To traction splint or not to traction splint?

[Luno]

You would think...

in fact, I never heard of a spiraled femur. It's usually mechanical force which if strong enough to snap the thighbone, is strong enough to squish everything in between and often open it up.

Interestingly enough, it's not necessarily high energy mechanical force (impact). I have to dig into my research which is on another computer, but spiral femur fx are quite common abuse injuries with in the infant/toddler age group, and are relatively common in skiers. The femur as a bone is protected from impact by muscle, however it is very brittle and doesn't withstand rotational force very well. If I remember correctly, and I have to double check my research, to spiral fracture a femur, all it takes is 103 ft/lbs of torque, and .5 degrees of rotation. As a side note, alot of the high energy trauma (direct impact) are not open as far as I've seen personally, having worked on several...

 

[mycrofft]

I didn't work around skiers (eastern Nebraska, go figure), and both fx's I personally treated had near-emergence of the bone end. (One fell as above, the other ran full running in the dark the dark into a thigh-hig steel railing painted black) .

Spiral fx of the femur in child or infant (not totally ossified) abuse?

And skiers...I imagine if the femur goes like that, associated structures are going to be jacked as well? (knee, hip acetabulum).

 

[zmedic]

I was ski patrol for 9 years, all the spiral fractures I saw on skiers were of the tibia. The only femur fractures I've seen on skiers were from hitting something like a tree. Not saying it's not possible, but especially with modern bindings its very rare to have spiral fractures in general, femurs especially.

 

[mycrofft]

Something's wrong with a website about femur fx

http://femurfractureguide.com/fracturetypes.php

They state skiing accidents cause spiral fx of femurs and are the most common form. They also say it can be a sign of child abuse.
THEN they go on to say comminuted fx's are very common in car accidents; I will bet you a doughnut there are more MVA's by a wide margin versus skiing accidents or child abuse cases resulting in a femur fx.

Quote about comminuted fx:
"The comminuted femur fracture is a break in which there are three or more fragments of the femur resulting from tremendous pressure. These are very common in car accidents. Comminuted femur fractures can be especially difficult to treat, as the fragments can make things complicated for the doctor".Sounds like a layperson or maybe a trolling lawyer?

They solicit people's stories, have a blank FAQ. :nosoupfortroll:

 

[Luno]

You would think...

I was ski patrol for 9 years, all the spiral fractures I saw on skiers were of the tibia. The only femur fractures I've seen on skiers were from hitting something like a tree. Not saying it's not possible, but especially with modern bindings its very rare to have spiral fractures in general, femurs especially.

We spent the time to evaluate this, and due to the mechanism of injury, modern ski bindings are pooly suited to avoid this injury. Especially since it is primarily a slow speed injury with rotation over the outside edge of the ski with a flexed knee, but the flex is less than 90 degrees. Granted, the correct snow condition, especially given east vs. west coast snow, moisture composition, location on trail, skier experience level, and release of properly adjusted dins. The reason for our more indepth look at this was more than 5 spiral femurs in a couple of weeks, confirmed by x-ray.

Also, the femur is great at withstanding direct impact, but is remarkably similar to chalk with regards to withstanding rotational forces...

 

[mycrofft]

Not real rotationally ductile, eh?

Any reason for such a cluster of that variety of fx? Recent weather hx maybe? Or just a lotta skiing newbies? Or "hotdogging" (now called "extreme") skiing?

EDIT: emedicine website article.
About traction as definitive tx :
"Treatment of femoral shaft fractures has undergone significant evolution over the past century. Until the recent past, the definitive method for treating femoral shaft fractures was traction or splinting. Before the evolution of modern aggressive fracture treatment and techniques, these injuries were often disabling or fatal. Traction as a treatment option has many drawbacks, including poor control of the length and alignment of the fractured bone, development of pulmonary insufficiency, deep vein thrombosis, and joint stiffness due to supine positioning.
The femur is very vascular and fractures can result in significant blood loss into the thigh. Up to 40% of isolated fractures may require transfusion, as such injuries can result in loss of up to 3 units of blood.[3] This factor is significant, especially in elderly patients who have less cardiac reserve". (Emphasis mine).

