78. Femur

From Primary Surgery

78.1 How serious are shortening and distraction?

When the femur is fractured, the fragments sometimes overlap, so that the patient's leg is short. How serious is this and how much trouble should you take to prevent it? Traction can usually correct shortening, but it may not be convenient or desirable to do so, because moderate shortening (up to 4 cm in an adult) is harmless. So treat the patient, not his X-ray, and don't worry too much about the position of the fragments of his femur. Moderate overlap is acceptable and may even be beneficial. A patient's legs can vary in length by up to 1.5 cm, even before they are broken, and he can compensate for up to 4 cm by tilting his pelvis. If he does complain of shortening, you can easily raise the heel of his shoe. Always do this if his leg is more than 4 cm short, because backache can complicate a short leg, and this will lessen the risk of it. Up to 1.5 cm of shortening can even be an advantage in a child, because a fracture is often followed by this degree of bony overgrowth at the epiphyseal lines. This is useful because it will allow you to treat a child's fractured femur in a hip spica without causing permanent shortening. Distraction is much more serious than shortening, and although a fractured femur may unite even if the ends of the fragments do not touch, it will unite more quickly if they do. Sometimes, even 2 mm of distraction between the bone ends will prevent union, so make sure that nobody adds extra weights to the traction apparatus by mistake!

78.2 Fractures of the shaft of the femur in younger children-gallows traction.

At birth fractures of the femur are common injuries, and heal themselves. Massive callus forms quickly, and a year later all signs of the fracture will have gone. Bandage the baby's thigh to his abdomen as in the foetal position for 10 days. Don't apply traction.

Under 3 years you have two alternatives-gallows traction or a plaster spica. Gallows traction: (1) does not need plaster and (2) makes nursing easier. But (3) it may cause ischaemia and later Volkmann's contracture in the injured leg or the normal one, especially in larger children (70.4). It can also cause gangrene. Don't send a child home in a gallows traction, because many families find nursing a child in them difficult, and a child's mother is less likely than the ward staff to diagnose ischaemia early. A plaster spica avoids this risk, and makes home treatment more practical, but even with a spica, nursing is not easy, and the spica soon becomes soiled. You can combine these methods, and it may be convenient for treatment to start in gallows and end in a spica.

FRACTURED FEMURS IN CHILDREN UNDER 3

GALLOWS TRACTION

INDICATIONS (1) Fractures of the shaft of the femur from soon after birth until the child weighs 15 kg at 1 to 3 years. Don't use gallows traction in larger children. (2) Prolapse of the rectum.

EQUIPMENT (1) Use a beam above a cot or bed. Or, put a bar across the sides of a cot. If necessary, you can hang several children from the same beam. (2) Ask a carpenter to make several gallows in a range of sizes. The base and the gallows should be the same length.

SETTING UP GALLOWS TRACTION Apply traction to both the child's legs. Pad his malleoli and the head of his fibulae. Paint his legs with compound tincture of benzoin (optional). Wait until this is tacky, and then apply adhesive strapping directly to his skin, and not over encircling bandages. Keep the knots away from his malleoli. Wind a crepe bandage around the strapping. Suspend his legs so that his pelvis is just clear of the bed, and you can slip your hand under his buttocks. The weight of his pelvis will reduce the fracture, and hold the fragments in position.

If you do not have any crepe bandage, and have to use adhesive strapping, apply it as two figure of eight spirals, one clockwise, and the other anticlockwise, as on the right leg of the child in Fig. 78-1.

If his fracture is subtrochanteric, avoid an adduction deformity by keeping his legs well apart.

CAUTION ! (1) Don't apply circular strapping around his leg, for it will be likely to impair its circulation. (2) Watch to make sure the strapping does not slip. (3) Check the circulation in his toes on both sides, especially during the first 3 days. Feel his dorsalis pedis pulses. (4) Don't cover his legs with a sheet, because this will make his circulation less easy to monitor. (5) Don't apply traction to one leg only-it makes him much too mobile.

Crying is the first sign of ischaemia, so if he cries, examine him carefully. Pain on stretching his calf muscles is another early sign. Test the movement of his toes, and check sensation over his foot. If you fail to relieve his circulation early enough, Volkmann's contracture and perhaps gangrene may follow (70.4). Watch for pressure sores, especially on his heels, and over his Achilles tendon.

Keep him in traction for 3 weeks. By the second week the strapping will be showing signs of strain, and by 3 weeks it will be wearing out, he will want to be set free, and he can go home. Gentle weight bearing can start at 6 weeks.

