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1984;66:529-539. J Bone Joint Surg Am.RA Winquist, ST Hansen and DK Clawson

hundred and twenty casesClosed intramedullary nailing of femoral fractures. A report of five

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C opy rig ht 19 84 b y Th e J ourn a l o f B one and Jo in t Su rge ry In co rpo ra te d

V O L . 66-A , N O . 4 . A P R IL 1984

52 9

C lo sed In tra m ed u lla ry N a ilin g o f F em o ra l F ra c tu res

A R E P O R T O F F IV E H U N D R E D A N D T W E N T Y C A SE S*

B Y R O B E R T A . W IN Q U IST , M .D .t, SIG V A R D T . H A N S E N , JR ., M .D 4, A N D

D . K A Y C L A W SO N , M .D . SE A T T L E , W A SH IN G T O N

F ro m U niv ersi ty H osp ita l a nd H a rbo rvie w M e dic a l C en te r Se a tt le

A B S T R A C T : In tram ed u llary n a iling w a s p er form ed

on 520 fem o ra l frac tu res in 500 p atien ts. T h e ser ie s in -

c lu d ed e igh ty-six o p en frac tu res an d 26 1 com m in u ted

fra ctu res. C lo sed in tram ed u llary n ailin g w a s u sed in 497

fem o ra an d op en in tra m ed u llary n ailin g w ith cercla ge

w irin g , in tw en ty-th ree. T h e u n ion rate w as 99 . 1 p er

cen t. T h e ran g e of m otion of th e k n ee at fo llow -u p av -

eraged 1 30 d egrees . C o m plica tion s in c lu d ed fo u r in fec -

tio n s (0 .9 per cen t) . S h orten in g of m ore th an tw o

cen tim eters occu rred in ten p a tien ts (2M p er cent) an d

m alrota tio n of m o re th an 2 0 d egrees w as ob served in

tw e lve p a tien ts (2 .3 p er cen t). A fter p rom p t em erg en cy

m ea su res h ad b een tak en , rou tin e treatm en t in c lu ded

stro n g p reop erativ e trac tio n fo llo w ed b y a ccu rate p osi-

tio n in g of th e p atien t o n th e op era tin g tab le ; se lec tion

of th e correc t in ser tion p oin t for a p rop er ly sized , p re -

b en t, flex ib le , bu lle t-t ip p ed n ail; an d a ccu rate red u ction

of th e fra ctu re C arefu l reh ab ilita tio n of th e p a tien t a lso

con tr ib u ted to th e excellen ce o f th e resu lts .

In 19 40 , K {2 52} n tsche r’8 sta ted tha t clo sed in tram ed u lla ry

na ilin g of

the fem ur o ffe rs an idea l ana tom ica l, fun ctio na l,

and p hys io log ica l trea tm en t fo r fre sh fem o ra l frac tu re s . S u b-

sequ en t repo rts o f th e re su lts in m an y se rie s have su bstan -

tia ted th is s tatem en t’

.2 .5 .6 .8 . 0 . 1 7.2 7.2 9.3 4

A t U niv ersity H osp i-

ta l and H arbo rv iew M edica l C en te r, w e b eg an to ap p ly

K {2 52} n tsche r’s p rin c ip le s in 196 8 , an d w e reported our in itia l

resu l ts

w ith c losed in tram edu lla ry na iling in

19716 .

W e h ave

con tin ued to use the p roced ure ex tens ive ly , and a re p re-

sen ting o ur re su lts in a large se r ies o f frac tu re s o f the fem o ra l

sha ft trea ted by in tram edu llary na iling . W e also su m m arize

the p reo pe ra tive treatm en t, o pe ra tive tech n iqu e , an d post-

op era tive m anagem en t, em p hasiz ing the chan ges th at w e

ha ve in stitu te d.

C lin ica l M ater ia l

W e rev iew ed a se ries o f 5 20 frac tu res o f the fem o ra l

sha ft in 50 0 pa tien ts w h o w ere treated b y in tram edu llary

na iling a t U n ive rs ity H osp ital an d H arbo rv iew M ed ica l C en-

ten ,

S ea ttle , be tw een 1 96 8 and 197 9 . T h is con secu tive se rie s

in c luded the firs t fem oral frac tu re trea ted w ith c losed in tra -

R ea d in p art a t the A nn ual M ee tin g of T he A m er ica n A ca dem y of

O rtho pae dic S urge ons . N e w O rlean s, L ouis ian a. Ja nua ry 23. 1 982.

t

9 01 B o ren , S u ite 1 60 0 . S ea ttle , W a sh ing ton 9 810 4 .

D epa rtm en t of O rth op aed ics , U n ive rsi ty o f W ashin g to n , S ea ttle ,

W ash in g to n 9 819 5 .

§ U niv ersi ty o f K an sas M edic al C en ter , 2A . 39 th a nd R a inb ow B o u-

leva rd , K ansas C ity , K a nsa s 6 61 03 .

m ed u lla ry n a ilin g a t ou r institu tio n and a ll su bsequen t fem -

o ra l frac tu re s tha t w ere m an aged by th is m e thod , inc lud in g

fo rty -fiv e tha t w ere rep orted on prev iou sly6 . T he pa tien ts

ranged in age fro m ten yea rs and ten m on ths to n in ety -tw o

y ea rs o ld (m ean , 2 9 .5 y ea rs). T he re w ere 3 47 m en an d 153

w om en . O ne hun dred and e igh ty -sev en p atien ts w ere trans-

ferred to our institu tio ns fo r th e ope ratio n . A lthou gh m any

sta ff an d re siden t phy sic ian s pe rfo rm ed th e su rg ica l p ro -

cedure s, w e sup erv ised alm ost all o f them .

E ig h ty -six frac tu re s w ere o pen , and th e rem a in in g frac -

tu re s w ere clo sed . T he so ft-tis sue in ju rie s w ere c la ssified

as gra de I, II , o r III, depend in g on the size o f the sk in

w oun d an d , m ore im portan tly , the ex ten t o fso ft- tissu e strip -

p in g from bo ne , re f lec ting d isru p tion o f th e ex te rna l b lood

sup p ly . T h ere w ere sev en ty -s ix g rade -I frac tu res (sm a ll sk in

w o und w ith m in im um or n o str ipp in g of so ft tissu e from

bo ne ), e igh t g rade -lI frac tu re s (m od era te sk in and m usc le

in ju ry w ith w o und con tam ina tion ) , and tw o grad e -I ll f rac -

tu re s (seve re in ju ry w ith dev ita lized sk in , m u sc le, and n eu -

rom u scu lar struc tu re s th rea ten ing the su rv iv a l o f the lim b )9 .

In gene ral, pa tien ts w ith a g rade -I ll o pen fem oral frac tu re

w ere trea ted by o the r m e tho ds.

T h e frac tu re w as lo ca ted in the p rox im al one -th ird o f

the fem ur in eig h ty -f ive lim bs , in th e m id d le one -th ird in

325 , and in the d ista l one -th ird in 1 10 . T he re w ere 1 24

transve rse frac tu re s; 10 1 short ob liq ue frac tu re s; th irty sp iral

o r lo ng ob lique frac tu re s; 26 1 com m inu ted fractu re s , in -

clu d ing tw en ty -six seg m en ta l frac tu re s; and fo ur lon g itu -

d ina l fra ctu res .

T h e com m inu tio n of the frac tu re s w as catego rized as

type I , I I , I II , o r IV , depend ing on th e d eg ree (F ig .

In th e n in ety -tw o frac tu re s w ith ty pe -I com m inu tio n , o n ly

a sm a ll p iece o f bon e h ad broken aw ay . T h e fif ty -fou r frac-

tu res w ith ty pe -I l com m inu tio n had a la rge r b u tte rf ly frag -

m en t, bu t th e co rtex w as at lea st 50 pe r cen t in tac t, allo w in g

co n tro l o f ro ta tio n an d leng th . In f ifty -fou r frac tu res w ith

ty pe -I ll com m inu tion a la rge bu tte rfly fragm en t w as p resen t,

p rec lud ing con tro l o f ro tatio n o r len g th , o r b o th . T he re w ere

th irty -f ive frac tu re s w ith type -IV co m m in u tion ; tha t is , se -

ve re com m inu tion w ith no abu tm en t o f co rtice s a t the leve l

o f th e frac tu re to p reven t sh o rten ing .

In ju ry w as caused by a va rie ty o f m echan ism s: au to -

m o b ile accid en ts (21 6 frac tu re s) , m o to rcyc le acc iden ts (10 8

frac tu res) , au tom ob ile -p edestrian acc iden ts (sev en ty -n ine

frac tu res) , and m iscellaneou s cau ses ( tw en ty -th ree frac -

tun es). T h irty -f ive fractu re s w ere su sta ined in a fall from a

h eig h t and tw en ty -tw o , from a fall a t h om e . T w en ty -one



Type I Type II Type III

Comminuted

C om minuted Com m inuted

,/ ‘

i

Type IV

Comminuted

Segmental

Transverse

L

i i

c

Segmental

O b k q u e

and

Comminuted

Spiral

4

Prox imal

Oblique

Proximal

Comminuted

‘5

T

:

Distal

Transverse

71

‘ 5

Distal

Obhque

f

Distal

omminute

530 R . A . W IN Q U IST , S . T . H A N SE N , J R . , A N D D . K . CL A W SON

T H E J O U R N A L O F B O N E A N D J O IN T S U R G E R Y

FIG. I

T he typ es of c om m inu ted frac tur es a re illu stra ted . O u r re com m end ed trea tm en t m etho d (sta nd ard in tr am ed ulla ry n ail o r in terlock ing na il) for fem ora l

f ractures of var ious patterns

i s al so

indicated.

f ractures w ere sustained in sports acti v i ti es; tw elve, i n a

bicycle accident; and four w ere a gunshot w ound.

