Supracondylar skeletal traction and open interlocking nailing for neglected fracture of the shaft of femur – Retrospective study

Abstract

Background

Neglected trauma is a common problem faced by Orthopaedic surgeons practicing in developing countries. Nothing much in English literature is available regarding the practical difficulties and guidelines for treating neglected trauma of long bones.

Methods

In our institution from November 2003 to October 2009 we treated 25 cases of neglected fracture of shaft of femur. Patients underwent either of three types of management protocols depending upon the preoperative manual traction radiographs. The fracture was fixed with open interlocking nail. Primary bone grafting and bone shortening procedures were not performed in any of the patient.

Results

The fractures united in all patients at an average duration of 17 weeks. Two patients had limb length discrepancy.

Conclusion

Careful preoperative evaluation is mandatory for good results. Preoperative skeletal traction and two stage surgical procedure may be required to avoid limb length discrepancy and neurovascular complication.

1. Introduction

Neglected trauma is a common problem in developing countries. In India the commonest cause of neglected trauma is initial treatment done by traditional bone setters. There are reported to be about 70,000 traditional healers and bone setters in India and they treat 60% of all trauma.¹ In developing countries most of the patients have to pay for the medical expense out of their own pockets. They prefer traditional treatment because it is less expensive, easily available and is common advice from neighbourhood, without understanding the fracture's nature. There is a dearth of English literature regarding guidelines for treating neglected trauma of long bones, as the condition is rare in developed countries. Fracture not properly treated for more than few weeks will give soft tissue contractures, muscular atrophy and joint stiffness. Existing fracture management principles has to be changed from case to case to get good results. We had the opportunity to treat a series of neglected fractures of the shaft of femur at our institute. We have critically analyzed our management protocols and results retrospectively.

2. Material and methods

In our institute, from November 2003 to October 2009, we treated 25 cases of neglected fracture of the shaft of femur which were initially treated by traditional bone setters. The time interval between injury to reporting at our hospital ranged from eight weeks to 72 weeks, with average interval being16 weeks. The male to female ratio was 17:8 and the age varied from 21 years to 56 years. All our patients had knee joint stiffness of variable range. Four patients had severe disuse osteoporosis. When the patients report to hospital many weeks after the injury, established principles of fracture management have to be modified according to the case. Since there are no guidelines for treatment of these fractures we formed our own protocol considering all the complications of neglected trauma and their treatment.

All our patients came from traditional bone setting treatment. After removing the native bandage, limb was cleaned with soap and water then limb was placed in Thomas splint. Povidone-Iodine scrub was given twice daily for two days to clean the skin to avoid infection during the surgery. After two days patient underwent assessment for shortening and knee movements.

All our patients underwent traction X-ray by manual traction without anaesthesia while monitoring distal neuro vascular status. If traction X-rays showed overlapping of fracture ends less than one cm, the patient was taken up for definitive surgery as soon as he/she was fit for anaesthesia. If traction X-rays showed overlapping more than one cm (Table 1) and no adhesion like partial union or malunion, patient underwent skeletal traction before surgery till overriding was corrected (Fig. 1). Patient underwent a two stage surgical procedure if any partial union/malunion or more than 5 cm overriding between fracture ends was present. In the first stage of surgery the adhesions between bone ends were removed and skeletal traction was applied till fracture ends had no overriding. In the second stage the patient was taken up for definitive surgical procedure i.e fracture fixation with interlocking nail (Fig. 2).

Table 1.

Shortening after manual traction.

Shortening	Femur
No shortening	0
Up to 1 cm	5
1–5 cm	18
5–7.5 cm	2

Fig. 1.

Group II patient with skeletal traction before surgery a) Preoperative X-ray with manual traction b) X-ray after pin traction c) immediate postoperative X-ray d) X-ray after union.

Fig. 2.

Two stage surgical procedure a) intra operative picture after removal of pseudo arthrosis and adhesion b) X-ray after removal of pseudo arthrosis and adhesion c) Clinical picture of pin traction after stage I surgery d) X-ray after correction of deformity by pin traction e) immediate postoperative X-ray.

In the traction programme, single pin was applied to the lower end of femur and leg was placed in the Bohler–Braun splint. The foot end of the cot was elevated two inches so that body weight would give the counter traction. Skeletal traction was started with three kg initially and was gradually increased half kg to one kg every day, according to the patient's tolerance with neuro vascular monitoring like intolerable pain, paraesthesia, pallor and absence of pulse, till there was no overlapping of the bone ends. X-rays with traction were taken every 72 h. Once overriding of the fragments was corrected, traction with the same weight was maintained for another 48 h.

In surgical procedure all patient underwent open reduction. After freshening the bone ends fracture was reduced and fixed with interlocking nail in antegrade manner and locked proximally with jig and distally by free hand technique. None of the patient underwent bone shortening procedure for reduction. Wound was closed in layers with suction drain.

More than one cm overlapping seen in twenty patients underwent skeletal traction with periodical increase of weights with neuro vascular monitoring before definitive surgery and five patients underwent traction after the first stage of surgery. Skeleton traction was applied for five days to 14 days, an average of ten days. Weight required for achieving the length varied from 5 kg to 12 kg, an average of 9 kg.