Alternatively, when the first few days are over, you can, if necessary, send a child home in a spica (77.3).

A PLASTER SPICA FOR A FRACTURED FEMUR

Apply a plaster spica for 6 to 10 weeks, depending on the child's age (77.3). Take care to make this strong enough. Apply extra plaster at the hip.

CATASTROPHES WITH GALLOWS TRACTION

If THE CHILD'S FOOT GOES COLD AND BLUE, it is a sign of ischaemia. This can be the result of: (1) too tight a bandage, (2) suspending too much of him-only his pelvis should be suspended, or, (3) using gallows traction when he is too old. A conscious child will begin screaming as soon as ischaemia starts. But if he is unconscious from a head injury, for example, he cannot scream, so that a head injury with a fractured femur is particularly dangerous-he should not be on gallows traction!

Ischaemia is particularly likely to occur if gallows are used to treat children weighing more than 15 kg, because more traction is needed with heavier children. So treat these children in extension traction as in the next method.

Fig. 78.1:GALLOWS TRACTION IN A FRAME. A traction frame is not suitable for home treatment, unless the child's mother is unusually reliable. B, if you don't have a crepe bandage, use two turns of 2 cm strapping in a figure of eight. NEVER put circular strapping around a leg. Kindly contributed by Andrew Pearson, John Stewart, and Richard Batten

Fig. 78.2:GALLOWS TRACTION FROM A BEAM. If necessary, you can suspend several children from the same beam-watch the circula. tion in their toes! Ischaemia is particularly likely to occur if you use gallows to treat children weighing more than 15 kg, because more traction is needed with heavier children. So treat these children in extension traction as in the next method.

78.3 Fractures of the shaft of the femur in older children-extension traction

Fig. 78.3:EXTENSION TRACTION. A, one method of fixing the cord to the strapping. B, skin extension traction in action. C, fixing a spreader to the strapping. D, try to make the patient's injured leg (1) match his normal one (4). If you put it in position 2 it will rotate internally into position 3 when he walks (as shown by the arrow) and will cause severe disability. His anterior superior iliac spine, his patella, and the space between his first and second toes normally lie in a straight line. E, a derotation bar in use. Note that it lies under the patient's ankle, not his heel. Don't fit a derotation bar to a damp cast, or it may cause a pressure sore. Kindly contributed by Richard Batten, Andrew Pearson, and John Stewart.

A child over 3 years is too heavy for gallows traction so he has to be treated by applying traction to his extended lower leg. The traction cord passes over a pulley at the foot of his bed which is raised to apply counter-traction. Use extension traction for patients from the age of 3 until the age of 18 when the proximal tibial epiphysis fuses with the shaft. If you use a pin in a patient who is under 18, you may damage his epiphysis. Extension traction keeps a patient's leg extended so that he cannot exercise it. This is less important in children and teenagers because their immobilized joints are much less apt to stiffen. The great value of Perkins traction in preventing knee stiffness in older patients is thus unnecessary in younger ones.

A fracture of the femur in an older child is usually spiral. Extension traction corrects angulation, rotation, and lateral shift. It also usually corrects overlap too, but if some persists, this is not important, because subsequent growth soon corrects shortening. The danger of extension traction is that it does occasionally cause Volkmann's ischaemic contracture. An alternative is a hip spica. Don't use a Thomas splint or a Boehler-Braun frame.

Controlling rotation in fractures of the femur. One of the beauties of Perkins traction is that the patient's bent knee controls the rotation of the fragments of his femur when he sits up and exercises it. But with extension traction you need to watch rotation of the fragments carefully.

At rest, the external rotators of the leg at the hip are stronger than the internal rotators, so they externally rotate the upper fragment This means that you have to rotate the lower fragment externally to match it. The important thing not to do, therefore, is to rotate the lower fragment internally in the position of rest. If you do this, for example by making a patient's patella point to the ceiling (foot 2 in Fig. 78-3), he will end up with a considerable degree (20 or 30°) of internal rotation (as shown by the arrow in this figure) and will walk pigeon toed on the injured side (as in foot 3). This will be a considerable disability, and he may need a corrective osteotomy. The position of rest of a normal leg in bed is 30 to 45° of external rotation (foot 4), so if you make his injured foot (foot 1) match his normal one, the degree of rotation will probably be about right. Increased external rotation is little disability, so this is the side to err on. If you want to check the degree of rotation of the upper fragment, take a film to show both a patient's lesser trochanters and to compare their position.

