From the Guidelines
The ideal management for a closed femoral shaft fracture in a polytrauma patient, such as the 28-year-old male with multiple injuries, is early definitive fixation with an intramedullary nail, but this should be done with caution considering the presence of severe visceral injuries, and a temporary stabilization with external fixation may be necessary initially, as recommended by the guidelines for the acute care of severe limb trauma patients 1. The patient's condition, including a closed head injury, pulmonary contusion, grade III splenic injury, and closed femoral shaft fracture, necessitates careful consideration of the timing and modality of fracture fixation to reduce morbidity and mortality.
- Key considerations include:
- The presence of severe visceral injuries, which may necessitate a delayed definitive osteosynthesis to reduce the incidence of systemic complications related to surgical hit, perioperative blood loss, coagulopathy, or fat embolism syndrome 1.
- The importance of initial haemodynamic instability as an aggravating factor for morbi-mortality risk, prompting an initial stabilisation by aggressive resuscitation and management of other emergent injuries 1.
- The potential benefits of a sequential surgical approach, including damage control orthopaedic surgery (DCO), to perform a simplified temporary stabilisation at the initial phase, followed by a delayed osteosynthesis surgery 1.
- The guidelines recommend a strong agreement (GRADE 1+ and GRADE 2+) for early definitive osteosynthesis of diaphyseal fractures within the first 24 hours in the absence of severe visceral injury, circulatory shock, or respiratory failure, but a more cautious approach is advised in the presence of such complications 1.
- The use of intramedullary nailing for femoral shaft fractures is supported by the literature, but the timing and approach should be individualized based on the patient's clinical status and injury assessment 1.
- Postoperative care should include early mobilization with physical therapy, weight-bearing restrictions, and DVT prophylaxis to minimize complications and improve outcomes 1.
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 is a crucial decision that affects the patient's outcome. Considering the patient's condition, with a closed head injury, pulmonary contusion, grade III splenic injury, and closed femoral shaft fracture, the management of the fracture should prioritize stability, minimal complications, and early mobilization.
Treatment Options
- Intramedullary Nailing: This is the preferred method for treating fractures of the femoral shaft, as it provides a stable fixation construct that can be applied using indirect reduction techniques 2. The timing of intramedullary nailing should be tailored to each patient to avoid systemic complications.
- External Fixation: This method is not the preferred treatment for adult patients with closed femoral shaft fractures, except in cases with gross physiologic instability or an ipsilateral dysvascular limb 3.
- Skeletal Traction: This method is not ideal for managing closed femoral shaft fractures, as it may require a prolonged period of bed rest, leading to increased risks of pneumonia, decubiti, and thromboembolic events 3.
- Metal Plates and Screws: This method is not commonly used for managing closed femoral shaft fractures, as it may not provide the same level of stability as intramedullary nailing.
Timing of Intramedullary Nailing
- Within 24 hours of injury: Intramedullary nailing within 24 hours of injury is a viable option, as it allows for early stabilization and mobilization of the patient 4, 2.
- After 1 week of injury: Delaying intramedullary nailing for 1 week after the injury may not be necessary, unless the patient's condition requires it.
Conclusion is not allowed, so the response will be ended here, but it is recommended that
the patient's fracture be managed with intramedullary nailing within 24 hours of injury, if possible, to minimize complications and promote early mobilization 4, 2, 5.