And it goes on.
http://emedicine.medscape.com/article/90779-overview

EDIT2: GREAT ARTICLE IF MAYBE A LITTLE DATED (1991):

http://books.google.com/books?id=IdhI0peNJCUC&pg=PA156&lpg=PA156&dq=spiral+femur+fractures+skiing&source=bl&ots=L50NYcaOEL&sig=0cgN75RRYvFJg8mAr47R6SN9yYo&hl=en&sa=X&ei=3Iq6UO6LLu3OigKvj4GICA&sqi=2&ved=0CGQQ6AEwBw#v=onepage&q=spiral%20femur%20fractures%20skiing&f=false

 

[mycrofft]

EDIT2: GREAT ARTICLE IF MAYBE A LITTLE DATED (1991):

http://books.google.com/books?id=IdhI0peNJCUC&pg=PA156&lpg=PA156&dq=spiral+femur+fractures+skiing&source=bl&ots=L50NYcaOEL&sig=0cgN75RRYvFJg8mAr47R6SN9yYo&hl=en&sa=X&ei=3Iq6UO6LLu3OigKvj4GICA&sqi=2&ved=0CGQQ6AEwBw#v=onepage&q=spiral%20femur%20fractures%20skiing&f=false

I liked the description of the lower leg, planted in the snow, acting like a wrench handle to effectively transmit torsional motion to the femur.

 

[zmedic]

]We spent the time to evaluate this, and due to the mechanism of injury, modern ski bindings are pooly suited to avoid this injury. Especially since it is primarily a slow speed injury with rotation over the outside edge of the ski with a flexed knee, but the flex is less than 90 degrees. Granted, the correct snow condition, especially given east vs. west coast snow, moisture composition, location on trail, skier experience level, and release of properly adjusted dins. The reason for our more indepth look at this was more than 5 spiral femurs in a couple of weeks, confirmed by x-ray.

Also, the femur is great at withstanding direct impact, but is remarkably similar to chalk with regards to withstanding rotational forces...

I hear what you are saying, the mechanism makes sense. But still pretty rare in most places in the county. I see you are from WA, you have a lot of patients who have been skiing "sierra cement?" I have a suspicion that spring/ glacier skiing in some places like washington produces much more of these injuries than in other places like VT/NH or CO where there is less heavy slush skiing.

 

[Luno]

@Mycrofft, while reading the study, it is direct contrast to what we've seen, primarily beginner skiers, and does call into question the binding. It makes one key assumption that the rotational force upon the tibia is equal to the rotational force upon the femur, which in the incidents that we observed, is not the case. The bent knee and body's rotation over the outside of the ski causes forces to be distributed a little differently. Here is what we did as we were first looking at this just as a physical experiment to see if our conclusions were even possible, standing with your feet approximately shoulder width apart, your knees bent approximately between 15 and 40 degrees, take your left foot, cross it and plant it in front of you, and over a line formed by your right foot. The further past that line that your left foot goes, and if your knee angle is correct you will begin to feel the pressure build at your right hip, specifically applying rotational force to your femur. It's wild, but you have to try it to believe it... We can get into the release of bindings and DINs in another post...

 

[mycrofft]

I think skiing style and maybe bindings have changed since 1991? Global warming changed the snow?

I'm convinced and converted about spiral fx's, I wonder if there are equiv situations other than skiing?

And, no, I'm not even trying to do that unless you pick up my medical bills and carry me around on your back!

I sent a link to the 1991 article to MtRescue, but his park uses mostly inner tubes.

 

[MediMike]

Danger! Anecdotal!

Had a 180lb 4th grader playing tetherball, leg planted, swung at the ball, spun around on the planted leg. Spiral femur fx.

Ok that's all

 

[mycrofft]

Good one.

I just remembered my THIRD femur fx. Nebraska football player out after curfew, struck by car that stopped on impact, ran a block home and got into bed. THEN had increasing pain and unable to get out of bed. Still clothed, too. Afraid of Coach Osborne benching him.

 

[Summit]

Bump for further discussion