EXTENSION TRACTION

EXTENSION SKIN TRACTION

INDICATIONS (1) Fractures of the shaft of the femur between the ages of 3 and 18. (2) I ntertrochanteric fractures in adults when you have no Steinmann pin. (3) Separation of the upper femoral epiphysis. (4) An unstable hip after the reduction of a dislocation.

METHOD Apply compound tincture of benzoin (optional) to the child's skin and then apply a long length of broad adhesive strapping from just distal to the fracture down to his lower leg. Pass it around a block of wood to act as a spreader, and then up the outer side of his leg as far as the fracture but not beyond it. Prevent the longer length of strapping sticking to his ankle by sticking a shorter piece to it. Pass this around the other surface of the spreader.

If necessary, make small cuts in the strapping to make it fit more closely to his leg. Pass a cord through the hole in the spreader and fix it to the foot of his bed. Raise the foot of his bed 40 to 50 cm, or use a weight as in Fig. 78-3.

Start with traction equal to one seventh of his body weight, and compare the lengths of his legs with a tape measure (Fig. 77-3) to make sure you have not distracted the fragments. Encourage him to move about in bed.

Wait 6 weeks for clinical union (Fig. 69-4) and then take a check X-ray. If union is satisfactory, get him up on crutches.

CAUTION 1 (1) Watch carefully for signs of ischaemia, especially calf pain and pain on dorsiflexing his foot. (2) Make sure the strapping does not press on his common peroneal nerve as it winds around the head of his fibula.

EXTENSION PIN TRACTION

INDICATIONS An adult who cannot sit up and exercise his knee, for example if he has a dislocated hip, or has some internal injury. This form of traction is contraindicated in anyone young enough for his upper tibial epiphysis not to have united, because a pin might damage it.

Insert the pin as for Perkin's traction (78.4), but don't sit the patient up, and don't remove the lower part of the mattress.

CONTROLLING ROTATION ( both forms of extension traction) Make sure that the rotation of the patient's injured leg matches his normal one. If necessary, fit a derotation bar: (1) Fit it to his ankle, not to his heel, where it may cause pressure sores. (2) Wait for the cast to harden before you fit it, or this too may cause a pressure sore.

DIFFICULTIES WITH EXTENSION TRACTION

If there Is OUTWARD BOWING of the patient's femur to begin with, put both his legs in traction, and keep them wide apart.

If there is OUTWARD BOWING LATER, correct it with a spica. If necessary, bend his leg straight under anaesthesia, then apply the spica. You may be able to do this as late as 6 weeks.

78.4 Perkins traction

Fig. 78.4:PERKINS TRACTION. Thomas pin mounts are better than a Bohler stirrup. If necessary, you can cut a Bohler stirrup and make two pin mounts from it.

Your aim in treating an adult's fractured femur should be to make his bone unite in a good position without his knee becoming stiff. Perkins traction does this admirably using the principles discussed in Section 69.3. Put a pin through the upper end of his tibia, and apply enough traction to it to keep the fragments in place, to pull his leg to its normal length, and to correct any angulation or rotation. Meanwhile, sit him up in bed, and see that he exercises his knee as actively as possible, and as soon as he can so that: (1) controlled movement and compression of the bone ends encourages union, (2) his knee does not become stiff, (3) the tone of his quadriceps muscle is maintained, and (4) the exercises he does keep him fit and free from thrombosis and hypostatic pneumonia.

Perkins traction differs from extension traction in that in the latter a patient's leg is held straight and he does not sit up and exercise it. Except for the few special indications for extension traction in Section 73.3, Perkins traction is much the most useful method.

Perkins traction uses the same simple equipment for all sizes of patient, it prevents knee stiffness more effectively than other methods, and it gives a patient a wide range of knee movement, which is important in societies where people squat. Excessive shortening is rare, and as soon as the end of the patient's bed has been dropped, and he is flexing his knee, malrotation of the lower fragment is impossible. Physiotherapy and nursing care are easy, and after a few days he can lift himself on to a bedpan. Most patients spend 6 to 8 weeks in traction, followed by 2 weeks, exercising their legs over the end of the bed, and then 2 more on partial weight bearing. They are out of hospital in 8 to 10 weeks with at least 90° of knee movement, and without noticing that their injured legs are a centimetre or two short. Finally, if a patient's tibia has also been fractured, you can treat this at the same time that his femur is in traction.

