CHAPTER XXXVIII. FRACTURES OF THE FEMORAL SHAFT. (Part 2)

the retention of fragments but are seldom really efficient in accomplishing good results. The fact that these positions are needed to favor reduction and retention 568 FRACTURES AND DISLOCATIONS usually means that the case should be subjected to operation to accomplish really good apposition. In children under ten years of age, fractures of the femoral shaft are best treated by vertical suspension of the lower extremity, while the child rests on a Bradford frame in the recumbent position. A Buck's extension apparatus is applied as already described in the treatment of fractures of the hip, with this exception, the line of extension is vertical instead of horizontal. The cord passes through a pulley directly over the middle of the bed and on a vertical line with the hip. The lower extremity is thus maintained in a position perpendicular to the trunk. It is best to have the child secured to a Bradford frame, which greatly facilitates the after-care of the case and prevents the patient from moving about to the extent of disturbing the fixation. This position of vertical extension is maintained for about two weeks, after which the lower extremity is lowered to an inclined plane (about 40 degrees), and extension kept up in this position for another week. A plaster spica of the pelvis and lower extremity, or a hip brace, may then be applied and the patient allowed up and about with the aid of crutches and a high sole on the shoe of the opposite foot. The thigh should not be subjected to strain until the surgeon is sure of solid union, otherwise a bowing deformity may result. (See Fig. 632.) Fractures of the thigh in patients advanced in years present some of the same problems already described under the treatment of fractures of the hip in the aged (see page 547). Hypostatic pneumonia or bedsores and other complications may develop if the patient is long confined to bed. Accordingly some form of ambu- latory treatment should be adopted as soon as the shock and traumatic reaction have subsided. The Thomas hip splint, plaster cast, or "ambulatory pneumatic splint" with hip attachment ma}^ be used in getting the patient on his feet. In very old and feeble persons it is often best to employ the cast (see page 548) with the thigh and knee flexed so that they may sit in a chair during the day and rest in bed at night. In fractures of the femoral shaft in the new-born the thigh is best treated in complete flexion, being bound to the trunk in this position. The foetal attitude is thus taken advantage of to secure immobilization. The thigh and abdomen are previously dried and powdered and a few layers of soft linen placed between them, before the thigh is fixed. FRACTURES OF THE FEMORAL SHAFT 569 In fractures of the lower third with backward displacement of the lower fragment the double incline plane may be used instead of the plaster cast and is much more appropriate in the early part of the after-treatment, during the time the acute traumatic inflamma- tion is at its height. Operative Treatment. — A large proportion of fractures of the femoral shaft demand operative intervention if the best possible results are to be obtained. Fractures of the upper and middle thirds are usually of the spiral or oblique type and nothing, as a rule, will secure the fragments in accurate apposition except direct fixation following open reduction. In the lower third of the shaft it is more often possible to secure good reduction by non-operative treatment, yet fracture in this region often demands the open method. The shaft of the bone is usually best exposed through a longitudinal incision on the outer aspect of the thigh in the region of the fracture. AVith the fragments exposed, strong traction is made on the lower extremity and the serrated surfaces fitted Fig. 635. — The Nichols frame. An appliance of great advantage in operating on fractures of the femoral shaft. A steady and powerful traction is maintained on the limb during the operation. together. They are then secured by means of wire or a heavy Lane plate. The Nichols extension frame is one of a number of appli- ances which are of value in exerting traction and countertraction during operation (see Fig. 635). Nowhere in the body is internal fixation subjected to greater stress than here in the shaft of the femur, and the material used should be strong enough to serve the purpose, pending the formation of bony callus. A good example of the fixation of a double spiral fracture of the middle of the femoral shaft with wire is shown in Figs. 636 and 637. When wire is employed two points of fixation should be had to secure the proper leverage and to prevent angular deformity. If the wire is passed circularly about the shaft it will often accomplish as much as if it were passed through drill holes in the bone. In encircling the shaft 570 FRACTURES AND DISLOCATIONS the instrument carrying the wire should hug the bone closely to avoid injuring the femoral artery or one of its perforating branches which, in the middle third of the shaft, lie in close relation with the internal border of the bone. If a Lane plate is used it should be heavy and long, preferably of the Sherman-Pierce type, and should be provided with six screw holes. When the fixation is completed Fig. 636. — Double spiral fracture of femur with uuattached fra2:ment. X-ray p.ate taken after everything in a non-operative way had been done to accomplish reduc- tion. Fig. 637. — Same ca&e after operation. Fragments in accurate apposition with the result that the lower extremity shows no shortening. the thigh should be raised from the table and in this position it should be capable of sustaining the weight of the leg without giv- ing. The muscles should be brought together with a running suture of catgut and the skin closed with silk-worm gut or horse hair. A plaster cast should then be applied, after proper dressings have been placed on the wound and the lower extremity covered FRACTURES OF THE FEMORAL SHAFT 571 with sheet cotton. The cast should extend from the waist to the foot, leaving- the toes exposed, so that the condition of the circula- tion in the extremity may be watched during the after-treatment. Twenty-four to forty-eight hours following the operation a window should be cut in the cast, the wound inspected and gentle pressure Fig. G38. Fia-. 