A ssociated injuries w ere ex trem ely com mon and

played an important part i n the determ ination of ini ti al treat-

ment of the f racture and in the rehabi l i tati on of the patient.

O ne hundred

and

f orty - three patients had injur ies to the

head, chest, or abdom en. T w enty -sev en had a bi l ateral f em -

oral f racture; f i f ty -f our had ipsi l ateral f emoral and tibial

f ractures; and tw enty -seven had an ipsi l ateral f racture of the

hip, i ncluding f emoral neck and intertrochantenic f ractures.

E ighteen had an ipsi l ateral patel lar f racture and tw enty -three

sustained signi f i cant ipsi l ateral l i gam ent injuri es of the k nee.

O nly tw elve patients had an associated arterial i njury and

only ten had an associated nerve injury .

reopera tive T rea tm en t

M e th o d s

Emergency care w as given, w i th special attenti on to

cardiopulm onary status, abdom inal status, and the status of

the central nerv ous sy stem . R oentgenogram s of the injured

femur w ere then m ade, as w el l as routine roentgenogram s

of the pelv i s and ipsi l ateral k nee. Ex am ination of the k nee

for points of tenderness al l ow ed detecti on of related l i ga-

ment injuri es. T he arterial status of the low er l imb w as

analyzed caref ul l y , parti cular l y w hen the f racture w as in the

distal one-thi rd of the femur. T he patient w as then placed

in skeletal tracti on in the emergency room. U sual l y balanced

suspension tracti on w as used because i t prov ided greater

comf ort f or the patient, but f i x ed tracti on w as appl i ed i f the

patient had to be transported. W e used rather strong tracti on,

ranging f rom tw enty -f i ve to thi r ty - f i v e pounds (elev en to

si x teen k i logram s) in w om en and f rom thi r ty - f i ve to f orty -

f i ve pounds (si x teen to tw enty k i l ograms) in men. Suf f i cient

tracti on w as appl i ed to restore normal f em oral l ength or to

sl i ghtl y di stract the f racture. L ateral roentgenograms w ere

m ade to ascertain the adequacy of the tracti on because an-

teroposterior roentgenograms can lead to a f al se measure-

m ent of di str acti on’ { 176} .

Earl y in the series, the need f or preoperati ve distracti on

of the f racture w as not suf f i cientl y appreciated. Exper ience

show ed, how ever, that w hen the f racture w as al l ow ed to

shorten, reduction became extremely di f f i cul t. T hus, w e

began to emphasize tracti on as a v i tal part of the delay ed

procedure. W e prefer to gain sl i ght di stracti on preopera-

ti vel y on the hospi tal w ard and to use m inimum tracti on

dur ing operati on.

A l though w e used prophy lacti c antibioti cs routinel y ,

w e changed the drug regimen during the period o f t h e study.

I ni ti al l y , w e gav e methici l l i n and k anamycin tw elv e hours

preoperati vel y and seventy -tw o hours postoperati vel y6, but



C L O SE D I NT R A M E D UL L A R Y NA IL I NG O F F E M O R AL F R A C T UR E S

53 1

V O L . 66-A , N O .

4 . A PR IL 198 4

late r w e changed to a cephalospon in , w ith one do se adm in-

iste red one hour be f ore operation and fou r doses g iv en dur-

ing the tw en ty -f ou r hours af te r o peration .

A s em phasiz ed in our prev iou s report”, ro en tgeno-

gram s o f the no rm al f em u r w ere m ade at a tu be-to -p late

distance of on e m ete r, u sin g an ossim eter to allow accu rate

m easu rem en t o f the leng th o f the f em ur and th e w id th o f

the m edullary canal. T h ese m easu rem ents allow ed th e phy -

sic ian to an tic ipate the app ropriate siz e o f the nail. T he

norm al f em ur w as m easured f rom the tip o f the trochan ter

to th e lateral jo in t- lin e o f the k nee because th is m easurem ent

gave the m os t accu rate de term ination o f leng th . T he in itial

roen tgenogram s w ere also u sed to d eterm ine th e correc t

insertio n po in t f o r the nail in th e reg ion o f the tro chan ter.

T h e tim ing o f the operatio n w as con sidered care f u lly

f o r each patien t. In itially w e de lay ed the op eration fo r f iv e

to sev en day s, as

had been em phasiz ed in prev iou s re -

por ts46’923’ . O ne ad v an tage o f th is de lay w as an increased

rate o f un ion42 {176 } 3 ’ . A

second adv an tage , em phas iz ed b y

K { 252} n tscher’9 and by C law son e t al.6 , w as th at the danger o f

dev e lo pm ent o f a fat-em bolism sy ndrom e w as past. A th ird

adv an tag e w as that the surgeon and operatin g-room team

had add itional tim e to consider and prepare fo r the ind iv idual

patien t. A f te r w e had gain ed ex tensiv e ex perience w ith m ul-

tip ly in jured patien ts, h ow ev er, it b ecam e ev id en t th at th ere

w as an adv an tag e to im m ediate stab iliz ation o f the f em oral

f ractu re so as to prov id e b ette r in itial treatm en t and decrease

the m o rtality rate3”25 . B ecause the cond ition o f the m u ltip ly

in jured patien t tends to w orsen tw o to th ree day s af te r in ju ry

rather th an to im p ro v e , prom p t stab iliz atio n o f the f rac ture

or f ractu res decreases f urthe r b lood lo ss and in jury to the

so f t tis sues and allow s earlier m obiliz ation o f th e patien t

w ith chest and abdom inal in juries . W hen a patien t had an

associated h ead in ju ry w e perform ed c losed in tram edu llary

nailing as early as po ssib le .

T h e po ten tial f or d ev e lopm en t o f a fat-em bolism sy n -

drom e w as an im portan t co nsid eration in the tim ing o f the

op eration . Patien ts w ith m u ltip le in ju rie s, inc lu d ing those

w ith m o re than one lo ng-bone f rac ture , w ere ob serv ed rou -

tine ly fo r tw en ty -f ou r hou rs in an in tensiv e-care un it, w ith

f requen t m onitoring o f b lo od gases and if necessary adm in-

istration o f p roper pu lm onary

suppor t .

In our early ex per-

ien ce w ith de lay ed nailing o f 250 acu te f rac tures, w e d id

no t hav e a s ing le p atien t w ith clin ically s ign if ican t f at em -

bo lism pos toperativ ely , and there f ore w e conc lud ed that

the nailing con trib u tes v ery little to th e chance o f f at

em bo lism 28 . B ecau se the onse t o f a fat-em bolism sy ndrom e

generally o ccurs tw e lv e to th irty -six hou rs af ter in jury , w e

now p re f er e ither to perfo rm the nailing im m ediate ly o r to

de lay the op eration fo r f iv e to sev en day s. T he e f f ec ts o f

hem o rrhage and m u sc le spasm , w h ich are m ax im um in the

in terv en ing th ree to fo ur day s, m ak e clo sed redu ctio n tech-

n ically d if f icu lt du ring th at in te rv al.

O ur treatm en t f or p atien ts w ith an open f rac ture

changed som ew hat w ith ex p erience . A t the b eg inn in g o f th e

serie s, w e treated all op en f rac tures w ith prim ary d { 233 } b ride -

m ent, w ound c losu re approx im ately sev en day s af ter in jury ,

and in tram edu llary nailing at an av erag e o f f ou rteen day s

af ter in jury . L ater in th e serie s, w e perf orm ed prim ary cer-

c lage w iring o f bu tte rf ly f rac tures at th e tim e o f the in itial

d { 233} bridem ent, bu t con tin ued to d elay in tram edu llary nailing

f or approx im ate ly fo urteen day s. O u r approach by th e end

o f the serie s w as to p erfo rm prim ary d { 233} bridem ent and im -

m ediate in te rnal f ix ation w ith an in tram edu llary nail in all

grade-I

an d

grade-L I o pen f em o ral f rac tures, leav in g the

w ound open w ith an an tib io tic cov erage32 , and c losin g the

w ound af te r f iv e to sev en day s. A f urther chang e in th e care

o f p atien ts w ith an op en f rac ture w as th e recogn ition th at

nu trition p lay s a v ital ro le in rehab ilitation; n u tritio nal n eeds

are now analy z ed , m et rou tin ely , and fo llow ed care f u lly .

A t th e b eg inn in g o f th e serie s w e consid ered the m m -

im um age for treatm en t w ith in tram edu llary nailing to be

six teen y ears, b u t in 1973 w e began to low er the age-lim it.

B e tw een 1973 and 1979 , c losed in tram edu llary nailin g w as

perform ed in th irty f em o ral f rac tures in tw en ty -e igh t patien ts

rang ing in ag e f rom ten y ears and ten m onths to f if teen y ears

and sev en m onth s o ld . In fo urteen patien ts, f usio n o f the

ep iph y sis w as ev id en t roen tg enograph ically ; in th e o th er

fo urteen , th e leng th o f the nail w as selec ted to ensu re th at

the nail d id no t pen etrate the d istal f em oral ep iphy sis.

