compIications become aggra- vated, it is advisabIe to keep the patient in bed from a few days to a week. Another possibIe source of discomfort and discharge may be bony absorption around

NEW SERIES VOL. XXXIX, No. 3 Anderson-Fractures of Femur American JO,,~~~I of surgery 545

the ends of the haIf-pins, a resuIt of faiIure danger can be avoided in many instances to 1 transfix the femur compIeteIy with the by using Iarger dressings and covering hall F-pins. Here again, mereIy keeping the their vuInerabIe aspect with transverse

FIG. 9. Cornminuted intercondyIar T-fracture into knee joints before reduction. Since the distal portion was so short, a singIe Kirschner wire was put through both fragments of the T, while the second transtixion, a Steinmann pin, was put through the upper tibia, with cast 6 inches below the knee. Latter transfixion removed at an early date.

patient off his feet for a few days usuaIIy suffices to aIIay the difflcuIty, and only occasionally is it necessary to reinsert the haIf-pins.

Suppuration and distress around the dista1 transfixions from sidewise movements may occur on recession of sweIIing in those cases in which the two dista1 transfixions have been inserted paraIIe1 to each other. For this reason these transfixions shouId be pIaced in obIique reIa- tionship to each other. Danger of infection is practicaIIy nil; we have yet to have our first case of bone infection from the use of these transfixions. An itching of the skin may cause an uncobperative patient to scratch and infect the pin wounds, but this

strappings of adhesive. With weak-minded or seniIe patients, it may be advisabIe to extend the cast upwards in the form of a spica, with pIaster so thin over the abdo- men that the body portion is semi-ffexibk.

Locked Fractures. The fracturing force that causes a spira1 fracture wiI1 frequentIy dispIace the fragments so that the fractured surfaces do not face each other. As iIIus- trated in Figure 2~, traction may overcome a11 shortening in this type without effect- ing apposition, and therefore to get reduction by traction, it is actuaIIy obIigatory to Iengthen the thigh from one to severa inches before the fragments sIip past each other. We refer to these dispIacements as the Iocked fracture. Such cases in the past


have n0sI.s

BY

come to open operation on the diag- upper fragment can be readiIy corrected by of intervening muscIe. routine measures. However, the upper mechanica manipuIations of the haIf- haIf-pin shouId be inserted into the superior

FIG. IO. Same patient as in Figure g, after reduction.

pins, these fractures can now be simpIy unIocked by passing an end of one fragment either above or beIow the other fragment so that both fractured surfaces face each other. This is an initia1 maneuver, so that when traction is appIied, reduction is quickIy achieved.

AIthough radiographs may revea1 just a simple spira1 fracture, subsequent careIess handIing in moving patient to operating room may resuIt in a sIipping with conse- quent Iocking of the fragments. If traction faiIs to effect speedy reduction, the fracture shouId be checked by Auoroscopic or x-ray examination; and if locked, traction is reIeased, and the fragment unIocked, after which traction soon resuIts in reduction.

In subtrochanteric fractures, abduction, Aexion and externa1 rotation of the short

edge of the trochanter, aIthough the occasion may require the smaIIer half-pin unit with haIf-pins in cIoser proximity.

In supracondyIar fractures, posterior dispIacement of the dista1 fragment is overcome by puIIing anteriorIy on the uppermost dista1 transfixion unti1 the knee joint is fuIIy extended, with the Iower femora1 fragment in a straight Iine with the tibia. After this the fracture is routineIy reduced. This procedure is more easiIy accompIished by utiIizing the overhead suspension rod set into the center post of the fracture tabIe.

Comminuted fractures are managed rou- tineIy, except that pIaster shouId be more snugIy appIied. The infrequent case in which a Iarge, Ioose centra1 fragment is dispIaced (usuaIIy to the media1 side by

New SERIES VOL. XXXIX, No. 3 Anderson-Fractures of Femur American Journal of Surgery 547

the puII of the adductor muscles) can be compIeteIy immobiIized in the spIint for controIIed as foIIows: A Iarge hoIe over the as many weeks as desired. dispIacement, or in fact the quarter section End Results. The technique described

FIG. I I. Final resuIts in patient shown in Figures g and IO, three months later.

of the side of the cast, may be cut out in order to force against the dispIaced fragment a roI1 of sheet wadding, three to four inches in diameter and about six inches Iong, so that it contacts the major fragments when a bandage is passed over the roI1 and around the remaining part of the cast.

