Injury (1985) 16,371-373 Printedin

371

Great Britain

External fixation of ipsilateral fractures of the femur

and tibia
60 Riitjser and Per Hansson
Department

of Orthopaedic

Surgery, tfalmstad

County Hospital, Sweden

Summary
In five patients with ipsilateral femoral and tibia1 shaft
fractures the Hoffmann apparatus was used to stabilize the
fractures of both the femur and tibia. The patients walked
early and there were no disturbances of fracture healing. The
pin track became infected in three patients. It is suggested
that in patients with ipsilateral fractures of the femur and tibia
external fixation is indicated for the tibia and that the fracture
of the femur should be stabilized by closed medullary nailing.
If the patient is critically ill or if there is gross comminution of
the femur external fixation is indicated for this fracture as
well.

INTRODUCTION
PATIENTS with simultaneous

fractures of the femur and

tibia in the same limb pose a therapeutic problem. They

Concomitant injuries
There were three fractures of the upper extremity, one
fracture of the knee, one fracture of the ankle, one
fracture of the facial bones, one patient with thoracic
injury and two patients with concussion.
METHOD
In all cases the Hoffmann apparatus was used in
double-frame configuration on the tibia and in threepoint fixation on the femur (Fig. 1). All frames except
one were applied as neutralization forces. One frame
was applied to the tibia in compression. The fixation
was done as an emergency procedure in three patients,
on the 5th day in one patient and on the 9th day in
another patient. Active exercises for the knee and

are often multiply injured and in poor general condition due to the high energy of injury (Gillquist et al.,
1973; Edwards, 1979). There is also a high risk of
permanent disability (McBryde and Blake, 1974).
There is no generally accepted principle of treatment
of these fractures and recommended methods differ
widely. Winston et al. (1972) recommend not operating
on either fracture, while Ratliff (1968) proposes internal fixation of both fractures if possible. According to
Hayes (1961) and Omer et al. (1968) the key to
successful treatment is stabilization of the femur which
in selected cases can be accomplished by internal
fixation.
We report five patients with fractures of the femur
and tibia in the same leg treated by external fixation of
both fractures.
MATERIAL
There were five male patients aged 16-84 years who all
sustained their injuries in traffic accidents. One fracture
of the femur and two of the tibia were open fractures of
first degree (Mueller et al., 1979) while the rest of the
fractures were closed, with varying states of contusion
of skin and other soft tissue. Of the ten fractures seven
were cornminuted, one was segmental and two were
transverse. They were followed up for between 155 and
3 years.

A preliminary report was presented at Svenska LIkaresBllskapets RiksstBmma, Stockholm, 1-3 December 1982.

Fig. 1. A 25year-old man walking and bearing weight about 3

weeks after the accident.

Injury: the British Journal of Accident Surgery (1985) Vol. WNo.

372

ankle were started as soon as the general condition

allowed and the patients were out of bed with partial
weight bearing within a few days.
The femoral and tibia1 frames were removed at the
same time. This was done after an average of 9.8 (range
7-14) weeks, when the callus provided some stability.
A hinged cast-brace was then applied for an average of
3.6 (range 2-5) weeks. In four patients a below-knee
walking cast was thereafter applied for an average of
8.5 (range 4-12) weeks.

though this could be reapplied after about 14 days

without any recurrence of infection. Two weeks after
having discarded his cast-brace one patient fell heavily
and sustained an undisplaced fracture in the region of
the previous open fracture of the femur. The limb was
put in a cast-brace and the fracture healed in about 8
weeks. There was no case of adult respiratory distress
syndrome and no case of osteomyelitis. In one patient a
deep vein thrombosis in the calf was verified.
DISCUSSION

RESULTS
Mobilization

All patients were out of bed in a wheelchair or on

crutches within 2 weeks. Four of the five patients were
discharged from hospital within 6 weeks of injury. The
fifth patient, aged 84, became periodically mentally
disoriented and developed recurrent urinary tract
infections. After 16 weeks he was transferred to a
rehabilitation clinic, where he walked with the aid of
crutches.
Healing of the fractures

