DISTAL FEMORAL FRACTURE
Can you describe the radiographs?
This is a highly comminuted distal femoral fracture. There is gas in the soft tissues as well as within the joint, therefore most likely representing an open fracture. The open nature of the injury, plus the degree of comminution and displacement sug- gests this is an extremely high-energy injury.
The patient is found to have a cold and pale foot in the emergency department. How would you proceed?
This is an emergency situation. The patient must be assessed and concurrently resus- citated along ATLS guidelines. This may represent a serious arterial injury although spasm or kinking of the vessel may be responsible. Life or limb-saving intervention may be required emergently.
The neurological status of the limb should be assessed as well as the vascular sta- tus examined for warmth, pulses and capillary refill. The limb should be realigned and splinted. Open fracture treatment guidelines should be followed.
Following temporary revascularisation and debridement, I would reassess the wound, soft tissues and the overall patient condition. If suitable for primary fixation I would apply a site-specific, distal femoral plate through a direct lateral approach to stabilise the fracture in a reduced position; otherwise, I would apply a temporary external fixator spanning the knee.
What are the features of critical ischaemia in a limb?
The six Ps are indicative of critical ischaemia and should be looked for when per- forming a vascular status assessment in any fracture. There are three symptoms (pain, paraesthesia, paralysis) and three signs (pale, pulseless, perishingly cold).
How would you manage this injury in the operating theatre?
This would be a joint case with involvement of the vascular surgeons and the plas- tic surgery team due to the open nature of the injury. The primary aim of surgery is to restore blood flow to the affected limb, and this is achieved using an extra- anatomical shunt, therefore minimising the warm ischaemic time. I would then turn my attention to skeletal stability, which is required prior to definitive vascular repair or grafting. My approach with this injury would be to apply standard open fracture treatment with a systematic debridement and washout of the open wound, in addition to washout of the knee joint itself if gas is present on the radiographs. I would apply a site-specific, distal femoral plate through a direct lateral approach to stabilise the fracture in a reduced position.
Once skeletal stability is secured, this allows the vascular surgeons to complete their procedure with a formal repair or graft, without the problem of fracture insta- bility. Where the warm ischaemic time has been greater than 6 hours, compartment syndrome secondary to reperfusion syndrome is likely: prophylactic fasciotomies of the leg (two incision, four compartment) are therefore performed.
Given the above information, how would you classify this open fracture?
Using the Gustillo and Anderson open fracture classification, this is a grade 3C: An open fracture with an arterial injury requiring repair