Injury (1985) 16,371-373 Printedin Great Britain 371

External fixation of ipsilateral fractures of the femur and tibia

60 Riitjser and Per Hansson

Department of Orthopaedic Surgery, tfalmstad County Hospital, Sweden

Summary In five patients with ipsilateral femoral and tibia1 shaft fractures the Hoffmann apparatus was used to stabilize the fractures of both the femur and tibia. The patients walked early and there were no disturbances of fracture healing. The pin track became infected in three patients. It is suggested that in patients with ipsilateral fractures of the femur and tibia external fixation is indicated for the tibia and that the fracture of the femur should be stabilized by closed medullary nailing. If the patient is critically ill or if there is gross comminution of the femur external fixation is indicated for this fracture as well.

INTRODUCTION PATIENTS with simultaneous fractures of the femur and tibia in the same limb pose a therapeutic problem. They are often multiply injured and in poor general condi- tion due to the high energy of injury (Gillquist et al., 1973; Edwards, 1979). There is also a high risk of permanent disability (McBryde and Blake, 1974).

There is no generally accepted principle of treatment of these fractures and recommended methods differ widely. Winston et al. (1972) recommend not operating on either fracture, while Ratliff (1968) proposes inter- nal fixation of both fractures if possible. According to Hayes (1961) and Omer et al. (1968) the key to successful treatment is stabilization of the femur which in selected cases can be accomplished by internal fixation.

We report five patients with fractures of the femur and tibia in the same leg treated by external fixation of both fractures.

MATERIAL There were five male patients aged 16-84 years who all sustained their injuries in traffic accidents. One fracture of the femur and two of the tibia were open fractures of first degree (Mueller et al., 1979) while the rest of the fractures were closed, with varying states of contusion of skin and other soft tissue. Of the ten fractures seven were cornminuted, one was segmental and two were transverse. They were followed up for between 155 and 3 years.

A preliminary report was presented at Svenska LIkaresBll- skapets RiksstBmma, Stockholm, 1-3 December 1982.

Concomitant injuries There were three fractures of the upper extremity, one fracture of the knee, one fracture of the ankle, one fracture of the facial bones, one patient with thoracic injury and two patients with concussion.

METHOD In all cases the Hoffmann apparatus was used in double-frame configuration on the tibia and in three- point fixation on the femur (Fig. 1). All frames except one were applied as neutralization forces. One frame was applied to the tibia in compression. The fixation was done as an emergency procedure in three patients, on the 5th day in one patient and on the 9th day in another patient. Active exercises for the knee and

Fig. 1. A 25year-old man walking and bearing weight about 3 weeks after the accident.

372 Injury: the British Journal of Accident Surgery (1985) Vol. WNo. 6

ankle were started as soon as the general condition allowed and the patients were out of bed with partial weight bearing within a few days.

The femoral and tibia1 frames were removed at the same time. This was done after an average of 9.8 (range 7-14) weeks, when the callus provided some stability. A hinged cast-brace was then applied for an average of 3.6 (range 2-5) weeks. In four patients a below-knee walking cast was thereafter applied for an average of 8.5 (range 4-12) weeks.

RESULTS Mobilization All patients were out of bed in a wheelchair or on crutches within 2 weeks. Four of the five patients were discharged from hospital within 6 weeks of injury. The fifth patient, aged 84, became periodically mentally disoriented and developed recurrent urinary tract infections. After 16 weeks he was transferred to a rehabilitation clinic, where he walked with the aid of crutches.

Healing of the fractures All fractures healed spontaneously without secondary procedures. The average healing time for the femur was 13.4 (range 11-16) weeks, and for the tibia 20 (range 13-26) weeks.

Alignment of the fractures Nine of the ten fractures healed with an angulation of less than 10. One tibia healed with an angulation of 14. Shortening was in all cases less than l-5 cm and in three patients less than 1 cm.

Movement of joints One and a half to three years after the injury two of the five patients had a normal range of movement in the knee. One patient had lost 15, while the remaining two patients had a restriction of movement of 20. One of these patients also had an avulsion fracture at the tibia1 end of the posterior cruciate ligament. The other patient was already suffering from osteoarthritis. Two patients had a normal range of movement of the ankle, two patients lost 15 while one patient, who also had a bimalleolar fracture, lost 20.