Primary definitive surgery was performed in five patients. Twenty patients underwent traction regimen before definitive surgical procedure in which five patients had traction after the first stage of surgery (Table 2).

Table 2.

Management of the patients.

Fracture region	No of cases in group I – immediate definitive surgery	No of cases in group II – skeletal traction before surgery	No of cases in group III – surgical release of adhesion and skeletal traction before surgery
Femur	5	15	5

Intra operative findings were variable like, fibrous union, partial malunion and pseudo arthrosis. Three patients had soft tissue interposition, six patients had fibrous union, three patients had partial malunion and one patient had pseudo arthrosis. No significant findings were seen in twelve patients. All femur fracture were treated by static interlocking nails. All our patients required open reduction, bone shortening procedure was not done in any patients and in none of the patients bone grafting was done.

Six patients had second surgical procedure of dynamization after definitive surgery as static interlocking nails were used in all patients. All our patients underwent strict physiotherapy regimen after definitive surgery to regain the movements of stiff knee joint and strengthening of muscle power of hip and knee.

Patients were advised not to bear weight on affected limb with walker support initially. Patients were reviewed every week till the functional range of knee movement was achieved. The radiographs were taken once in four weeks. Depending on the progress of bone union patients were advised to put gradually increasing weight on the affected extremity. All patients were advised to take calcium supplement with vitamin D3. All patients were followed up till union of fracture and occupational rehabilitation.

3. Results

All our follow up cases attained bony union and returned to their previous jobs. Fracture united between 11 weeks and 34 weeks, average was 17 weeks (Table 3). None of our patients developed infection. Two patients who had limb length discrepancy less than 2 cm. None of our patients had postoperative neuro vascular problems.

Table 3.

Results.

Time of union	No of cases
Within 16 weeks	19
4–6 months	4
6–8 months	2

All our patients regained good range of knee movements. Fifteen patients got full range of movements, Eight patients got more than 120° flexion and none had less than 90°. Extension lag present in seven patients, an average of 11° (Table 4).

Table 4.

Knee movements.

Flexion	No of patients	Extension	No of patients
<90°	0	0°	18
90°–130°	10	0°−10°	6
Full range	15	10°–20°	1

4. Discussion

Neglected trauma is more common in developing countries for various reasons like poverty, illiteracy, false belief and easy availability of traditional bone setting treatment. The western literature discusses neglected trauma of the joints but not the problems associated with neglected long bone fractures and guidelines to treat such fractures. Gavaskar et al treated neglected fracture of shaft of femur with open interlocking nail, bone grafting and shortening procedure with good results.²

Kempf et al performed eighteen femoral lengthening 'Z′ osteotomy in malunited femur fractures between 1976 and 1984 and fixed with intramedullary nails, with primary cortico cancellous bone grafts.³ In their series they had one nonunion, three deep infections, four significant shortening and four femoral nerve palsies. For the first two days after the operation their patients remained in bed with hip flexed to 30° and the knee flexed to 90°. The knees were progressively extended from the third postoperative day. In their study they concluded that more than four cm is lengthening associated with nerve palsies and interlocking nails were a good method of fixation.

Yadav S.S described a technique double oblique diaphyseal osteotomy for lengthening of short limbs in short duration in which 6–16 cm lengthening was obtained in 3–6 weeks duration by skeletal traction. The traction weight was gradually increased up to 30 kg without any major complications.⁴

In our series we formed our protocol considering all possible complications of neglected trauma like malunion, nonunion, stiffness of neighbouring joint, and neuro vascular complications. In this series, we performed primary definitive surgeries if overlapping was less than one cm, because usually under anaesthesia with muscles relaxation and careful subperiosteal elevation one cm overlapping can be overcome without undue tension.

Fifteen patients with more than one cm overlapping underwent skeletal traction with periodical increase of weights with neuro vascular monitoring before definitive surgery. These patients had no adhesions like partial union or malunion on radiographs. The stretching of soft tissue and correction of overriding was possible with gradually increased traction weights.

Five patients who had overriding more than 5 cm or had partial union or malunion underwent first stage surgery followed by traction. The first stage surgery helped in removal of adhesions leading to effective use of traction for correction of overriding.

By using these strict protocols none of our patient developed neuro vascular complications postoperatively. All our patients underwent immediate strict postoperative physiotherapy regimen to get back their joint movements since there is no tension on neuro vascular bundle. All our patients had regained good range of knee movements.

5. Conclusion

After analyzing our treatment protocol and results we came to the following conclusions.

• 1.Preoperative traction X-rays are mandatory to plan the management.
• 2.Preoperative gradual and monitored skeletal traction is compulsory to avoid unacceptable limb length shortening and neuro vascular complications.
• 3.In some cases staged surgical procedures may be required.
• 4.Primary bone grafting is not necessary in all patients.
• 5.Bone shortening procedure not necessary for reduction.

Conflicts of interest

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.