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