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FEM ORAL SHAFF FRACTURES TREATED BY

14 TH E JOURNAL OF BONE AND JO INT SURGERY

ENDER NA IL S U S ING A TROCHANTER IC APPROACH

JOHAN WALTERS , W ILL IAM SH EPHERD -W IL SON , T IM OTHY LYONS , ROGER CLOSE

F rom G roo te S ch uur H o sp ita l an d the U n ive rsity o fC ap e Tow n

W e descr ibe th e use o f Ende r n ails fo r th e in te rna l fix a tio n o f fem ora l sh a ft frac tu res by a c losedtechn iqu e v ia th e greate r trochan ter and repo rt the treatm en t of 10 0 patien ts w ith 1 0 6 f ra ct ur es , of w h ich 88w ere rev iew ed 12 m on th s o r m ore a fte r op era tion . T here w as prim ary un io n in 85 frac tu re s (96 .6% ) ands ig nifican t an gulation , ro ta tio n o r leg len gth d iscrepancy in e igh t (9% ). W e d iscu ss th e pr in c ip les o fm an ag em en t w h ich w e have evo lved .

T he u se o f in tram edulla ry n ails is now w ide ly accep tedas the idea l fo rm o f in te rn al f ixa tion o f fem ora l sha ftf rac tu re s. I t w as no t u n til the la st decad e or so tha t theb ene fit o f clo sed prog rade in tram edu llary na iling w asackn ow led ged , add in g fre sh im pe tus to the po pu la r ity o fth is te ch n iqu e (B #{246}h le r1 968 ; C law son , Sm ith and H ansen1971 ; R asche r e t a l 1 972 ; R o thw e ll 19 82 ; W inqu ist,H ansen and C law son 1984 ).

Ender and S im on-W eidne r (1970) firs t repo rted th eu se o f m u ltip le f lex ib le n ails fo r the fix a tion o f in te rtro -ch an ter ic an d sub trochan ter ic fractu re s by a m ed ia lsup raco ndy lar approach . T h is w as la ter ex tended tofem oral sh af t fractu re s by the sam e approach (E riks sonan d H ov eliu s 19 79 ; P ank ov ich , G o ld flie s and P earson1 979 ; M uck le and S id d iq i 19 82 ). W e en co un te red a h ighin cid en ce o f pos to pe ra tiv e knee p rob lem s, so w e deve l-o ped a tro chan te ric ap proach . O u r m eth od can b e u sedfo r a w ide range o f fractu re s o f th e fem o ra l sh af t,in clu d ing sim p le, com m inu ted or segm en tal in ju r iesex ten d ing from the sub trochan te r ic to the su praco ndy larreg ion s (F ig . 1 ). T h e m eth od is com para tive ly easy andqu ick and requ ire s little sp ecia lised in strum en ta tion .

PAT IEN TS , M ATER IA LS AND M ETHODSF rom June 1984 to D ecem ber 1986 , 10 0 pa tien ts w ith10 6 fem o ra l sha ft f rac tu re s w ere trea ted by in te rn alJ. W alte rs , F CS (O )(SA ), Sen io r C onsu ltan t/L ec tu re rW . Sh eph erd-W ilson , FR CS , A ssociate P rofesso r and H ead of T raum aServ ice1 . L yon s, F RC S, R egis tra rR . C lo se, M B , C hB , S en ior R egistra rUn ive rsityofCap eT ow n, D epa rtm entofO rth op aed icS urg ery , M edic alSchool, O bserv a to ry 7 925 , C ape Town , R epub lic o fSou th A frica .C orrespond en ce shou ld be sen t to D r J . W a lte rs. 1989 B ritish E dito ria l Soc ie ty o f B one and Jo in t Surgery0301-620X /90/l 1 96 $2 .00J B o ne Jo in t S u rg [B r] 1990 ; 72-B : 14-8 .

fixa tion w ith Ender na ils at G ro o te S chuur H osp ita l,C ape Tow n. O n adm ission th e pa tien t w as p laced inheavy sk ele ta l tra c tion (9 kg ) in a Thom as sp lin t. S u rge ryw as pe rfo rm ed on th e nex t ava ilab le ope ratin g lis tp rov ided the p atien t w as fit fo r anaesth esia .