All fractures healed spontaneously without secondary

procedures. The average healing time for the femur
was 13.4 (range 11-16) weeks, and for the tibia 20
(range 13-26) weeks.
Alignment

of the fractures

Nine of the ten fractures healed with an angulation of

less than 10. One tibia healed with an angulation of
14. Shortening was in all cases less than l-5 cm and in
three patients less than 1 cm.
Movement

of joints

One and a half to three years after the injury two of the
five patients had a normal range of movement in the
knee. One patient had lost 15, while the remaining two
patients had a restriction of movement of 20. One of
these patients also had an avulsion fracture at the tibia1
end of the posterior cruciate ligament. The other
patient was already suffering from osteoarthritis. Two
patients had a normal range of movement of the ankle,
two patients lost 15 while one patient, who also had a
bimalleolar fracture, lost 20.
Functional

results

The patient with a bimalleolar fracture in the same leg

experienced mild pain in his ankle with strenuous
activities such as running 1% years after the accident.
Another patient with avulsion of the tibia1 end of the
posterior cruciate ligament had periodic swelling and
moderate pain from the knee. The three full-time
working patients were back to manual work within 11
months. One patient had reassumed his studies after
about 2 months. One patient, aged 84, was transferred
to a rehabilitation clinic after about 4 months. Until his
death 2% years after the accident he could periodically
live at home.
COMPLICATIONS

Three pin tracks became infected. Two of these healed

after systemic antibiotics and local toilet. In one case
the infection necessitated the removal of a frame

Patients with ipsilateral fractures of the femur and tibia

are often multiply injured, In these patients prevention
and treatment of pulmonary complications are of
utmost importance (Edwards, 1979; Browner et al.,
1981). The more mobile the patient, the easier the
physiotherapy for the chest. Furthermore, nursing of
wounds and preventing pressure sores are much easier
in a patient who is easy to turn in bed (Edwards, 1980).
Early and good stabilization of both the femur and the
tibia therefore seems attractive. This strategy is recommended by Karlstr(im and Olerud (1977a), who reported 31 patients and found early rigid fixation of both
fractures to give functional end results that were
superior to not operating on both fractures. The overall
complication rate was also lower in the former group.
In contrast, Fraser et al. (1978) demonstrated a 30 per
cent incidence of osteomyelitis among 27 patients when
both fractures were treated with internal fixation, but
they found a 30 per cent incidence of delayed union and
non-union in 99 patients when both fractures were
managed without operation. They recommended internal fixation of the femur and external tixation or
cast-bracing of the tibia. Hiijer et al. (1977) reported 21
patients and recommended early internal or external
fixation of the tibia and medullary nailing of the femur
after l-2 weeks because the risk of complications has
been reported to increase when medullary nailing is
performed immediately (Smith, 1964).
External fixation is now a well-established method of
treating open fractures of the shaft of the tibia
(Karlstriim and Olerud, 1977b; Krempen et al., 1979;
Jorgensen, 1980; Lawyer and Lubbers, 1980) and
primary external fixation of the femur was reported by
Edwards (1979), Karaharju and Santavirta (1979))
Slatis (1980) and recently by Dabezies et al. (1984).
Although the cases presentedhere are few, it seems
that external fixation has offered an opportunity for
early and stable fixation of fractures with a minimum of
operative injury, which is important in seriously ill
patients. Furthermore,
the stable fixation made the
patients easy to nurse and permitted effective physiotherapy for their chests. The patients were easy to
mobilize and active exercises could be started early.
There was no non-union, which can possibly be
attributed to early weight bearing and conversion from
external fixation to fracture bracing during the stage of
active healing of the fractures (Aho et al., 1983).
Shortening and restriction of joints mobility were
slight. The functional end results were also satisfy&g,
with four of the five patients back to their previous
activities within 1 year. We agree with Jorgensen (1980)
that ipsilateral fractures of the femur and tibia are an
indication for external fixation of the tibia, especially
when the fracture is cornminuted. We do not, however,

373

Rijtiser and Hansson: lpsilateral femoral and tibia1 fractures

advocate that the femur should be routinely treated by

external fixation because of the risks of stiffness and
non-union, both being well-known complications of
external fixation (Green, 1981). Closed medullary
nailing should, in our view, be the method of choice for
stabilizing the femur. However, if there is gross
comminution, or if it is desirable to stabilize the femur
in a critically ill patient, external fixation is an adequate
method that causes little damage.

Jorgensen E. T. (1980) Closed tibia1 fractures. In: Johnston

R. M. (ed.) Advances in External Fixation. Miami:
Symposia Specialists Inc., 11.
Karaharju E. 0. and Santavirta S. (1979) Treatment of
complicated fractures of the lower leg by osteotaxis. J.
Trauma 19, 719.

Karlstram G. and Olerud S. (1977a) Ipsilateral fracture of the

femur and tibia. J. Bone Joint Surg. 59A, 240.
Karlstriim G. and Olerud S. (1977b) Stable external fixation
of open fractures. A report of five years experiences with
the Vidal-Audrey Double-Frame method. Orthop. Rev. 6,
25.

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Requests for reprints should be addressed to: Bo Radser

Paper accepted 24 September

MD,

1984.

Department of Orthopaedics, University Hospital, S-221 85 Lund, Sweden.