Thigh and knee

CLASSIFICATIONFRACTURES OF THE FEMUR[1 ]Fracture of the neck of the

femur, and[2]Fracture of the trochanteric

region[3] Fracture of the shaft of the

femur [4] Supracondylar fracture [5] Condylar fracture

INJURIES OF THE KNEEFractures of the patellaInjuries of the extensor mechanismDislocation of the knee jointDislocation of the patellaInjuries of the ligaments of the kneeTears of the menisci of the kneeTraumatic effusions in the knee

• FRACTUREOFTHESHAFTOFTHEFEMURFracture of the shaft of the femur occurs at any age,

usually from severe violence such as may be caused by a road accident or aero plane crash.

Radiographic examination. Radiographs should always include the hip and knee. A recognized error is to overlook a dislocation of the hip coexisting with a fracture of the femoral shaft.

TreatmentThe well-tried method of conservative

treatment by sustained weight traction with the limb supported in a Thomas's type splint has now been largely replaced by intramedullary nailing with interlocking screws as the method of choice of treatment.

1-Conservative treatment by traction and splintage. The principles of this method are to 1-reduce the

fracture by traction and manipulation, 2-to support the limb in a Thomas's splint and 3-to maintain continuous traction by the application of a suitable weight to preserve length until healing occurs.

Fig. 15,1 Comminuted fracture of the shaft of the femur.

Rehabilitation. Exercises for the lower leg and foot are

important in preserving muscle tone and in preventing deformity especially that of equinus and they should be begun immediately.

As soon as the initial pain of the fracture begins to settle usually about 1 week after the injury active quadriceps and knee exercises are begun. Knee flexion through about 60° may be allowed, but more important than flexion is the ability to extend the knee fully by quadriceps action. These activities do not interfere with union of the fracture and may be encouraged with full confidence.

• The duration of splintage varies from case to case, Except in children, few fractures of the femoral shaft are firmly joined in 12 weeks: most take 16 weeks or even longer. When the stage of sound union is reached the splint is removed and the patient is allowed to exercise freely in bed before walking is begun. Thereafter rehabilitation is continued until full function is restored.

2-Cast or functional bracing. In appropriate cases usually those of fracture of the lower half of the femur and especially when the fracture is of the transverse or short oblique

3-Treatment by external fixation. The method is applicable mainly to open fractures with contamination or to infected fractures, in which internal fixation may be unduly hazardous. External fixation offers the advantage that any wound is easily accessible for treatment

Fig. 15.4 Continuous traction with balanced suspension, using a Thomas's (or similar) splint with Pearson knee flexion attachment. This is the standard technique of traction for fractures of the shaft of the femur. The larger diagram shows the general layout of the cords and pulleys. The traction grip on the leg may be obtained by adhesive skin strapping or by a pin through the tibia (as shown here and in Fig. 15.4). There are two systems of cords and weights. The purpose of one system is to support the splint and the contained limb from the overhead beam. This weight is adjusted until the limb is nicely balanced. The purpose of the other system is to exert continuous traction in the line of the femur. Counter-traction is through the cords that suspend the splint from the beam, particularly the cord that is attached to the distal end of the splint; so it is unnecessary to raise the foot of the bed on blocks. Many modifications of this method of traction are in use but the basic principles are the same. One modification is shown in the smaller diagram: here a screw traction device attached to the end of the splint is used instead of the traction weight. This technique is termed 'fixed traction' as distinct from the 'sliding traction' shown in the larger diagram.

Fig. 15.5 Functional brace with plastic knee hinges used in the later stages of treatment of a mid shaft fracture of the femur.

4-Operative treatment with internal fixation. Internal fixation, usually by a long intramedullary nail, is now the accepted treatment of choice for the majority of adult femoral shaft fractures.

The advantages of early mobilization, with the reduction in the incidence of muscle wasting and joint stiffness, outweigh the slight risk of infection complicating the operation.

Locking screws. In recent years there has been an increasing trend towards locking the nail in place at the upper and lower ends by the insertion of cross-screws through holes provided at each end of the nail. The locking screws prevent rotation of the nail and thus increase stability.

Post-operative treatment. If it has been possible to secure rigid fixation with a strong nail of adequate diameter there is no need to immobilize the thigh in plaster or a splint. The patient may lie free in bed and practice exercises for the hip and knee joints and related muscles. Walking may be begun with the partial support of crutches 2 or 3 weeks after operation, or sometimes even sooner.

Fig. 15.7 In open nailing of the femur the nail is first driven into the proximal fragment from the fracture site [a} and out through the greater trochanter [b}. After reduction of the fracture the nail is then engaged in the distal fragment [c] and driven home. (In practice a curved nail to match the natural curve of the femoral shaft is preferred to a straight nail.)

ComplicationsThe following complications of femoral shaft fractures

will be considered:1)Simultaneous dislocation of the hip2)Injury to a major artery. 3)Injury to a nerve. 4)Infection. In cases of open (compound) fracture5)Delayed union. Four months is a fair average time for

union of a fractured femoral shaft in an adult. 6)Non-union. If union fails to occur and the fracture

surfaces are becoming rounded and sclerotic, operation should be advised.

7) Mal-union. Without constant supervision the fragments may suffer redisplacement in the form of angulations or overlap,

8) Stiffness of the knee.