206 Injury, 8.

206-212

Printed in Great Britain

Combined fractures of the femoral and

tibia1 shafts in the same limb
Ii. HCjer, J.
Department

Gillquist and S.-O. Liljedahl

of General Surgery, University Hospital, Linkliping,

Summary

This paper reports a study of ipsilateral fractures of

the femoral and tibia1 shafts in 21 patients treated
according toa detailed planincluding shock treatment,
prophylaxis against fat embolism, soft-tissue and
fracture treatment.
Death due to hypovolaemic
shock was eliminated and the incidence of fat embolism (93 per cent) reduced in comparison with an
earlier series. The tibia1 fracture was stabilized by
plaster or internal fixation as soon as conditions
allowed. In most cases the femoral fracture was
treated by medullary nailing. Results have improved
compared with earlier series. All fractures healed
within 15 months, and functional end results have
been excellent in the majority of the surviving
patients (89 per cent).

INTRODUCTION
THE INCREASING number

of road

accidents

Table 1. Plan for treatment of combined shaft

fractures of the femur and the tibia in the same leg
1. Aggressive prophylaxis or treatment in hypovolaemic shock
2. Prophylaxis against fat embolism
3. The tibia1 fracture should be fixed as soon as the
general condition of the patient permits
4. Treatment of the femoral fracture with traction for
7-14 days followed by medullary nailing
5. Soft-tissue injuries should be treated by wound
excision and the wound allowed to heal by
secondary intention

Table /I. Number and type of operations in 21

patients with ipsilateral femoral and tibia1 shaft
fractures

has

fractures in the same leg, caused

by high-energy violence, more common. As
victims of traffic accidents often have associated
injuries taking immediate precedence over the
treatment of long-bone fractures, conservative
treatment with traction or plaster casts has been
the policy followed in many places. Combat
injuries handled successfully with spicas, as well
as legal aspects, have no doubt influenced this
philosophy in the United States (Burkhalter and
Protzman, 1975).
Omer et al. (1968) reviewed the problem of
combined fractures of the femur and the tibia in
the same leg. Their report gave one of us the
impulse to undertake a retrospective study of 52
patients with this combination
of fractures,
treated at four different Swedish hospitals from
1951 to 1970, which included 25 cases from our
hospital (Gillquist et al., 1973). A definite plan
made multiple

Sweden

Type
Laparotomy
Urethral rupture repair
Blackburn skull traction
Tracheostomy
Internal fixation
Total

No. of
operations
4
1
:
9
17

No. of
patients
2
1
:
7
12121

of treatment
for fractures of the shaft of the
femur and the tibia was considered essential to
achieve acceptable functional end results. We
have outlined such a plan (Table I).
A review of our results after treatment according to this plan should be of a more general
interest, as this type of injury continues to
increase in number.
In this report we have examined 21 patients
treated accordingly.

Hojer et al. : Femoral and Tibia1 Fractures

no=4

n dd7
I
0

20

21
30

In
31
40

41

50

51

so

61
70

age

Fig. 1. Sex and age distribution in 21 patients with

ipsilateral fractures of the femur and tibia.

CASE SERIES
This series comprises all patients with combined
fractures of the tibia and femur who were alive
on admission and treated between 1970 and 1974
at the Department of General Surgery, University
Hospital, Linkoping. It consists of 21 patients,
4 women and 17 men. Two patients had bilateral
fractures of both the femoral and the tibia1
shafts. The mean age was 40 years. The age and
sex distribution is shown in Fig. 1. It does not
differ significantly from the earlier series.

Bc
Fig. 2. Cause of injury in 21 patients. MC, motor-cycle
accident; Bc, bicycle accident; Ped, pedestrian run
over by car; Car, car accident.

Aetiology
Traffic accidents caused all the injuries. Unprotected groups such as motor-cycle riders and
pedestrians constituted 72 per cent of the patients
(Fig. 2).

