Repair of the left femoral fracture

	Internal fixation is preferred for the femur due to the difficult access.  The 
recommended approach for femoral fracture repair is an interlocking nail.  Interlocking 
nails are recommended for diaphyseal fractures of the femur, humerus and tibia.  Before 
performing the surgery, we would take radiographs of the contralateral femur to estimate 
the size of the femoral medullary cavity to select the appropriate diameter and length of 
the nail.  The nail serves as a buttress to prevent the collapse of the fracture.  The screws, 
which are placed through the nail, provide rotational stability.  We would be careful to 
place the nail deep within the trochanteric fossa to avoid damaging the gluteal muscles 
and the sciatic nerve.  Also, the hip joint must be positioned in extension and adduction 
when the proximal screws are placed to avoid the sciatic nerve.
 
	The nail is placed across the fracture site into the most distal fragment.  Using 
small stab incisions, the screws are placed into the bone.  Care must be taken to avoid 
disturbing the developing hematoma as this provides scaffolding for macrophages, 
fibroplasia and angiogenesis.  The smaller bone fragments can either be left in place or 
reduced.  The distal screws are placed first; then, once the proper rotation, alignment and 
bone length are confirmed, the proximal screws are inserted.  Cerclage wires can be 
placed after the screws are in place depending on the degree of fragmentation.  These 
wires stabilize fissure lines and fragments.  However, cerclage wires can disrupt the soft 
tissue and hematoma so they should only be used when absolutely necessary.  

	The complications associated with interlocking nails include sciatic nerve 
damage, delayed union, nonunion, and nail breakage.  Nail breakage usually occurs at the 
proximal screw hole in the distal fragment.  The nail breaks because the screw holes are 
the weakest points of the nail.  To avoid this, you should choose a correctly-sized nail and 
place the screws away from the fracture site.  Delayed union can occur if the hematoma 
or surrounding soft tissue is significantly disturbed during the procedure.  The soft tissue 
is responsible for providing the blood supply to the fracture site during the first ten days.  
Without the appropriate blood supply, the growth factors and fibrin are not carried to the 
fracture site.  Also, sciatic neuropathy can occur.

	If everything goes as plans, union should occur in eight weeks and this should be 
confirmed radiographically.

Repair of the Right Tibia

Because the tibia is a very accessible area with little tissue coverage, an 
external fixation is preferred. This technique will less likely induce infection, preserve 
the boneÕs blood supply, and allow us to adjust the fixation later in healing if 
necessary. This type of fixation wonÕt impinge on other parts of the body. The 
fracture should first be reduced with closed reduction because of the comminution 
(bones broken into many small fragments are highly susceptible to infection), and 
the fact that the patient is only 17 months old (rapid healing). We will place six 
threaded pins, three above and three below the fracture (the pins adjacent to the 
fracture will be at least a centimeter from the fracture itself), being careful to avoid 
incorporating any overlying structures such as muscles, vessels, or nerves. The pins 
will be placed via power driving to help control their placement more effectively, but 
at a low enough speed and with enough patience to avoid excessive heating which 
will result in necrosis. Because rigid metal sidebars require somewhat specific pin 
placement, we will instead use corrugated plastic tubing along either side of the limb 
(at least 1 cm from the skin) and fill it with acrylic/composite. The tubing is placed 
over the pins, then radiographs should be taken to view correct alignment following 
fracture reduction before injecting the acrylic into the tubing mold. While the acrylic 
is hardening (8-10 minutes), a metal side bar can be used on the opposite side to 
prevent movement. The hardening is an exothermic reaction; cold water can be used 
to cool the connecting bar and reduce damage from heat. Acrylic-filled tubing will be 
used on both sides of the limb. Postoperative care is very important in the case of 
external fixation and is described in Client Education. 
Unloading of the frame can be started if a good callus is present at the 6 
week radiographic recheck.  Complete removal is done when bony bridging is visible 
radiographically.
The most common complications of this procedure are pin tract sepsis, which 
can result in osteomyelitis, and premature pin loosening, from improper insertion, 
pins in fissure lines, improper pin size, excessive patient activity. Pressure necrosis 
of the skin from placing external fixators too close to the skin to allow sufficient 
swelling, iatrogenic bone fracture from placing pin to close to the fracture line, and 
soft tissue impalement (pins through muscle, tendon, nerves, vessels).