The man, a teacher, lives with his two adult daughters and their families. He recently lost his wife. As a teacher, he earns approximately 43 euros per month. He had never been admitted to a hospital before and was not on any medication. 

On the day of the accident, he was returning from a shop where he had bought items for his grandson. As he was about to enter the driveway with his motorbike, he collided with another motorbike that fell on top of him. He remained conscious throughout and immediately realized that his left upper leg was broken. He did not see any bone protruding through his skin. Bystanders helped him onto a motorbike and brought him to Bo Government Hospital. After contacting Masanga Hospital, he was transferred there by ambulance two days later.

Upon arrival at Masanga Hospital, the patient was hemodynamically stable with a GCS score of 15. Examination revealed swelling of the left upper leg, a deep laceration on the left knee, a superficial cut on the right hand and a contusion of the right wrist.

Laboratory investigations showed a hemoglobin level of 10.8 g/dL.

The X-ray of the left femur showed a distal femur fracture type AO/OTA 32B2 with mild shortening and posterior dislocation of the distal fragment. It was unsure based on these X-rays whether the fracture continued into the knee joint.

The day after admission, the patient went for surgery under spinal anesthesia. The preoperative plan was surgical debridement, bone stabilisation by modular external fixation and for soft-tissue management a primary closure. 

Debridement and exploration

Exploring the laceration at the knee revealed continuity with the fracture side. Necrotic tissue at the wound edges was resected and contamination was removed by flushing with 1L saline through the wound site. After debridement it was classified as a Gustilo-Anderson Grade 2. The fracture was explored using a lateral approach of the distal femur. The distal fracture line extended into the knee joint, but was undisplaced here. The fracture was exposed, bone edges debrided and cleaned. The medullary canal was opened with a sharp spoon. The displaced butterfly segment seen on the preoperative x-ray was well attached to soft tissue and therefore left in situ. 

Reduction and fixation

The distal intra-articular fracture was secured by placing a pin (in the absence of internal screws in the hospital) perpendicular over the fracture line. Next a test-reduction was performed and showed adequate reduction with the butterfly segment in acceptable position. Two pins were placed in the proximal femur with diaphyseal bone as far as possible from each other and respecting adequate distance from the fracture zone. The pins were interconnected with pin-to-bar clamps and a bar. Distal, two pins were placed in the femur and connected with a 5-hole pin clamp because there was insufficient space between the pins left to create a pin-to-bar construct here. Pin placement followed the standard steps to minimize the risk of loosening and infection.

Two bars were placed to connect the proximal and distal segment, using bar-to-bar clamps. Definitive fracture reduction was performed before the bar-to-bar clamps were fully tightened. To strengthen the fixator, we added an additional diagonal bar, enhancing overall stability. As a check, one more time all clamps were well tightened. The pin placed to secure the intra-articular fracture was not attached to the rest of the external fixator construct. 

Soft tissue management

The bone was well covered with muscle and the skin could be closed primarily without tension using interrupted nylon skin sutures. A pressure bandage was performed from foot to groin. Pin site incisions were extended longitudinally if necessary to prevent skin tension and povidone drenched gauzes were applied around the pins and at the wound.   

Daily dressing was done. Antibiotics were discontinued after the surgery. The patient was allowed to mobilise with crutches. Minimally weight bearing (tipping) , and ankle and knee flexing exercises were encouraged.

Follow up after 4-6 weeks

Five weeks after the surgery, the patient developed an infection at both proximal pin sites. Pus came out of both pin sites while the pins remained stable. Cultures of the pus identified bacteria sensitive to cotrimoxazole, which was subsequently started. Additionally, flushing of the pin site was intensified from the moment the infection was seen. The infection quickly resolved. The patient was mobilising with two crutches and weight bearing was increased.

Follow up after 3 months

Three months post-surgery, the patient made significant progress while still hospitalized. He was able to walk over a hundred meters with minimal pain using two crutches.

At three months, X-rays showed a good amount of callus formation. This led to the decision to remove the external fixator and discharge the patient home. 

Follow up after 6 months

The patient showed ongoing progress when we visited him at his house. He was ambulating with a single crutch over a distance of approximately 20 meters, experiencing minimal pain. His wounds had healed well without any new complications. He described his quality of life as excellent and could flex his knee up to 100 degrees and extend fully, At six months, X-rays showed continued healing in a good position with increased callus formation.

Follow up after 12 months

Twelve months after surgery, we visited the patient at home for the final follow-up.

He was walking confidently along the sidewalk without crutches or assistive devices. The video showed him moving easily around the compound, making turns, bending his knees up to 90 degrees and performing full-weight-bearing squats without pain. His wounds had healed well and he reported no complaints. X-rays confirmed increased consolidation, reflecting good recovery. He had fully returned to work and rated his quality of life as excellent.

1. Suspect an open fracture also when a wound is not directly located at the fracture site. Open fractures may not always present with visible bone protrusion or wounds directly over the fracture site. A high index of suspicion, supported by imaging and a thorough understanding of the trauma mechanism, is essential for timely recognition and appropriate initial management of open fractures.
2. Tug-test. To decide if a cortical diaphyseal bone fragment is vital and can be left in place, the ‘tug-test’ can be performed. All cortical fragments that can be easily removed using a pair of forceps or 2 fingers are assumed to be inadequately perfused via surrounding soft tissue and periosteal blood supply and should be to be discarded.
3. Daily local pin tract care is at least as critical as systemic antibiotic therapy in case of a pin tract infection
4. The successful resolution of pin tract infections through consistent local wound care and daily flushing—even when antibiotic therapy is incomplete—highlights the crucial role of meticulous daily care in postoperative management.
5. Femur shaft fractures treated with a modular external fixator can result in good outcomes when adhered to the principles of application of an external fixator. The construct stability can be reinforced in various ways, including adding extra bars. 

Authors R.Wierper, Y. van Streun