Skin traction for reduction of a cervico-trochanteric fracture with below-knee amputation and knee stiffness: a case report

¹Department of Orthopaedics and Traumatology, Military Hospital Moulay Ismail, BP 50000, Meknes, Morocco

^&Corresponding author
Mouad Guenbdar, Department of Orthopaedics and Traumatology, Military Hospital Moulay Ismail, BP 50000, Meknes, Morocco

Introduction    

Trochanteric femur fractures are generally treated by closed reduction and internal fixation with a dynamic hip screw or an intramedullary device using a fracture table [1,2]. These fractures when encountered in patients with below-knee amputations raise a specific issue concerning positioning on the fracture table [3]. We present a case of cervico-trochanteric fracture in patient with below-knee amputations. The inverted boot method could not be applied because the range of motion of the knee was limited that is why we used a skin traction to reduce the fracture. Furthermore, a manual traction is very difficult and a skeletal traction method is related to the different risks.

Patient and observation     

A 60-year old gentleman, who was presented to the emergency department with a complaint of left hip pain after a high-speed motorcycle collision, denied any loss of consciousness and had no immediately life-threatening injuries. He is a war veteran who was victim of a traumatic left below-knee amputation 30 years ago following land-mine injury. Until the accident, the patient was completely independent with a prosthesis.

Diagnostic assessment

Radiographs and CT scan of his pelvis is consistent with a minimally displaced cervico-trochanteric fracture of the left hip (Figure 1). An intramedullary fixation with a short femoral nail was planned, but the question was how to position the patient on the fracture table for the surgery, particularly given that our patient had a limited knee flexion (0-70°).

Therapeutic intervention

The surgical treatment by closed reduction and internal fixation was performed 24 hours after the accident. After spinal anesthesia, the patient was placed supine on a radiolucent fracture table with the legs placed in a scissored position. A well-padded perineal post was used. Then, we strapped the below-knee stump of the affected limb to the boot of the traction table by an adhesive bandage. This strapping was extended from the boot to 3 cm proximal to knee (Figure 2). Reduction manipulation was performed. First, a sufficient amount of traction and then internal rotation were done. We fixed the fracture using short femoral nail. In the intraoperative radiography, the reduction and the position of the nail were satisfactory (Figure 3, Figure 4). Postoperatively, the rehabilitation was started on the next day.

Follow-up and outcomes

There was no complication diagnosed. After three months, the functional outcome was satisfactory: The patient is independent again and can walk with full weight bearing using prosthesis. Thus, the healing of the fracture was achieved.

Informed consent: informed consent was obtained from the patient.

Patient perspective: the patient was initially thought that the fracture could be reduced and fixed using this safe technique.

Discussion     

Different methods have been described for patients with a below-knee amputation to obtain reduction of intertrochanteric femur fractures. Patients with below-knee amputations and trochanteric femur fractures on the ipsilateral side have a specific issue: positioning the leg on the fracture table is difficult because of the absence of the foot [3]. We dealt with a minimally displaced cervico-trochanteric fracture in a relatively young patient (60 years old). The operative treatment was performed urgently, aiming at obtaining and maintaining anatomic alignment with stable fixation to allow early patient mobilization so as to resume his preinjury level of function. An intramedullary nail with fixation inserted into the femoral head (cephalomedullary fixation) was used and could usually be performed through small incisions with fluoroscopic guidance.

Conclusion     

Hip fracture reduction in a patient with below-knee amputation poses a surgical challenge. The skin traction method is simple and allows achieving and maintaining safe reduction during fixation especially in patients with limited range of motion of the knee.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

MG and MB wrote the article. TC and HZ have reviewed the literature. JL and LA are responsible for the corrections. All authors have read and approved the final manuscript.

Figures     

Figure 1: CT scan of pelvis and anteroposterior radiographs of left hip showing a minimally displaced cervico-trochanteric fracture of the left hip

Figure 2: positioning of patient on traction table; strapping and securing of stump onto traction boot using elastic adhesive bandage

Figure 3: intraopertative anteroposterior radiographs of left hip; the reduction and the position of the nail were satisfactory

Figure 4: intraopertative lateral radiographs of left hip; the reduction and the position of the nail were satisfactory

References