Fractured Hip Under Austere Conditions?

[Reasonable Rascal]

A thought occurred to me this evening. What would likely produce the best results so far as returning as much function as possible to someone who suffers a fractured hip from a fall, when regular medical assistance is not available? This could be because they reside in a 3rd world area and travel to the nearest clinic is several days on foot, or because the system is broken down, or because they are located in the backcountry and have one companion to tend to them or pack horse out for help.

Thoughts?

RR

[jagdkampf]

It would depend on the conditions you find yourself in. In a "I gotta get out of here now" situation, a traction splint would be the way to go until you get to a more stable situation. In a stable situation, I would go with a balance traction type of affair and immobilization. This presupposes that the fracture is not open and that you have no means of x-ray to determine the nature of the fracture. The military is drmo'ing a bunch of their field splint sets. If you see one in good condition, pick it up. They are very good.
Now, if you have an open fracture of the proximal femur or hip, you are looking at a very bad situation. Best you can do would be to cleanse the site with antiseptic sol. and apply a field dressing. Splint and try to get to a hospital.
Fractures of the hip in the elderly without surgery and fixation are tough to deal with. Immobilization and laying flat on your back almost always produce atelectasis and pneumonia. Without antibiotics and surgery it's almost a death sentence unless they have a very strong constitution.
Sorry to be so gloomy but there is no real good way to deal with proximal femur and hip fractures in the outback.
Jag

[RESQDOC]

Well, first off, we need to define “hip fracture” as this encompasses quite a bit of
territory. The hip joint consists of the pelvis, in particular the hip socket - known as the acetabulum; the head of the femur that fits into the acetabulum - known as the ball; the connecting bone from ball to the femoral shaft - known as the neck; and of course muscles, ligaments, connective tissue, nerves, and most important, the blood supply.

Everybody get your anatomy book out.

The blood supply is often the problem. It is rather complicated to the ball and socket joint, and easily disrupted by injury. Often the blood supply does not heal well, leading to poor circulation, poor bone healing, even lack of bone healing. This “avascular necrosis” i.e. poor healing due to poor blood supply, results is repeat fractures, collapse of the bone and joint involved, and significant pain for life.

Lets start with the acetabulum. Fractures of this are usually associated with other pelvic fractures (very serious, potential for large blood loss) or dislocations of the ball, either anterior or posterior. The fractures of the acetabular socket can be serious but often are fairly small. Closed management followed by traction and bed rest for several weeks of the fracture is generally preferred to ensure proper reconstruction of the socket. Sometimes surgery is needed to get things back in position or to clean out bone chips from the joint space. In austere conditions without availability of x-ray, closed reduction and traction is the only alternative. If the fracture of the acetabulum is the superior “top” part results are often poor due to loss of support for the ball and increased risk of dislocation. In any case, management would be immediate reduction of the dislocation and traction to the leg, 5 pounds or more as needed to overcome thigh muscle spasm, with the leg slightly abducted (pulled away from the body’s center line), maintain traction for 2 weeks then crutches & physical therapy for 10 weeks or so. If the ball is pushed through the acetabulum into the pelvis it can also be reduced and managed with a more complicated traction set up pulling the hip laterally away from the body as well as inferior down the leg, with 25 pounds or more each, and prolonged course of 6-10 weeks traction then crutches. Outcomes are fair.

Fractures of the ball, if not displaced, usually heal fairly well with bedrest of 8-12
weeks, although we usually pin or screw them in place to allow early mobility and range of
motion. If displaced, we often replace the whole ball with a prosthesis, or outcome can be poor, i.e. avascular necrosis, loss of range of motion, and significant pain.

Fractures of the neck of the femur is the area of the greatest number of fractures,
especially in the elderly. Again, we usually operate these, either with a fixation device or replacement of the ball with a prosthesis. These can heal with bedrest, somewhat, and this is what we do with elderly that are not surgical candidates, although chronic pain and loss of function - like never walking again - is common.

And of course this does not begin to address the problems of open fractures, prolonged recovery, femur fractures, etc.

Five year mortality after “hip” fractures run about 50% due to loss of mobility, pain, and general negative impact on health.