There are several less satisfactory alternatives to Perkins traction. They are:

(1) Some form of internal rod or plate fixation which requires a wide range of nails or plates as well as reamers, guide wires, and extractors, all of which are seldom available in district hospitals. Many tragedies have followed attempts to fix these fractures in hospitals with limited equipment and expertise (69.3). Although modern methods of closed rodding, when done under ideal circumstances, enable a patient to be walking in 10 days, if you attempt them with inadequate equipment in a theatre of questionable sterility, there will be too many complications. This is a method for experts working under ideal conditions.

(2) Bohler-Braun traction (Fig. 79-10) takes longer to achieve union, and because it does not allow active knee exercises, a patient's quadriceps atrophies, and his knee usually stiffens, unless it is carefully exercised daily. Bohler-Braun traction is so much less satisfactory, that it should now be used only for the few special indications in Section 79.13. One of the most important changes that is needed in the orthopaedic practice of many hospitals is to change from traction in a Bohler-Braun frame to Perkins traction for fractured femurs.

(3) Thomas splints are excellent for first aid, and for treatment during the first few days, but not for definitive treatment. They too will stiffen a patient's knee, and may cause pressure sores in his groin. They also make nursing more difficult.

(4) A hip spica enables a patient to be discharged in a few days, but it causes prolonged disability and seriously stiffens an adult's knee. It may also cause excessive shortening. A hip spica is much more satisfactory in a child, whose knee does not stiffen, and whose femur will grow and compensate for shortening.

It is sometimes said that Perkins traction lengthens a patient's stay in hospital, and increases the pressure on scarce beds. Admittedly, internal fixation gets most patients up quicker, but some of them develop such serious complications of non-union and infection that they may remain in hospital 2 years or more, so greatly extending the average stay of patients treated by this method.

Although cast bracing is an excellent method, we have not described it here. It allows you to discharge a patient 3 weeks earlier, but under your circumstances it is probably not worth the extra trouble.

Although cast bracing is an excellent method, we have not described it here. It allows you to discharge a patient 3 weeks earlier, but under your circumstances it is probably not worth the extra trouble.

WHEN IS PERKINS TRACTION INDICATED?

Fig. 78.5:THE INDICATIONS AND CONTRAINDICATIONS FOR PERKINS TRACTION. The indications are on the left and the contraindications are on the right. Kindly contributed by Peter Bewes and John Stewart.

INDICATIONS As you will see in Fig. 78-5, Perkins traction can be used for some fractures of the pelvis, and for most fractures of the femur. The line AB in Fig. 78-5 is approximately that of the attachment of the capsule. Fractures proximal to it on the avascular neck of the femur are not suited to Perkins traction (with the rare exception of incomplete fractures of the neck), whereas most fractures on line AB or distal to it are suitable.

Vertical fractures of the pelvis with upward displacement of one fragment (76.2;. (1) Undisplaced incomplete fractures of the neck of the femur (77.7). (2) All intertrochanteric fractures (77.11).(3) Those subtrochanteric fractures in which the contraction of the iliopsoas has not flexed the upper fragment so much as to bring it seriously out of line with the shaft (77.12). (4) All fractures of the shaft of the femur in patients over 18, including overlapped, double, spiral, comminuted and open fractures, and fractures with severe soft tissue injury. Perkins traction is particularly well suited to comminuted fractures. (5) Those supracondylar fractures in which the lower fragment has not been too severely flexed by the contraction of gastrocnemius (79.13). (6) All condylar fractures of the femur, except those in which a condyle has rotated completely (79.15).

CONTRAINDICATIONS TO PERKINS TRACTION (7) All complete fractures of the neck of the femur (77.7). (8) Displacement of the proximal femoral epiphysls (77.10). (9) Subtrochanteric fractures with severe flexion of the proximal fragment (77.12). (10) Supracondylar fractures with marked flexi on of the distal fragment (79.13). (11) Displacement of the distal femoral epiphysis (79.16). (12) Fractures of the condyles i n which a fragment has rotated completely (79.15). Other contraindications include: (a) All patients under 18. Their epiphyses will not have united and the pin may damage the epiphyseal plate. (b) Arthritis of the knee, or a stiff knee from any cause, which will make exercise impossible without moving the fragments too much. (c) Non-union in fractures treated by other methods.

Perkins traction only gives good results if you persist with it, and follow the details carefully. The secret of success is to start periods of 10 to 30 minutes of active exercise several times a day from the third day onwards. This early movement is critical. It is the callus formed during the first 10 days that determines the outcome. Most supposed failures are due to not starting exercise early enough, or not doing it vigorously enough. Patients need to be coaxed into exercising their knees. Let them do their exercises together, so that they can encourage one another. Quadriceps exercises by themselves are not enough to achieve satisfactory union.