Oper ati ve Tr eatment

T he op erativ e techn iqu e has been m od if ied sligh tly

since the tim e o f our f irs t report6 . T he m odif icatio ns inc lud e:

1 ) a change in the positio n o f the patien t o n the f ractu re -

tab le, 2) a change in the in sertion po in t f or th e nail in the

reg io n o f th e trochan ter, 3) a decrease in th e am oun t o f

ream ing , and 4) a change f rom the orig in al s traigh t

K { 252} ntscher nails to pre -ben t n ails .

E arly in the series, w hen w e po sitioned th e patien t on

t

f rac tu re -tab le w e allow ed th e un in v o lv ed low er lim b to

drop in to w ide abduc tion , bu t th is positio n w as aw kw ard

f or th e patien t and im peded the surgeon’s v iew of th e lim b

to be operated on . In 1974 w e began to p lace the un inv o lv ed

low er lim b in a straig h t lin e w ith the body , and the h ip o f

th e in ju red ex trem ity w as p laced in sligh t f lex ion and sligh t

adduc tion w ith straig h t tractio n . I f strong trac tion w as re -

qu ired o r if the f ractu re w as d istal, a sm all K irschner p in

w as p laced in th e d istal

part

of the f em ur at o peration , th e

k nee w as f lex ed , and trac tion w as app lied through the f em -

o ral p in to prev en t stretch in g o f the sc iatic nerv e.

W e stro ng ly p re f er to p lace the patien t in the lateral

p ositio n’ { 176} . E ven now w e use the sup ine positio n o ccasion -

ally , b u t on ly to av o id m ultip le positio n ing s f or the m u ltip ly

in ju red patien t or to fac ilitate re trog rade in tram edu llary nail-

ing in ip silate ral f rac tures o f the f em oral n eck and shaf t.

W e hav e f ound , h ow ev er, that the su p ine po sition po ses

m o re techn ical d if f icu ltie s than does the lateral pos ition w ith

regard to in sertion o f the nail, particu larly w ith m ore com -

p l e x f r a c t ur e s.

D uring the stu dy period a v arie ty o f f rac ture -tab les and

im age in tensif ie rs w ere used , and it becam e apparen t th at

th e tw o m us t f un ctio n w ell toge ther and that the orthopaed ist

m u st be fam iliar w ith bo th . T he tab le that has been used



53 2 R . A . W IN Q U IS T , S . T . H A N S E N , J R ., A N D D . K . C L A W S O N

T H E JO U R N A L O F B O N E A N D JO IN T S U R G E R Y

during th e la st few y ea rs has a pen inea l pos t tha t can be

offse t d is ta lly . T h is tab le a lso a llow s trac tion d urin g op e r-

atio n an d easy access w ith an im age in tens if ie r. W e sw itched

to an im ag e in ten sif ie r th at is sm a lle r and m ore m ob ile than

the o lde r un its , a llow s be tte r v isu aliza tion of th e frac tu re

site , an d h as im age re ten tion , w h ich m ark ed ly decreases

rad ia tion expo su re .

W h en th e pa tien t w as p laced o n the tab le, the pe rin ea l

post w as sw u ng d ista lly to a llo w visu aliza tion of the tro -

chan te r in the an te rop oste r io r and late ral p lan es . T he ax illa

w as sup ported to p rev en t neu ra l in ju ry . T h e un inv o lved

lo w er lim b w as then p laced in trac tion in a stra ig h t line w ith

th e b ody . T he te ste s w ere a llow ed to hang free . T he th igh

o n the side tha t w as no t to be op era ted on w as ca re fu lly

sup po rted , e ithe r by ra is in g th e pe lv ic p ad or b y low ering

the pe rin ea l pos t. T h is supp ort p rev en ted ven ous cong es tion

of the invo lved ex trem ity an d abd uc tion o f th e p ro x im a l

frac tu re frag m en t by the pe rineal pos t.

A fte r the p atien t w as p osition ed on the tab le, co rrec t

po sition in g of th e fragm en ts w ith refe rence to ro ta tion w as

essen tia l. W e o rig ina lly arran ged the lim b so th at the pa te lla

w as pa ra lle l to the floo r, b u t u n fo rtuna te ly th is p rac tice led

t o ex t e r n a l r o t a t ion a t

th e frac tu re site in seve ra l p atien ts2 2 .

In sub seq uen t pa tien ts w e ro tated the lim b gen tly inw ard

an d ou tw ard to ach iev e th e p ro pe r ro ta tiona l p osition

th roug h relaxa tion of the so ft tis sues. C a refu l atten tio n to

the sk in fo lds then a llow ed us to de tect ex cessiv e tens io n

from in te rna l o r ex te rna l ro ta tion . T h is m e thod prov ed to

be b o th accu ra te and easy .

T h e clo sed red uc tion requ ired an exp erien ced un -

sc ru bbed su rgeon w ho p artic ipa ted ac tive ly th rou gho u t the

op era tion . F irs t, he o r sh e exam in ed the p reope rativ e an -

terop oste rio r and la te ra l roen tg enog ram s care fu lly to de te r-

m ine th e d irec tion of redu ctio n of each fragm en t. T rac tion

w as th en ap p lied to a llo w the app ro priate len g th to be

ga ined . T h e su rg eo n had to take ca re to avo id excessive

trac tion , w h ich w o u ld have p u lled th e so ft tissues to o tig h tly ,

making the redu ctio n ev en m o re d iff icu lt, an d a lso w ou ld

po ten tia lly have jeop a rd ized the p eron ea l n erve b y stre tch in g

it. A fte r s tudy ing th e ro en tgenog ram s , the un sc ru bbed sun -

geon pe rfo rm ed the redu ctio n b y app ly ing lo ca lized p re ssu re

just p rox im a l and d ista l to the frac tu re w ith e ithe r lead ed

g lov es o r r ings . H e or sh e checked th e reduc tion w ith an -

terop oste rio r f luo ro sco py an d he ld it ca refu lly , con ve rting

to la te ra l flu o roscopy to ascerta in tha t the redu ctio n had

been

ach ieved . A t th is p o in t the su rgeon had to th in k in

th ree d im ensio ns ra the r th an con tin u ing to w o rk in a sing le

p lane . T he feasib ility o f red uc ing the frac tu re w as ensu red

an d the m echan ism of redu ctio n w as asce rtain ed be fo re the

pa tien t w as p repa red an d drap ed .

A ro tato ry m an ipu latio n w as frequ en tly requ ired , and

o ccasion ally an inc rea sed an gu la tion w as n eeded’ { 176 } , be fo re

red uc tion o f ob lique frac tu res cou ld b e ach iev ed . In p rox -

im a l fractu re s , an in tram edu llary na il w as inse r ted in the

p ro x im a l cana l d u rin g o pe ra tion to aid the red uc tion . W e

con side red prox im al fractu re s to be su itab le fo r in tram ed-

ullary na iling if they w ere a t least 2 .5 cen tim e ters d ista l to

th e trochan ter’9 27 . In m o re d ista l frac tu re s a fem oral trac tion

p in w as inse rted an te rio rly just p rox im a l to th e add uc to r

tu be rc le to allo w reduc tion of the d ista l fragm en t, w h ich

w as be ing pu lled p oste rio rly b y the gastrocnem ius m usc le s

a nd poste rio r par t o f th e capsu le . T he p in w as d rilled fro m

in fe ro m ed ia l to supe ro la tera l to a llow u s to p u ll the frac tu re

o u t o f v alg us an gu la tion . T he knee w as then flexed to a llow

th e g as trocn em ius m usc le and p oste r io r

par t

of th e capsu le

to relax , and tractio n w as app lied th ro ugh the fem o ra l p in .

he

foo t w as p laced on a M ay o s tan d , w h ich w as ra ised or

lo w ered to con tro l ro tatio n . F or in tram edu llary na iling o f

d istal fractu re s w e prefe r tha t the re be a t lea st ten cen tim e ters

o f in tac t bon e ab ove the in tercond y la r no tch .

O b ta in ing the co rrect po in t o f in se rtion on the tro -

chan te r is the m os t im p ortan t fea tu re o f the op e ra tive p ortion

o f treatm en t. K { 25 2}n tsche r’9 and M u ller e t aL 2 4 adv ised th e

se lec tion o f a po in t on the la tera l a spec t o f the troch an ter

t o r ed u ce th e r isk o f

in tracap su la r in fec tion and av ascu lar

n ec rosis o f the fem o ra l h ead . W e fo llow ed th is adv ice ea rly

in ou r ser ie s . U nfo rtuna te ly , because tha t po in t is so far

la te ra l to th e ax is o f th e m ed u lla ry cav ity , eccen tr ic ream in g

and co m m in u tion of the frac tu re s ite freq uen tly o ccu rred in

th e

m ed i a l

par t

of the fem o ra l co rtex du ring inse rtio n of the

na il, pa rticu la r ly in th e m o re p rox im al frac tu re s . T hus , w e

h av e ch osen an in se rtion po in t in the p ir ifo rm is fossa ju st

m ed ia l to th e bod y of th e tro ch an ter an d pos ter io r to th e

g lu teus m ed ius m usc le . W e n ow ch eck th is po in t ca refu lly

w ith an te rop oste r io r and la te ra l flu o roscopy b e fo re p ro -

ceed ing fu rthe r w ith the op e ra tion . Inspec tion o f th is p o in t

un de r b o th an te ropo ste rio r and la te ra l im ag e in tensif ica tion

probab ly the m o st im po rtan t tech n ica l a spec t o f the op -

erat ion

ensu re s tha t the in se rtio n po in t is accu ra te .

