192 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
FEMUR
CHAPTER 73Application of an External Fixator
to the Femur
INDICATIONS affected limb up. Drape the limb out from a hanging position to
Candidates include animals with single or comminuted femoral allow maximal manipulation during surgery. Prepare the ipsilat-
diaphyseal fractures. eral proximal humerus or ilial wing for harvesting a cancellous
bone graft.
OBJECTIVES
• To achieve anatomic reduction of single fracture lines or PROCEDURE
restoration of normal bone alignment for comminuted Approach: Incise the skin and subcutaneous tissue on the
fractures lateral surface of the thigh, from the greater trochanter to the
The stiffness of the fixator can be increased for animals with femoral condyles. Incise the tensor fascia lata along the cranial
low fracture-assessment scores by adding fixation pins, incor- border of the biceps femoris to expose the vastus lateralis and
porating an intramedullary (IM) pin or using biplanar frames.1 biceps femoris muscles.2 Retract the muscles to expose the
The IM pin and fixator combination resists axial loading, femur (Plate 73A). Insert the IM pin into the proximal femur in
bending, and rotational forces at the fracture. either a normograde or retrograde manner. Use an “open but do
not disturb the fragments” technique to expose the proximal
ANATOMIC CONSIDERATIONS and distal bone segments with minimal disturbance of the frac-
The narrowest part of the medullary canal, the isthmus, is ture hematoma and bone fragments for nonreducible fractures.3
located within the proximal third of bone, just distal to the third Incise the skin, and create soft tissue tunnels to the bone for
trochanter. The distal femur has a pronounced cranial bow in fixator pin placement.
most dogs, but it is straight in the cat. Both anatomic features Reduction: Place an IM pin (sized to equal 60% to 70% of
constrain the size of IM pin selected. The trochanteric fossa is the medullary canal at the isthmus) in the proximal segment.
directly in line with the medullary canal, allowing normograde Retract the pin within the medullary canal of the proximal seg-
or retrograde placement of an IM pin. The adductor magnus ment. Reduce transverse and short oblique fractures by tenting
muscle attaches to the caudal surface of the femur and serves the bone ends and levering the bone back into position. Reduce
as a guide for rotational alignment. Additionally, the greater long oblique fractures by distracting the bone segments and
trochanter is 90 degrees to the patella when the femur is in approximating the fracture surfaces. Use pointed reduction for-
correct rotational alignment. The proximity of the abdomen ceps to manipulate the bone segments into reduction. Drive the
prohibits use of bilateral frames in the proximal femur. pin distally to seat in the femoral condyle. Maintain the reduc-
tion manually for transverse fractures and with pointed reduc-
EQUIPMENT tion forceps for oblique fractures. Reduce comminuted
• Surgical pack, Senn retractors, small Hohmann retractors, nonreducible fractures by distracting the distal femur with the
Gelpi retractors, Myerding retractors, periosteal elevator, IM pin and aligning the major segments of the bone (see Plate
Kern bone-holding forceps, pointed reduction forceps, Jacob 73A). Be sure to restore length and normal rotational alignment
pin chuck, IM pins, low-speed power drill, external fixation to the bone.
equipment, pin cutter, bone curette for harvesting graft Continued
PREPARATION AND POSITIONING
Prepare the rear limb circumferentially from dorsal midline to
tarsus. Position the animal in lateral recumbency, with the
CHAPTER 73 A P P L I C AT I O N O F A N E X T E R N A L F I X AT O R T O T H E F E M U R 193
P L AT E 7 3
Vastus
lateralis
muscle
retracted
Biceps femoris
muscle retracted
Shaft
of femur
Adductor magnus
Vastus muscle
intermedius
muscle
A
194 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
Stabilization: Apply an IM pin and a type Ia external monitor healing. The fixator should be destabilized by removing
fixator to the lateral surface of the femur. Place fixation pins in the unilateral frame (from a type Ia and IM pin combination) or
the metaphysis of each segment and close to the fracture line. the cranial frame (from a modified type Ib fixator) when bone
The external fixator can be connected or tied in to the IM pin to bridging is observed. If a tie-in is used, the top fixation pin and
strengthen the fixation (Plate 73B).4 Apply a modified type Ib its connection to the IM pin should be retained. The IM pin, the
external fixator and an IM pin to a comminuted nonreducible remaining external fixator, or both should be removed when the
fracture.5 Place a cancellous bone autograft at the fracture site fracture has healed.
(Plate 73C). Long oblique fractures benefit from cerclage wire
or lag screw fixation in addition to the IM pin and external EXPECTED OUTCOME
fixator (Plate 73D). Bone healing is usually seen in 12 to 18 weeks, depending on
fracture and signalment of the animal. The animal will experi-
CAUTIONS ence limited function while the external fixator is in place but
It is important to avoid major nerves, vessels, and joint surfaces should eventually have a good return to function.
with the fixation pins and to avoid the distal joint surface with
the IM pin. The range of motion of the stifle should be palpated
to detect pin interference in the joint. Rotational alignment References
should be monitored during the realignment of comminuted
1. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and
fractures. fracture management: Decision making in fracture management. In
Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis, Mosby,
POSTOPERATIVE EVALUATION 2002.
Radiographs should be evaluated for bone alignment and 2. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
implant placement. Rotational malalignments should be cor- Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
rected by loosening the clamps and realigning the fixation pins Saunders, 2004.
on the connecting bar. 3. Aron DN, Palmer RH, Johnson AL: Biologic strategies and a bal-
anced concept for repair of highly comminuted long bone fractures.
POSTOPERATIVE CARE Compend Cont Educ Pract Vet 17:35, 1995.
4. Aron DN, Dewey C: Experimental and clinical experience with an
Gauze sponges should be packed around the pins, and the
IM pin external skeletal fixator tie-in configuration. Vet Comp
sponges should be secured with a bandage. The animal should Orthop Traumatol 4:86, 1991.
be confined, with activity limited to leash walking. External 5. Aron DN: External skeletal fixation system application to the
fixator management includes daily pin care and pin packing as humerus and femur. In Proceedings of the 10th Annual Complete
needed. Physical therapy is needed to restore stifle range of Course in External Skeletal Fixation, University of Georgia,
motion. Radiographs should be repeated at 6-week intervals to 127–141, 2002.
CHAPTER 73 A P P L I C AT I O N O F A N E X T E R N A L F I X AT O R T O T H E F E M U R 195
P L AT E 7 3
Cancellous
bone
autograft
C D
