ww.sciencedirect.com

j o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a uma 4 ( 2 0 1 3 ) 1 1 0e1 1 4

Available online at w

ScienceDirect

journal homepage: www.elsevier .com/locate/ jcot

Original Article

Supracondylar skeletal traction and openinterlocking nailing for neglected fracture of theshaft of femur e Retrospective study

R. Krishnakumar D (Ortho), DNB (Ortho)a,*, G. Thiruvenkitaprasad DNB(Ortho)a, Dayanand Kaliaperumal MS (Ortho)a, Nandkumar SundaramFRCS, MSc (Ortho) (Lon)b,c

aAssociate Consultant, Department of Orthopaedic Surgery and Trauma, Nova Specialty Surgery, Velachery,

Chennai, Tamil Nadu 600020, Indiab Prof, HOD, Department of Orthopaedic Surgery and Trauma, Nova Specialty Surgery, Velachery, Chennai, Tamil

Nadu 600020, India

a r t i c l e i n f o

Article history:

Received 17 April 2013

Accepted 14 May 2013

Available online 7 June 2013

Keywords:

Supracondylar skeletal traction

Neglected trauma

Interlocking nail

* Corresponding author. Plot No 269, 17th E9551667000 (mobile); fax: þ91 4422553744.

E-mail addresses: krishnaorth@hotmail.coc Tel.: þ91 9841052275 (mobile).

0976-5662/$ e see front matter Copyright ªhttp://dx.doi.org/10.1016/j.jcot.2013.05.003

a b s t r a c t

Background: Neglected trauma is a common problem faced by Orthopaedic surgeons prac-

ticing in developing countries. Nothing much in English literature is available regarding the

practical difficulties and guidelines for treating neglected trauma of long bones.

Methods: In our institution from November 2003 to October 2009 we treated 25 cases of

neglected fracture of shaft of femur. Patients underwent either of three types of man-

agement protocols depending upon the preoperative manual traction radiographs. The

fracture was fixed with open interlocking nail. Primary bone grafting and bone shortening

procedures were not performed in any of the patient.

Results: The fractures united in all patients at an average duration of 17 weeks. Two pa-

tients had limb length discrepancy.

Conclusion: Careful preoperative evaluation is mandatory for good results. Preoperative

skeletal traction and two stage surgical procedure may be required to avoid limb length

discrepancy and neurovascular complication.

Copyright ª 2013, Delhi Orthopaedic Association. All rights reserved.

1. Introduction setters in India and they treat 60% of all trauma.1 In devel-

Neglected trauma is a common problem in developing coun-

tries. In India the commonest cause of neglected trauma is

initial treatment done by traditional bone setters. There are

reported to be about 70,000 traditional healers and bone

ast Street, Kamaraj Naga

m, krishnaorth@gmail.co

2013, Delhi Orthopaedic

oping countries most of the patients have to pay for the

medical expense out of their own pockets. They prefer tradi-

tional treatment because it is less expensive, easily available

and is common advice from neighbourhood, without under-

standing the fracture’s nature. There is a dearth of English

r, Thiruvanmiyur, Chennai, Tamil Nadu 600041, India. Tel.: þ91

m (R. Krishnakumar).

Association. All rights reserved.

j o u rn a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a uma 4 ( 2 0 1 3 ) 1 1 0e1 1 4 111

literature regarding guidelines for treating neglected trauma

of long bones, as the condition is rare in developed countries.

Fracture not properly treated for more than few weeks will

give soft tissue contractures, muscular atrophy and joint

stiffness. Existing fracture management principles has to be

changed from case to case to get good results. We had the

opportunity to treat a series of neglected fractures of the shaft

of femur at our institute. We have critically analyzed our

management protocols and results retrospectively.

2. Material and methods

In our institute, from November 2003 to October 2009, we

treated 25 cases of neglected fracture of the shaft of femur

which were initially treated by traditional bone setters. The

time interval between injury to reporting at our hospital

ranged from eight weeks to 72 weeks, with average interval

being16 weeks. The male to female ratio was 17:8 and the age

varied from 21 years to 56 years. All our patients had knee

joint stiffness of variable range. Four patients had severe

disuse osteoporosis. When the patients report to hospital

manyweeks after the injury, established principles of fracture

management have to be modified according to the case. Since

there are no guidelines for treatment of these fractures we

formed our own protocol considering all the complications of

neglected trauma and their treatment.

All our patients came from traditional bone setting treat-

ment. After removing the native bandage, limb was cleaned

with soap and water then limb was placed in Thomas splint.