A fte r in ser tion of a sha rp aw l, a T -hand led hand-d rill

w as used to pene trate the p rox im a l m etaph ysea l b one . A

bu lb -tip ped gu ide w ith a sligh t bend w as inse r ted . T he b en d ,

w i

is e ssen tia l fo r c losed reduc tion , is on ly tw o cen ti-

m e te rs fro m th e en d of the b u lb to a llo w passage a ro und

corn e rs . T h e b u lb -tipp ed gu ide w as m oved g en tly d ow n to

the fractu re site . T he unscrub bed su rg eo n reduced the frac -

tu re, and the sc rubb ed su rgeon lined up the bu lb -tip ped

gu ide app rox im a te ly . B o th su rgeons rem a ined still w h ile

th e im ag e in ten sifie r w as sw itched to a late ral p lane . M m -

im um ad ju stm en ts w ere m ade , an d the bu lb -tip ped gu id e

w as inser ted w ith ligh t tap p ing o f a m a lle t. I f the redu ctio n

w as in q uestion , b o th v iew s w ere ch ecked rep ea ted ly un til

the bu lb -tipped g u ide w as successfu lly p laced in the d ista l

fractu re fragm en t. T he gu id e w as then m o ved do w n to the

sub ch ond ra l b one of the d istal p ar t o f the fem ur, and its

leng th w as m easu red to p ro v ide a fina l de te rm in atio n of the

len g th o f t h e n a il.

T he ream ing w as sta r ted w ith an e igh t o r n ine -m illi-

m e te r end-cu tting ream er. D uring each p as sag e of a ream er

across the reduced fractu re site , ca re fu l m o n ito r ing of the

red uc tion w as requ ired to p reven t eccen tric ream in g . T he

size o f th e ream ers w as p ro gre ssiv e ly inc rea sed by one m il-

lim e te r in d iam ete r un til the su rgeon felt th a t the ream er

w as in con tac t w ith the co rtex . T h e ream ing then prog re ssed



C L O SE D INT R A M E D UL L AR Y NA IL IN G O F F E M O R AL F R A C T U R E S

53 3

V O L . 66 -A , N O . 4 . A PR Il. 198 4

b y on e-half -m illim e ter in crem ents. I t w as essen tial that the

bu lb -tip ped gu id e rem ain ed cen trally p laced and th at the

redu ctio n rem ain ed accurate . O bserv atio n o f the f ractu re

w ith bo th an tenoposten io r and lateral f luo ro scopy prev en ted

ex cessiv e th inning o f

the cortex . T h e bu lb -tipp ed gu ide w as

he ld du rin g ream ing to prev en t it f rom back ing ou t, and the

surg eon w as care f u l to k eep sponges and g lov es f rom be ing

w rapped up in the ream er.

Early in th e serie s w e ream ed th e co rtex to th e th ick n ess

necessary f or o btain in g a 2 .5-c entim e ter on e-in ch)

leng th

o f con tac t b e tw een th e nail and the co rtical w all bo th prox -

im al and d is tal to the f ractu re . O f ten the co rtex w as ream ed

to as m uch as one-h alf o f its o rig in al th ick n ess. W e fo und

that th is ream ing w as ex cessiv e , how ev er, becau se it n e-

cessitated the u se o f a nail w ith a larg er d iam eter, w h ich

increased the tendency tow ard com m inu tion o f th e f rac ture ,

w ith a resu ltan t lo ss o f stab ility . L ater w e tend ed to ream

the cortex at th e isthm us o f the m edu llary canal f or on ly

one to three m illim e ters at the m os t and to use sm alle r nails .

From our o rig inal av erage nail d iam e ter o f six teen m illi-

m ete rs in m en and 14 .5 m illim e ters in w om en , w e sw itched

t o a n a ve r age

diam eter o f 1 4 .5 m illim e ters in m en and 13 .5

m illim eters in w om en . T h is chang e seem ed to p rev en t f u r-

th en com m inu tio n o f the f rac ture f ragm ents during d riv in g

o f the nail.

W e f requen tly ov er-ream ed the prox im al f ragm ent by

0 .5 m illim et e r . excep t in

f rac tures o f the pro x im al on e-th ird

o f the f em ur. B reak age o f th e ream er w as no t u ncom m on

in our ex p erience; rem ov al o f the bu lb -tip ped gu ide allow ed

re triev al o f th e bro k en ream er. O ccasio nally a ream er

jam m ed as it w as back ed ou t, particu larly if a sm all com -

m inu ted f ragm ent had b een pu lled up f rom the f rac ture site

in to the isthm us, w here it b lock ed ex tractio n o f the ream er.

In that ev en t, a sm all g u ide w as passed along side the ream er

to push th e f ragm ent dow n to the f rac ture site and allow th e

b rok en ream er to b e ex tracted .

A lthough w e alw ay s tend ed to u se f lex ib le c lov erleaf

K { 252 } n tscher nails , the techn ically im p ro v ed v ers ions w ere

em p loy ed as th ey b ecam e av ailab le. T h e clo v erleaf nail that

w as u sed in itially w as straig h t, w ith a b lu n t tip . B ecause

th e shape o f th is nail d id no t m atch the con tour o f the f em u r,

its use led to sp littin g and f urth er com m inu tio n o f the bon e .

W e th en chang ed to a pre-ben t nail w ith a bu lle t tip . T h e

p re -b en t asp ec t o f th is nail decreased the inc iden ce bo th o f

sp li t t ing and of f urther com m inu tio n o f th e f em ur, and the

bu lle t tip allow ed eas ier passage across th e f ractu re s ite . A t

the end o f the s tudy p eriod w e sw itched to a pre-ben t do -

v erleaf nail w ith a con ical tip , w h ich fu rth er f acilitated pas-

sage of the nail acro ss the f rac ture site. T h is nail ex tend s

the fu ll leng th o f th e f em oral canal dow n to subchondral

b one and is tw e lv e m illim e ters in d iam eter o r m o re .

A f te r ream ing , w e inserted a larg er nail-d riv ing gu id e

to he lp k eep th e nail cen tral in th e canal. A gain , as the nail

passed the f ractu re s ite . accu rate reduc tion w as n ecessary

to prev en t com m inu tion o f bon e. S upportin g the f rac ture

du rin g f inal driv in g o f the nail w as im portan t, p articu larly

in d istal f ractu res. O nce the nail w as in po sition , the w ound

w as c losed and th e patien t w as transf erred to a regu lar b ed ,

w here the trac tio n p in w as rem ov ed and the k nee lig am en ts

w ere ex am ined care fu lly 26 . R o tation o f th e ex trem ity w as

also check ed , and if it w as no t accurate the patien t w as

turned to a pron e po sition and attem pts w ere m ade to correct

it . T h e low er lim b w a s th en se t gen t ly in a n a n t ir o t a t ion a l

splint.

For f ractu res requ irin g cerclage w irin g , such as ty pe -

I I I o r IV com m in u t ed fr a c t u r e s , t h e p a t ien t w a s a lso

placed

in the lateral p osition on the f ractu re -tab le and the lateral

aspec ts o f the h ip and th igh w ere prepared w ith io d ine al-

coho l d ow n to th e k nee to allow lateral ex posu re o f the

f em ur if op en reduc tion becam e necessary . T he f rac ture w as

approached through a lateral inc isio n , and the cerc lag e w ire

w as app lied to th e f ragm en t b ef ore ream ing w as b egun . T he

nailing w as then p erfo rm ed in a m anner sim ilar to that

already d escribed .

Postoper ati ve M anagement

A fter the op eration the patien t w as tak en to the recov ery

room and receiv ed b lood trans fus ions on ly if necessary .

Q uadricep s m u sc le -se tting ex erc ises and straigh t leg -lif tin g

w ere b egun on th e m orn ing af ter op eratio n . A s soon as the

patien t had con tro l o f the ex trem ity , he o r she w as allow ed

to beg in

w alk ing w ith cru tch es and p ro tec ted w e igh t-bear-

ing . T he patien t w as en courag ed to use th e cru tch es fo r at

leas t six w eek s, un til g ood con tro l o f the quadricep s m usc le

had been ob tained .

A n im portan t chang e that w as m ade in postop erativ e

m anagem en t w as an increased em phas is o n quadriceps re-

h ab ilitatio n af te r the patien t’s d ischarge f rom the ho sp ital.

E arly in ou r serie s, the patien t w as d ischarged f rom th e

hosp ital w h ile still u sing cru tches,

an d

little atten tion w as

g iv en to con tin u ing rehab ilitatio n . L ater w e cam e to realiz e

th at it w as im portan t f or th e patien t to w ork w ith a phy sical

th erap ist f o r abou t three m on ths to streng then the quadriceps

an d

to regain m o tion o f the k nee m ore rap id ly . A f te r the

hosp italiz ation perio d , quad riceps m u scle rehab ilitation con-

sis t ed on ly o f st r a igh t leg -lif t in g w it h

w eigh ts and w as care-

fu lly sup erv ised f or at leas t three m on th s25 . R ange-o f -m otio n

ex ercises o f the k n ee w ere g iv en m in im um atten tion f or th e

f irst f ou r to six w eek s. O nce the patien t had gain ed 90

d eg rees o f k nee m otion , h e or she attem p ted to gain com -

p lete k nee f lex io n w ith an ex erc ise that inv o lv ed sittin g back

g en tly o n the h ee ls f rom a k n eelin g po sition . Patien ts w ith

sev ere quad riceps-m usc le in ju ry or w ith in f lam m ato ry callu s

th at loo k ed sim ilar to m y ositis w ere no t encouraged to pur-

sue the ex erc ises fo r range o f m o tion o f the k n ee to o v ig -

o nou sly because early m an ipu lation s caused increased

in f lam m ation and p rov ided on ly a transien t gain in m otio n .

