206 Injury, 8. 206-212 Printed in Great Britain

Combined fractures of the femoral and tibia1 shafts in the same limb

Ii. HCjer, J. Gillquist and S.-O. Liljedahl Department of General Surgery, University Hospital, Linkliping, Sweden

Summary

This paper reports a study of ipsilateral fractures of the femoral and tibia1 shafts in 21 patients treated according toa detailed planincluding shock treatment, prophylaxis against fat embolism, soft-tissue and fracture treatment. Death due to hypovolaemic shock was eliminated and the incidence of fat embol- ism (93 per cent) reduced in comparison with an earlier series. The tibia1 fracture was stabilized by plaster or internal fixation as soon as conditions allowed. In most cases the femoral fracture was treated by medullary nailing. Results have improved compared with earlier series. All fractures healed within 15 months, and functional end results have been excellent in the majority of the surviving patients (89 per cent).

INTRODUCTION THE INCREASING number of road accidents has made multiple fractures in the same leg, caused by high-energy violence, more common. As victims of traffic accidents often have associated injuries taking immediate precedence over the treatment of long-bone fractures, conservative treatment with traction or plaster casts has been the policy followed in many places. Combat injuries handled successfully with spicas, as well as legal aspects, have no doubt influenced this philosophy in the United States (Burkhalter and Protzman, 1975).

Omer et al. (1968) reviewed the problem of combined fractures of the femur and the tibia in the same leg. Their report gave one of us the impulse to undertake a retrospective study of 52 patients with this combination of fractures, treated at four different Swedish hospitals from 1951 to 1970, which included 25 cases from our hospital (Gillquist et al., 1973). A definite plan

Table 1. Plan for treatment of combined shaft fractures of the femur and the tibia in the same leg

1. Aggressive prophylaxis or treatment in hypo- volaemic shock

2. Prophylaxis against fat embolism 3. The tibia1 fracture should be fixed as soon as the

general condition of the patient permits 4. Treatment of the femoral fracture with traction for

7-14 days followed by medullary nailing 5. Soft-tissue injuries should be treated by wound

excision and the wound allowed to heal by secondary intention

Table /I. Number and type of operations in 21 patients with ipsilateral femoral and tibia1 shaft fractures

Type No. of No. of

operations patients

Laparotomy 4 2 Urethral rupture repair 1 1 Blackburn skull traction Tracheostomy : : Internal fixation 9 7 Total 17 12121

of treatment for fractures of the shaft of the femur and the tibia was considered essential to achieve acceptable functional end results. We have outlined such a plan (Table I).

A review of our results after treatment accord- ing to this plan should be of a more general interest, as this type of injury continues to increase in number.

In this report we have examined 21 patients treated accordingly.

Hojer et al. : Femoral and Tibia1 Fractures

n

I

no=4

n dd7

0 7

2 2 2

I In

5 21 31 41 51 61 20 30 40 50 so 70 age

Fig. 1. Sex and age distribution in 21 patients with ipsilateral fractures of the femur and tibia.

CASE SERIES This series comprises all patients with combined fractures of the tibia and femur who were alive on admission and treated between 1970 and 1974 at the Department of General Surgery, University Hospital, Linkoping. It consists of 21 patients, 4 women and 17 men. Two patients had bilateral fractures of both the femoral and the tibia1 shafts. The mean age was 40 years. The age and sex distribution is shown in Fig. 1. It does not differ significantly from the earlier series.

Aetiology Traffic accidents caused all the injuries. Unpro- tected groups such as motor-cycle riders and pedestrians constituted 72 per cent of the patients (Fig. 2).

Type of injuries The fracture of the femur was open in 9 cases and the fracture of the tibia in 12. Three patients also had fractures of the pelvis or hip joint. The accidents in this series resulted in many associated injuries (Fig. 3).

Peripheral circulatory collapse was present in 20 cases. Brain injuries occurred in 48 per cent, and 58 per cent of the surviving patients required one operation or more in addition to those performed on the injured leg (Table II). The average number of injuries, including those requiring no specific treatment, was 4.6 per patient (Fig. 4).

Treatment General As initial treatment we gave Ringers lactate or acetate while waiting for blood. Liberal replace- ment with blood and sometimes with plasma, in many cases with guidance from blood volume

Bc Fig. 2. Cause of injury in 21 patients. MC, motor-cycle accident; Bc, bicycle accident; Ped, pedestrian run over by car; Car, car accident.

