Devant la rareté des publications sur la fixation externe (FE) dans les fractures fémorales, les auteurs rapportent leur expérience à propos d'une série rétrospective monocentrique de 53 cas chez 49 patients. Il s'agissait d'adultes jeunes (m = 31 ans) à prédominance masculine, victimes de traumatisme à haute énergie. Tous étaient polyfracturés sauf 7 et 24 étaient polytraumatisés. Quarante-quatre fractures étaient ouvertes (2 types I, 10 types II, 4 types IIIA, 23 types IIIB, et 5 types IIIC de Gustilo). La fracture était diaphysaire 27 fois, et métaphyso-épiphysaire distale 26 fois. Neuf foyers présentaient une perte de substance corticale dont 4 segmentaires totales. Le fixateur axial dynamique monoplan femoro-fémoral (Orthofix) a été seul utilisé. Trois patients ont été amputés après infection ou échec de revascularisation. Un est décédé (lésion bilatérale) en raison d'un traumatisme crânien sévère. Trente-huit des 53 fémurs étaient alignés à 5° près dans les deux plans et 23 étaient de longueur égale. Pour 10 patients, la F.E. a été rapidement convertie en ostéosynthèse interne, et ceux-ci ont consolidé en 7,4 mois en moyenne. Sur les 34 fractures restantes, 25 (17 diaphysaires et 8 métaphyso-épiphysaires) ont consolidé en première intention sans apport osseux en 7,3 mois mais deux ont présenté une fracture itérative. Neuf fractures ont évolué vers une pseudarthrose (5 diaphysaires, 4 métaphysaires distales) reprises avec succès par 5 enclouages et 4 plaques dont deux compliquées d'infection et d'une fracture itérative. Quatorze mobilisations sous anesthésie et 14 arthrolyses ont été nécessaires. L'intolérance des fiches en raison de douleurs ou d'infections superficielles a été fréquente. Au recul minimum de 1 an, la flexion active moyenne du genou était de 90°. Parmi les 34 patients évalués, 4 genoux étaient quasi bloqués. Cette expérience valide les indications classiques de la fixation, souligne les difficultés réductionnelles, la lenteur de l'ostéogenèse et la fréquence des échecs de la consolidation.

External fixation has not been widely used for femoral fractures and few series are reported in the literature. External fixation is generally reserved for severe open fractures, for vessel injury or multiple trauma with life threatening. We present a retrospective analysis of a serie treated in a single center in order to detail the indications of this fixation technique.

From 1984 to Jun 2002, 49 patients with femoral fractures were treated by external fixation. The series included 36 men and 13 women, mean age 31 years. All were victims of high-energy trauma: traffic accident (n = 40), fall from high level (n = 4), firearm wound (n = 5). Multiple fractures were present in all patients except seven and 24 patients had multiple injuries. Forty fractures were open fractures: two type 1, ten type 2, four type 3a, 23 type 3b and five type 3c in the Gustilo classification. Twenty-seven were shaft fractures and 26 involved the distal metaphyseoepiphyseal portion of the femur. Loss of cortical stock was noted in five cases and total loss of a segment in four. Surgery was deferred in 19 patients, mean six days. A single-plane external fixation was used (Orthofix) with a femorofemoral frontolatateral assembly. Transepiphyseal screw fixation was also used to stabilize the distal fracture in eleven cases.

One patient with a bifocal fracture of the femur died from head trauma. Three patients required above knee amputation after failure of a vessel bypass or due to septic necrosis of the reconstruction flap. Five patients required a second reduction within days of external fixation. On the AP view, femoral alignment was successfully reestablished at ± 5° in 45 cases, ranged from 5° to 10° in seven and was greater than 10° in one. On the lateral view, alignment was between 5° and 10° in 42 cases and greater than 10° in one. Femur length was equal to the healthy side in 23 cases, and was shortened 1-2 cm in 26. Four metaphyseal fractures resulted in a 3 cm shortening. Bone healing time was available for 42 patients (1 death, 3 amputations, 3 lost to follow-up). Elective conversion to internal fixation was performed in ten patients (five lateral cortical plates and five centromedullary nailings). These patients all achieved first-intention bone healing with a mean time of 7.4 months. Exclusive external fixation was planned for 34 fractures. First-intention healing was achieved in 25 (17 shaft and 8 distal) without bone graft with an average time of 7.3 months. Ten patients had one or more osteitis foci on pin tracts. Two patients in this group developed recurrent fracture after removal of the external fixator. Nine fractures did not heal and required revision with centromedullary nailing (n = 5) or plate fixation with autograft (n = 4). Nailings for nonunion were successful but plate fixation was compromised by infection in one patient and recurrent fracture after plate removal in another. Fourteen patients underwent joint mobilization under general anesthesia and 14 had open arthrolysis. Mean follow-up was 2.8 years. Mean active flexion was 90° (30-130°). Ten patients exhibited flexion between 30° and 60° and 19 between 70° and 100°. Knee flexion was greater than 110° in 15 patients. Residual 10° flexion was noted in six knees. Mean leg length discrepancy was 0.4 ± 0.6 after distal fracture and 0.8 ± 1.3 after diaphyseal fracture.

The indications and results of external fixation in this series are in line with reports in the literature. For diaphyseal fractures, healing is long and difficult, partly because of the insufficient mechanical properties of external fixation. The rate of infection and stiff knee is high, particularly for distal fractures of the femur.

External fixation remains the only solution to stabilize certain open diaphyseal fractures or for patients with life-threatening multiple injuries. This techniques allows control of the other traumatic lesions while waiting for internal fixation. For fractures of the distal femur, external fixation can only be advocated for metaphyseodiaphyseal fractures with an intact or reconstructed epiphyseal portion.