Functional results The patient with a bimalleolar fracture in the same leg experienced mild pain in his ankle with strenuous activities such as running 1% years after the accident. Another patient with avulsion of the tibia1 end of the posterior cruciate ligament had periodic swelling and moderate pain from the knee. The three full-time working patients were back to manual work within 11 months. One patient had reassumed his studies after about 2 months. One patient, aged 84, was transferred to a rehabilitation clinic after about 4 months. Until his death 2% years after the accident he could periodically live at home.

COMPLICATIONS Three pin tracks became infected. Two of these healed after systemic antibiotics and local toilet. In one case the infection necessitated the removal of a frame

though this could be reapplied after about 14 days without any recurrence of infection. Two weeks after having discarded his cast-brace one patient fell heavily and sustained an undisplaced fracture in the region of the previous open fracture of the femur. The limb was put in a cast-brace and the fracture healed in about 8 weeks. There was no case of adult respiratory distress syndrome and no case of osteomyelitis. In one patient a deep vein thrombosis in the calf was verified.

DISCUSSION Patients with ipsilateral fractures of the femur and tibia are often multiply injured, In these patients prevention and treatment of pulmonary complications are of utmost importance (Edwards, 1979; Browner et al., 1981). The more mobile the patient, the easier the physiotherapy for the chest. Furthermore, nursing of wounds and preventing pressure sores are much easier in a patient who is easy to turn in bed (Edwards, 1980). Early and good stabilization of both the femur and the tibia therefore seems attractive. This strategy is recom- mended by Karlstr(im and Olerud (1977a), who re- ported 31 patients and found early rigid fixation of both fractures to give functional end results that were superior to not operating on both fractures. The overall complication rate was also lower in the former group. In contrast, Fraser et al. (1978) demonstrated a 30 per cent incidence of osteomyelitis among 27 patients when both fractures were treated with internal fixation, but they found a 30 per cent incidence of delayed union and non-union in 99 patients when both fractures were managed without operation. They recommended inter- nal fixation of the femur and external tixation or cast-bracing of the tibia. Hiijer et al. (1977) reported 21 patients and recommended early internal or external fixation of the tibia and medullary nailing of the femur after l-2 weeks because the risk of complications has been reported to increase when medullary nailing is performed immediately (Smith, 1964).

External fixation is now a well-established method of treating open fractures of the shaft of the tibia (Karlstriim and Olerud, 1977b; Krempen et al., 1979; Jorgensen, 1980; Lawyer and Lubbers, 1980) and primary external fixation of the femur was reported by Edwards (1979), Karaharju and Santavirta (1979)) Slatis (1980) and recently by Dabezies et al. (1984).

Although the cases presentedhere are few, it seems that external fixation has offered an opportunity for early and stable fixation of fractures with a minimum of operative injury, which is important in seriously ill patients. Furthermore, the stable fixation made the patients easy to nurse and permitted effective phy- siotherapy for their chests. The patients were easy to mobilize and active exercises could be started early. There was no non-union, which can possibly be attributed to early weight bearing and conversion from external fixation to fracture bracing during the stage of active healing of the fractures (Aho et al., 1983). Shortening and restriction of joints mobility were slight. The functional end results were also satisfy&g, with four of the five patients back to their previous activities within 1 year. We agree with Jorgensen (1980) that ipsilateral fractures of the femur and tibia are an indication for external fixation of the tibia, especially when the fracture is cornminuted. We do not, however,

Rijtiser and Hansson: lpsilateral femoral and tibia1 fractures 373

advocate that the femur should be routinely treated by external fixation because of the risks of stiffness and non-union, both being well-known complications of external fixation (Green, 1981). Closed medullary nailing should, in our view, be the method of choice for stabilizing the femur. However, if there is gross comminution, or if it is desirable to stabilize the femur in a critically ill patient, external fixation is an adequate method that causes little damage.

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Paper accepted 24 September 1984.

Requests for reprints should be addressed to: Bo Radser MD, Department of Orthopaedics, University Hospital, S-221 85 Lund, Sweden.