Type of injuries
The fracture of the femur was open in 9 cases and
the fracture of the tibia in 12. Three patients
also had fractures of the pelvis or hip joint. The
accidents in this series resulted in many associated
injuries (Fig. 3).
Peripheral circulatory collapse was present in
20 cases. Brain injuries occurred in 48 per cent,
and 58 per cent of the surviving patients required
one operation or more in addition to those
performed on the injured leg (Table II). The
average number of injuries, including those
requiring no specific treatment, was 4.6 per
patient (Fig. 4).
Treatment
General
As initial treatment we gave Ringers lactate or
acetate while waiting for blood. Liberal replacement with blood and sometimes with plasma, in
many cases with guidance from blood volume

Fig. 3. Associated injuries requiring specific treatment

in 21 patients. The number of fractures in the limbs,
and the abdominal, thoracic and skull injuries are
shown as well as open fractures of the femur and tibia.

measurements, was the rule. Prophylaxis against

fat embolism
according
to Liljedahl
and
Westermark (1967) was given initially to all
patients save two (Tables ZZZand IV). Heparin
was withheld in cases of intracranial injury and
on suspicion of internal haemorrhage.
Fracture of the femur
During the first week, traction through the tibia1
tuberosity was used to maintain a satisfactory

208

IrIjury: the British

Journal

of

Accident Surgery Vol. ~/NO. 3

0
5

plaster

d b
A0

MN
Fig. 4. Treatment of 23 femoral shaft fractures

pleater
&g. 5. Treatment of 23 tibia1 shaft fractures in 21
patients. A0 = dynamic compression plate; Vidal =
external fixation according to Adrey-Vidal; t = preoperative death.

patients.
death.

Table IV. Prophylaxis against fat embolism

MN = medullary nailing;

in 21
t = preoperative

Table ///. Fat embolism

No. of
patients

Present upon admission

Verified at autopsy
Clinically suspected
Initial prophylaxis given
Fat embolism
Initial prophylaxis not given
Symptoms disappeared upon treatment

1
1
17121
0
2
1

position
of the fracture.
After l-2 weeks of
traction, 11 cases were treated by medullary
nailing with a clover-leaf nail after reaming.
Additional
internal
fixation with encircling
wires was used in 3 comminuted
fractures.
Immediate nailing was done in 3 cases. In 5
instances traction
was continued
until the
fractures healed. The fracture was unsuitable
for medullary nailing in 3 of these cases (liig. 4).
Fracture of the tibia

Five cIosed fractures with no tendency to displace

were treated from the beginning by closed reduction and plaster. Immediate open reduction and
internal fixation with an A0 compression plate
was used in 5 patients. In 5 cases with associated
injuries, after these and soft-tissue lacerations
had been dealt with, traction was followed by
elective internal fixation with an A0 compression

1. Adequate ventilation with monitoring of Pcoz,

PoZ and pH. Respirator without delay
2. Daily thrombocyte count and chest radiography
3. Heparin i.v. 2500 IUx6,
starting 8 hours after
the accident
4. o-receptor-blocking
substances (i.e. Hydergin
(Sandoz) 1.2 mg or chlorpromazine 100 mg in a
lytic cocktail containing 50-I 00 mg pethidine or
50-75 mg promethazine/lOO
ml 5.5% glycose)
5. Infusion of carbohydrate-containing
solutions
(200 g of carbohydrates daily). A daily calorie
intake of up to 2000 Kcal

plate. External fixation according to Adrey-Vidal

(Connes, 1973) was used in 3 cases because of
extensive lacerations of the soft tissues (Fig. 5).

