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, typically within 24 hours of injury if the patient is hemodynamically stable, as this approach reduces morbidity and mortality, and improves quality of life 1. In this patient's case, with a closed head injury, pulmonary contusion, grade III splenic injury, and closed femoral shaft fracture, careful consideration of the timing of surgery is crucial to avoid exacerbating the inflammatory response and to optimize outcomes.
- Initial management includes pain control with appropriate analgesics, temporary stabilization with skeletal traction or a splint, and thorough assessment for associated injuries.
- Damage control orthopedics with temporary external fixation should be considered for unstable patients before converting to definitive fixation once the patient stabilizes, as this approach has been shown to reduce operative delays and blood loss in unstable or severe trauma patients 1.
- Prophylactic antibiotics should be administered before surgery, and thromboprophylaxis with low molecular weight heparin should be started when safe.
- Early mobilization and physical therapy are essential post-operatively to prevent complications and restore function. The approach of early definitive fixation with an intramedullary nail within 24 hours of injury, if the patient is hemodynamically stable, is supported by the most recent and highest quality study, which recommends early definitive osteosynthesis of diaphyseal fractures to reduce the incidence of local and systemic complications 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 topic of discussion among orthopedic surgeons. 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 be tailored to avoid systemic complications.
Treatment Options
- 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.
- External Fixation: This can be used temporarily for damage control or definitively in patients with severe associated injuries 3.
- Timing of Definitive Fixation: The timing of definitive fixation for major fractures in patients with multiple injuries is controversial. However, studies suggest that early definitive stabilization with intramedullary nailing can be beneficial in stable patients, but may be associated with a higher incidence of lung dysfunctions in borderline patients 4.
Recommendations
Based on the studies, the ideal management of the patient's closed femoral shaft fracture would be:
- Intramedullary Nailing within 24 hours of injury: This is a viable option, as it provides stable fixation and can help avoid systemic complications 5, 2. However, the patient's condition and associated injuries should be carefully considered.
- Consideration of Patient's Condition: The patient's closed head injury, pulmonary contusion, and grade III splenic injury should be taken into account when deciding on the timing and method of definitive fixation. In borderline patients, external fixation and later conversion to intramedullary nailing may be a better option to avoid lung dysfunctions 4.
Relevant Studies
The studies by 5, 2, and 3 support the use of intramedullary nailing for femoral shaft fractures, while the study by 4 highlights the importance of considering the patient's condition and associated injuries when deciding on the timing and method of definitive fixation. The study by 6 emphasizes the need for vigilance in patients with multiple injuries and the potential for complications such as fat embolism syndrome.