Austere management will require excellent physical diagnosis skills, anatomy knowledge,and patience, as mostly this is management by bedrest and pain control, with the understanding that loss of motion, perhaps loss of ability to walk, and chronic pain are the near inevitable outcomes to one extent or another.

Prevention is obviously important. Excellent calcium plus Vit.D intake, along with a significant exercise program to increase the strength of the muscles involved are the best bet.

I HIGHLY recommend older editions of “Fractures and Dislocations - Closed
Management” by Connolly to all with an interest in Ortho injuries. The new ones are
steep, but the older editions are very reasonable and have a ton of both basic and advanced non-surgical management of every sort of injury.

NEWS FLASH - just dx'd an avascular necrosis in an elderly hip, I'll put up a copy of the x-ray as soon as I can!

_________________
Do No Harm. Do Know Harm.

[Reasonable Rascal]

I have a 1939 2nd Edition of Textbook of Surgery, edited by Frederick Christopher, M.D. Dated to be sure and the pics are B/W rather than color, but it does offer some good illustrations of the types of basic traction appliances you mention.

I'll have to look for the other book Resqdoc mentioned. Used books are great for saving money. We need info more than glossy pages. One reason I collect old books, the methodology is low tech by comparison to today and beats striking blindly if it comes to that.

Love to see that film Doc. I don't recall ever seeing one like that before, or else it wasn't pointed out to me at the time.

RR

[jagdkampf]

Kind of off subject, but does anybody know what happened to Napoleon MacCallum. He was a wide reciever out of the Naval Academy. He was picked up by the Oakland Raiders and had a devastating knee injury. I never heard the whole Dx, but it looked like a complete posterior dislocation. I heard a rumor that he had seriously damaged the popliteal artery and disrupted all the ligaments. Follow up anyone.
Jag

ps - If you ever make it to Fredricksburg,MD, the Civil War Medical Museum there has an interesting collection of textbooks and techniques.

[Reasonable Rascal]

On 2002-01-31 22:33, jagdkampf wrote:
ps - If you ever make it to Fredricksburg,MD, the Civil War Medical Museum there has an interesting collection of textbooks and techniques.

Now he tells me. Was in Maryland last Oct. and could have swung by. Oh well, next trip. There is also a medical museum in Prarie du Chien, WI I've been meaning to visit.
Gettsburg has a modest medical exhibit amongst the other topic areas. Some shall we say very interesting devices. And a wonderful ghost story of recent vintage concerning the field hospital that was set up in the basement of the (current) admin building, the cupola'ed one the South spotted artillery from. Care of comminuted fractures as occurred from soft lead balls and Mini's consisted of amputation. Very central to the story.

RR

[RESQDOC]

Here are two xrays of the avascular necrosis of the hip I mentioned. This is my first attempt to get some photos up, so let me know if any problems...

General xray of left hip:
http://www.villagephotos.com/viewpubimage.asp?id_=123700

Close up:
http://www.villagephotos.com/viewpubimage.asp?id_=123692


...It's Alive, It's Alive! Boy can I start putting up some good stuff now...
_________________
Do No Harm. Do Know Harm.

[Reasonable Rascal]

Decent films! And a free host site too, very rare these days. Now if I could just get the scanner working here I could toss up some very interesting Fx's, though they might cause nightmares....

RR

[Jonas Parker]

To restate the scenario: someone has a tib/fib or femur fracture, open or closed, out in the boonies somewhere 2-3 days from proper medical treatment. Maybe I'm missing something here, but I'd clean/ debride/ disinfect the wound site (and give procain-g penicillin) if open, then apply a traction splint to avoid further soft tissue damage and reduce pain while moving the patient. If a tib/fib fracture, I'd probably set it myself... a femur fracture would be helped with a traction splint whether it would fully reduce or not. In either case, I'd then put the patient in MAST trousers and inflate the injured leg, again to provide stability, then onto a streacher or backboard with my faithful native carriers for the hike to the hospital.

Anything to add, RR?