FOLLOW-UP
Final examinations were undertaken after radiological healing of both fractures, between 9
months and 4 years after the accident. Limitations in the range of movement of the hip, knee
and ankle joints were recorded. Deformities in
the fracture area were measured on the X-ray
films and by clinical examination of the patient.
Subjective symptoms including limitations
at
work and leisure were recorded, as well as the
interval between accident and return to work.
Results were classified as excellent when the
range of movement was normal in the adjacent
joints, and when deformity and major subjective

Hajer et al. : Femoral and Tibia1 Fractures

209

Table V. Complications

100
I

Femur
Infection

New injury leading to

malposition
Refracture
Plate fatigue fracture
Delayed healing

Tibia
4
(3 cases of
external
fixation)

?J 50%

1
1

1
1
2
6

symptoms causing limitations

were lacking.

at work or leisure

RESULTS
Two patients died before operation could be
performed, one a few hours after admission from
a cerebral injury and the other after a week from
septic shock originating in a pulmonary infarction. A third patient with severe brain injuries
died 3 months after the accident without having
regained consciousness.
Fat embolism
In 2 patients symptoms developed within the first
few hours, before treatment had been instituted.
The diagnosis in one case was verified at postmortem examination.
The second case died
3 months later and there were no signs of fat
embolism in the brain at autopsy.
Initial prophylaxis was provided for 17 patients
(Table III) and all remained free of symptoms.
Two cases did not receive initial prophylaxis, and
one developed mild symptoms, which disappeared
after initiating treatment. Fat embolism was
never the sole cause of death.
Fracture of the femur
All fractures healed within a normal time, after
4-12 months. There was no case of delayed
healing or pseudarthrosis. Complications were
few (T&e V). There were 2 infections, 1 of
which was deep but healed after removal of a
sequestrum. This infection probably originated
from an infected soft-tissue injury in the leg. The
second case had a superficial infection which
healed quickly after treatment. A new injury a
few weeks after operation resulted in rotational
malposition in one patient. Fracture of a compression plate occurred in an insufficiently
stabilized concomitant
supracondylar
fracture.

12

16

24

30

36 months

Fig. 6.

Interval between the accident and return to

work in 15 patients. Only surviving and unretired
patients have been included.

loo-

-.I
e
8
t

50-

;
6

12

18

24

30

36 months

Fig. 7.

Interval between the accident and radiological

healing in both fractures. -,
represents the present
series 1970-4; - - -, represents an earlier series from
the same hospital 1951-69.

A medullary nail was inserted, and the fracture

healed 12 months after the accident.
Fracture of the tibia
There were 2 cases of delayed healing. One of
these patients, treated with external fixation, had
a severe soft-tissue laceration combined with
loss of bone substance. Primary amputation
would probably have been a better solution.
The second fracture, initially treated with plaster,
healed uneventfully after fixation with an A0
compression plate at 6 weeks. One refracture
occurred immediately after the removal of the
external fixation apparatus. This fracture healed
after osteotomy of the intact fibula and treatment
with a patellar-tendon-hearing
plaster. Postoperative infection was seen in 4 patients with
open fractures. Three were deep and they all

Injury: the British Journal of Accident Surgery Vol. ~/NO. 3

Fig. 8. 51.year-old female, with a closed short oblique fracture of the femoral shaft, a closed tibia1 shaft

fracture and a fracture-dislocation of the head of the humerus. Immediately after admission open reduction
and internal fixation of the humerus and tibia was performed, and reaming and nailing of the femoral
fracture after a week. X-ray films show: a, Anteroposterior views before and after fixation. b, Lateral
view before and after fixation.
Tab/e W. Functional end results in

Excellent
New injury (malposition)
Non-classifiable
Primary mortality
No. of patients

21 patients

Femur

Tibia

16
1

17

:
21

1
3
21

sequelae of the accident have made a return to

work impossible.
The interval between the accident and radiological union in this series has been compared
with a series treated between 1951 and 1969 at
the same hospital (Gillquist et al., 1973). The
interval was significantly shorter in the present
series (P<@Ol) (Fig. 7).
Radiographs of a typical case are shown in
Fig. 8.