639 Fig. 638. — Same case two years following operation. Perfect restoration of func- tion. Fig. 639. — Same case six years aft«r operation. Note the condition of the callus and wires, also the reopening of the medullary canal. made to express any dead blood which may have collected in the wound. In compound fractures of the thigh operative intervention is practically always indicated. The wound should be enlarged if necessary and all devitalized tissue trimmed away. When this has been done the wound should be washed with a few gallons of sterile salt solution and the muscles and skin accurately approx- 572 FRACTURES AND DISLOCATIONS imated (see "Treatment of Compound Fractures," page 789). After-Treatment. — The duration of the after-treatment varies considerably with the accuracy of apposition and the age of the patient. Union will therefore take longer in non-operated cases than in cases which have been subjected to the open method (see "OperatiA^e Treatment of Fractures," page 754). In a healthy adult, union will usually have taken place in from six weeks to two months, although refracture may easil}^ occur at this time if the limb is subjected to any considerable strain. In children union can usually be expected in from four to six weeks. In the aged union may be very much delayed and in some cases it may be impossible to obtain bony union at all. No matter w^hat line of treatment is followed the case should receive the most careful atten- tion during the after-treatment. The patient should be seen daily for the first few weeks. If tlie fracture is treated by extension and splints, frequent adjustments will be necessary to keep the patient comfortable and to maintain the fragments in proper position. During the first few days the weight should be heavy (usually about twenty-five pounds in the adult) to control the spasm in the thigh muscles which, at this time, is at its height. The weight should be gradually diminished as the muscles become exhausted and the spasm less active. Frequent measurements of the lower extremity should be made to determine the extent of the shortening and the influence of the extension apparatus in overcoming it. If the cast or ambulatory splint is used it will require adjustment from time to time and the parts with which it comes in contact should be care- fully^ watched for evidences of irritation. If, during the time the cast is being worn, the patient complains of persistent irritation in a given place, a window should be made to determine the condition of the skin or to treat a sore if one has developed. Following oper- ative intervention the temperature chart should be w^atched for evidences of infection and the wound should be inspected within the first few days. Infection need not be expected, however, if the proper surgical technique has been followed out. If ambulatory treatment is not employed it is usually best to keep the patient in bed for a week or so following the removal of the splints. During this time massage and passive motion should be instituted. When the patient is first allowed up no weight should be borne on the injured member until he is thoroughly adept with the crutches. The thigh should be inspected daily during the time FRACTURES OF THE FEMORAL SHAFT 573 he is beginning to bear weight on it and if the slightest evidences of bowing develop he should be again placed in bed and extension apparatus applied. It is advisable at this time to have an X-ray plate made to determine the condition of the callus. Prognosis. — Fracture of the femoral shaft is always a serious accident and the prognosis should be guarded. In unoperated cases shortening is the rule and angular or rotary deformity is not uncommon. If the shortening is less than an inch or an inch and a half, and the general alignment of the shaft is not changed, the result is said to be good. If the shortening is not greater than an inch and a half the tipping of the pelvis will compensate for the deficiency in the length of the lower extremity so that walking will be practically normal. Pain and weakness in the injured thigh are common following fracture of the femoral shaft and often persist for years. Little can be done to alleviate them. The more perfect the reduction the more complete and prompt will be the restoration of function. The results following the open treatment with internal fixation of the fragments are decidedly better than those following the non-operative method. It is often possible to secure union without shortening, even in spiral fractures, if recourse is had to operative intervention. If infection follows a compound fracture the outlook is often serious. With free drainage of the parts the danger is greatly reduced and bony union may follow.