[Reasonable Rascal]

Yeah, where'd you find the MAST? ;-)

For improvisation purposes KED's applied upside down can make an effective hip immobilizer and I'd feel comfortable rigging a Sager-like traction splint using a crutch or similar. After that, some sort of strecther as you say, but one that considers the normal curves of the human anatomy. My own experiences laying on a spineboard convinced me that they are medieval torture devices without humanitarian merit. I lug a canvas/pole stretcher with me on campouts I'm medic'ing. I have a speedclip board of my own but for long transports it's not my first choice.

RR

[pa4ortho]

Austere hip fx (leg short and externally rotated)regardless of exact location is a major surgery to enjoy the benefits of early mobilization and higher Fx union rates.
We treat fractures like this routinely in those with to many medical comorbidities to tolerate surgery. (saw one today in clinic at 4 weeks post injury) some actually heal their fractures and do ok. others get wild malunions, others never heal. first year mortality in high in these already debilitated patients.
Initially tx with bedrest and 5 lbs gentle traction. as needed for spazm. frequent turns in spite of complaints.
after a few days the spazm resolves. After a few weeks the patient can transfer with toe touch weight bearing.
6-10 weeks for fx healing. let pain, vibration auscultation or x-ray guide weightbearing progression. armpit deep water walking initially or a walker to limit weight while walking.

Hip dislocation. (leg short and internally rotated)(saw one of these today also) reduce imediately, sedation or valium if available, reduction is patient prone, hip and knee at 90 degrees, your assistant holds the pelvis to stabilize it, cross fingers behind the leg just below the knee whule stradeling the lower leg facing towards the head of the patient, pull up by leaning back, rotate the hip in external rotation (foot towards midline knee out to side) you will feel a klunk..... on a good day. if you feel grinding crepitus.... it was probably a fracture dislocation. place patient in a knee imobilizer... yes a knee imobilizer. the goal is to prevent motions for the next 6 weeks that promote dislocation. forward flexion past 90 degrees, internal rotation (foot out knee in towards midline) and adduction (foot crossing midline) the knee imoboilizer makes it tough to do the above motions while sleaping.

pa4ortho

[WolfBrother]

WB Edited to specific:


I HIGHLY recommend older editions of “Fractures and Dislocations - Closed
Management” by Connolly to all with an interest in Ortho injuries. The new ones are steep, but the older editions are very reasonable and have a ton of both basic and advanced non-surgical management of every sort of injury.



From Albris Co URL (http://www.alibris.co.uk/search/books/isbn/0721626017)

I found 3 copies available for $106, $144, and $442. (the first 2 in the US - the last ships from Germany). They were listed as either ex-library copies or remainders.

ISBN: 0721626017
Fractures and Dislocations--Closed Management
by John F Connolly, Chief


Do you have an opinion of?


Depalma's the Management of Fractures & Dislocations: An Atlas, 1 (v. 1) (Hardcover)
by John F. Connolly (Editor)
# Hardcover: 1000 pages
# Publisher: W.B. Saunders Company; 3rd edition (October 1, 1981)
# Language: English
# ISBN-10: 0721627021
# ISBN-13: 978-0721627021
Amazon dot com URL (http://www.amazon.com/Depalmas-Management-Fractures-Dislocations-Atlas/dp/0721627021)

The one review of this:

By Nancy K. Oconnor (PAWHUSKA, OK United States)
(REAL NAME)
Years ago when I was a doctor at an isolated African hospital, I found DePalma's book a great help.
Got a fracture? Go to the page, read instruction, follow illustrations, and voila, you can treat the patient.
With modern surgical techniques, and with few Family doctors setting fractures nowadays, one suspects few specialists will use this book.
But if you know a missionary in the midst of no where, this is your gift. Too bad it isn't on a PDF file for a palmpocket, or I would recommend it for third world backpackers too...

[Austerenurse]

I think if I had to manage a hip fx in an austere environment I would try to determine if it was a intra or extra capsular fracture.

If it was intra-capsular and I could not evacuate them to a place where proper prosthetic replacement or internal fixation could occur then I would:

1)If non-displaced or impacted: I would apply light skin traction and give a set of gentle range of motion exercises for 8 - 12 weeks until the fracture healed.