Fig. 3. Associated injuries requiring specific treatment in 21 patients. The number of fractures in the limbs, and the abdominal, thoracic and skull injuries are shown as well as open fractures of the femur and tibia.

measurements, was the rule. Prophylaxis against fat embolism according to Liljedahl and Westermark (1967) was given initially to all patients save two (Tables ZZZ and IV). Heparin was withheld in cases of intracranial injury and on suspicion of internal haemorrhage.

Fracture of the femur During the first week, traction through the tibia1 tuberosity was used to maintain a satisfactory

208 Ir Ijury: the British Journal of Accident Surgery Vol. ~/NO. 3

t

MN Fig. 4. Treatment of 23 femoral shaft fractures in 21 patients. MN = medullary nailing; t = preoperative death.

Table ///. Fat embolism

No. of patients

Present upon admission Verified at autopsy 1 Clinically suspected 1

Initial prophylaxis given 17121 Fat embolism 0

Initial prophylaxis not given 2 Symptoms disappeared upon treatment 1

position of the fracture. After l-2 weeks of traction, 11 cases were treated by medullary nailing with a clover-leaf nail after reaming. Additional internal fixation with encircling wires was used in 3 comminuted fractures. Immediate nailing was done in 3 cases. In 5 instances traction was continued until the fractures healed. The fracture was unsuitable for medullary nailing in 3 of these cases (liig. 4).

Fracture of the tibia Five cIosed fractures with no tendency to displace were treated from the beginning by closed reduc- tion and plaster. Immediate open reduction and internal fixation with an A0 compression plate was used in 5 patients. In 5 cases with associated injuries, after these and soft-tissue lacerations had been dealt with, traction was followed by elective internal fixation with an A0 compression

0 5 plaster

d b A0 pleater

&g. 5. Treatment of 23 tibia1 shaft fractures in 21 patients. A0 = dynamic compression plate; Vidal = external fixation according to Adrey-Vidal; t = pre- operative death.

Table IV. Prophylaxis against fat embolism

1. Adequate ventilation with monitoring of Pcoz, PoZ and pH. Respirator without delay

2. Daily thrombocyte count and chest radiography 3. Heparin i.v. 2500 IUx6, starting 8 hours after

the accident 4. o-receptor-blocking substances (i.e. Hydergin

(Sandoz) 1.2 mg or chlorpromazine 100 mg in a lytic cocktail containing 50-I 00 mg pethidine or 50-75 mg promethazine/lOO ml 5.5% glycose)

5. Infusion of carbohydrate-containing solutions (200 g of carbohydrates daily). A daily calorie intake of up to 2000 Kcal

plate. External fixation according to Adrey-Vidal (Connes, 1973) was used in 3 cases because of extensive lacerations of the soft tissues (Fig. 5).

FOLLOW-UP Final examinations were undertaken after radio- logical healing of both fractures, between 9 months and 4 years after the accident. Limita- tions in the range of movement of the hip, knee and ankle joints were recorded. Deformities in the fracture area were measured on the X-ray films and by clinical examination of the patient. Subjective symptoms including limitations at work and leisure were recorded, as well as the interval between accident and return to work.

Results were classified as excellent when the range of movement was normal in the adjacent joints, and when deformity and major subjective

Hajer et al. : Femoral and Tibia1 Fractures

Table V. Complications

Infection

Femur Tibia

2 4 (3 cases of

external fixation)

New injury leading to malposition 1

Refracture 1 Plate fatigue fracture 1 1 Delayed healing 2

symptoms causing limitations at work or leisure were lacking.

RESULTS Two patients died before operation could be performed, one a few hours after admission from a cerebral injury and the other after a week from septic shock originating in a pulmonary infarc- tion. A third patient with severe brain injuries died 3 months after the accident without having regained consciousness.

Fat embolism In 2 patients symptoms developed within the first few hours, before treatment had been instituted. The diagnosis in one case was verified at post- mortem examination. The second case died 3 months later and there were no signs of fat embolism in the brain at autopsy.

Initial prophylaxis was provided for 17 patients (Table III) and all remained free of symptoms. Two cases did not receive initial prophylaxis, and one developed mild symptoms, which disappeared after initiating treatment. Fat embolism was never the sole cause of death.

Fracture of the femur All fractures healed within a normal time, after 4-12 months. There was no case of delayed healing or pseudarthrosis. Complications were few (T&e V). There were 2 infections, 1 of which was deep but healed after removal of a sequestrum. This infection probably originated from an infected soft-tissue injury in the leg. The second case had a superficial infection which healed quickly after treatment. A new injury a few weeks after operation resulted in rotational malposition in one patient. Fracture of a com- pression plate occurred in an insufficiently stabilized concomitant supracondylar fracture.

