Case report | Volume 7, Article 13, 18 Nov 2021 | 10.11604/pamj-cm.2021.7.13.31553

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

Mouad Guenbdar, Mourad Bennani, Mohamed Hajjioui, Taoufik Cherrad, Hassan Zejjari, Jamal Louaste, Larbi Amhajji

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

Received: 08 Sep 2021 - Accepted: 20 Oct 2021 - Published: 18 Nov 2021

Domain: Orthopedic surgery

Keywords: Cervico-trochateric fracture, amputation, skin traction, knee stiffness, case report

©Mouad Guenbdar et al PAMJ - Clinical Medicine (ISSN: 2707-2797). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cite this article: Mouad Guenbdar et al . Skin traction for reduction of a cervico-trochanteric fracture with below-knee amputation and knee stiffness: a case report. PAMJ - Clinical Medicine. 2021;7:13. [doi: 10.11604/pamj-cm.2021.7.13.31553]

Available online at: https://www.clinical-medicine.panafrican-med-journal.com/content/article/7/13/full

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Case report

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

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

Mouad Guenbdar1,&, Mourad Bennani1, Mohamed Hajjioui1, Taoufik Cherrad1, Hassan Zejjari1, Jamal Louaste1, Larbi Amhajji1,

 

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

 

 

Abstract

Trochanteric fractures and positioning for their surgical treatment pose a difficult problem when encountered in patients with below-knee amputations. We present a case of a 60-year old gentleman with a below-knee amputation on his left who was victim of traffic accident. The patient is a war veteran who was victim of a traumatic left below-knee amputation 30 years ago following land-mine injury. Radiographs of his pelvis is consistent with a minimally displaced cervico-trochanteric fracture of the left hip. He had a stiff knee. The surgical treatment by closed reduction on radiolucent fracture table and internal fixation using short femoral nail was performed. We used an adhesive bandage to strap the below knee stump of the affected limb to the boot of the traction table. The reduction and the position of the nail were satisfactory. After three months, the patient could walk with full weight bearing using a prosthesis on his affected limb. 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.

 

 

Introduction    Down

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 Up    Down

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 Up    Down

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.

 

In our case, the skin traction was used to reduce the cervico-trochanteric fracture. We used also adhesive bandage to strap the stump to the leg support. Simplicity is one of the advantages of this technique as it can be applied in the case of limited range of motion of the knee and if the stump length is less than 12cm, so the risk of skin injury and infection is low. However, Rethnam U et al. reported that manipulation and maintenance of fracture reduction may be difficult with this technique [3]. Nagesh H et al. describes a simple technique for operative management of trochanteric fractures in patients with ipsilateral below-knee amputation using the inverted boot method. With this technique, the fracture reduction and manipulation are effective and the risk of skin injury and infection is reduced. But, the length of the distal stump must be greater than 12cm and the stump should ideally be flexed to 90 degrees angle to permit appropriate attachment [4]. In our case, this method cannot be applied because of the limited range of motion of the knee (0°-70°).

 

Gamulin A et al. describes a skeletal traction using a Steinmann pin to reduce fractures of the proximal and diaphyseal femur for patients with a below-knee amputation. The major advantage of this technique is the ability to provide a rotational and traction force control that is similar to the standard use of a fracture table in a nonamputated patient. The risks using this technique are related to the injury of the stump soft tissues, infection, and pullout in the case of osteopenia [5]. Practically, the manual traction by assistant proves to be very difficult and cannot provide a satisfactory reduction in case of displaced fracture [4]. The major advantage of the technique described here is the ability to provide a rotational and traction force control that is similar to the standard use of a fracture table in a non-amputated patient. The major advantage of the technique described here is the ability to provide a rotational and traction force control that is similar to the standard use of a fracture table in a nonamputated patient. The major advantage of the Technique described here is the Ability to provide a rotational And traction force control that Is similar to the standard use of A fracture table in a nonamputated patient. The major advantage of the technique described here is the ability to provide a rotational and traction force control that is similar to the standard use of a fracture table in a nonamputated patient The major advantage of the technique described here is the ability to provide a rotational and traction force control that as similar to the standard use of a fracture table in a nonamputated patient to our knowledge, this is the first case published in the literature about management of a cervico-trochanteric fracture in patient with below-knee amputation.

 

 

Conclusion Up    Down

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 Up    Down

The authors declare no competing interests.

 

 

Authors' contributions Up    Down

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 Up    Down

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 Up    Down

  1. Berg AJ, Bhatia C. Neck of femur fracture fixation in a bilateral amputee: an uncommon condition requiring an improvised fracture table positioning technique. BMJ Case Rep. 2014 Feb 21;2014:bcr2013203504. PubMed | Google Scholar

  2. P. Adam. Treatment of recent trochanteric fracture in adults. Orthop Traumatol Surg Res. 2014 Feb;100(1 Suppl):S75-83. PubMed | Google Scholar

  3. Rethnam U, Yesupalan RS, Shoaib A, Ratnam TK. Hip fracture fixation in a patient with below-knee amputation presents a surgical dilemma: a case report. J Med Case Rep. 2008 Sep 9;2:296. PubMed | Google Scholar

  4. Lee BH, Ho SW, Kau CY. Surgical fixation of a comminuted inter-trochanteric fracture in a patient with bilateral below knee amputation. Malays Orthop J. 2018 Mar;12(1):54-56. PubMed | Google Scholar

  5. Gamulin A, Farshad M. Amputated lower limb Fixation to the fracture table. Orthopedics. 2015 Nov;38(11):679-82. PubMed | Google Scholar

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case report

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

Case report

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

Case report

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