T hese patien ts requ ired a lo nger period to ob tain k n ee m o -

tio n , bu t w ith gen tle w ork and patience th ey con tinu ed to

gain m otio n ov er f our or f iv e m on ths. T ow ard the end o f

th e series , the patien ts w ere tested on an isok in etic m usc le -

train ing m achin e C y bex II) w h enev er po ssib le to ob tain an

ob jectiv e m easure o f the lev e l o f rehab ilitatio n .

Pos to perativ e trac tion or a sp ica cast w as som etim es



F IG . 2 -A F IG . 2 -B

F ig . 2-A : A tw enty-s ix -y ea r-o ld m an su sta ine d a se gm ental fractu re o f th e fem ur in a fa ll from a pow er po le .

F ig . 2-B : E lev en m on ths afte r in ju ry the bo ne has un ited .

53 4 R . A . W IN Q U IS T , S . T . H A N S E N , J R . A N D D . K . C L A W S O N

T H E JO U R N A L O F B O N E A N D JO IN T S U R G E R Y

requ ired fo r p atien ts w ith a som ew ha t unstab le frac tu re o r

w ho w ere co nside red to be u nre liab le35 . O ccasio na lly , a

p atien t w ith a d ista l frac tu re w as kep t non -w e igh t-bea rin g

w ith a cast-b race pos tope rativ ely . T h is trea tm en t w as g en -

era lly co n tinu ed fo r fo u r to six w eeks, af te r w h ich pa rtia l

w eig h t-bea ring w as

a llow ed . In pa tien ts w ith a slig h tly co rn -

m in u ted frac tu re , such as a type -Il in ju ry , toe -to uch w e igh t-

b ear ing w as p rescribed for

th e f irs t s ix w eeks .

T he pro to co l fo r p reven tin g pu lm on a ry em bo lism in

our pa tien ts w as to p re sc rib e asp irin an d to have the p atien t

begin w alk in g as so on as pos sib le .

O ur rou tin e fo r rem ova l o f the na il w as lim ited to yo un g

p eo p le , an d the p rocedure w as d one one yea r o r m o re a fter

in ju ry , as

conv en ien t. R em ova l o fthe na il requ ired p lan n ing

and ap pro priate equ ipm en t bu t tend ed to be rela tive ly sim -

p Ie . In o ur se rie s w e rem o ved 16 9 na ils and d id n o t en -

cou n te r any tha t cou ld no t b e rem o ved . T he p atien ts w ere

a llow ed un lim ited w e igh t-bea rin g w ith ou t c ru tch es a f ter re -

m o va l o f the n a il. N o stre ss frac tu re s o f th e fem oral neck

o r sha ft occu rred .

R e s u l t s

T h e p atien ts ’ p rog re ss w as fo llow ed by m eans o f d in -

ical exam ina tion s an d roen tg en ogram s by us and by the

refe rr ing p hysic ians. F o rty -s ev en pa tien ts w ere lo st to fo l-

low -u p , an d e lev en d ied w ith in on e yea r o f in ju ry . T he o the r

44 2 p atien ts w ere fo llow ed fo r a t lea st o ne y ea r .

O f th e e leven pa tien ts w ho d ied w ith in a yea r o f in ju ry ,

on e d id so tw o m onth s af ter in ju ry from co m plica tion s o f

sev ere b rain traum a; five

d ied from asso cia ted m u ltip le in -

ju r ie s; th ree pa tien ts , ave rag in g sev en ty -fiv e years o ld , d ied

in a nu rsin g h om e tw o , six , and n ine m on th s a fte r in ju ry ;

an d the rem ain ing tw o pa tien ts d ied of cau ses unre lated to

the in ju ry . N o death w as d irec tly re la ted to th e fem oral

f r c t u r e

T h e av e rage tim e from in ju ry to na iling w as sev en days .

F orty -o ne na iling procedure s w ere pe rfo rm ed acu te ly in p a-

t ien t s w it h an o p en f r a ct u r e or in m ultip ly in ju red pa tien ts .

W e ten ded to pe rfo rm m ore acu te n ailin g p ro cedu re s as the

series pro gre sse d. F o r p atien ts w ith an iso la ted fem ora l frac -

tune , the ave rag e ho sp ita l tim e w as 13 .3 days, th e tim e

be fo re w alk ing w ith c ru tches w as begun ave rag ed 3 .2 days

afte r op era tion ,

and the tim e o n cru tches av eraged 5 .8

w eek s. F or m ultip ly in ju red p atien ts , the to tal ho sp ita l tim e

ave rag ed 26 .9 d ays.

T h e tim e to bo ne un io n , a s d e term ined fro m roen tg en -

og ram s, w as d iff icu lt to asce r tain . A ccord ing to ou r ju dg-

m en t, 87 pe r cen t o f the fractu re s ap peared to b e so lid ly

un ited a t th ree m on th s. T he o pe ra ting tim e fo r ind iv idu al

pa tien ts decreased during the stu dy pe rio d and w as app ro x-

im a te ly an ho ur b y the end o f th e ser ie s . B ecau se o f a s-

soc ia ted b loo d loss fro m the in ju ry , th e b lo od lo ss attr ib -



C L O SE D IN T R AM E DU L L AR Y N A IL IN G O F F E M O R AL F R AC T U R E S

5 35

V O L . 66-A . N O. 4. A PRI L 984

utable to the operati ve procedure i tsel f w as di f f i cul t to de-

t e r m in e, b u t it w a s a b ou t on e a n d on e -h a lf t o tw o u n it s ,

i ncluding losses f rom ream ing and subsequent bleeding at

the f racture si te.

I n patients w ho w ere younger than f i f ty years, the av-

erage diameter of

the nai l w as 13.3 m i l l im eters in w omen

and 14.6 m i l l im eters in men. I n both men and w omen w ho

w ere older than f i f ty y ears, the av erage diam eter of the nai l

w as 16.0 m i l l im eters. T he incidence of signi f i cant injuri es

to the k nee l i gaments w as 9.0 per cent26.

T he postoperati v e range of m otion of the knees w as

excel l ent, averaging 132 degrees (Figs. 2-A and 2-B ). O nly

thi r teen patients had k nee f lex ion of less than 125 degrees;

the least am ount of f l ex ion w as 90 degrees, in a patient w i th

an ipsi l ateral ti bial f racture. T w o patients attained 100 de-

grees of f lex ion; three pati ents, 105 degrees; four, 1 10 de-

grees; and three, 1 1 5 degrees.

C o m p l i c a t i o n s

Despite

the closed nai l i ng technique and caref ul m an-

agem ent of the open f ractures, there w ere four infecti ons in

the series, gi v ing an inf ecti on rate of 0.9 per cent.

O ne inf ecti on developed around a closed f racture in a

f orty -three-year-old chronic

alcohol i c w ho had had prev ious

inf ecti ons in mul ti ple areas. U nf ortunatel y , prophy lacti c an-

ti bioti cs w ere not adm inistered, and thi s oversight m ay have

had a role in the development of the infecti on. T he nai l i ng

i tsel f w as technical l y f aul tl ess, but tw o months af ter oper-

ati on a ser ious w ound infecti on and pain developed about

the hip. T he patien” s sedimentati on rate w as 105 m i l l i -

meters pen hour. B oth the f racture si te and the si te at the

prox imal end of the nai l w ere decompressed, and

S taphy

lococcus aureu s

w as grow n on cul ture.

T he w ounds w ere

packed, a larger nai l w as inserted (because the or iginal nai l

w as back ing out) ’ 42, and antibioti c treatm ent w as begun.

H eal ing w as unev entful , and the nai l w as remov ed one y ear

later. A t nine years of fol l ow -up the patient had not had a

recurrence.

T he second infecti on w as in a patient w i th an open

fracture

that w as debrided routinel y . A delayed closure w as

performed

af ter one w eek, at w hich tim e the w ound ap-

peared clean. T he f racture w as nai l ed f ourteen days af ter

injury , and again the w ound appeared benign. T w o w eek s

af ter nai l i ng a f ever developed and there w as ery them a about

the w ound. T he w ound w as drained again at the f racture

si te and at the prox imal end of the nai l , and

Clostr idium

per fr ingens w as grow n on cul ture. T he patient w as treated

w i th antibioti cs and w ound dressings. T he f racture pro-

ceeded to union, and the nai l w as rem ov ed one year later.

A l though spores w ere seen in the specim ens tak en at the

ti me of nai l rem ov al , the infecti on did not recur in f our

years of f ol l ow -up.