developed in fractures treated with external

fixation. Removal of the apparatus after fracture
union healed these infections. The use of the
wrong types of screws caused inadequate rigidity
and fracture of one compression plate. This
fracture healed after replating (Table V).
Clinical healing course
Of the surviving patients, 67 per cent were in
hospital for more than 2 months, but only 22 per
cent for more than 4 months. The interval
between accident and return to work is shown in
Fig. 6. Thirteen surviving patients have returned
to work, 3 patients are retired and in 2 cases

Functional end results were excellent in 16

patients with 17 fractures of the femur. One
patient had a severe rotational deformity after a
new injury and reoperation is planned. One
patient with bilateral fractures and concomitant
intra-articular injuries to the knee joints cannot
be classified (Table VZ).
In 17 patients with 18 fractures of the tibia the
results were excellent. The above-mentioned
patient with severe soft-tissue injury was considered non-classifiable (Table VI).
DISCUSSION
Improved methods

of shock

treatment

have

HBjer et al.

: Femoral

and Tibia1 Fractures

increased the survival rates after traffic accidents.

This means that more patients have to be
treated for multiple fractures of the long bones
and that this type of injury has become a common
therapeutic problem.
Comminuted
fractures and extensive softtissue injuries caused by high-energy violence in
traffic accidents are common. Associated injuries
to the thorax and the abdomen require immediate
attention and delay in the definitive treatment of
long-bone fractures.
In this series, as well as in earlier series (Omer
et al., 1968; Gillquist et al., 1973), severe abdominal and thoracic injuries have been present in
20 per cent of cases. Elderly pedestrians and
young motor-cycle riders were the two groups
most frequently involved.
The primary mortality was 9.5 per cent, which
is lower than the 13 per cent in the previous
series (Gillquist et al., 1973). Causes of death
were mainly the same, with the exception of
hypovolaemic shock. In the previous study hypovolaemic shock caused 37.5 per cent of the
deaths. Of prime importance is a well-trained
and rapid ambulance service so that shock
prevention can be started early by giving balanced
salt solution infusions. Despite watching out for
extensive blood loss and liberal replacement
with blood, we underestimated the amount of
lost blood in some of these patients. Repeated
determinations of the circulating blood volume
are of great importance during replacement.
Fat embolism continues to be a serious event
in patients with multiple fractures of the long
bones. Gillquist et al. (1973) reported an incidence
of 13 per cent in a series of identical injuries,
when all cases dying immediately after admission
were included. In our series all patients alive on
admission have been excluded, and the incidence
is 9.5 per cent. Prophylactic treatment against fat
embolism (Liljedahl and Westermark, 1967) was
received by nearly 90 per cent of eligible patients.
Among these, there was no single case of fat
embolism, which is in agreement with the results
achieved at Karolinska Sjukhuset (Gillquist et
al., 1973).
The combination
of hypovolaemic
shock,
severe brain injury and early appearance of fat
embolism, verified in one case and suspected in
another, represents a category which seems to
be beyond therapy. Our second case of verified fat
embolism had mild symptoms, which disappeared
after the commencement of treatment. Thus, the
prophylaxis described by Liljedahl and Westermark (1967) has been effective in these patients.
Our preference for primary internal fixation

