Bilateral Femur Fracture – Part 2

Notes from the receiving surgeon

My initial plan involved retrograde intramedullary nailing (IMN) the right femur immediately. I debated external fixation versus a distal femoral traction pin for the left femur. If Khan remained stable, I planned on antegrade IMN of the left femur in 24 to 48 hours and open reduction, internal fixation (ORIF) of the left ankle and metatarsals in 7 to 10 days.

Safely “stabilizing” long bone fractures in the field can be challenging without traditional equipment. I did want to treat the left femur fracture with an intramedullary device sooner rather than later and did not want to have external fixation pins in the proximal segment if I did not need to wait. I therefore placed a distal femoral traction pin and improvised skeletal traction with some borrowed weights. When doing so, because we did not have standard frames, slings, and pulleys for balanced traction, I used padding to support the thigh and leg and elevated the vector of traction to try to keep it “in line” with the femur.

 

Postoperative day 2

 

Overnight nursing reported Khan being “oxygen dependent.” He desaturates very quickly when weaned from oxygen. A work up showed:

  • Khan was a 2 pack per day smoker
  • Arterial blood gas (ABG) on 50% FiO2 showed hypoxemia with mild shunting
  • A sonosite showed femoral veins are “compressible”

I wondered if this indicated a differential diagnosis of pulmonary embolism (PE), fat embolism syndrome (FES), chronic obstructive pulmonary disease (COPD), or a combination of all three. Fortunately, a contrast CT was available and I diagnosed a PE.

We heparinized him immediately, but Khan could not be transported to a higher level hospital. We were to be his definitive care facility. Fortunately, he remained hemodynamically stable despite the pulmonary embolism. Unfortunately, we did not have an interventional radiologist nor a vascular surgeon assigned to our facility. I considered options of definitive fixation with external fixation alone, which could be done through a short window in his heparin therapy with percutaneous technique by sending large external fixation pins up the femoral neck in conjunction with shaft pins to maximize the fixation in the proximal segment. Trying to ream for immediate IMN in this setting would likely be too risky, as the emboli to his lungs might push him over the edge of cardiopulmonary stability. Any additional surgeries during full medical anticoagulation might allow for large hematoma formation.

What would be your next steps as the treating surgeon? Check back to learn how the surgeon proceeded in this austere environment.

4 thoughts on “Bilateral Femur Fracture – Part 2”

  1. I just got the link so know what you did and what happened. But a few comments. The patient with bilateral femur frctures is “at risk” If stable, i.e. well hydrated and oxygenating , it is best to fix the femurs early. A retrograde nail on the right, and if still stable an antegerade nail on the left. but don’t forget that plates work well for prox third femur. Without image a plate work well because it is an open reduction. Ext fixation for prox third femurs doesn’t work well. The problem with the traction you used is that if he has pulmonary complications, which he did, your choices become limited. Had you plated him initally, he would now be fixed and the issue of how to treat the fracture and the PE would not be there. One of the many benefits of early stabilization. Treating him with ext fix pins is less than ideal. It will be his definitive fixation and has a history of poor out come with prox third femur fractures. If his oxygenation improves and you are comfortable temporarily removing his heparin, I would consider a minimally invasive plating to reduce the post op bleeding. If his lungs remain a problem then you live with the fixator and hope it doesn’t fall a part or get infected.

  2. Dr. Bone,
    Thank you for your excellent points and comments.
    I actually did not use an external fixator in this case….there was a “mis-type” by the staff that has now been corrected.

    Regarding plate fixation for the proximal femur…we had limitations on what implants were available. I did have an old DHS set, locking small frag, standard large frag, mix and match periarticular plates (distal femoral locking plate, but not proximal, and not able to get all sizes or types of locking screws). No blade plate unless I “made” one for the patient.

    I agree that in the rural setting these patients live in, external fixation is not ideal–esp in this moderately portly gentleman.

      1. Dr. Bone,
        I was actually considering doing that! The large central locking screw would be my blade plate equivalent augmented with the peripheral screws. It was on the list of options….but I ended up selecting a different solution.

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