T he thi rd inf ecti on developed in a nineteen-year-old

w oman w i th mul ti ple injuri es, i ncluding a grade-I open,

spl i t segm ental f racture of the r ight femur. I ntram edul lary

nai l ing and cenclage w i ring of the f ragm ents w as performed

several day s af ter

ddbridem ent of the w ound. T he f racture

f ragm ents had no sof t-ti ssue attachm ents. Six w eeks af ter

nai l i ng, a fever dev eloped and there w as marked sw el l i ng

of the thigh. Cul tures grew E nterococcus c loacae . T he f rac-

tune w as again debr ided and drained, and the prox imal end

of the nai l w as decom pressed. Serial dressing changes w ere

perform ed. A f ter fur ther heal i ng of the bone, the nai l w as

rem oved and a large sequestrum w as debnided. A W agner

ex ternal -f i xati on dev ice w as appl i ed, and open cancel l ous

bone-graf ti ng w as perf ormed. A t f our-year fol l ow -up ex -

am ination the patient had sol i d bone union, no signs of

inf ecti on, and 135 degrees of k nee f lex ion.

A fourth inf ecti on w as seen in a f i f ty -seven-year-old

m an w i th chest and abdom inal i njur i es and mul ti ple f ractures

of long bones. H e underw ent closed intramedul lary nai l i ng

of a closed fem oral f racture and an inf ecti on developed af ter

he had a gram-negati ve septi cem ia related to the abdom inal

i njur i es. A f ter d { 233} bnidem ent of the f racture si te and de-

compression of the nai l , the w ound healed w i thout any sign

of subsequent infecti on.

T here w ere four patients w i th non-union, an incidence

of 0.9 per cent for the ser ies” . One non-union occurred in

a seventy -three-year-old w oman w i th a grade-l I open f rac-

tune in the distal one-thi rd of the f em ur. T he w ound w as

debr ided and intramedul lary nai l i ng w as performed im me-

diatel y . T he w ound healed uneventf ul l y , but nine months

af ter the injury the patient sti l l had sl i ght aching at the

f racture si te; roentgenograms show ed a non-union. T he nai l

w as replaced w i th a larger one, and f our months later the

bone appeared to have uni ted.

T he second non-union occurred in an eighteen-year-

old w oman w hose injuries included a m assivel y sw ol len

thigh and a spl i t segmental f racture of the f emur. T he f rac-

tune w as nai l ed tw o w eek s af ter injury , and despi te attempts

to maintain the length of the femur by tracti on, shortening

occurred. T he nai l w as reinserted but again shortening be-

came ev ident despi te the appl i cati on of thi r ty - f i v e pounds

(si x teen k i l ograms) of tracti on, and the nai l w as again rein-

serted. A t three months the f racture w as sti l l tending to

shorten even w i th tw enty -f i ve pounds (elev en k i l ogram s) of

tracti on, and i t w as thought that the f racture w as not heal i ng

i n a sati sf actory posi ti on. T herefore the f racture w as exposed

surgical l y , cerclage w ining w as appl i ed, and re-nai l i ng and

bone-graf ti ng w as perf ormed. T he patient w as considered

to have had a non-union despi te the f racture’ s progress to

union af ter thi s treatm ent.

T he thi rd non-union occurred in a six ty -seven-year-old

m an w ho had had a plate inserted in the f em ur f or a f racture

at the age of sev en y ears and had sustained a stress f racture

distal to the plate si x ty years later. T hat f racture w as treated

w i th closed intram edul lary nai l i ng, but i t f ai l ed to uni te and

requi red subsequent treatm ent.

A fourth non-union occurred in a six ty -three-year-old

m an w i th m ul ti ple injur i es, i ncluding a contralateral abov e-

the-k nee amputati on. N ai l i ng of the open femoral f racture

posed no technical problems. T he patient w as not perm itted

to bear w eight for four m onths, but at eleven m onths the

f emur sti l l had not healed. W e remov ed the nai l and inserted



53 6

R . A . W I N Q U I S T , S . T . H A N S E N , J R .

, A N D D . K . C L A W S O N

TH E JO U R N A L O F B O N E A N D JO IN T S U R G E R Y

a large r one usin g c losed tech n iqu e, and the bo ne subse -

q uen tly u n ited .

S horten ing o f m ore than tw o cen tim e te rs o ccu rred in

ten (2 p er cen t) o f the p atien ts . T h e m ax im um am oun t o f

sho rten ing w as 5 .0 cen tim e ters , in a pa tien t w ith a sp lit

segm en ta l typ e-IV com m inu ted frac tu re. T h e pa tien t re fu sed

pos to pe ra tiv e trac tio n an d signed ou t o f the h osp ital aga inst

m ed ical adv ice . S horten ing of 2 .8 to 4 .0 cen tim e ters oc -

cu rred in th ree o th er pa tien ts w ith a typ e-IV com m inu ted

frac tu re and in th ree w ith a frac tu re th at w as com m inu ted

du ring in tram ed u lla ry na iling . S horten ing o f 3 .0 to 4 .5 cen -

tim e ters occu rred in tw o frac tu res th at becam e com m inu ted

w hen th e pa tien ts fe ll a t ho m e afte r d ischa rg e from the

h osp ital. A lso , o ne pa tien t w ith a typ e-I com m inu ted frac -

tu ne of th e p rox im a l one -th ird o f the fem ur h ad 2 .5 cen ti-

m e te rs o f sho rten in g . T hree pa tien ts had sh orten ing of 2 .1

to 2 .4 cen tim ete rs .

S ho rten in g o f 1 .0 to 2 .0 cen tim e te rs occu rred in th ir ty -

seven lim b s (7 . 1 p er cen t) , p r im arily in p atien ts w ith a type -

II (f ive o f fif ty -fo u r) , type -Ill (e igh t o f f ifty -fo u r), o r type -

IV (eig h t o f th ir ty -fiv e) co m m in u ted frac tu re and in eld erly

p atien ts w ith a sp ira l frac tu re (n ine o f th irty ). S horten ing

ra rely occu rred in pa tien ts w ith a ty pe -I com m inu ted frac tu re

(tw o o f n ine ty -tw o ), a seg m en ta l fractu re (th ree o f tw en ty -

six ), o r a fra ctu re

w ith stab le p a ttern3 4 th at is , a sho rt

ob lique (th ree o f 10 1) o r a transve rse fractu re (n one of 128 ).

P atien ts w ith 2 .0 cen tim e ters o f sh o rten ing or les s

ra rely had any lim b o r back p a in30 36 . O ur p resen t gu id elin es

a re to accep t 1

5 c en t im e ters of shor ten ing in yo un g pa tie n ts

an d as m uch as 2 .5 cen tim e te rs o f sho rten ing in m ost pa -

tien ts w ho a re m ore than six ty -f ive yea rs o ld , pa rticu la rly

if the frac tu re is sp ira l.

W e used op en redu ctio n and ce rc lage w in in g in tw en ty -

t h r ee p a t ien t s t o

o b ta in ro ta tion al stab ility and rega in leng th ,

an d w e used posto pe ra tive trac tion in th ir teen to m a in ta in

leng th .

E x te rna l ro ta tion al m a lun io n ( 1 0 degrees o r m ore ) o c-

cu rred in fo rty - th ree pa tien ts , an d in tw e lv e o f them the

d e fo rm ity w as m ore th an 20 degrees. O n e pa tien t had 6 0

d egrees o f de fo rm ity , tw o had 45 d egrees, and six h ad 30

to

40 d eg rees. In te rn al and ex te rn a l ro tatio n w as m easu red

by a g on io m e te r w ith th e pa tien t p rone and th e kn ee flex ed

90 degrees. I t is in te re sting tha t f ive o f the tw elv e p a tien ts

w ith the g rea test ro ta to ry de fo rm ity had a frac tu re o f th e

p rox im a l one -th ird o f th e fem ur, w he reas the m ax im um

ro ta to ry d efo rm ity in any d ista l frac tu re w as 2 0 degrees.

T he re w ere no in te rna l ro tatio na l de fo rm itie s . S even p atien ts

had p ain in the kn ee an d an aw kw ard ga it b ecause o f th e

de fo rm ity . T w o o f these p atien ts , in w hom th e de fo rm ity

wa s

d etec ted be fo re u n ion o f the frac tu re , had m an ipu latio n

un de r anesth esia to a lign the bon es b efo re they un ited . T he

de fo rm ities (60 an d 4 5 degrees) w ere co rrec ted . T h ree pa -

tie n ts req u ired

c losed in tram ed u lla ry d en o ta tion osteo tom y;

t he ir d ef or m it ies m easu red 2 0 , 3 0 , and 45 d eg rees. T w o

o th er p atien ts , w ith 30 and 40 degrees o f de fo rm ity , w ere

symptomatic bu t d ec ided no t to und ergo su rg ica l co rrec tion .

T h ere w ere f ive causes o f ro tato ry m a lun ion in the

p a tien ts in ou r se rie s , and often the re w as m ore th an on e

cause in a pa rticu la r pa tien t.

1

E arly in th e se rie s , ex te rn al ro ta tion al de fo rm ities

w ere p rodu ced by th e positio n of th e pa tien t on the o pe ra ting

tab le, w ith th e pa tella pa ralle l to the flo o r. T h is p rob lem

w as elim ina ted w hen w e p erm itted the low er lim b to ro ta te

free ly and de te rm ined the co rrec t ro ta tion fro m the re lax ed

po sition o f the so ft tissues.

2 . M alro ta tion a lso o ccu rred on o ccasion im m ed ia te ly

a fte r ope ratio n , be fo re th e p atien t had ga ined g ood m u scle

con tro l. T he unre stra ined low er lim b tend ed to fall in to

ex te rn a l ro ta tion , an d a de fo rm ity w as p ro duced . L a te r w e

beg an to u se an an tiro ta tion al sp lin t d u ring th e ea rly pos t-

op e ra tive p eriod .