T he ind ication s fo r op e ra tio n w ere unaccep tab lefractu re a lignm en t, and the desire to rehab ilita te thepa tien ts a s soon as po ssib le . W e reco rded d eta ils o f allfem oral sha ft frac tu re s trea ted in th is w ay from 75 mmbe low th e tip o f the g rea te r tro chan te r to 45 m m abov eth e in tercondy lar no tch as m easured from the m ostp rox im a l o r d is ta l ex ten t of th e fractu re. T he su rge ry w asp erfo rm ed by seven spec ialists and 13 reg is tra rs w ithva ry ing su rg ica l ex pe rtise .a fica tio n of fractu re s. A cla ss ifica tio n based on tha tdesc r ibed b y P ankov ich e t a l (19 79) and Tence r et a l(198 4) w as ado p ted in o rd e r to ra tion a lise the posto pe ra -tive m an ag em en t (F ig . 2 ) .Type A : B icor tica l con tac t. S im p le transve rse o r sh o rtobliqu e fractu re s w ith b icortica l con tact w h ich m a in-tam ed lo ng itu d ina l and la te ra l s tab ility .Type B : U n icortica l co n tac t. F ractu re s w ith a b u tte rf lyfragm en t an d /o r u n ico rtica l com m inu tion m a in ta in in glon g itud ina l bu t no t la tera l s tab ility .Typ e C : N o co rtica l co n tac t. Comm inuted or lo ng ob liqu efractu res , w ith no co rtical con tact and thus no long itu d i-na l o r late ral s tab ility .O pera tiv e techn ique . U nder g en era l anaes the sia , thepa tien t is p laced sup ine on an orth opaed ic trac tion tb lein a w in d-sw ep t p ositio n , m ak ing the tro ch an te r o f thefrac tu red lim b prom in en t. T h e foo t o f the sam e side israis ed m ax im a lly an d the con trala te ra l leg is dep re ssedm axim ally (F ig . 3 ) to facil ita te th e la te ral flu oro scop icv iew o fthe p rox im al fem ur. T he trac tio n is app lied eithe rth rou gh the ex isting ske le tal tra c tion p in and stirrup o rv ia th e boo t o f th e o rth opaed ic tab le.

T he frac tu re is reduced u nde r im age in tens if ic atio n .

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A sim p le transverse frac tu re (a) and a segm enta l frac tu re (b ) o fth e fem ora l shaft trea ted by c losed reduc tio nand in te rna l fixa tion by pro grade Ender na ils.

TYPE A TYPE B TYPE CB ic o rtica l C on tac t U n ico rtica l Con tac t N oC o rtica l Con tac t

HH Fig . 2C lass ification o f fem ora l sh aft frac tu res.K :Ic: EE 2a

Fig . 3The w ind -sw ep t pos ition w ith the un in ju red lim b depressed tofaci lita te la tera l fluo roscopy o f the fra ctu re.