2) If displaced, I would place in light traction for a few weeks (to control the pain if nothing else, as these are quite painful injuries) and then move to a regime of sitting the casualty up then onto walking with crutches.

If it was an extra-capsular fracture (be it inter-trochanteric or sub-trochanteric) and I was unable to evacuate them for proper surgical fixation I would opt to place a pin in the proximal tibia and then provide Perkin's traction as skeletal traction. (See: www.jbjs.org.uk/cgi/reprint/63-B/3/362.pdf). As tolerated I would move this along to traction while sitting (which is possible with Perkin's traction) thus allowing some light physiotherapy on the knee and hip joint while at the same time lessening the risks of pressure sores and pneumonia. I have seen this done in he developing world with good results.

Hip dislocations...

1. Reduction as soon as possible, using any acceptable method.

2. Place in post-reduction skin traction for a few days then start non-weight bearing (read: crutches) ambulation. After 12 weeks move to partial then full-weight bearing. If they have a large posterior rim fracture I would leave the casualty in traction for the full 8-12 weeks until the fracture heals.

More food for fodder...

AN

[pa4ortho]

good food for thought.
I am doing some research on the risk benifit ratios. im digging out my old editions of rockwood etc... best studies are really old ones. consider roller traction. have reviewed with 4 Orthopedic docs. will post more later. good luck on your trip. email any unexpected gear needs and I will see what I can mail you. oh and stay out of the way of the bullets. say hi to the guys from carson helicopters. they are doing contracted mail runs for the military. they are from where i live. great resource for routine travel in country and for emergencies.
--- pa4ortho

[pa4ortho]

Austere Treatment of femur fractures

Femur fractures are almost universally treated with internal fixation with intramedullary rodding. (rod inside the cavity of the femur. Exceptions to this rule are: 1. inability to tolerate surgery 2. massive infections or complex open wounds with periosteal stripping and high potential for infection 3. lack of resources.

The advantages of rodding fractures is clear with high union rates, early mobilization (same day wt bearing), and low complication rates. Union comes from early impaction and loading on the fracture with equal loading on the circumference of the femur. Plate fixation suffers from stress shielding of the bone resulting in lower union rates, and higher re-fracture rates. Plates also strip the periostium (the nutrient layer).

The goal is early functional bone strength, with the least morbidity/ mortality.

Other options include traction, bed rest, casting, amputation and judicious last resort therapeutic GSW to the head. (Apologies to the tender hearts, and those who’s ethics force the obviously soon to be dead suffer without pain meds or worse suffer prolonged capture)

Austere (lack of resources) medicine can be a wide variety of circumstances. From “garage medicine”, a hospital in the developing world, wilderness environment, Theoretical collapse of civilization scenarios, infectious disease isolation, veterinary hospital, insurgency/criminal/covert hospital, military medicine. The approach to the care of the femur fracture will depend on the available resources to include surgical skill, equipment, and resources to feed, care for the invalid and provide rehabilitation.

The femur is normally deep in vascular muscle. Due to this it has great perfusion and great ability to heal in contrast to the tibia. The main problem is not non union but mal union and deconditioning form prolonged recovery.

Incidence in the general population can be divided into 30-40% young trauma patients and 60-70% osteoporosis related fractures.

In the absence of penetrating trauma nerve injury is rare.

Vascular injury can present early or late. Symmetrical pulses are always a good sign. Sequential systolic blood pressure checks to bilateral ankles can pick up on arterial injury. A difference of more than 10% demonstrates a possible arterial acute injury or late occlusion due to damage to the intimal (inner) lining of the vessel.

Palpate all muscle compartments for compartment syndrome. If there is prolonged ischemia (>4-6 hrs in a tourniquet) consider 4 compartment fasciotomy due to the high incidence of reperfusion compartment syndrome.

For open arterial vascular injuries with prolonged evacuation a heprinized vascular shunt sewn into the major (works well in the femoral) artery can restore distal perfusion.