3 . A th ird cause o f m alro ta tion , in stab ility o f th e frac -

tun e, w as co m m o nly seen in ty pe -I ll and IV co m m in u ted

fractu re s3 5 . T o con tro l n o ta tion in th ese fractu re s , w e b eg an

to use a ce rc lage w ire , a p ostop era tive sp ica cast, po stop -

e ra tive trac tion , o r a com b ina tion of these m eth od s.

4 . M alro ta tion w as som e tim es ob served , p re sum ab ly

becau se o f m usc le im ba lan ce , in s ligh tly co m m in u ted o r

transv e rse frac tu re s o f the p ro x im a l on e-th ird o f the fem ur.

B y th e end o f the study pe rio d , w e som etim es used a sin g le -

h ip sp ica cas t posto pe ra tive ly if the frac tu re site app ro ached

the p rox im a l lim its fo r th e use o f an in tram edu lla ry na il.

O ccasiona lly w e o p ted to u se a d ifferen t im p lan t, su ch as

the Z icke l na il.

5

A fifth cause o f m aln o ta tion w as a fall b y a pa tien t

w h ile w a lk in g w ith c ru tches. F ive pa tien ts w ith a ro tatio na l

m a lun io n fe ll a t ho m e during the firs t tw o to th ree w eeks

afte r na iling . N o m alun io n h ad been ob served in these p a-

tien ts p rio r to the fa ll.

V a lgus ang u la tion o ccu rred in e ig h t p a tien ts in our

se r ies ; a ll h ad a frac tu re in the d ista l o ne -th ird o f th e fem u r.

S even o f th ese de fo rm itie s w ere du e to techn ica l co m pli-

ca tion s re la ted to the na iling . Inadequa te sup port o fth e th igh

and co nsequ en t inad eq ua te redu ctio n o f th e frac tu re du rin g

the p rocedu re cau sed th e fractu re to b e na iled in a va lgus

p osition ’ {17 6} . I n the eig h th pa tien t, a seg m en ta l frac tu re w ith

a d ista l ob liq ue fractu re lin e s lipped a fte r na iling , an d th e

frac tu re frag m en ts d rif ted in to va lgus angu latio n . T he an -

g u la tion , w h ich ranged fro m

5

to 1 1 degrees in th e eig h t

p atien ts , w as neve r sym p tom a tic and d id no t req u ire con -

rectio n . T ow ard th e end o f the ser ie s , w e began to u se

cy lin de r cas ts o r ca st-b races fo r fou r to six w eek s fo r pa tien ts

w ith an uns tab le d is tal fractu re . V a ru s an gu la tion occurred

in fou r pa tien ts , a ll w ith a m id -sha ft fractu re . T he b ow of

the na il w as tu rn ed to o far la tera lly , an d th e na il push ed the

frac tu re in to sligh t va rus an gu la tion . T h e angu la tio n , w h ich

d id no t exceed 5 d eg rees, w as asym p tom a tic in a ll pa tien ts

and d id n o t req u ire co rrec tion .

T en p atien ts had a pe ro neal-nenv e pa lsy . In six the p alsy

w as caused by th e in itial in ju ry . In the o th er fou r it w as

re la ted to th e su rg ica l p rocedure ; tha t is , in ad eq ua te d is-

trac tion of the frac tu re b e fo re op era tion necessita ted ve ry

stro ng trac tion d uring op era tion . T hese fo u r cases o f pa lsy

occurred early in the se r ies ; recov ery w as com ple te in th ree



C L O SE D INT R A M E D UL L AR Y N A IL I NG O F F E M O R A L F R A C T U R E S 53 7

V O L . 6 6 -A . N O . 4 . A PR IL 1 984

patien ts

and about 80 per cen t in th e f ou rth . N o palsie s

o ccurred af te r w e changed the positio n o f th e patien t o n th e

fracture-table. T he un inv o lv ed low er lim b is now pulled in

a s trai gh t

line w ith th e body ; the ex trem ity to be operated

on is sligh tly f lex ed at the h ip and the k n ee is k ep t straigh t.

T h is positio n sim ulates a straigh t- leg -raising test, an d if

strong tractio n is app lied the sc iatic nerv e can be stretched .

T here f ore, if s trong trac tio n is to be u sed in the operatin g

room , w e now in sert a f em oral p in in th e d istal

part

o f th e

f em ur and k eep the k nee ben t to relax the nerv e .

A fat-em bolism sy nd rom e

.

o r a du lt re sp ira to ry - di st re ss

sy ndrom e, w as seen in f if ty -f iv e patien ts and w as re lated to

th e sev erity o f th e in itial in jury and accom pany ing sho ck .

T hese patien ts w ere g iv en rou tine treatm en t, inc lud in g pu l-

monary

suppor t . T here w ere no deaths, and all o f the pa-

tien ts recov ered com plete ly .

T h ere w ere n ine patien ts w ith a pu lm onary em bolism .

E ig h t had m ultip le in jurie s and th e n in th patien t, w ho d ied

f rom th e em bolism , had an iso lated f em oral f rac ture.

Discu s s i o n

In the p resen t serie s o f 520 f em oral-sh af t f ractu res

treated by the sam e m ethod , in tram edu llary nailing , it is

im po rtan t to no te that alth ough w e chose th at sin g le fo rm

o f treatm en t w e m odif ied and ref ined it in im portan t w ay s

o v er the e lev en-y ear stud y p eriod . W e con tinue to rev ise

ou r pro cedures w ith ex p erience. W e hav e m ade m ajo r

changes in our approach to the patien t, in th e equ ipm en t

and techn iq ue used f or in tram edullary nailing , and in the

ind ications f or th is f ix ation m ethod w ith regard to f ractu re

pattern.

In the y ears encom passed by th is stud y there w ere

m ajo r adv an ces in traum a care at ou r institu tion , and ou r

ov er-all ap proach to patien ts w ith f rac tures o f the f em u r

changed accord ing ly . In 1968 , w h en th is serie s began , the

prev alen t attitu de w as that if the patien t surv iv ed af te r h ours

in the em ergency room and day s or w eek s on th e hosp ital

w ard or in the in tensiv e -care un it, h e o r sh e w as then con -

s idered a cand idate for in tram edullary nailing . W ith con -

tinued im p ro v em ents in the care o f the traum a v ic tim at

ev ery stag e o f treatm en t, w e g radually changed to a m ore

agg ressiv e approach , and now attem pt im m ediate f rac ture

f ix ation . T he ob jec tiv e is to aid th e patien t’s su rv iv al as

w e ll as to enhan ce the fu nc tion o f the lim b . C on tinual up-

g rad ing o f o ur city ’s param edic sy stem ov er the past ten

y ears has been im po rtan t in adv an c in g traum a care , as has

th e dram atic im p rov em ent in the response o f the em ergency -

room staf f at our traum a cen ter. In the las t sev en y ears,

p lacem ent o f the traum a patien t u nder the care o f the g en eral

surg eon , w ith th e orthopaed is t as the con su ltan t, has also

enhanced patien t care.

E arly in the serie s o ur g reat concern ov er th e po ssib ility

o f f at em bolism f rom in tram edullary ream ing and nailing

led us to d elay the nailing fo r f iv e to sev en day s af te r in jury .

D uring the last d ecade , how ev er, w e hav e p erfo rm ed in tra-

m edullary nailing earlier relativ e to the tim e o f in jury , and

w e hav e no ticed no increase in the inc idence o f f at em bo-

lism . R ap id resto ration o f f lu id s in th ese patien ts m ay hav e

aided in p rev en tin g th is com plicatio n . A lso , b ecause b lood

gases w ere care f u lly m onitored in the in ten siv e -care un it,

no deaths o ccurred f rom a f at-em bolism sy ndrom e alon e.

W ith atten tion to b lood-gas m easurem en ts, th is sy ndrom e

w as an tic ipated early and treated p rom ptly in the f if ty - f iv e

patien ts w ho sustained th e com plication . S tu d ies b y M eek s

t

al.22 and R isk a e t al.28 support our f ind in g that im m ediate

f ix atio n o f the f em oral f rac ture do es no t in crease th e risk

o f f at em bo lism . Fu rth erm o re , a prim ary adv an tag e o f early

f ix atio n o f all lon g-bon e f rac tures is th at it allow s earlie r

m obiliz atio n o f the patien t, thu s fac ilitatin g pu lm onary care

and prev en ting secondary com plications related to p ro -

longed bed rest and trac tio n .

A s w e reached the end o f th e stud y perio d , im m ediate

in te rn al f ix atio n w as p erf orm ed in all patien ts w ith m ultip le

long-b one f rac tures, inc lud ing tho se w ith b ilate ral f em oral

f ractu re or ip silateral f ractu res o f the f em ur and tib ia and

tho se w ith a f em o ral shaf t f ractu re and con com itan t in ju rie s

to th e h ead , ch est, or abdom en . I t is im po rtan t to no te that

the m o re seriously in jured the patien t w as, the greater w as

the need for earlie r in ternal f ix atio n .

O u r chang e, late in th e ev o lu tion o f the reg im en , to

im m ediate in te rn al f ix ation o f all grade-I and II o pen f em -

oral-sh af t f ractu res produ ced no increase in the num ber o f

in f ec tio ns and eased th e care o f the patien ts consid erab ly .

T h e increased atten tion to the nu tritio nal needs o f the pa-

tien ts also seem s to hav e con trib u ted to the ex ce llence o f

o ur re su lts .

