What is the ideal management for a closed femoral shaft fracture in a patient with multiple injuries, including a closed head injury, pulmonary contusion, and grade III splenic injury?

From the Guidelines

The ideal management for a closed femoral shaft fracture in a polytrauma patient with closed head injury, pulmonary contusion, and grade III splenic injury involves early fracture stabilization with damage control orthopedics, focusing on temporary external fixation rather than immediate intramedullary nailing. This approach is supported by the guidelines for the acute care of severe limb trauma patients, which recommend a staged approach to reduce the risk of complications such as fat embolism syndrome, acute respiratory distress syndrome, and multiple organ failure 1. The patient's multiple injuries, including a closed head injury, pulmonary contusion, and grade III splenic injury, increase the risk of systemic complications, making a delayed definitive osteosynthesis a more appropriate option 1.

The initial treatment should focus on temporary external fixation of the femur, which allows stabilization of the fracture while minimizing additional physiological stress in an already compromised patient. This approach is in line with the recommendations for damage control orthopedics, which prioritize temporary stabilization over immediate definitive fixation in unstable or severe trauma patients 1. The patient should receive appropriate analgesia, such as IV opioids, with careful monitoring due to the head injury, and DVT prophylaxis with mechanical compression devices should be initiated, with chemical prophylaxis delayed until the splenic injury is addressed or deemed stable by the trauma team.

Once the patient is hemodynamically stable with improved pulmonary function and controlled intracranial pressure, conversion to definitive fixation with an intramedullary nail can be performed. This staged approach reduces the risk of complications by avoiding the "second hit" phenomenon of major orthopedic surgery in a physiologically vulnerable patient during the initial inflammatory response to trauma 1. The guidelines for the acute care of severe limb trauma patients support this approach, recommending a delayed safe definitive orthopaedic surgery based on clinical and injury criteria 1.

Key considerations in the management of this patient include:

• Temporary external fixation of the femur to stabilize the fracture and minimize additional physiological stress
• Appropriate analgesia and monitoring due to the head injury
• DVT prophylaxis with mechanical compression devices and delayed chemical prophylaxis
• Conversion to definitive fixation with an intramedullary nail once the patient is hemodynamically stable
• A staged approach to reduce the risk of complications and avoid the "second hit" phenomenon.

From the Research

Ideal Management of Closed Femoral Shaft Fracture

The ideal management of a closed femoral shaft fracture in a patient with multiple injuries, including a closed head injury, pulmonary contusion, and grade III splenic injury, is a crucial decision. Considering the patient's condition, the following options are available:

• Intramedullary Nailing: This is the preferred method for treating fractures of the femoral shaft 2. It provides a stable fixation construct that can be applied using indirect reduction techniques, yielding high union rates and low complication rates 2. The timing of femoral intramedullary nailing should be tailored to each patient to avoid systemic complications 2.
• Timing of Intramedullary Nailing: The study by 3 suggests that definite fracture fixation can often be implemented in the early total care concept in management of multiple injured patients. Another study 4 found that approximately 57% of patients underwent definitive surgical care within the first 24 hours.
• Other Options: External fixation is often used as a temporary measure, but it can be used as a definitive treatment in certain cases 5. However, it may result in a significant decrease in the range of motion of the knee 5. Skeletal traction and the use of metal plates and screws are not the preferred methods for treating femoral shaft fractures.

Key Considerations

When deciding on the ideal management of a closed femoral shaft fracture, the following factors should be considered:

• The patient's overall medical condition and associated injuries
• The timing of fracture stabilization
• The use of reaming and the starting point for intramedullary nailing
• The potential risks and benefits of each treatment option

Recommended Approach

Based on the available evidence, intramedullary nailing within 24 hours of injury (option c) is the recommended approach for managing a closed femoral shaft fracture in a patient with multiple injuries 6, 2, 4, 3. This approach provides a stable fixation construct, allows for early mobilization, and reduces the risk of complications.