Recognizing and Dealing with Complications of Femoral Shaft Fractures

1
Recognizing and Dealing with Complications of
Femoral Shaft Fractures

• January 18, 2008
• Southeast Fracture Symposium
• Charleston, S.C.

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Objectives

• Common Complications of IM Nailing
• Patient related - Pulmonary
• Malunions
• Nonunions
• Infection
• Solutions
• Literature
• Personal

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Why ?

• Common procedure treatment of choice
• complacency
• Locking allowed extension of technique
• Leads to more difficult fractures nailed
• Medical legal
• AAOS survey IM nail complications most common
  for suits filed

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Pulmonary Problems and Reaming

• 1980s - recognition that reaming created ?
  embolic phenomemon Christie
• 1990s - reamed nails in patients with chest
  trauma ? mortality Pape
• Great controversy Europe vs USA
• Research into reaming

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Reaming Solutions

• All reamers are now deep fluted with thin drive
  shafts but no speed change
• Reamer Irrigator Aspirator (RIA)
• Bilateral tibias, femurs
• ? Pulmonary compromise chest injury, CXR, ?PaO2

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Patient Care Solutions

• Unreamed Nails - probably not effective COTS
• Bosse plate vs reamed nail study
• Minimally invasive plating
• Relative stability with locking internal fixators
• ? for unstable patient

More awareness by surgeons M.I.P chest/shock
Bilateral femurs or tibias ? Better intraop
and post op monitoring ( pulse oximetry on
wards x 24 hours)
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Malunions

• Recognition
• History
• Functional deficit
• Cosmetic problem
• Pain

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• 38 year old male
• 8 yrs after fracture with diffuse aching thigh
  pain with activity
• Limits ability to work at heavy labor or sports

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Malunions

• Recognition
• History
• Functional deficit
• Cosmetic problem
• Pain
• Physical
• Inspection
• Gait
• LLD and rotation
• LLD gt 1 2 cm, must be symptomatic
• Rotation must get past neutral

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Prevention

• Do it right the first time !

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Leg Length Discrepancy

• Fracture pattern related - Complex (C1, C3)
  length unstable
• Acceptable limit lt 1.5 cm
• Most commonly a result of poor reduction
• Rare to see as post op complication unless
  unlocked

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Solutions Length

• Technique of assuring equal leg lengths
• Measurement of opposite femur not leg
• Maintaining reduction with fracture table or
  distractor
• Bilateral fracture make equal
• Static locking
• Postop check in OR
• In post op period, do CT scan to determine
  alignment
• Adequate History

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Rotation

• Commonest cause of legal problems
• Most difficult to avoid
• Do not need to be perfectly equal
• assure both internal and external rotation are
  equal

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Solutions Rotation

• Vigilance to detail
• Fracture table sets rotation pre op
• Lateral Decubitus on fracture table tends to ?
  internal rotation
• No fracture table - requires a method to
  maintain rotation
• Always lock both ends Brumback

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Solutions Rotation

• Vigilance to detail
• Surface anatomical method
• Skin creases, patella 10 - 15 ext rotation
• Confirm by radiological techniques
• Check at beginning and end of procedure
• If in post op period do CT

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Technique

• Assess rotation on normal leg
• Knee flexed, extended

Foot progression angle
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Solutions Rotation

• Confirm by radiological techniques
• Width of cortices in each fragment
• Anteversion condylar axis

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Malunions

• Management

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Leg Length Discrepancy

• Symptomatic (gt2cm), most are short
• Lengthening
• Up to 5 cm acute (distractor, table)
• gt5 cm progressive lengthening
• Osteotomies
• Step cut
• Oblique
• Transverse (closed osteotomy technique static
  locked IM nail)

Plate and bone graft
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22 yr old female with femoral shaft fracture
treated with expandable nailLLD 2.5cmlimp, does
not want lift or shortening
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Rotational Malunions

• Closed intramedullary osteotomy technique

Varus Valgus Malunions

• Usually in metaphyseal regions after nailing
• Improper reductions, malposition of guide wire
• Usually requires open osteotomy and plate
  fixation

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Case Example varus- flexion deformity
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Non Unions

• Uncommon lt 5
• Usually 6 months to 9 months wait
• Femur - exchange nail plus bone graft unless
  hypertrophic non union

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Exchange Nailing

• Removal of nail, reaming to larger size(2mm) and
  insertion of larger nail
• Biology ? periosteal blood supply ? new bone
  formation, ? Reaming debris
• Mechanical ? stability by larger nail, more
  cortical contact and more locking screws

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Exchange Nail
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Results Exchange Nailing

• Webb 96 success for non unions treated with nail
• 49 were exchange nails no data available on
  these
• Rest of the literature
• 108 cases, 83 united with one exchange nail 77
• 4 months to heal
• Hak, Weresh, Pihlajamaki, Banaszkiewicz

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Exchange nail

• Bone graft - gt 30 to 50 cortical defects
• - after multifragmented
  fracture
• - open procedure to correct
  deformity
• Supplemental locked plate graft
• Plate controls rotational instability
• Failure of first may exchange again but bone
  graft

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Oligotrophic Non union
Post op
Pre op
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Oligotrophic Non union
6 Months
Exchange Nail Graft
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Oligotrophic Non union
6 months sp Ex Nail Graft
3 months sp Plate Graft
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Infections

• Uncommon for closed fractures
• More common in nailed open fractures
• If lt 3 months and nail stable debride fracture
  site, IV antibiotics X 6 weeks and bone graft if
  needed at 6 - 12 weeks

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Chronic Infected Non Union

• If gt 3months , infection not draining
• remove nail, ream canal,
• renail /-graft
• antibiotics (suppressive)

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Chronic Infected Non Union

• If gt 3months and draining
• - remove nail, ream canal,
• - debride soft tissue and bone
• - obtain stability ex fix or traction
• - antibiotics per cultures (antibiotic PMMA)
• - when drainage stopped , soft tissues OK,
  labs normalizing may reamed nail /- bone graft
• - suppressive antibiotics till union

34
Cove, J.A. JOT 11513 520, 1997
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Summary

• Complications are uncommon
• Mal unions - Prevention is the best cure!
• Non unions need appropriate assessment and
  consideration for graft
• Infections don't delay can become a problem