M ajor m odif icatio ns hav e been m ade in the equ ipm ent

and surg ical techn ique fo r in tram edullary nailing . O nly the

basic con cep t o f c losed nailing rem ained the sam e th rough -

ou t the serie s; all o f th e procedural f ace ts o f th e reg im en

itself w ere re f in ed as our ex perience grew . W e u sed strong

preoperativ e tractio n w hen de lay ed open reduc tio n w as

p lann ed , w e chang ed to a be tter f rac tu re -tab le and im age

in tensif ier, and w e m od if ied the patien t’s p osition on the

tab le. T h ese three re f in em en ts led to a sim p ler techn ique

fo r c losed reduc tion o f the f rac ture. A change in the po in t

o f in sertion for th e in tram edu llary nail, f rom the tip o f the

tro chan ter to th e p in if orm is fos sa, p rev en ted eccen tric ream -

ing and com m inu tio n o f the m edial

part

of the f em o ral

cortex ; a change in the shape and s iz e33 o f the nail, as

techn ically im prov ed nails becam e av ailab le , led to a d e-

crease in th e com plications o f sp litting and fu rth er co rn -

m inu tion o f the bon e and also p erm itted easier passage o f

the nail acro ss th e f rac ture site ; and our em phas is o n re -

hab ilitation o f the quadricep s also con tribu ted greatly to the

im pro v em ent in postop erativ e range o f m otion o f the k n ee

in our patien ts av erag e, 1 32 d eg rees, w ith no patien t hav in g

less th an 90 degrees) . T h ese resu lts f ar surpass those ob-

t m e w ith any o ther m eth od o f treating f em oral f rac tures23 .

A lthough f or the y oung er patien t there are alte rn ativ e

m eth ods o f f rac ture treatm en t w ith a low risk , w e th ough t

t h a t a f t e r ga in in g a few yea r s’ exp e r ien ce w it h in t r a m ed u l-

lary

nailin g ou r techn ical ex pertise w as su f f ic ien tly great,

and the com plicatio n rate w as su f f icien tly low , to sh if t th e



53 8 R . A . W IN Q U IS T , S . T . H A N S E N , J R .

A N D D . K . C L A W S O N

T H E JO U R N A L O F B O N E A N D JO IN T S U R G ER Y

risk -b en efit ratio in fav or o f in tram edu llary n ailin g in th is

pop u la tion . In te rna l fix atio n of the fem ora l fractu re o ffe red

a sign if ican t bene fit o ve r o the r m e tho ds in y oun ge r p atien ts

w ith a h ead in ju ry , m u ltip le in ju r ie s , an o pen frac tu re , o r

an ips ilatena l tib ia l frac tu r& 5 .

A rev iew o f our re su lts h as led u s to m od ify our p ro -

ced ure som ew h at w ith rega rd to ce rtain frac tu re pa tte rn s.

B ecause ou r in itial app roach o f pe rfo rm ing c losed in tra-

m edu lla ry na iling fo r alm ost a ll fem ora l-sh aft frac tu re s led

to un satis fac to ry am oun ts o f ro ta tion 7 an d shorten ing in sev -

e ra l typ es o f fractu re s , w e n ow use in te rlock in g na ils in

those situ atio ns’2 ’3 ’6 (F ig . 1 ), tw o sc rew s u sua lly be in g used

in the d is tal fragm en t and on e, in the p rox im a l fragm en t.

In o ur ex pe rience , tran sve rse fractu re s in th e m id d le

one -th ird o f the fem ur a re id ea l fo r in tram edu llany na iling ,

an d w e h av e n o t encoun te red ro ta to ry m a lun io n in th em o r

in transve rse frac tu res in the d ista l on e -th ird o f th e bo ne .

B ecause sig n ifican t ro tato ry m a lun ion has occu rred in trans-

ve rse frac tu res in the p rox im a l o ne -th ird o f the bo ne , w e

have recen tly used an in te r lock ing n ail w ith a p rox im al

screw in these frac tu res .

O b liqu e frac tu re s p resen t a sim ila r p ro b lem . W e have

foun d th at ob liq ue frac tu res in the m id -pa rt o f th e sh aft o f

th e fem u r a re w e ll su ited fo r in tram edu lla ry na iling , b u t

w ith ob liq ue frac tu re s in th e p rox im al pa rt o f th e fem ur bo th

sho rten in g and ro ta tion m ay occur becau se o f the w ide

m e taphy sis . S h orten ing an d angu latio n a lso tend to occur

in ob liq ue frac tu res in

the d ista l p ar t o f the fem ur. T h e re fo re ,

w

n ow tend to use in ter lock in g na ils in o b liqu e fractu re s

nea r e ithe r end of the fem ur.

A lth oug h th e p atien ts w ith a sp ira l frac tu re in th is se rie s

had on ly abou t tw o cen tim e ters o f sho rten ing , w e fou nd

t h a t in t e r lock in g n a ils o f f er ed a b e t t e r t r ea tm en t o p tion fo r

them as w e ll. T h ro ugh ou t the ser ie s , w e usua lly treated

sp in al frac tu res w ith cenc lage w in in g an d in tram ed u lla ry na il-

ing , bu t w e n ow be liev e tha t th e use o f in te rlo ck ing na ils

is a sup erio r m ean s o f m a in ta in in g leng th tha t still a llow s

us to adhe re to th e p rin cip le o f c losed reduc tion . T h is p rim -

c ip le is pa rticu la r ly im po rtan t in o lde r p a tien ts , in w ho m

long sp ira l frac tu re s p red om in ate .

W e have fou nd tha t s eg m en ta l frac tu res can gene rally

b e t r ea t ed w it h sim p le c losed in tram ed u lla ry na iling if the

pe rim ete r o f th e co rtex in the in te rca la ted segm en t is in tac t.

If th e frac tu re is near the p ro x im a l o r d ista l end of the fem ur,

o r if it is com m inu ted a t e ithe r fractu re site , a t p re sen t w e

often u se in te r lock ing m a ils . W e ca refu lly as ses s each lev el

o f the fractu re to d ete rm ine w h ere an in te rlock ing n ail m igh t

b e n eed ed F ig . 1 .

O u r stu dy show ed th at typ e -I com m im u ted frac tu res can

be trea ted su ccessfu lly w ith in tram edu lla ry na iling a lon e .

T y pe -I l f rac tu re s o f th e m id -pa rt o f the sha ft cam b e trea ted

wit

sim p le in tram edu lla ry na iling , b u t ro ta tion a l p rob lem s

in pro x im al o r d ista l frac tu re s w ith th is deg ree o f com m i-

n u tion h av e led us to co nside r th e use o f in ter lock in g n ails .

P o or ro ta to ry co n tro l and sh orten ing in type -Ill com m inu ted

frac tu re s h av e led us to change ou r trea tm en t fo r them as

w e ll. W e fo und th at a sp ica cast w as o ften n ecessa ry fo r

m ain ta in ing ro ta to ry co n tro l in som e of these fractu re s , o r

th at ce rclage w in in g w as req u ired fo r rea ttach ing a b u tte rf ly

fragm en t to co n tro l n o ta tion and m a in ta in len g th . B lo od loss

w as con side rab le w hen cenc lage w in ing w as p erfo rm ed , an d

a ltho ugh fo rtu na tely the re w ere no in fec tion s in th is g rou p

o f frac tu res , the appea l fo r trea ting th is ty pe of frac tu re in

a

c losed m anne r p ersis ted . A lth oug h w e sw itch ed to the u se

o f in tram edu llary na iling com bined w ith tractio n , sh o rten ing

still o ccu rred . T hus , o u r cu rren t p re ference is to treat ty pe -

I I I com m inu ted frac tu res w ith in te rlo ck ing n ails . B ecause

o f th e need fo r co n tro l o f ro ta tion and leng th in type -IV

com m inu ted frac tu re s , w e trea ted these w ith na iling and

trac tion or na iling and ce rc lage w iring . S ince the com p letio n

o f the stu dy w e h av e sw itched to th e use o f in te rlo ck ing

na ils in these frac tu re s to m a in ta in c losed red uc tion and

a llow rap id m ob iliza tion of the pa tien t.

T he exce llen t resu lts in our la rge se r ies su ggest tha t

in tram ed u lla ry na iling is an ideal trea tm en t fo r pa tien ts w ith

a fem o ra l sha ft fractu re . T he fractu re p atte rn s tha t are ap -

p rop ria te fo r treatm en t w ith th is m e thod a re read ily nec -

og n izab le. W h en p ro pe rly se lec ted , fem oral sha ft fractu re s

can be treated success fu lly by in tram ed u lla ry n a ilin g w ith

m in im um com plicatio ns. T h e im m ed iate use o f th is m e tho d

dem and s th a t the pa tien t b e ev alu ated ca re fu lly fo r a ssoc i-

a ted in ju r ie s and b e re suscita ted adequ ate ly . T h e techn ique

of in tram ed u lla ry na iling is d em and in g , and the con stan t

up grad in g of the eq u ipm en t neces sitate s up -to -d ate kno w l-

edge . T h us, w e recom m end tha t p rim ary n ailin g no t be

a ttem pted in the m u ltip ly in ju red pa tien t un less an exp en i-

enced m u ltid isc ip lin ary team is av ailab le to m an ag e po ten -

tia l p ro ble ms .

N O T E : T h e a u th o rs w ish to th a n k L a u rie G lass . Pa tty V an W a g n e r. a n d K a re n M o rte n fo r th eir

ass is tance.

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