Povidone-Iodine scrub was given twice daily for two days to

clean the skin to avoid infection during the surgery. After two

days patient underwent assessment for shortening and knee

movements.

All our patients underwent traction X-ray by manual

traction without anaesthesia while monitoring distal neuro

vascular status. If traction X-rays showed overlapping of

fracture ends less than one cm, the patient was taken up for

definitive surgery as soon as he/she was fit for anaesthesia. If

traction X-rays showed overlapping more than one cm

(Table 1) and no adhesion like partial union or malunion, pa-

tient underwent skeletal traction before surgery till overriding

was corrected (Fig. 1). Patient underwent a two stage surgical

procedure if any partial union/malunion or more than 5 cm

overriding between fracture ends was present. In the first

stage of surgery the adhesions between bone ends were

removed and skeletal traction was applied till fracture ends

had no overriding. In the second stage the patient was taken

up for definitive surgical procedure i.e fracture fixation with

interlocking nail (Fig. 2).

Table 1 e Shortening after manual traction.

Shortening Femur

No shortening 0

Up to 1 cm 5

1e5 cm 18

5e7.5 cm 2

In the traction programme, single pin was applied to the

lower end of femur and leg was placed in the BohlereBraun

splint. The foot end of the cot was elevated two inches so that

body weight would give the counter traction. Skeletal traction

was startedwith three kg initially andwas gradually increased

half kg to one kg every day, according to the patient’s toler-

ance with neuro vascular monitoring like intolerable pain,

paraesthesia, pallor and absence of pulse, till there was no

overlapping of the bone ends. X-rays with traction were taken

every 72 h. Once overriding of the fragments was corrected,

traction with the same weight was maintained for another

48 h.

In surgical procedure all patient underwent open reduc-

tion. After freshening the bone ends fracture was reduced and

fixed with interlocking nail in antegrade manner and locked

proximally with jig and distally by free hand technique. None

of the patient underwent bone shortening procedure for

reduction. Wound was closed in layers with suction drain.

More than one cm overlapping seen in twenty patients

underwent skeletal traction with periodical increase of

weights with neuro vascular monitoring before definitive

surgery and five patients underwent traction after the first

stage of surgery. Skeleton traction was applied for five days to

14 days, an average of ten days. Weight required for achieving

the length varied from 5 kg to 12 kg, an average of 9 kg.

Primary definitive surgery was performed in five patients.

Twenty patients underwent traction regimen before definitive

surgical procedure inwhich five patients had traction after the

first stage of surgery (Table 2).

Intra operative findings were variable like, fibrous union,

partial malunion and pseudo arthrosis. Three patients had

soft tissue interposition, six patients had fibrous union, three

patients had partial malunion and one patient had pseudo

arthrosis. No significant findings were seen in twelve patients.

All femur fracture were treated by static interlocking nails. All

our patients required open reduction, bone shortening pro-

cedure was not done in any patients and in none of the pa-

tients bone grafting was done.

Six patients had second surgical procedure of dynamiza-

tion after definitive surgery as static interlocking nails were

used in all patients. All our patients underwent strict phys-

iotherapy regimen after definitive surgery to regain the

movements of stiff knee joint and strengthening of muscle

power of hip and knee.

Patients were advised not to bear weight on affected limb

with walker support initially. Patients were reviewed every

week till the functional range of knee movement was ach-

ieved. The radiographs were taken once in four weeks.

Depending on the progress of bone union patients were

advised to put gradually increasing weight on the affected

extremity. All patients were advised to take calcium supple-

ment with vitamin D3. All patients were followed up till union

of fracture and occupational rehabilitation.

3. Results

All our follow up cases attained bony union and returned to

their previous jobs. Fracture united between 11 weeks and 34

weeks, average was 17 weeks (Table 3). None of our patients

Fig. 1 e Group II patient with skeletal traction before surgery a) Preoperative X-ray with manual traction b) X-ray after pin

traction c) immediate postoperative X-ray d) X-ray after union.

Fig. 2 e Two stage surgical procedure a) intra operative picture after removal of pseudo arthrosis and adhesion b) X-ray after

removal of pseudo arthrosis and adhesion c) Clinical picture of pin traction after stage I surgery d) X-ray after correction of

deformity by pin traction e) immediate postoperative X-ray.

j o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a uma 4 ( 2 0 1 3 ) 1 1 0e1 1 4112

Table 2 e Management of the patients.

Fractureregion

No of cases ingroup I e immediatedefinitive surgery

No of cases in groupII e skeletal traction

before surgery

No of cases in group III e surgicalrelease of adhesion and skeletal

traction before surgery

Femur 5 15 5

Table 3 e Results.