209

100 I

E ?J 50-

%

6 12 16 24 30 36 months

Fig. 6. Interval between the accident and return to work in 15 patients. Only surviving and unretired patients have been included.

loo-

e

8 50- t

-.I

r ; 6 12 18 24 30 36 months

Fig. 7. Interval between the accident and radiological healing in both fractures. -, represents the present series 1970-4; - - -, represents an earlier series from the same hospital 1951-69.

A medullary nail was inserted, and the fracture healed 12 months after the accident.

Fracture of the tibia There were 2 cases of delayed healing. One of these patients, treated with external fixation, had a severe soft-tissue laceration combined with loss of bone substance. Primary amputation would probably have been a better solution. The second fracture, initially treated with plaster, healed uneventfully after fixation with an A0 compression plate at 6 weeks. One refracture occurred immediately after the removal of the external fixation apparatus. This fracture healed after osteotomy of the intact fibula and treatment with a patellar-tendon-hearing plaster. Post- operative infection was seen in 4 patients with open fractures. Three were deep and they all

Injury: the British Journal of Accident Surgery Vol. ~/NO. 3

a b

Fig. 8. 51.year-old female, with a closed short oblique fracture of the femoral shaft, a closed tibia1 shaft fracture and a fracture-dislocation of the head of the humerus. Immediately after admission open reduction and internal fixation of the humerus and tibia was performed, and reaming and nailing of the femoral fracture after a week. X-ray films show: a, Anteroposterior views before and after fixation. b, Lateral view before and after fixation.

Tab/e W. Functional end results in 21 patients

Femur Tibia

Excellent 16 17 New injury (malposition) 1 Non-classifiable 1 Primary mortality : 3 No. of patients 21 21

developed in fractures treated with external fixation. Removal of the apparatus after fracture union healed these infections. The use of the wrong types of screws caused inadequate rigidity and fracture of one compression plate. This fracture healed after replating (Table V).

Clinical healing course Of the surviving patients, 67 per cent were in hospital for more than 2 months, but only 22 per cent for more than 4 months. The interval between accident and return to work is shown in Fig. 6. Thirteen surviving patients have returned to work, 3 patients are retired and in 2 cases

sequelae of the accident have made a return to work impossible.

The interval between the accident and radio- logical union in this series has been compared with a series treated between 1951 and 1969 at the same hospital (Gillquist et al., 1973). The interval was significantly shorter in the present series (P

HBjer et al. : Femoral and Tibia1 Fractures 211

increased the survival rates after traffic accidents. This means that more patients have to be treated for multiple fractures of the long bones and that this type of injury has become a common therapeutic problem.

Comminuted fractures and extensive soft- tissue injuries caused by high-energy violence in traffic accidents are common. Associated injuries to the thorax and the abdomen require immediate attention and delay in the definitive treatment of long-bone fractures.

In this series, as well as in earlier series (Omer et al., 1968; Gillquist et al., 1973), severe abdomi- nal and thoracic injuries have been present in 20 per cent of cases. Elderly pedestrians and young motor-cycle riders were the two groups most frequently involved.

The primary mortality was 9.5 per cent, which is lower than the 13 per cent in the previous series (Gillquist et al., 1973). Causes of death were mainly the same, with the exception of hypovolaemic shock. In the previous study hypo- volaemic shock caused 37.5 per cent of the deaths. Of prime importance is a well-trained and rapid ambulance service so that shock prevention can be started early by giving balanced salt solution infusions. Despite watching out for extensive blood loss and liberal replacement with blood, we underestimated the amount of lost blood in some of these patients. Repeated determinations of the circulating blood volume are of great importance during replacement.

Fat embolism continues to be a serious event in patients with multiple fractures of the long bones. Gillquist et al. (1973) reported an incidence of 13 per cent in a series of identical injuries, when all cases dying immediately after admission were included. In our series all patients alive on admission have been excluded, and the incidence is 9.5 per cent. Prophylactic treatment against fat embolism (Liljedahl and Westermark, 1967) was received by nearly 90 per cent of eligible patients. Among these, there was no single case of fat embolism, which is in agreement with the results achieved at Karolinska Sjukhuset (Gillquist et al., 1973).

The combination of hypovolaemic shock, severe brain injury and early appearance of fat embolism, verified in one case and suspected in another, represents a category which seems to be beyond therapy. Our second case of verified fat embolism had mild symptoms, which disappeared after the commencement of treatment. Thus, the prophylaxis described by Liljedahl and Wester- mark (1967) has been effective in these patients.

