Use of Tourniquet to Achieve Closed Reduction for a Distal Femoral Fracture With an Intramedullary Device

Distal femoral fractures are injuries involving the region from the distal metaphyseal-diaphyseal junction to the articular surface of the knee, typically a result of traumatic injury. To allow early return to function, surgery is often recommended as the standard of care, with intramedullary fixation being one of the most commonly performed procedures. Although it is common to perform an open reduction for these types of fractures, there have been papers supporting the use of closed reduction to reduce complications such as disturbances to fracture hematoma, risk of deep tissue infection, and prolonged healing time.1 By reducing the disturbance of the fracture hematoma and minimizing tissue damage, earlier healing time can be achieved. However, successful closed reduction is technically challenging to perform.1 Because of the presence of antagonistic muscles around the femur, performing and maintaining the reduction can be difficult. These methods require multiple attempts and are largely surgeon-dependent, which leads to increased radiation exposure from intraoperative imaging. Currently there is no standardized instrument used for closed reduction of distal femoral fractures. Many devices have been proposed to improve the effectiveness of closed reduction. These include using Schanz pin as a percutaneous skeletal joystick or non-invasive external support devices,1 reduction braces2, and rapid reductors.3 However, the repeatability and operability of these methods are heterogenous given varying experience among surgeons, different fracture patterns, and availability of medical equipment. Hence, a simple novel method of using a pneumatic tourniquet to achieve closed reduction for a comminuted distal femoral fracture before insertion of an intramedullary device was developed, with the aim to improve reduction maneuvering by not creating further disturbances to the already comminuted fracture site. This study outlines a technical note describing the use of an external pneumatic tourniquet applied at the fracture site for closed reduction of a comminuted distal femoral fracture. SURGICAL TECHNIQUE Patient Positioning The patient is positioned on a radiolucent table with the knee of the operated leg slightly flexed at 20 to 30 degrees using a cylindrical-shaped packed roll placed under it. This position facilitates the entry of the intramedullary nail and also aids in fracture reduction, especially posterior sagging of the fragments, which is often hard to reduce. Fracture Reduction Intraoperative fluoroscopy is utilized to characterize the fracture configuration before reduction. The placement of a packed roll under the fracture site may facilitate fracture reduction, as discussed above. Before inflating the tourniquet to the desired pressure, attempts should be made to reduce the fracture. These include applying longitudinal traction to reduce the length of the femur, varus/valgus stress to reduce the coronal alignment, and flexion/extension to achieve good sagittal reduction. In some circumstances, direct manipulation at the fracture using a reduction tool such as Bristow may be required to dis-impact the fragments (Fig. 1).FIGURE 1: (Left) Fracture reduction with a Bristow, (middle) Fracture site before torniquet inflation, (right) Fracture site after torniquet inflation.Application of External Pneumatic Tourniquet Once acceptable alignment is achieved, the sterile external pneumatic tourniquet that is placed over the fracture site is then inflated to hold the reduction (Fig. 2). Before its application a sterile cotton wrap or similar should be used to protect the underlying skin. High pressure is primarily used to hold the reduction during the insertion of the nail. The tourniquet is not used for extended periods, as the fracture reduction process is relatively brief. Once the nail is inserted, the tourniquet pressure can be reduced and the remainder of the procedure can proceed with or without the tourniquet on as per surgeon preference. The required tourniquet pressure also depends on the size of the patient's thigh; a larger thigh circumference may require higher pressure due to increased soft tissue. In our experience, higher pressures are better able to hold the reduction of the fracture particularly when the surgeon is manipulating the limb to try to get entry for the guidewire or nail. Existing literature suggests that thigh tourniquet pressures in podiatric operations typically range from 200 to 500 mmHg with minimal complications. The most commonly used pressures are between 300 and 400 mmHg, although our recommendation is a slightly lower range of 300 to 350 mmHg.FIGURE 2: Clinical photograph showcasing patient positioning and application of the sterile tourniquet over fracture site.In cases where severe comminution preclude the possibility of anatomic reduction, the surgeon recommends applying longitudinal traction to achieve a reasonable femur length and alignment and subsequently using the tourniquet as an aid for fracture reduction. Figure 1 also displays the intraoperative fluoroscopy images before and after inflating the torniquet to aid in fracture site reduction and maintenance of said reduction. Hence, the use of pneumatic tourniquet can 1. maintain the reduction, 2. aid in holding the fragments together and 3. achieve a more anatomically accepted alignment. Fracture Fixation After application of the