211

of the tibia1 fracture was enhanced by the introduction

of the dynamic compression
plate
(Allgiiwer et al., 1970) and the fact that postoperative infection, although still a serious matter,
is no longer a disaster, when treated according to
the principles outlined by Willenegger (1970).
These authors have shown that infection can be
controlled by antibiotics if the internal fixation
is rigid.
Omer et al. (1968) stated that non-operative
management of both the tibia and the femur
was safest and most reliable, even if requiring a
somewhat longer time in hospital. However,
internal fixation of the tibia1 fracture within the
first week improved the results (Gillquist et al.,
1973). In the previous series, primary suture after
excision of damaged tissue often led to infection
and necrosis. In this series the majority of wounds
have been left open to heal by secondary intention after wound excision.
We regard immediate open reduction with
internal fixation as the best method of avoiding
further soft-tissue damage, reducing the infection
rate and healing the fracture in a correct anatomical position.
Immediate gross reduction and splinting with
a vacuum pad (Camp Vat) should be done in
the emergency room. As soon as conditions
allow, definitive fixation should be provided, and
we prefer the A0 DCP (dynamic compression
plate), because of the limited exposure required
for a rigid fixation. In cases of extensive tissue
damage, heavy comminution
or loss of bone,
external fixation should be applied without delay,
using the method of Adrey-Vidal (Connes, 1973).
The wound is left open under rigid aseptic conditions for later split-thickness grafting or a crossleg flap.
Closed and stable fractures of the tibia should
be immobilized in plaster as soon as possible,
if necessary in combination with transfixion pin
or wires. Later a patelar-tendon-bearing
plaster
according to Sarmiento (1967) is applied.
Our present opinion is that the femoral shaft
fracture should be treated by traction followed
by delayed internal fixation after l-2 weeks.
This is based on the results reported by Smith
(1964) and by Tophoj and Sorensen (1968), as
well as on our own experience. A concomitant
thoracic injury, when the leg is better mobilized
to ease nursing, is an exception. We have mainly
used primary medullary nailing without reaming
in such cases. In elective operations reaming
has been the rule, with the exception of very
young patients and badly comminuted fractures.
Reaming has reduced the risk of nail impaction.

Injury: the BritishJournal of Accident Surgery Vol. ~/NO. 3

212
It offers greater stability and demands perhaps a
shorter period of time before full weight bearing
without support can be allowed (DanckwardtLilliestriim, 1972; Hcjer and Liljedahl, 1977).
Rates of infection and healing disturbances have
not differed between the two methods.
Following this policy we have achieved results
that are superior to those of an earlier period at
this hospital and to those reported by Omer et
al. (1968) and Gillquist et al. (1973). Hospital
stays have been shortened, full weight bearing
without support has begun earlier, and the
interval between the accident and the return to
work or school has been reduced significantly,
REFERENCES

for reprinfsshould

Acta Chir. &and. 111, 177.

Omer G. E., Mall J. H. and Bacon W. L. (1968)

Combined fractures of the femur and the tibia in a
single extremity. J. Traama 7, 1026.
Sarmiento A. (1967) A functional below the knee cast
in tibia1 fractures. J. Bone Joint Surg. 49A, 855.
Smith J. (1964) The results of early and delayed
internal fixation of the shaft of the femur. J. Bone
Joint Surg. 46B, 28.

Allgijwer M., Perren S. M. and Matter P. (1970) A

new plate for internal fixation. The dynamic
compression plate (DCP). Injury 2,40.
Burkhalter W. E. and Pro&man R. (1975) The tibia1
shaft fracture. J. Trauma 15,785.
Cannes H. (1973) Hoffmans Double Erame External
Anchorage. Paris, Gead.

Requests
Sweden.

Danckwardt-Lilliestrijm G. (1972) Intramedullary

nailing of femoral shaft fractures after reaming of
the medullary cavity. Acta Chir. Stand. 139, I55.
Gillquist J., Rieger A., SjSdahl R. et al. (1973)
Multiple fractures in a single leg. Acta Chir. Scund.
139, 167.
Hiijer H. and Liljedahl S.-O. (1977) To be published.
Liljeclahl S.-O. and Westermark L. (1967) Etiology
and treatment of fat embolism: report of 5 cases.

Tophiij K. and Siirensen F. (1968) Osteosynthesis

coreoris femoris a.m. Ktintscher: 59 tilfaelde.
Noid. Med. 80, 1550.

Willenegger H. (1970) Klinik und Therapie der

pyogenen Knocheninfektion. Chirurg. 41,215.

be addressed to: Dr Henning Hiijer, Department of Surgery, University Hospital, S-581 85 Linkaping,