Knee ligament injuries occur in in 15-55% of fractures depending on who’s study you belive. They are difficult to diagnose due to the fracture. Arthroscopic study demonstrated 48% partial ACL and 5% complete acl rupture. 5% partial PCL and 2.5% total PCL. I was unable to easily find data on MCL and LCL injuries. Meniscus injuries were also common at 12% medial and 20% lateral. A MCL or LCL injury can limit traction options. Look for effusion on the knee. If present, aspiration of bloody fluid from the joint capsule indicates inter-articular injury. (ACL PCL Fx) MCL and LCL injury is extra articular for the most part.
MCL medial (inside) collateral ligament
LCL lateral (ouside) collateral ligament
ACL anterior cruciate ligament
PCL posterior cruciate ligament

Sorry EMT’s but Hypotensive shock is rare from a single isolated closed femur fracture. Look for other hidden injuries. 0.5-2.5 liters of blood loss can usually be compensated for. …I have done autopsies on bilateral closed femur fx…..

Initial management includes protecting any open wound, tourniquet as indicated, Traction splint VS high padding under lower legs, liter, wrap to other leg etc…
Traction splint for Neuro vascular compromise or spazm and pain control with movement.
Kendrick traction device is my preferred but I rarely carry it anymore.
See external fixation below

Definitive treatment options:

IM rod- for those over 12 yrs of age, fracture below the trochanter and above 6-8cm above the end of the distal femur. Locked proximal to distal. May be placed antegrade or retrograde. Ideally placed within 24hrs to assist with other care issues in the poly trauma patient. No surgery before normal base deficit, normal lactate levels, normotensive, normothermic, and not coagulopathic. Increased respiratory complications if delayed greater than 72 hours.

When I asked 3 US ortho surgeons what they would do in garage medicine I of course got 3 different answers. “it depends’
Surgeon A (hip specialist) said 1. bedrest 2. skin traction 3. skeletal traction. He prioritized goals/orthopedic risks as 1. conservative avoidence of death/complications (pulmonary, skin, urinary infections) 2. avoidance of amputation. The risk of amputation increases based on soft tissue injury levels. 3. non union = non functional 4. delayed union with prolonged bed rest and deconditioning is very bad 5. mal union beats delayed or non union 6. anatomical union is the best outcome. – skin traction = daily checks – he said if he had a basic operative capability a threaded screw or pit could be used in balance or roller traction for 4-5 weeks. A hip spika or hinged knee cast based on location of fracture is an option. That’s what we do for kids with open growth plates that cant be rodded. While the risk of infection with a pin is minimal it = amputation.

Surgeon B (airforce, sports medicine) as above but swelling can distort anatomy suprizingly. He advocated caution with pin placement . “risk of osteomylitis and infection is to great” risk to artery if improperly placed. He would want flouro. Yes he knows docs in third world countries place them blindly on the wards but in his hands he wants flouro and proper pins or its bed rest.
Surgeon C (spine) says good luck. Throw some pins in if you want and see what happens. It’s a bad injury. A bad outcome is expected in bad circumstances. Anything gained is a victory.

Bed rest- or buck traction have the same outcomes. 100% mal union. This is not alwase the worst of outcomes. I waited to write this to report final outcomes of 2 patient treated this way.
#1 was a 67 yo moderately obese diabetic with borderline renal function and severe deconditioning. History of multiple falls, osteoporosis. CAD. Ground level fall resulted in sub trochanteric femur fracture. She is not likely to survive a surgical intervention due to comorbidity. She was treated with bedrest. Q2hr turns. Incentive sirometry. Low airloss bed. Dietician consult. Despite pre injury anemia Hemaglobin drops only a little. Traction was determined to be too high a risk for skin breakdown and pulmonary issues. Infection is a high risk due to the brittle diabetes. At 4 weeks pain is decreasing. Leg is clearly shorter and externally rotated. Early passive motion initiated. Up in Wheelchair qday. 6 weeks callus noted on x ray, gentle active assist to passive rom. Isometrics, 8 weeks 25% wt bearing progressing by 25% per week until full weight bearing. 12 weeks big callus. Walking 65 ft with walker (pre-injury baseline 60ft) 6cm short compensated for with a big shoe lift on her diabetic shoe. She insists on going home despite fall risk. She will fall again and it will likely kill her.
#2 periprosthetic mid shaft femur fracture in a frail 85 year old with severe osteoporosis and unstable angina, diabetes, mild dementia. In short healed up in similar time frames. 2cm short. No rotation. Walks the halls of the memory care center all day long. Still forgets her walker. 3 monthes post op admitted to the ICU with pneumonia. Currently on a vent as of this AM.
Bucks traction or skin taping to traction has benefit for the first initial period to reduce spazm for comfort purposes. I cant find any data that supports reduced mal union. There is risk to the skin. With prolonged use of either of these options.
With limited resources or poor operative candidates bed rest is a viable option.