tourniquet, fixation of the fracture may then be performed with a retrograde femoral nail. The insertion of guidewire should be technically simple once the fracture is reduced. This is followed by opening the nail entry, reamer to enlarge the femoral canal as desired, insertion of adequately sized nail, and placements of the relevant distal and proximal screws. The tourniquet may be deflated once the final nail has been placed in situ. Postoperative Protocol Postoperatively, radiographs are taken to show the final position of the implants (Fig. 3). The weight-bearing status should be individualized based on the fracture configurations, difficulties encountered during surgery, and patient factors; not limited to age, activity level and comorbidities. During the early postoperative phase, it is important to closely monitor the soft tissue around the thigh, neurovascular status and to observe for any signs of compartment syndrome or rhabdomyolysis.FIGURE 3: (Left) Right femur radiographs immediately postoperatively, (right) Right Femur Radiographs taken at 1 year showing interval bony union.EXPECTED OUTCOMES Although there may have been some advocates for open femoral reduction before nail placement, many papers support closed intramedullary nailing as the gold standard treatment for femoral fractures.4 This reduces exposure of the surgical site and decreases the risk of poor union and infection. There have been many methods and devices implemented to assist in closed reduction. Sadigighi et al5 reported the effectiveness of Schanz screws in maintaining closed reduction in femoral shaft fractures. The Schanz screw helps to maintain a soft tissue sleeve around the fracture, with or without using a fracture table, and improves the manipulation of fracture fragments. But the insertion of a Schanz screw is an additional invasive procedure that may increase the probability of infections. Furthermore, it imposes a risk of screw breakage inside the bone. Gao and colleagues reported the efficacy of a reduction brace in closed reduction of femoral shaft fracture. Advantages included low cost, simple installation and disassembling, as well as a short learning curve. However, the material used for the brace could be improved as the frame of the brace was bent intraoperatively. Other complications including swelling and constriction of muscle were also observed.2 Chen and colleagues has shown how a rapid reductor can maintain reduction during the intramedullary nailing process. This device was reported to be easy to use resulting in shorter operative time and thus reduced blood loss. Despite that, there is still an increased risk of infection as the device requires additional incisions for the pins.3 Our aim in this surgical technique discussion is to provide a reduction maneuver that is simple, easily available, and preclude the need for any additional incisions. In our experience, the pneumatic tourniquet-assisted reduction method tends to be most useful in comminuted femur shaft to distal fractures of which the surgeon is able to achieve a closed reduction in regards to length and rotational alignment of which the tourniquet is then used to hold said reduction. However, this technique should not be used in proximal femur fractures as placement of tourniquet will be challenging. In addition, the use of external compression may not preclude plate fixation, and minimally invasive plate osteosynthesis (MIPO) technique can still be performed. By using the same concept, we believe that this technique may also be used in other comminuted long bone fractures, including the tibia and humerus, where lower tourniquet pressure may be considered. COMPLICATIONS The use of a pneumatic tourniquet can effectively aid in and maintain closed reduction of mid to distal femoral fractures. In our experience, this method has been successful in holding the reduction for most cases where closed reduction of midshaft to distal femoral fractures is achievable. The application of a high-pressure pneumatic tourniquet holds the reduction securely. However, in cases where closed reduction is not possible—such as in the presence of significant bone loss or soft tissue interference—the tourniquet's effectiveness would be limited. There are theoretical concerns with this reduction technique which we would recommend a few mitigating factors. Firstly, prolonged tourniquet use may lead to compartment syndrome, rhabdomyolysis, muscle necrosis, and injuries to the skin. As such, we recommend that high pressure only be used during reduction and nail insertion, after which the tourniquet pressure can be reduced to a lower level for example, 250 mmHg should the surgeon prefers. Second, this method should be avoided in patients with poor soft tissue conditions over the torniquet site such as open wounds, infected limbs, and vascular diseases. It should also be used with caution in obese patients due to the increased risk of complications such as subcutaneous fat necrosis, infection, deep vein thrombosis, and nerve palsy. In patients with conditions or predispositions as the above, alternative closed reduction methods, or open reduction can be considered. In summary, the application of a pneumatic tourniquet to aid in the closed reduction of a distal femoral shaft fracture treated with an intramedullary device has shown good outcome, both during surgery and postoperative recovery. This technique is simple to execute with good fracture reduction, bony union and carries a low risk for complications.