The wounds of compound fractures may be debrided and primariIy cIosed, or packed with Orr’s vaseIine gauze. If the anatomic splint is empIoyed, the wounds may be chemicaIIy Iavaged, or treated with maggots or any other accepted method that the surgeon eIects, because the thigh may be Ieft fuIIy exposed, reduced and

has been routineIy used on our service for a11 femora1 shaft fractures, regardIess of Iocation or type. Reduction has been obtained in every case; we have not as yet had a singIe incidence of a transfixion osteomyeIitis; we have obtained initia1 bony union in every case when a period of four months has eIapsed since date of accident.

PRECAUTIONS

We are fuIIy cognizant of the fact that a surgeon is not made by the mere purchase of a scaIpe1, but we do know that the mechanicaIIy incIined surgeon can obtain

548 American Journd of Surgery Anderson-Fractures of Femur MARCH, 1938

A B C 0

FIG. II. Fracture of dista1 third, reduction by D. M. Meekison, orthopedist, of Vancouver, Canada. In a persona1 communication, Dr. Meekison states that since his acquaintance with this method, he has employed it routinely on al1 femoral shaft fractures, obtaining reduction in al1 cases, and bony union in every case of over three months’ standing.

A B

FIG. 13. Patient aged Q years with comminuted fracture of both femora. A, before reduction. B, after reduction.


exceIIent fracture resu1t.s if he adheres cIoseIy to the technica detaiIs of this new method and avoids certain pitfaIIs. We therefore admonish the surgeon :

To repeat Roentgen exam’ination during convalescence.

To instruct the patient to keep fingers and sticks out of the cast.

FIG. 14. Same patient. Final resuIt a IittIe over three months Iater.

FIG. 15. Same patient as in Figures 13 and 14. A single distal transfixion was used on each side and casts extended to the Iower leg. since knee stiffness is not a factor in children. A few turns of plaster bandage may be put around the waist in children or in seniIe patients, in order to keep their hands away from the haIf-pins.

To Iocate fragments by probing with Kirschner wire.

To pierce through and beyond the media1 cortex with the media1 haIf-pins.

To unIock fracture before attempting reduction.

To refrain from any inspection or dress- ing of pin wounds.

To Ieave transfixions unti1 x-ray caIIus is reveaIed.

To obtain direct end-to-end contact reduction.

To protect green caIIus foIIowing remova of transfixions.

To verify apposition by x-ray fIIms before appIying pIaster.

To avoid excessive traction with fragment separation.

To empIoy the best grade of plaster bandages.

SUMMARY

To incorporate transfixions secureIy in 1

For femora1 shaft fractures a simpIe means of transfixing the proxima1 fragment provides a method for immediate, successfu1 reduction. Furthermore, this system with its pIaster incorporated skeIe- ta1 traction and countertraction trans-

the cast. fixions suppIies absoIute immobiIization,


FIG. 16. PathoIogic fracture, tabetic, dista1 third.

A B c FIG. 17. A and B, fina resuIt in case shown in Figure 16, three months Iater. c, reduction and bony union

regardIess of the fact that fifteen years previousIy patient had received fracture of neck with non-union, compIete absorption of the head and resuIting disIocation of the trochanters upward.

NEW SERIESVOL.XXXIX,NO.~ Anderson-Fractures of Femur ~~~~~~~~ ~~~~~~~ oc surgery 55 I

despite the fact that onIy a short pIaster painIess convaIescence, benefits epitomized cast is appIied to the thigh. The physio- by a fuIIy dressed patient, compIeteIy Iogic and economica advantages are nu- crutch-ambuIatory.

FIG. 18. Same patient as in Figures 16 and 17. Patient was crutch-ambulatory on the ninth day, in spite of the absorption of the femoraI head and the tabetic condition, plus the recent spiral shaft fracture.

merous, incIuding immediate freedom of REFERENCE

hip and knee joint movements, a brief I. ANDERSON, R. Ambulatory method of treating frac-

hospita1 stay, minimum after-care and tures of shaft of femur. Surg., Gynec. @ Obs~ 62:

865, 1936.

ambulatory method of treating femoral shaft fractures, utilizing fracture table for reduction

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