There are many important points of nursing, so teach your staff about them, and make sure they understand the principles of Perkins traction. Setting up and managing Perkins traction is not difficult and medical assistants soon learn to manage it most competently.

Fig. 78.6:CONVERT AN ORDINARY BED FOR PERKINS TRACTION. You may find it convenient to convert several beds like this. Kindly contributed by Peter Bewes.

78.5 Applying Perkins traction

After a severe accident the patient is shocked and cannot walk. He has a painful, deformed, and very swollen thigh, and sometimes also a dislocated hip (77.4). So palpate his buttocks and trochanters and look at the position of his hip on the Xray. Suspect that his hip might be dislocated if the proximal fragment of his femur is strongly adducted.

PERKINS TRACTION FOR FRACTURES OF THE SHAFT OF THE FEMUR

Fig. 78.7:ALIGN A STEINMANN PIN so that it is at 90° to the shaft in both planes. Kindly contributed by Peter Bewes.

INDICATIONS AND CONTRAINDICATIONS See Section 78.4, and Fig. 78-5.

SHOCK If the patient is severely shocked, he may need 2 to 4 units of blood or intravenous fluid, particularly if his fracture is comminuted. Careful splinting (51.2) on the way to hospital will minimize blood loss.

PERIPHERAL PULSES Have you checked these?

INITIAL X-RAY Take an AP and a lateral view and X-ray his hip.

EQUIPMENT FOR PERKINS TRACTION (1) An ordinary hospital bed from which the lower springs have been removed or tied back. You may have some broken beds you can use, and you may find it convenient to convert several beds for Perkins traction permanently. Ideally, these beds should have large casters so that you can wheel a patient to the X-ray department in traction. (2) You can use a mattress in two parts, or let the lower half of an ordinary mattress hang down. (3) Fracture boards to go across the lower half of his bed. (4) Blocks to raise the foot of the bed 25 to 50 cm. (5) A sharp, thick (4 mm) Steinmann or Denham pin. Sharpen it on a grindstone regularly. (6) Thomas pin mounts or a BOhler stirrup. If you use an unmodified Boehler stirrup, it will rub on the patient's skin, or the rope will get in the way of his skin, so convert it into two Thomas pin mounts by cutting and bending it, as in Fig. 78-4. (7) Picture cord, or orthopaedic traction cord. (8) Weights of 2 and 5 kg. These can be bags of sand, or bricks. (9) A set of pulleys to fix to the foot of the bed. These are not essential, and the cords can, if necessary, pass directly over the rail at the end of the bed, preferably over a cylinder of oId X-ray film rolled round the rail. If the lower rail is too low, consider reversing the bed, and using the rail at its head.

INSERTING THE PIN Do this in the theatre, or in a treatment room off the ward, using local anaesthesia, as in Section 70.11.

SETTING UP PERKINS TRACTION Apply weights to each end of the pin. Apply traction equal to one seventh of the patient's weight. A man needs 10 to 14 kg (5 to 7 kg on each end of the nail) and a small woman only perhaps 7 kg. Raise the foot of the bed 4 cm for each kilo. You will find 25 cm blocks useful. If possible, pass the cords over pulleys, and make sure they clear his toes.

CAUTION ! The cords must pull equally on each end of the pin, see Fig. 70-14.

Put a folded towel or small pillow under the fracture to give his femur the correct degree of anterior bow.

X-RAYS FOR PERKINS TRACTION The need for X-rays to adjust traction varies with the site of the fracture. Take them while the patient is in traction.

Fig. 78.8:PERKINS TRACTION during the first 2 days. A, on the third day the fracture boards should be removed and the patient must start exercising. B, shows the effect of incorrect traction. Insufficient weight was applied and the foot of the bed was not raised. C, D, and E, show various methods of arranging the weights. If you don't have a pulley, pass the cord through the ring of the weight to equalize the pull on each side. Kindly contributed by Peter Bewes and John Stewart.

In a fracture of the proximal third of the femur, take a lateral X-ray while he is in traction. Face the X-ray tube into his inner thigh, with the cassette above the crest of his ilium. If the proximal fragment is sharply flexed, '90-90 traction' (77.12) will be more appropriate than Perkins traction.

In fractures of the distal third, including supracondylar fractures, take an X-ray to make sure the distal fragment is not excessively flexed. If it is goto Section 79.13.

