The patient is a married woman and mother of two, currently pregnant and living with her family in Kabala, Sierra Leone. After being forced to leave school at an early age to help support her parents, she spent many years working as a cook in a hotel. Over the past two years, her life had begun to steadily improve. She recently managed to start her own small utility shop in Kabala Town and had become the main provider for her family. Determined to give her children the opportunities she never had, she takes great pride in keeping them in school and providing for them.

Accident

That sense of stability changed suddenly when she was involved in a serious road-traffic accident. Seated in the back of a car, the driver, distracted by his phone, struck a large water-filled pothole and lost control. The car veered off the road, rolled, and came to rest against a tree.

It soon became clear that all passengers were badly injured. The driver had sustained severe facial trauma, and her husband suffered a head injury with extensive facial lacerations. The patient was not wearing a seatbelt, and stayed conscious throughout. She felt immediate pain in her left leg and noticed blood and a bone visibly protruding through the wound.

Bystanders soon arrived and alerted the local police. After her leg was immobilised with cardboard, she was taken by ambulance to Makeni Hospital. There, she received analgesics (diclofenac and tramadol), Augmentin, and tetanus prophylaxis. X-rays were obtained, demonstrating a multifragmentary mid-shaft fracture of her left femur, consistent with an AO/OTA 32-C2 injury (see Fig 2-3). Recognising the severity of the fracture, the clinicians advised referral to a more specialised orthopaedic centre.

She presented at Masanga Hospital one day after the accident.

Upon arrival at Masanga Hospital, the patient was haemodynamically stable and alert with a GCS of 15. Bruising was present on the face and head, but there had been no loss of consciousness and no maxillofacial bleeding. Paracetamol, thrombosis prophylaxis (aspirin), and empirical antibiotics (ceftriaxone 2 g and metronidazole 500 mg) were administered according to local protocol.

Examination of the leg showed diffuse bruising and an 8-cm laceration on the lateral aspect of the left thigh (see Fig. 4-5). No bone was visible, and there were no signs of contamination, infection, or active bleeding. Her limb showed a slight varus malformation, lay in external rotation, and appeared shortened compared with the right side. The limb was neurovascularly intact.

Laboratory investigations showed a hemoglobin level of 9.6 g/dL and a hCG test came out positive, confirming pregnancy.

The improvised cardboard backslap was swapped for a backslab.

Throughout her admission, the patient was restless and at times uncooperative. She later explained that this was largely driven by fear. She was worried her leg might be amputated. With her husband admitted in Makeni and no one at home to care for the children, they had come with her to Masanga, unable to attend school. The situation weighed heavily on her: she had worked hard to provide for her family and keep her children in school, something she never had herself. Now, unable to keep them in school, she felt sad and guilty, as though her own childhood struggles were repeating themselves.

Four days after the accident, the patient was taken to the operating theatre and underwent surgery under spinal anaesthesia. The preoperative plan included surgical debridement, followed by open fracture reduction and stabilisation with an external fixator. 

Debridement and exploration

The fracture was explored through the existing wound. Proximal wound excision was performed, removing necrotic tissue at the wound edges, confirming a Gustilo–Anderson grade II open injury. No signs of contamination or infection were encountered. Further exploration demonstrated vital, bleeding bone ends on both sides of the fracture. Two large bone fragments were encountered within the wound and were left in place during this phase (see Fig. 6).

Reduction and fixation

Stabilisation was achieved using a dual construct, with one frame placed laterally and one medially (see Fig 7).

Laterally, the proximal frame was created by two pins inserted cranial to the fracture: the most proximal approximately 5 cm distal to the greater trochanter, and the second positioned as close to the fracture zone as safely possible. The distal frame consisted of two pins placed caudal to the fracture, one roughly 10 cm above the knee and the other again positioned as close to the fracture as safely possible. Each pair was connected with a bar to form the proximal and distal frames, which were then linked with two additional bars. A Vicryl cerclage was used to secure a large fragment (see Fig 8), and reduction was performed with attention to length and rotation.

Despite this, a residual varus deformity remained. Because of that we decided to add stability on the anteromedial side. One pin cranial and one caudal to the fracture were placed on the anteromedial side using an open approach to avoid injury to the femoral artery. These pins were connected with a single bar.

A total blood loss of 400ml was estimated and one unit of packed red blood cells was administered.

Applying a temporary external fixator

Soft tissue management

After thoroughly flushing the wound with 1000 mL of saline, the soft tissues were closed primarily (see Fig. 7).

The patient's empirical antibiotics were continued until 5 days post-operative. A pressure bandage was applied for 48 hours, and the leg was kept elevated. A postoperative radiograph confirmed satisfactory reduction and fixation (see Fig. 8).

Mobilisation in bed was initiated after one week, with a focus on practising knee flexion. Thrombosis prophylaxis was continued throughout this period. Later, mobilisation was gradually increased: the patient was allowed to tip with crutches or walking frame for six weeks, with no full weight bearing permitted during this time.

A follow-up radiograph at six weeks was planned to assess alignment and consolidation.

Follow-up after 4-6 weeks

At four weeks, still admitted in the hospital the patient was gradually increasing her mobility with the help of the physiotherapist. She now carefully walks short distances using a walking frame, with no pain. Still hesitant, she needs to gain more confidence (see video 1). The wound is healing well, without signs of infection (see Fig. 10). The postoperative radiograph confirmed satisfactory alignment and early callus formation was confirmed (Fig. 11).

Follow-up after 3 months

At the three-month follow-up, she continued working on improving her mobility around the hospital grounds and was able to walk longer distances with crutches (see Fig. 12). Radiographs revealed osteolysis around the pins of the medial construct (see Fig 13-14), and clinical examination confirmed that the proximal pin was loose. This led to the team's decision of removing the medial frame. 

The plan was to increase weight bearing as tolerated, obtain a new radiograph in six weeks, and discuss the timing of frame removal within the team.

Last Follow-up

By the four-month mark, the patient had left Masanga and continued as an outpatient with the lateral frame still in situ. Around five months, a follow-up radiograph obtained in a nearby city showed starting consolidation and osteolysis around one of the pins (see Fig. 15-16). Based on this assessment, she was invited to return to Masanga for removal of the lateral frame. After this visit, contact became intermittent, although we were able to reach her by phone on several occasions.

At nine months, she sent us a video showing herself walking independently on the streets of Kabala, without the use of crutches (Fig. 17). Knee flexion has gradually improved over the past months, although it remains limited. We were unable to obtain a follow-up radiograph beyond the five-month mark.

In our final contact, the patient confirmed the birth of her healthy newborn child, born shortly after she left the hospital.

• The use of an additional frame for extra stability. In this case, the initial lateral frame left residual varus instability. Adding a medial construct partially corrected the alignment and improved overall stability. When external fixation is used as the final treatment, a second frame can be a simple and effective way to achieve more reliable, long-term fixation. However, the risk of femoral artery injury during medial pin placement must be carefully considered in the decision-making process.
• If no other options are available, open femur shaft fractures can be treated with an external fixator, but it is important to create sufficient stability.
• Early mobilisation, especially of the knee is important to prevent a stiff knee.

Authors

R. Wierper, M.O. Kamara, P. Bongers, W. ten Cate.