External fixation- is great initial stabilization with open wounds to manage and is all that is done in theatre in current military medicine with definitive fixation performed back in the states. It has poor union rates compared to rods and is poor definitive fixation. It limits muscle movement. Due to gross muscle movement pin tract infection rates are approaching 10% if left on for the duration of the fracture management period. Pin site infections can frequently become chronic draining wounds. 20% fracture non union in the best of hands.

Skeletal traction- most common treatment worldwide. Pins can be placed under local (ouch) anesthetic or with sedation. Distal femur avoids possible knee ligament injurys turning into a disaster. However interarticular infection risk through the suprapatelar pouch is a problem. Infection in the thigh can track to the pooled blood in the thigh and infect the fracture. Femoral pins can be used in conjunction with tibial pins to restore alignment in the distal fragment in a delayed “plastic slow bending” fashion at 3-4 weeks. The proximal tibia is the preferred site in the vicinity of the tibial tubercle. Caution If you are to shallow and just grab cortex is may cut out of the bone as the bone grows away from the pin.
3/16th threaded pin is the largest threaded pin used. To small a pin and it bends. Larger the pin the bigger the risk of infection and bone weakening. Small wires can be used but require tension pulling the ends of the wire apart like a spoke on a bike wheel to have any resistance to bending. They can cut out of soft bone like a cheese knife. Try to get an old Steinman pin holder. Smooth Steinman pins 3/16th to ¼ inch have been used and are easiest to put in. They have a sharp tip like a framing nail and are put in with a drill.

Local inject 5 cc 1% lidocane superficial and to the bone. On both sides! cut skin 1-2 cm. blunt dissect to the bone to avoid destroying nerves and vessels. Use a small tube slightly larger than the pin as a tissue protector and a guide. Also it will keep the pin from bending as the drills we use in the OR have a hole in the back so we can feed the pin through it and work close to the bone. dewalt doesn’t make them like that. Look from multiple angles to confirm alignment prior to punching out the other side. Drill through the skin. Slightly enlarge the hole on the exit side so there is no skin traction. Sterilize the pin and all tools. The drill can be non sterile as long as it is managed by a second person. The sterile operator loads the pin and the drill operator chucks it. The pin is placed. The dirty end in the drill is never taken into the wound. Old fashioned Hand powered drill/brace can be sterilized but speed under power is much less painfull.

I prefer roller traction with a hinged knee cast alternating with roller traction suspension to maximize mobility and minimize atrophy. Based on the nature of the fracture they can start mobilizing out of traction in the hinged cast at 1-4 weeks (use pain and or x-ray as a guide) as it is a load sharing device that supports less as the leg atrophies. It also allows stimulation to heel with early toe touch and progressive wt bearing activity. 2 weeks earlier union compared to other traction techniques and 2 weeks sooner discharge from the hospital. I will admit I have only used traction with a handful of patients. The real experts at this are outside the US.

Cast or cast brace combinations alone- 3 ½ month average heeling time, used in closed distal ½ femur fractures. We have used this in periprostecic femur fractures in non operative candidates. Apex anterior (or in other words bent in the same direction as the knee bends) is the common deformity.

enjoy!

[Austerenurse]

Great post! I really enjoy your posts and it gets me thinking about how to manage these difficult problems.

As aggressive as I am in treating things in the RAWTW there is no way I am putting in a rod. That takes a shit load of skill, and I have seen even seasoned orthopedic surgeons have bad outcomes. I have also seen poor results with external fixation, so I would not go that route either.

