CHRISMED Journal of Health and Research

MISSION HOSPITAL SECTION
Year
: 2015  |  Volume : 2  |  Issue : 4  |  Page : 379--382

Nonoperative management of adult femoral shaft fracture using the principle of controlled collapse in mission hospital in Central India


Deeptiman James 
 Department of Orthopedics, Christian Hospital Mungeli, Mungeli, Chhattisgarh, India

Correspondence Address:
Deeptiman James
Department of Orthopedics, Christian Hospital Mungeli, Mungeli - 495 334, Chhattisgarh
India

Abstract

Operative as well as non operative treatment methods have been described for management of femoral shaft fracture in adults. Non operative management of adult femoral shaft fracture is uncommon as operative management has better functional outcome. This report highlights the use of non operative method, described more than 60 years ago, to successfully manage adult femoral shaft fracture in a mission hospital located in a resource limited part of the country.



How to cite this article:
James D. Nonoperative management of adult femoral shaft fracture using the principle of controlled collapse in mission hospital in Central India.CHRISMED J Health Res 2015;2:379-382


How to cite this URL:
James D. Nonoperative management of adult femoral shaft fracture using the principle of controlled collapse in mission hospital in Central India. CHRISMED J Health Res [serial online] 2015 [cited 2019 Oct 17 ];2:379-382
Available from: http://www.cjhr.org/text.asp?2015/2/4/379/165735


Full Text

 Introduction



Intramedullary nailing based on the principle of load sharing is considered the preferred method of management of adult femoral shaft fractures.[1] The paucity of publications regarding the conservative management of adult femoral fractures over past three decades reflects the transition toward the surgical management of femoral shaft fractures.[2] The conservative methods of management of femur shaft fracture are described mostly for its historical significance.[2],[3] Interlocked intramedullary nailing of femur shaft fractures in adults is a tried and tested method and has very high union rates and good functional outcome.[1],[4] While interlocked intramedullary nailing remains the standard treatment for femur fractures in our center, lack of qualified anesthetist forced us to manage one patient conservatively. We adopted the controlled collapse principle used in a fixed traction device like Thomas splint to successfully manage this patient.

Regional block like subarachnoid block (SAB) or epidural anesthesia are used extensively for lower limb fracture fixation.[5] However, SAB is contraindicated in patients with aortic stenosis.[5] The following case report highlights the use of conservative method used for managing femur shaft fracture in a 54-year-old man.

A 54-year-old, male patient sustained isolated closed injury to his right thigh following a fall from his bicycle. Radiographs showed a displaced oblique fracture mid shaft of the right femur [Figure 1] and [Figure 2]. His systemic examination revealed severe mitral stenosis and aortic stenosis. Contraindication for SAB was established after online consult with anesthetist colleagues. Not having an in-house anesthetist at the time ruled out the option of general anesthesia. The fracture was manipulated with fluoroscopy guidance. Right thigh was immobilized in a fixed traction device using a Thomas splint. A traction unit comprising of a Steinmann pin through the tibial tuberosity incorporated in a light below knee (BK) plaster cast was applied [Figure 3] and [Figure 4]. A horizontal metal spatula incorporated in the plaster cast, resting on both bars kept the lower limb in 10° of external rotation. Nylon traction cords were tied to either end of the Steinmann pin and passed along the length of the splint and tied to the end of the splint. Padded ring of the Thomas splint was applied against the patient's perineum. A padded support was used to support the thigh over the 'master sling' [Figure 3]. A "moderator sling" was applied under the BK cast. There was no telecopy after reduction. Postreduction radiographs revealed 50% contact between the fracture fragments. There was no varus-valgus angulation, however there was 20° anterior angulation. Radiographs showed inadequate callus formation at 6 weeks. The limb was immobilization in the fixed traction device for 10 weeks. Traction device was discontinued after 10 weeks. A cast brace was applied over the patient's right thigh. Supervised progressive weight bearing and knee movement were encouraged. 5 months post closed reduction; clinical and radiological evidence of union was confirmed [Figure 5], [Figure 6], [Figure 7].{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}

