Identifying Surgical Options For A Patient With Mid-Shaft Fractured Femur

Surgical treatment options

Discuss about the Identify Surgical Options For A Patient Presenting With A Mid-Shaft Fractured Femur.

The surgery for mid-shaft fractured femur depends on time. Mid-shaft femur fractures are treated depending upon pattern of fracture. Femoral neck fractures, percutaneous pinning or sliding of hip screw and anthroplasty is done for the elderly patients like in the given case study of Mr.Brown. If the skin around the fracture is still not broken, then it is advisable to wait to make it stable before surgery. If the fracture is open, it might be exposed to environment and so need to be cleaned urgently to prevent infection before immediate surgery. The leg is placed in skeletal fraction or long-leg splint between the period of initial emergency care and surgery. This helps to keep the broken bones aligned and maintain length of leg. There are three surgical treatment options available for the mid-shaft fractured femur.

External fixation is a type of operation where screws or metal pins are placed in bones above and below the site of fracture. The screws and pins are attached to bar outside skin that act as stabilizing frame for the holding bones in proper position for fast healing. It is a temporary treatment where external fixators are applied which provide temporary and good stability until the femur is healed (Kulshrestha, Roy, & Audige, 2011).

Intramedullary nailing is another surgical option where and currently in use for the mid-shaft femoral fractures opted commonly by most surgeons. In this procedure, a specially designed metal rod is inserted in femur marrow canal. The rod then passes across fracture that helps to it in position. The intramedullary nail is inserted in the canal at the knee or hip in small incision. There is crewing at the bones at both ends. This keeps the bone and nail in proper position at the time of healing (Gelalis, et al., 2012).

Screws and plates are also done as a surgical operation when the bone segments are reduced or first repositioned in their normal alignment. Metal plates and special screws are attached to the bone outer surface. These screws and plates are often used during intramedulalry nailing which is not possible for the fractures that are extended to knee or hip joints (Smith, Parvizi, & Purtill, 2011).

Patients who sustain mid-line femur fracture after a traumatic accident like tractor accident of Mr. Brown, encounter complications depending upon the severity of break or fracture location. The complications include infection, bone healing problems, nerve damage, compartment syndrome or surgical complications (Kong & Sabharwal, 2014). In fractured femur, there can be bone breaking the skin and that increases the risk for infection. If there is wrong alignment of bones or infection that causes irritation, the healing process is delayed and there is requirement of further surgery. Nerve damage can also occur where there might be weakness or numbness that is a rare complication. Compartment syndrome is also a rare complication of femoral mid-shaft fractures where there is compression of blood vessels, nerves, muscles inside compartment or closed space within the body. This generally occurs within the thigh with bleeding or inflammation because of trauma that is associated with the fracture. In case of this syndrome, immediate operation is required. Surgical complications can also occur due to hardware failure that is required to stabilize bone or hardware piece that causes pain or irritation. Nerve damage is the possible surgical complication in mid-shaft femoral fracture (Park, Noh, & Kam, 2013).

External fixation

Depending on the femoral fracture, the major complications in mid shaft femoral fracture affects the knee, however, in a different way. Femur movement when it breaks, there is ligament damage in knee that demand immediate operation for repairing the damage. Heterotopic ossification, pudendal nerve injury and Acute compartment syndrome are major complications that might occur post-operation of fractured femur (Kaiser, et al., 2011).

Heterotopic ossification occurs with an incidence of 25% as a post-operative complication after femur fracture surgery. In this, there is varying severity where bone debris from endosteal canal reaming is deposited in soft tissues that surround the site of nail insertion in Intramedullary nailing surgery (Botolin, Mauffrey, Hammerberg, Hak, & Stahel, 2013). These debris are stimulate the heterotopic bone formation that decreases debris amount left in tissues after the nailing leading to heterotopic ossification. This complication occurs at the proximal end of reamed intramedullary femoral nail posing a complication after the procedure. The nursing intervention is the physical therapy where the nurse keeps the patient with involved joint at rest to maintain a functional position and perform Passive Range of Motion (PROM) where the body parts are moved within the available range without muscle activation (Martinez de Albornoz, Khanna, Longo, Forriol, & Maffulli, 2011). It is monitored by keeping into account the movement range of the patient and pain management.

Pudendal nerve injury is another main complication that is associated with the fracture surgery where there is static interlocking in the femur nailing. This neurologic injury is a combination of direct compression and localized ischaemia of perineum against post fracture countertraction. In this, there is branching of sensory terminals of pudendal nerve that appear susceptible to injury causing complications after the surgery. It is an important and common complication after intramedullary femur nailing that might result in complete sensory loss. The nursing intervention involves pain management and medical interventions. Nurses would reduce the pudendal nerve irritability through lifestyle changes. They would perform sitting modification, avoidance of physical activities that irritate nerves, bladder and bowel management help to prevent straining of nerves and its compression that might cause nerve irritation. Continuous monitoring and refereeing to a physiotherapist would help to relax the muscles and decrease nerve irritation. Acupunture and psychotherapy can also be helpful for reducing pain and irritation of nerve (Fisher & Lotze, 2011).            