Before I start to explain my management, you brought up a good point. A technique that I just learned about which is simple, effective and apt for use the the RAWTW. The ankle-brachial index (aka arterial pressure index). Learn this technique... it is simple and can really help if you are trying to determine if your patient has a vascular injury and you do not have any of the high-speed toys. See this article about half-way down for an explanation of technique:

http://www.orthosupersite.com/view.asp?rID=30519

Femur fracture... the dreaded femur fracture in the RAWTW. It is a hard one, and I like many of your suggestions. Here is how I would manage it...

Dx: Physical exam, check for open fracture, neurological exam (damage to the sciatic nerve), vascular exam (damage to the femoral artery), X-ray if I had one. If you have a vascular injury (especially an injury to the popliteal artery), and cannot repair it, you might need to amputate as a life-saving measure.

From here you can make the call as to the location of the fracture. They way I see it you have two types of fractures with respect to the femur:

1. Shaft
2. Distal near the knee

Tx of shaft fractures:

1. Open fractures - wash out and debride. Clean out all the badness under the most sterile conditions possible.

2. Traction: Once again I would use the Perkin's traction (in adults) that I described earlier in this thread, as it is as good as any technique for traction. When using this type of traction it is important to ensure proper alignment of the distal and proximal fragments. There is a tendency when you add the weight to the traction for the proximal fragment to be pulled out of alignment.

3. Nursing care: Three months in this archaic contraption. No need for someone to die from skin break down / pneumonia while the femur is healing. If at two months things seem to be healing up well you could move to a cast.

4. Casting: For an upper third fracture use a hip spica cast (non-weight bearing, but still allows for some ambulation). For anything lower use a brace cast with a hinged knee. I don't think you will ever see brace-casting used in the first world, but it is not all that uncommon in the developing world. Some neat stuff. If you are interested in the technique / discussion download the 1971 book below. Start reading around .pdf page 19 and jump ahead to .pdf page 120 if you want to read some case studies.

www.oandplibrary.com/assets/pdf/Cast_bracing_of_fractures.pdf

5. Outcome: Either you will get union or not. If you don't get union after steps 1-4 and you cannot internally fix the femur it is time to chop off the leg.

Tx of distal fractures:

The distal end of the femur is likely to fracture in one of three ways:

a. the end snaps off (a complete supracondylar fracture)
b. one of the condyles breaks off (intra-articular, often on the side of the fibula)
c. both of the condyles break off independently from each other (intra-articular)

1. If there is no displacement then put them in a long leg cast with no weight bearing until healed.

2. If there is displacement - the management is like you see for the shaft fracture above with a few twists.

3. Perkins traction as above with some flex (pillow under the knee) to keep everything in line.

4. For an inter-articular fracture you need to align the bits of bone as close as possible. You can try this closed (easier if you have x-ray and anesthesia) or if all fails (and you have the kit / skill) open up the joint and put the bits of bone where they should be.

5. Wait for it to heal. As soon as you can (with lots of pain control) start some physiotherapy exercises to strengthen the quads.

6. At 1.5 months put the patient in a long leg cast or a brace-cast with a knee hinge (as above).

7. At 3 months and you think things are healed start weight bearing.

8. No union (or less than functional union) - amputate the leg (unless PA Ortho has already put a bullet in your noggin - smile)

I hope that is of some interest to compliment PA Ortho's fine work...

AN

[pa4ortho]

agreed rod placement without full resources is "frought with peril" you need lots of sizes. its just not practical. I have an extensive OR kit. still not even close to thinking about big rods. orif patella no problem. im still working on the xray project. im thinking about possibly trying enders rods in the future as an option. my portable xray would have to be a dr system to
get images fast enough. passing rods on a displaced fx can be a challange. its to easy to place it extra medulary without a shark bite sized incision. if the SHTF here in the us, I will go get my big C arm from the office . unfourtunately its not very portable.

for those non licensed who are interested in surgical skills. find a local large animal vet. volunteer to assist in surgery. the vets do ditch medicine every day.

had to pull infected enders rods once that were 5 yrs old. resorted to mechanics bearing puller and a 5 lbs sledge on the 2nd wash out.


pa4ortho