If the fracture is elsewhere in his femur, a lateral X-ray is not essential, but a AP one is useful to see if you have corrected any excessive overlap, or if you have applied so much traction so that there is a gap between the bone ends.

If you cannot X-ray a patient, measure both his legs from his anterior superior iliac spines to his medial malleoli, to make sure are the same length (77-3). If necessary, adjust the traction weights and the elevation of the foot of his bed, so as to let the bony fragments overlap about 1 cm. A little overlap is safer than a little distraction. Up to 2 cm of overlap is acceptable. Check his leg length daily for 2 weeks, and adjust the traction as necessary. After 2 weeks the fragments will have started to stick together so that further adjustment will be more difficult, and need more weight. After a month it may be impossible.

If his fracture is comminuted, a little overlap is even more important.

CAUTION ! (1) Don't apply excessive traction, because bone ends far apart cannot unite. This is particularly important if there are multiple fragments. (2) Less traction is needed after the first 2 weeks, so reduce it as necessary.

EXERCISES FOR PERKINS TRACTION

Fig. 78.9:ENCOURAGE HIM TO EXERCISE HIS LEG. Early exercises are the secret of success with Perkins traction. Kindly contributed by Peter Bewes.

Start these as soon as possible, preferably by the third day. Remove the fracture boards from the lower half of the patient's bed, push down his mattress, and let him flex his knee. Replace the boards when he has completed his exercises.

Encourage him to bend and straighten his knee. To begin with this will be painful. You can minimize his pain in two ways: (1) Give him a mild analgesic for the first few days. (2) Hold his heel and let him flex his knee against resistance, then let him extend his leg freely. He will need help, but at the end of a week he should be able to flex and extend his knee unassisted. Encourage him by telling him that his exercises will soon be painless.

To begin with let him exercise for 10 to 30 minutes at least three times a day. Encourage him to exercise his leg longer and more vigorously each day. He should soon be exercising it at least 2 hours a day.

CAUTION ! (1) Make sure the nurses understand that these regular periods of exercise are an important nursing routine. (2) Check his leg length daily for 2 weeks, and then weekly until union is complete. Reduce traction as necessary.

Measure his legs soon after traction has been set up, and adjust it accordingly. Rotation will correct itself as soon as he can flex his leg to 90°. Check the knots daily.

TESTING FEMUR FRACTURES FOR CLINICAL UNION Each week, examine the fracture site for palpable callus, and look for the signs of union. These are: (1) No tenderness over the fracture. (2) The bone cannot be angled at the fracture site. (3) Trying to angulate the fracture site does not hurt. (4) The patient can exercise and lift his flexed leg fully without support.

CAUTION ! (1) Don't test for union by asking him to lift his straightened leg from his hip, because it angulates the fracture site. (2) Resist the temptation to apply a cast in order to discharge him early.

In fractures of the upper third of the femur, you may have to X-ray him to confirm adequate union. Elsewhere, X-rays are not really necessary. Often, clinical union will seem well advanced, when there is only a mass of callus on the X-ray.

X-ray him at 4 weeks, 6 weeks and 12 weeks.

If there Is no callus on the X-ray at 4 weeks, suspect that union is going to be delayed. Check his X-ray to make sure that: (1) there is no distraction (if so, reduce the weights), (2) there are no fragments of avascular bone (if so, he will need to be in traction much longer), and (3) there is no interposed soft tissue. Fortunately non-union is rare-if he exercises as he should!

Removing traction too early is worse than leaving it on too long. Don't decide in advance, or fix a day to remove it. Instead, give him the joy of suddenly finding it gone.

When there are definite signs of clinical union, usually at 6 to 10 weeks, remove the weights and continue exercises with his knees over the side of his bed, and the pin still in his tibia. If you were right, and his femur has united, his range of movement will increase progressively. But, if he gets pain at the fracture site and his range of movement decreases, his femur is not yet adequately united, so put him back in'traction. If pain or bowing of his femur occurs, keep him in traction longer, until his fracture is stable and his pain disappears.

If you are uncertain if union is satisfactory, continue traction, but with reduced weight.

If you are happy that union is far advanced, remove the pin. Keep him in bed for 2 more weeks while he exercises his legs over the side of his bed. When he can flex his leg to 90°, lie him on his abdomen and encourage him to flex it further.