FEMORAL SHAFT FRACTURES TREATED BY ENDER NAILS U SING A TROCHANTER IC A PPROACH 15

V OL . 72-B , N o . 1 , JA NUARY 199 0

I f c lo sed red uc tion is n o t po ssib le an add itiona l lim itedopen redu ction is p erfo rm ed . T hrou gh an 8 to 1 0 cmdirec t la te ra l ap p roach , the trochan te r ic bu rsa is ex posed .A n AO aw l is used to b ro ach the trochan te r nea r its tipand the h o le en la rged to abou t 2 cm by 1 c m w ith a bonen ibb le r . T he co rrec t len g th o fna il is s elec ted by using theim age in tens if ie r and its en d is b en t ap propria te lyacco rd ing to its d e stina tion in e ithe r the m ed ia l o r la te ra lfem o ra l condy le . T he first n a il is then inse rted an d p asseddow n the m edulla ry can a l to jus t short o f th e frac tu re .M anua l reduc tion th en allow s th e na il to be insin ua tedin to the d ista l fragm en t, its tip end in g in th e pos te rom e-d ia l aspec t o f th e m ed ia l fem o ra l co ndy le. T he n ex t n ailis s im ila rly in trodu ced and is d irected in to the la te ra lfem o ra l co ndy le and sub seq uen t na ils are inse r tedalte rna tely in to m ed ial and la te ra l co nd y le s. A fte r thein tro du ctio n of the firs t n ail, th e trac tion is re lea sed tom inim ise the ten dency to d istrac tion a t the frac tu re site .T he num ber o f n ails in trodu ced d ep ends u pon thecapac ity o f th e m edulla ry can al bu t m ore th an fou r a rerare ly necessa ry fo r ad equa te f ixa tion . Th e u se o f theim age in ten sifie r d u ring in trodu ctio n is im p era tive asco rtex p erfo ra tion o r p en etra tion a t the fractu re site caneasily be m issed .

T he w ound is w ash ed ou t an d a su c tio n dra inin ser ted . A n tib io tics are re served fo r h ig h risk ca se son ly . A t com ple tion of the o pera tio n , the knee is gen tlyf lexed th rou gh as fu ll a ran ge as p ossib le .P o stope rativ e m anagem en t. T he posto pe ra tive m an age -m en t is de term in ed by the frac tu re co nfigu ratio n .

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F ig . 7Ende r n ails bent to confo rm to their d est ina tion .

F ig . 8

FEM ORAL SHA FT FRACTURES TREATED BY ENDER NAILS U SING A TROCHANTER IC APPROACH 17

VOL. 72 -B . N o. 1 , J AN UARY 1990

had an gu la tion o r ro ta tion in excess o f 1 0#{176 } .eg leng thd isc repancy of ov er 1 0 m m occurred in fou r pa tien ts , allw ith T ype C frac tu res . O ne fem u r w as 15 mm long , dueto the in te rpo sition o fa bony fragm en t and the rem ain ingth ree w ere 25 , 30 , an d 45 mm short re spectiv e ly .

Th ere w as trochan te r ic d iscom fort in 21 p atien ts:1 3 se ttled spon tan eo usly , req u irin g no fu rthe r treatm en t,seven respon ded to the rem ova l o f p ro trud ing n a ils andon e se ttled a f ter in jec tion o flocal an aesth etic an d ste ro id .

DISCUSS IONU ntil 19 82 , the use o f E nde r na ils w as large ly con fined toin te r tro ch an ter ic and su b tro ch an te ric frac tu re s (BO hle r1 972 ; K ud erna , B #{246 }h leran d C o llon 1 976 ; C o rza tt andB o sch 1978 ; Chapm an et al 19 81 ; Hall an d A inscow1981 ), a ltho ugh a few pap ers repo rted the ir use fo r thef ixa tion o fsha ft frac tu re s (P ank ov ich et a l 197 9 ; E rikssonan d H ove liu s 1 979 ; M uck le and S idd iq i 198 2), andpa tho log ica l fractu re s (K a tzne r e t a l 197 6) .