Time of union No of cases

Within 16 weeks 19

4e6 months 4

6e8 months 2

j o u rn a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a uma 4 ( 2 0 1 3 ) 1 1 0e1 1 4 113

developed infection. Two patients who had limb length

discrepancy less than 2 cm. None of our patients had

postoperative neuro vascular problems.

All our patients regained good range of knee movements.

Fifteen patients got full range of movements, Eight patients

got more than 120� flexion and none had less than 90�.Extension lag present in seven patients, an average of 11�

(Table 4).

4. Discussion

Neglected trauma ismore common in developing countries for

various reasons like poverty, illiteracy, false belief and easy

availability of traditional bone setting treatment. The western

literature discusses neglected trauma of the joints but not the

problems associated with neglected long bone fractures and

guidelines to treat such fractures. Gavaskar et al treated

neglected fractureof shaft of femurwithopen interlockingnail,

bone grafting and shortening procedure with good results.2

Kempf et al performed eighteen femoral lengthening ’Z0

osteotomy in malunited femur fractures between 1976 and

1984 and fixedwith intramedullary nails, with primary cortico

cancellous bone grafts.3 In their series they had one nonunion,

three deep infections, four significant shortening and four

femoral nerve palsies. For the first two days after the operation

their patients remained in bed with hip flexed to 30� and the

kneeflexedto90�. Thekneeswereprogressivelyextendedfrom

the third postoperative day. In their study they concluded that

more than fourcmis lengtheningassociatedwithnervepalsies

and interlocking nails were a goodmethod of fixation.

Yadav S.S described a technique double oblique diaphyseal

osteotomy for lengthening of short limbs in short duration in

which 6e16 cm lengthening was obtained in 3e6 weeks

Table 4 e Knee movements.

Flexion No of patients Extension No of patients

<90�

0 0�

18

90�e130

�10 0

��10�

6

Full range 15 10�e20

�1

duration by skeletal traction. The traction weight was gradu-

ally increased up to 30 kg without any major complications.4

In our series we formed our protocol considering all

possible complications of neglected trauma like malunion,

nonunion, stiffness of neighbouring joint, and neuro vascular

complications. In this series, we performed primary definitive

surgeries if overlappingwas less than one cm, because usually

under anaesthesia with muscles relaxation and careful sub-

periosteal elevation one cm overlapping can be overcome

without undue tension.

Fifteen patients with more than one cm overlapping un-

derwent skeletal traction with periodical increase of weights

with neuro vascular monitoring before definitive surgery.

These patients had no adhesions like partial union or mal-

union on radiographs. The stretching of soft tissue and

correction of overriding was possible with gradually increased

traction weights.

Five patients who had overriding more than 5 cm or had

partial union or malunion underwent first stage surgery fol-

lowed by traction. The first stage surgery helped in removal of

adhesions leading to effective use of traction for correction of

overriding.

By using these strict protocols none of our patient devel-

oped neuro vascular complications postoperatively. All our

patients underwent immediate strict postoperative physio-

therapy regimen to get back their jointmovements since there

is no tension on neuro vascular bundle. All our patients had

regained good range of knee movements.

5. Conclusion

After analyzing our treatment protocol and results we came to

the following conclusions.

1. Preoperative traction X-rays are mandatory to plan the

management.

2. Preoperative gradual and monitored skeletal traction is

compulsory to avoid unacceptable limb length shortening

and neuro vascular complications.

3. In some cases staged surgical procedures may be required.

4. Primary bone grafting is not necessary in all patients.

5. Bone shortening procedure not necessary for reduction.

Conflicts of interest

No benefits in any form have been received or will be received

from a commercial party related directly or indirectly to the

subject of this article.

j o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a uma 4 ( 2 0 1 3 ) 1 1 0e1 1 4114

r e f e r e n c e s

1. Church John. Report on Work of Traditional Healers and BoneSetters. WOC News Letter; 1997.

2. Gavaskar AS, Kumar R. Open interlocking nailing and bonegrafting for neglected femoral shaft fractures. J OrthopSurg (Hong Kong). 2010 Apr;18(1):45e49. [PubMed PMID:20427833].

3. Kempf I, Grosse A, Abalo C. Locked intramedullary nailing. Itsapplication to femoral and tibial axial, rotational, lengthening,and shortening osteotomies. Clin Orthop Relat Res. 1986Nov;212:165e173. [PubMed PMID: 3769282].

4. Yadav SS. Double oblique diaphyseal osteotomy. A newtechnique for lengthening deformed and short lower limbs. JBone Joint Surg Br. 1993 Nov;75(6):962e966. [PubMed PMID:8245092].