WEIGHT BEARING AFTER PERKINS TRACTION After two weeks of exercises without traction, examine the patient again. If possible X-ray him with a portable X-ray, or take his bed to the X-ray department, because his leg may refracture on the way there if he walks there and it has not united. If you are happy that his femur has united, and his range of knee flexion is good, start protected weight bearing with crutches, as in Section 77.1, but at first he must only put his leg to the ground to balance with.

CAUTION ! Help him out of bed carefully. If union is weak his leg may refracture when he first starts to walk.

When he can walk safely on crutches send him home. Ask him to continue his exercises there. Most patients can be discharged with their fractures clinically united at 8 weeks. The period is shorter in younger patients and longer in older ones. Transverse and oblique fractures take longer than spiral ones.

When the time taken to achieve clinical union has doubled, he can discard his crutches and bear his full weight on his leg. For example, if clinical union took 8 weeks, he must keep his crutches for a further 8 weeks before discarding them. Usually, an X-ray is unnecessary at this stage and shows only massive callus.

Tell him to avoid violent exercise for a year. Teenagers are particularly likely to refracture their femurs.

78.6 Difficulties with a fractured femur

Don't be put off by this long list. Fractured femurs are common and most of these difficulties are rare. You will meet them less often with Perkins traction than with other methods. If you are careful you can avoid most of them.

DIFFICULTIES WITH A FRACTURED FEMUR

Fig. 78.10:TOILETING AN OPEN FRACTURE OF THE FEMUR. Treat an open fracture of the femur in the same way as any other open fracture. Do a wound toilet and get the fragments into the best position you can. Unless a fragment is completely loose, leave it in place. Provided the periosteum remains, the bone will reform. Keep the leg out to approximately its normal length in traction. Kindly contributed by Peter Bewes.

If a patient's femur FRACTURE IS OPEN, treat him as for any other open fracture (69.7). Do a wound toilet (54.1), and get the fragments into the best position you can. Unless a fragment is completely loose, leave it in place. Provided the periosteum remains, the bone will reform. Keep his leg out to approximately its normal length in traction. Don't close his wound for 3 to 5 days. Either close if by delayed primary closure, or by delayed skin grafting. Then start Perkins' exercises.

If his LEG IS PULSELESS AND COLD, the fragments of his femur have probably injured his femoral artery, so explore i t and, if necessary, attempt to repair it (55.6). Alternatively, apply traction and hope that his circulation will return when his fracture is reduced. If it does not, you may have to amputate his leg later.

If the BONE ENDS ARE MORE THAN 1 cm APART, they may be separated end to end, or side to side.

If the fragments are separated end to end, they may fail to unite. If the patient is traction you are probably applying too much weight, so reduce it. Or, there may be soft tissue between the bone ends. If you cannot reduce end to end separation, try manipulation.

If the fragments are separated side by side, this is less dangerous, and at least 1 cm of such separation is acceptable. Early active movements may promote callus formation across a gap of 2 cm, but if there is more than 1 cm of side by side separation, manipulate the fragments under anaesthesia until you can feel them grating.

If the SITE IN THE TIBIA WHERE THE PIN IS NORMALLY INSERTED IS INJURED OR INFECTED, insert the pin at the lower end of the patient's tibia (70.11), or through the lower end of his femur, as in 90-90 traction' (77.12).

The movement of a pin in the bone promotes infection. If you can stop it moving, infection will be less likely. So use l ow friction swivels, and, if possible, a Denham pin which you can screw into the tibia, rather than a Steinmann pin. Another precaution is to make sure that traction is applied equally and at right angles to the pin. Make sure the cords join through a pulley or a ring attached to the weight.

Another way of preventing movement of the pin is to incorporate it in a below-knee cast. Watch carefully for pain, but only if the patient complains should you window the cast, and look at the skin round the pin. Once a pin has become loose, a cast is useless.

If a STEINMANN PIN BECOMES LOOSE AND ITS TRACK INFECTED, you may have inserted it in an unsterile manner, or allowed the drill to get too hot, so that it has killed the bone around it and formed a ring sequestrum. Infection is usually not serious-if you diagnose it early and don't neglect it. But it can be a catastrophe, because osteomyelitis may result and infect the patient's knee. This is more common in oId patients with soft bones, because the pin pulls through the bone. Prevent this by incorporating the pin in a short leg cast to prevent movement.

Prevent this disaster by inspecting the pin track daily, and removing the pin if there is pain or any sign of redness or loosening. Either put the pin in again lower down, through healthy skin, or apply skin traction, or traction on a Boehler-Braun frame with the pin through the lower end of the patient's tibia, or his calcaneus (70.11).