 Discussion



Conservative management of adult femoral shaft fracture has been described by Charnley in his textbook, "The closed treatment of common fractures,"first published in 1950.[3] The primary aim of closed reduction was to align the fractured fragments with longitudinal traction. These methods are categorized into traction suspension methods (or "balanced" traction) and fixed traction device.[3],[4] In traction suspension methods, like Perkin's traction, gravity based traction is applied along the long axis of the limb. However, traction suspension methods have been criticized because gravity cannot correct posterior angulation deformity.[3] Fixed traction device is fundamentally different from traction suspension devices. In a fixed traction device, like the Thomas method, the tone of the resting muscles is the residual tension. The length of the limb remains constant in a fixed traction device, and the resting muscles are not unduly strained. Whereas, in traction suspension devices the constant pull of weight induces stretch reflex till the muscle goes into fatigue.[3] Thomas method uses the principle of "controlled collapse." The Thomas splint keeps the length of the femur constant while the muscle tone gradually diminishes. Controlled collapse encourages fracture union, whereas, a suspension traction system applying constant pull on the fascial tissues can distract the fracture.

In modified Thomas technique, the knee is kept in 20° flexion and the thigh lies in front of the bar. A large pad placed over the master sling acts as a fulcrum over which the posterior angulation is corrected.[3] Twenty degrees of knee flexion diverts the force vector away from the long axis of the femur, thus restoring the anterior bow of the femur shaft. The traction unit suspended over sling passing under the upper end of the BK cast moderates the pressure on the master sling.

Prolonged hospitalization and longer duration necessary for the union are common drawbacks of conservative management. Our patient was admitted in the hospital for 3 weeks, after discharge he was advised bed rest and isotonic quadriceps exercises for 3 more weeks. Radiographs taken 6 weeks after reduction did not show the adequate callus formation. Hence, immobilization was prolonged till 10 weeks. Radiological and clinical evidence of union were confirmed 20 weeks after the procedure.

Our patient has 1 cm of shortening of the affected limb. He had knee stiffness after discontinuation of the traction device. At 6 months follow up, he has a residual 5 degree knee contracture with active flexion up to 95° [Figure 8]. Superficial pressure ulcer over the tendo Achilles was treated successfully with daily saline dressing. He received supervised physiotherapy for quadriceps and hamstring muscles wasting.{Figure 8}

 Conclusion



Intramedullary nailing remains the gold standard for management of adult femoral shaft fracture. However, conservative management of femoral shaft fracture is a useful option for treating such fractures in areas with limited resources. Limited experience of this method and oblique fracture pattern resulted in excessive anterior angulation. However, his activities of daily living are minimally affected as he is able to independently ambulate and stand without pain and can squat with minimal difficulty. Interesting that such an archaic method of treatment came to the rescue of the patient who would have been otherwise left with significant disability.

References

1Ricci WM, Gallagher B, Haidukewych GJ. Intramedullary nailing of femoral shaft fractures: Current concepts. J Am Acad Orthop Surg 2009;17:296-305.
2Gosselin R, Lavaly D. Perkins traction for adult femoral shaft fractures: A report on 53 patients in Sierra Leone. Int Orthop 2007;31:697-702.
3Charnley SJ. The Closed Treatment of Common Fractures. 4th ed. Colt Books Ltd, Cambridge, in association with 'The John Charnley Trust'. 1999.
4Available from: http://www.rcsed.ac.uk/fellows/lvanrensburg/Femoral.htm. [Last accessed on 2015 May 27].
5Rokhtabnak F, Zamani MM, Kholdebarin A, Pournajafian A, Ghodraty MR. Anesthetic management for lower limb fracture in severe aortic valve stenosis and fat embolism: A case report and review of literature. Anesth Pain Med 2014;4:e13713.