Assessment and management of lower limb long bone fractures
by James Donaldson

Femur shaft fracture

History:
Age – young, high energy energy, often associated with life-threatening trauma. In elderly due to osteoporosis and low energy fall
Occupation.
Mechanism of injury - often road traffic collision
Time/date of injury

Past medical/surgical history

Medication/drugs and allergies

Last ate/drank (for timing of emergency surgery if needed)

Radiographs / Imaging:

• AP and lateral of whole femur
• AP and lateral of ipsilateral hip and knee
• CT can be considered to exclude ipsilateral femoral neck # if indicated
  

AP x-ray demonstrating displaced, angulated fracture of femoral shaft

Symptoms and signs:

• Pain, swelling and deformity in the thigh
• Unable to weight bear
• Ipsilateral femoral neck # seen in 2-6% but missed in up to 30% of cases
• Document neurovascular status

Initial management:

• ATLS principles. This is a significant injury
• Analgesia, IV fluids, skin traction for comfort
• Assess for other injuries
• Admit for surgical fixation. In elderly liaise with care of the elderly team if appropriate
• Call senior if patient is unstable, polytrauma, open fracture or neurovascular compromise

Definitive treatment:

• Nearly all need operative fixation

            - Unless medically moribund or paediatric patient

• Intramedullary femoral nail            - Antegrade is gold standard

            - Retrograde if ipsilateral femoral neck #, floating knee, acetabular #, bilateral femoral #s

• Consider damage control if polytrauma patient, neurovascular injury or significant soft tissue compromise

Complications:

• Malunion: sagittal, coronal, rotational, length
• Delayed union
• Nonunion
• Heterotopic ossification
• Infection
• Iatrogenic #
• Neurovascular injury

Tibial shaft fracture

History:
Age –    High energy fractures in young as a result of direct trauma.
Low energy fractures due to torsional forces

Radiographs:

• AP and lateral of tibia and fibula
• Ipsilateral knee and ankle recommended
  

AP x-ray showing segmental tibial shaft fracture

Symptoms and signs:

• Commonest long bone #
• Pain, swelling, deformity, inability to weight bear
• Crucial to assess:

            - Soft tissues – often an open #
            - Compartments – commonest location of compartment syndrome
            - Neurovascular status
            - Associated injuries

Open fracture classification (Gustillo and Anderson) of open fractures:
Grade -      1. Wound <1cm. Often inside out injury
                 2. Wound 1-10cm. Mild – moderate periosteal stripping
                 3.    a) significant soft tissue injury but adequate periosteal coverage
                        b) as above but inadequate periosteal and soft tissue coverage. Will require a flap
                        c) associated vascular injury requiring repair

Initial management:

• ATLS principles. This is a significant injury
• Analgesia, IV fluids, skin traction for comfort
• Admit for surgery. Call senior if open, neurovascular compromise or polytrauma
• Open fracture management (see BAPRAS guidelines):

            - Remove gross wound contaminants
            - Photograph and dress the wound
            - Antibiotics (1.2g co-amoxiclav or 600mg clindamycin if allergic) and anti-tetanus
            - Limb splintage eg. above knee backslab

• Immediate debridement if:

            - Gross contamination
            - Compartment syndrome
            - Devascularised limb
            - Multiply injured patient

• Otherwise debridement <24hrs of injury

Definitive treatment:

• Early debridement with further co-amoxiclav and 1.5mg/kg gentamicin
• Continue co-amoxiclav for until soft tissue closure or maximum of 72hrs
• At the time of stabilization vancomycin 1g or teicoplanin 800mg should be given
• Spanning ex-fix if the fracture is not definitively stabilized or the skin not closed at primary debridement
• Convert to definitive internal stabilization as early as possible if soft tissues allow – usually intramedullary nail

Complications:

• Malunion: sagittal, coronal, rotational, length
• Delayed union
• Nonunion
• Knee pain (if IM nail in >50%)
• Infection
• Compartment syndrome (1-9%)
• Neurovascular injury

Consider primary amputation if:

• Uncontrollable haemorrhage
• Incomplete traumatic amputation
• Segmental muscle loss > 2compartments
• Bone loss > 1/3 of tibia
• Avascular >6hrs
• 2 consultant decision

Fibula shaft fractures

Isolated shaft fracture:

• Often from a direct blow
• Check common peroneal nerve
• Analgesia and mobilise as tolerated
• POP or immobilisation is not needed
• # clinic follow-up 1-2 weeks

Associated with tibial shaft fracture:

• Fix tibia and follow above suggestions
• The fibula can be left untreated

Maisonneuve fracture:

• Is a proximal fibula fracture associated with an external rotation injury of the leg
• Ankle syndesmosis is disrupted and needs stabilization
• Obtain ankle radiographs if suspected
• The fibula fracture itself does not need fixing

AP x-ray demonstrating minimally displaced isolated fibula shaft fracture

AP x-ray demonstrating undisplaced fracture of proximal fibula

AP x-ray of ankle of same patient demonstrating ankle joint disruption due to Maisonneuve injury