Our preference for primary internal fixation

of the tibia1 fracture was enhanced by the intro- duction of the dynamic compression plate (Allgiiwer et al., 1970) and the fact that post- operative infection, although still a serious matter, is no longer a disaster, when treated according to the principles outlined by Willenegger (1970). These authors have shown that infection can be controlled by antibiotics if the internal fixation is rigid.

Omer et al. (1968) stated that non-operative management of both the tibia and the femur was safest and most reliable, even if requiring a somewhat longer time in hospital. However, internal fixation of the tibia1 fracture within the first week improved the results (Gillquist et al., 1973). In the previous series, primary suture after excision of damaged tissue often led to infection and necrosis. In this series the majority of wounds have been left open to heal by secondary inten- tion after wound excision.

We regard immediate open reduction with internal fixation as the best method of avoiding further soft-tissue damage, reducing the infection rate and healing the fracture in a correct ana- tomical position.

Immediate gross reduction and splinting with a vacuum pad (Camp Vat) should be done in the emergency room. As soon as conditions allow, definitive fixation should be provided, and we prefer the A0 DCP (dynamic compression plate), because of the limited exposure required for a rigid fixation. In cases of extensive tissue damage, heavy comminution or loss of bone, external fixation should be applied without delay, using the method of Adrey-Vidal (Connes, 1973). The wound is left open under rigid aseptic con- ditions for later split-thickness grafting or a cross- leg flap.

Closed and stable fractures of the tibia should be immobilized in plaster as soon as possible, if necessary in combination with transfixion pin or wires. Later a patelar-tendon-bearing plaster according to Sarmiento (1967) is applied.

Our present opinion is that the femoral shaft fracture should be treated by traction followed by delayed internal fixation after l-2 weeks. This is based on the results reported by Smith (1964) and by Tophoj and Sorensen (1968), as well as on our own experience. A concomitant thoracic injury, when the leg is better mobilized to ease nursing, is an exception. We have mainly used primary medullary nailing without reaming in such cases. In elective operations reaming has been the rule, with the exception of very young patients and badly comminuted fractures. Reaming has reduced the risk of nail impaction.

212 Injury: the British Journal of Accident Surgery Vol. ~/NO. 3

It offers greater stability and demands perhaps a shorter period of time before full weight bearing without support can be allowed (Danckwardt- Lilliestriim, 1972; Hcjer and Liljedahl, 1977). Rates of infection and healing disturbances have not differed between the two methods.

Following this policy we have achieved results that are superior to those of an earlier period at this hospital and to those reported by Omer et al. (1968) and Gillquist et al. (1973). Hospital stays have been shortened, full weight bearing without support has begun earlier, and the interval between the accident and the return to work or school has been reduced significantly,

REFERENCES

Allgijwer M., Perren S. M. and Matter P. (1970) A new plate for internal fixation. The dynamic compression plate (DCP). Injury 2,40.

Burkhalter W. E. and Pro&man R. (1975) The tibia1 shaft fracture. J. Trauma 15,785.

Cannes H. (1973) Hoffmans Double Erame External Anchorage. Paris, Gead.

Danckwardt-Lilliestrijm G. (1972) Intramedullary nailing of femoral shaft fractures after reaming of the medullary cavity. Acta Chir. Stand. 139, I55.

Gillquist J., Rieger A., SjSdahl R. et al. (1973) Multiple fractures in a single leg. Acta Chir. Scund. 139, 167.

Hiijer H. and Liljedahl S.-O. (1977) To be published. Liljeclahl S.-O. and Westermark L. (1967) Etiology

and treatment of fat embolism: report of 5 cases. Acta Chir. &and. 111, 177.

Omer G. E., Mall J. H. and Bacon W. L. (1968) Combined fractures of the femur and the tibia in a single extremity. J. Traama 7, 1026.

Sarmiento A. (1967) A functional below the knee cast in tibia1 fractures. J. Bone Joint Surg. 49A, 855.

Smith J. (1964) The results of early and delayed internal fixation of the shaft of the femur. J. Bone Joint Surg. 46B, 28.

Tophiij K. and Siirensen F. (1968) Osteosynthesis coreoris femoris a.m. Ktintscher: 59 tilfaelde. Noid. Med. 80, 1550.

Willenegger H. (1970) Klinik und Therapie der pyogenen Knocheninfektion. Chirurg. 41,215.

Requests for reprinfs should be addressed to: Dr Henning Hiijer, Department of Surgery, University Hospital, S-581 85 Linkaping, Sweden.