O u r expe rien ce w ith th e m ed ia l cond y la r app roachw as unsatis fac to ry because p ostop e ra tive kn ee s tiffne ssan d na il p ro trusio n w ere ve ry real p rob lem s; th is led usto ch an ge to th e trochan te r ic ap proach . S om e im portan tde ta ils em erg ed du ring our ex pe rience .B efo re opera tio n . Ske le ta l tra ctio n of a t le a st 9 k g isnecessary to ove rcom e any ten dency to sh orten in g(W in qu ist e t a l 19 84) . T h is m akes excessiv e o pe ra tivetrac tion un neces sary and decreases th e risk o f p erinea lin ju ry (H ofm ann , Jo nes an d S choenvoge l 198 2 ; L inden-baum , F lem ing and Sm ith 1982) . T h e na rrow est d iam e-te rs o fth e fem oral can al in the A P and la te ra l p ro jec tion so fstand ard rad iog raph s are m easu red . T h is g iv e s a ro ughidea as to the num ber o f na ils th at th e fem o ra l cana l canbe ex pected to accom m odate .A t o pe ra tio n. It is im portan t to con to u r the na il to su it itsd e stina tion ; a na il pa ssin g in to th e m ed ia l fem ora lco ndy le m u st be th e shape o f an e long ated S (F ig . 7 ).L ate in o ur se rie s , f rac tu re s w ith bu tterfly fragm en ts(Type B ) an d comm inu ted fractu re s (Type C ) w eresom e tim es treated by open red uc tion and the ap p licatio nof Partr idge band s (F ig . 8 ) (H #{228}gg lu nd , L idg ren an dN ordstrom 1982). Th is d id n o t sign ific an tly inc rea se

m orb id ity and g rea tly redu ced th e p rob lem of shorten ing ,thus p rov id ing an attrac tiv e alte rna tive to lock ing n a ilsy s t ems .

R ad io g rap h ic rev iew show ed tha t the fin a l po sitiono f th e fem ur w as the p osition atta ined a t the tim e offix a tion , in con tra st to repo rted ex pe rience w ith su b tro -chan te ric and in te rtrochan te ric frac tu re s. G reat ca re

Pa rtridge cerc lag e bands add ing stability to a longob liq ue frac ture.

sh ou ld the re fo re b e tak en to asse ss the ro tatio na l pos itio no f the p rox im a l an d th e d ista l fragm en ts and to co rrec tvarus , va lgu s, an te rio r and pos ter io r angu la tio n a t thetim e o f in se rtion o feach n ail. If the re is d is trac tio n at thefrac tu re, trac tio n sho u ld b e re lea sed as soon as the firs tna il h a s c ros sed the site , and be fo re it is f ina lly d r ivenh ome .A fter opera tion . O nce d re ss ing s have been app lied , theknee shou ld be flex ed th roug h as fu ll a rang e o f m ovem en tas po ssib le . Po stop era tive m anagem en t w as d ev isedem pir ica lly to su it e ach type of frac tu re; a flex ib lecomm onsense app ro ach is adv ised .

T rochan te r ic d is com fo rt re su lted from e ithe r p ro -tru d ing na ils o r d istu rbance o f the b ursa . The in cid en cew as m in im ised by ensu rin g tha t na ils w e re bu ried w ith inthe trochan te r and by m odify in g th e app ro ach to a m orep rox im al m in i-H a rd ing e typ e of inc isio n in th e g lu teusm ed ius tendo n an d en ter ing the bo ne n ear the tip o f th etrochanter .

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18 J . W ALTER S, W . SH EPH ERD -W ILSON , T . LYONS , R . C LO SE

THE JOURNAL OF BONE AND JO IN T SURGERY

W e hav e app lied th is m e thod of f ixa tion to a w iderange o f frac tu re typ es and lev els. S egm en tal frac tu re sare h ig h ly su itab le s ince to rsion of the loo se fragm en t ise lim ina ted . W e w ere su rp rised b y the v e rsa tility o f thetechn ique , fin d ing th at it p rov ided a so lu tion to m anyfrac tu re s tha t w ou ld h av e been d ifficu lt to fix in te rn allyb y any o the r m e th od .The au thors w ou ld like to thank M ichae l W yeth fo r th e artw ork ,M esd am es Jean van Eyssen and V era B arrow fo r sec retaria l a ssista nceand th e M ed ica l R esearch Coun c il fo r financ ia l su pport.No bene fits in any fo rm have been received or w ill be receivedfr om a comm ercia l p ar ty related d ir ect ly or ind ire ctly to th e su bject oft hi s a rt ic le .

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