If the whole of the proximal end of his lower leg becomes inflamed, you cannot reintroduce the pin. Don't put it in higher up, because you will infect his knee joint.

If an infected pin track heals over but his bone remains tender, open up the track and curette it.

If a pin track infection lasts more than a month, x-ray his tibia and look for a ring sequestrum round the track of the pin. If you find one, remove it.

CAUTION ! Remove a pin immediately it becomes loose.

Fig. 78.11:FRACTURES OF THE FEMUR AND TIBIA on both sides can readily be treated by Perkins traction. Below-knee casts have been used which enable the patient to exercise his knee. Kindly contributed by Peter Bewes.

If a PIN TRACK INFECTION HAS ALREADY INFECTED THE PATIENT'S KNEE JOINT, immediately incise and drain his knee through incisions on either side of his patella. Irrigate the joint (7.16), give him antibiotics and splint his knee in a plaster cylinder until the infection is quiescent. Infection can easily follow a neglected pin track infection. You should be able to prevent it by the methods described above.

If, during the first 2 or 3 days after a patient has fractured his femur, he becomes DISORIENTATED, DROWSY or COMATOSE, or he has a cough, shortness of breath and haemoptysis, suspect that he is suffering from FAT EMBOLISM. This is the result of globules of fat escaping from the injured marrow of his femur and entering the capillaries of his lung and brain. Look for petechiae over his chest, in his mouth and in his conjunctivae. Fat in his urine is useful confirmatory evidence if you find it. About 15% of patients die, usually from respiratory failure, due to the accumulation of fluid in their lungs. Give him oxygen, restrict his fluids, and give him diuretics.

If you DON'T HAVE A STEINMANN PIN or a Denham pin, you can use skin traction (70.10), with a plaster backslab to maintain the forward bow of his femur, but this is far from ideal. It is difficult to apply enough traction through his skin, he cannot exercise his knee, and the fracture takes longer to unite. Less callus is formed, so it should be followed by a walki ng caliper. There is a greater risk of non-union with skin traction and more physiotherapy is needed.

If he has FRACTURED HIS FEMUR AND THE SHAFT OF HIS TIBIA in the same leg, anaesthetize him, put in the Denham pin, and then reduce his tibial fracture. Apply a below-knee cast to maintain reduction of his tibial fracture and incorporate the nail in the cast. Leave enough space behind his knee for it to flex, then treat him as a fractured femur. Two fractures will divide his leg into three pieces, so make sure they are all correctly aligned, as in D, Fig. 78-3. His femur will probably unite before his tibia, so discharge him in a patellar weight bearing short leg walking cast (81.5).

If his fractured tibia needs calcaneal traction to reduce it, apply this for a few days first, then insert a Steinmann pin and put him into Perkins traction.

If he is unruly and PULLS DOWN HIS TRACTION, consider applying a hip spica (77.3).

If, after 16 weeks in traction, a patient's FRACTURED FEMUR HAS NOT UNITED, or union is poor, this may be due to: (1) Distraction of the bone ends, caused by too much traction. (2) Interposed soft tissue. (3) Exercises that were inadequate or started too late, or quadriceps exercises that you hoped would be enough. Consider referring him.

If his FEMUR FRACTURES AGAIN AT THE SAME SITE, apply Perkins traction again, and it will re-unite rapidly. Don't try internal fixation. Refracture is rare and usually follows a fall, particularly in a patient who is allowed up too early, or in a youth who plays football too soon.

CAUTION ! Don't stop traction too early.

If a patient's KNEE IS VERY STIFF, and the fracture was at or above the lower third of his femur, and is solidly united, stiffness may be due to adhesions around his knee joint. Firm, gentle manipulation under anaesthesia may restore movement. If the fracture is in the lower third, especially in the immediate supracondylar region, you will probably be unable to free the adhesions by a single manipulation. Refer him for a possible quadriceps plasty.

If a patient's KNEE BECOMES PAINFUL some years after a fractured femur, one cause is angulation of his femur, which disturbs the normal mechanics of his knee. Prevent it by correcting angulation early on during treatment. Late correction requires an osteotomy.

If, a year after a fracture, a patient returns with SEVERE BOWING OF HIS FEMUR, this is the result of discharging him before his fracture has adequately consolidated. Prevent this by warning him when you discharge him that his femur may angulate, and ask him to return immediately if it does. Be especially careful if he lives many kilometres away and cannot easily return. Once a severely angulated fracture has united, the only treatment is an osteotomy.