Acute compartment syndrome is a rare but important complication that takes place post femur fracture. It is a highly painful condition when the muscle pressure builds to alarming levels. This can decrease flow of blood preventing oxygen and nourishment from reaching muscle and nerve cells. The pressure need to be released or else can cause permanent disability. This requires surgery when the surgeon makes incisions in the muscle coverings and skin to relieve pressure (Kalyani, Fisher, Roberts, & Giannoudis, 2011). The  nursing intervention involves pain management by medications like epidural analgesia to relieve pain. Multimodal approach that includes use of non-steroidal anti-inflammatory drug (NSAID) and paracetamol along with an opioid considered best after pressure release through surgery. Patient education is also required before discharge after pressure release surgery by nurses for predisposition to this syndrome. The monitoring involves evaluation of any medication side effects and compartment pressure that should be less than 15mmHg via single pressure readings or continuous pressure monitoring.

Intramedullary nailing

Heterotopic ossification(HO)

In HO, there might be complications related to skin and musculoskeletal system where there might be problems regarding osteomyelitis and skin pressures. Skin complications can occur due to immobility, changes in flow of blood, improper positioning, venous stasis vasomotor tone loss and hypoxia. Contractures, muscle atrophy, osteoporosis, HO and spasticity can also occur due to immobility, joint stiffness, muscle atrophy, weakness and much more.

This nerve is stretched, damaged or can cause permanent neuropathy in the patient. There can be irreversible nerve damage that can cause impaired mobility and stretch injury  and permanent damage.

Acute compartment syndrome is surgical emergency that can cause permanent nerve damage and causes severe injury. This cam cause permanent damage of muscles and can prevent oxygen and nourishment to reach muscles and nerve causing permanent loss of nerve sensation.

Aubut, J. A., Mehta, S., Cullen, N., Teasell, R. W., & Team, G. t. (2011). A comparison of heterotopic ossification treatment within the traumatic brain and spinal cord injured population: an evidence based systematic review. NeuroRehabilitation, 151-160.

Botolin, S., Mauffrey, C., Hammerberg, E. M., Hak, D. J., & Stahel, P. F. (2013). Heterotopic ossification in the reaming tract of a percutaneous antegrade femoral nail: a case report. Journal of medical case reports, 90.

Fisher, H. W., & Lotze, P. M. (2011). Nerve injury locations during retropubic sling procedures. . International urogynecology journal, 439-441.

Gelalis, I. D., Politis, A. N., Arnaoutoglou, C. M., Korompilias, A. V., E., P. E., Vekris, M. D., & ... & Xenakis, T. A. (2012). Diagnostic and treatment modalities in nonunions of the femoral shaft. A review. Injury, 980-988.

Kaiser, M. M., Wessel, L. M., Zachert, G., Stratmann, C., Eggert, R., Gros, N., & ... & Rapp, M. (2011). Biomechanical analysis of a synthetic femur spiral fracture model: influence of different materials on the stiffness in flexible intramedullary nailing. . Clinical Biomechanics, 592-597.

Kalyani, B. S., Fisher, B. E., Roberts, C. S., & Giannoudis, P. V. (2011). Compartment syndrome of the forearm: a systematic review. The Journal of hand surgery, 535-543.

Kong, H., & Sabharwal, S. (2014). External fixation for closed pediatric femoral shaft fractures: where are we now?. Clinical Orthopaedics and Related Research, 3814-3822.

Kulshrestha, V., Roy, T., & Audige, L. (2011). Operative versus nonoperative management of displaced midshaft clavicle fractures: a prospective cohort study. Journal of orthopaedic trauma, 31-38.

Martinez de Albornoz, P., Khanna, A., Longo, U. G., Forriol, F., & Maffulli, N. (2011). The evidence of low-intensity pulsed ultrasound for in vitro, animal and human fracture healing. . British medical bulletin.

Masata, J., Hubka, P., & Martan, A. (2012). Pudendal neuralgia following transobturator inside-out tape procedure (TVT-O)—case report and anatomical study. International urogynecology journal, 505-507.

Mavrogenis, A. F., Soucacos, P. N., & Papagelopoulos, P. J. (2011). Heterotopic ossification revisited. . Orthopedics, 177-177.

Montoya, T. I., Calver, L., Carrick, K. S., Prats, J., & Corton, M. M. (2011). Anatomic relationships of the pudendal nerve branches. American journal of obstetrics and gynecology, 504-e1.

Park, S. S., Noh, H., & Kam, M. (2013). Risk factors for overgrowth after flexible intramedullary nailing for fractures of the femoral shaft in children. Bone Joint, 254-258.

Smith, E. B., Parvizi, J., & Purtill, J. J. (2011). Delayed surgery for patients with femur and hip fractures—risk of deep venous thrombosis. Journal of Trauma and Acute Care Surgery , E113-E116 .

Waterman, C. B., Laughlin, C. M., Kilcoyne, C. K., Cameron, K. L., & Owens, L. B. (2013). Surgical treatment of chronic exertional compartment syndrome of the leg: failure rates and postoperative disability in an active patient population. JBJS, 592-596.