im nail of femur

8/19/2019 IM Nail of Femur

1/11

C L O S E D O R O P E N IN T R A M E D U L L A R Y N A IL IN G

O F F E M O R A L S H A F F F R A C T U R E S ?

A C o m p a riso n w ith C on se r va tive ly T re a te d C ase s

P. R O K K A N E N , P. S L A T I S an d E . V A N K K A , H E L S IN K I, F IN L A N D

F rom the C lin ic fo r O rthop ae d ic s a nd T rau m ato log y , U n ive rs ity o f H e ls ink i

in tram ed u lla ry na iling of fem o ra l sha ft frac tu res , f irs t in tro duced b y H ey G ro ves in 191 8

an d late r po pu la r ised by K {25 2}n tsche r (194 0 , 19 58 , 1 967 ), B { 24 6}h ler1 951 ), S treet (1 951 ) and L o tte s

1953 ), is in m o st cu rren t tex tboo ks desc rib ed as a rou tin e su rg ica l op era tio n . I t is reg a rded

as

th e m e tho d of cho ice in tran sve rse and sho rt o b liqu e frac tu re s o f the fem o ra l sh a ft (B { 246 }h le r

1951 : M ulle r, A llgo w er an d W illenegg er 19 65) w h ere goo d to exce llen t re su lts have b een

rep orted . N ich o ls (19 63), rev iew ing the re su lts o f reh ab ilitatio n afte r fem ora l sha ft frac tu re s ,

a lso

repo rted b e tter en d-re su lts a fte r in tram ed u lla ry n ailin g th an a fter any o the r m e tho d o f

treatmen t .

P erusa l o f the litera tu re revea ls , h ow ev e r, som e d issa tisfac tion w ith the m eth od . T h e

techn ica l pe rfo rm ance of the op era tion is fa r from un ifo rm , and o bv io usly it o f ten fa lls fa r

sho rt o f the standa rd dem and ed by K U n tsch e r (R ehm and U eb ing 1 963 ). C h ro n ic oste itis ,

de lay ed un io n and non -u n ion a re seq ue lae frequen tly repo rted a fter in tram edu llary na iling

(L au ritzen 19 49 , P alm er 1 951

,

C harn ley and G uind y 19 61

,

O ’B rien 196 3). D encke r (196 5),

rev iew in g the resu lts o f d iffe ren t m e tho ds o f trea tm en t o f fem ora l sh aft fractu re s in S w ed ish

h osp itals from 1 952 to 19 54 , con clu ded tha t a lth oug h m an y o f the n ailed frac tu re s d id qu ite

w e ll, the rate o f co m plica tions w as so h igh tha t con se rv ativ e trea tm en t w ith trac tion sh ou ld

s till I g iven p re fe ren ce in ro u tine w ork in su rg ica l w ards.

R ecen t re f in em en ts in su rg ica l techn iq ues h ave m a ter ia lly a ltered in tram edu llary n ailin g .

T h e in tro duc tio n o f the stron g c love r-lea fed na il com b ined w ith th e p rinc ip le o f ream ing ou t

th e m edu llary cana l (K U n tsch er 195 8 , 19 59) and the deve lop m en t o f im ag e in tensif iers h av e

rev iv ed in te re st in c losed na iling . B o th K U ntsch er(1 959 )and B {2 46} h le r(19 65)rep orted en co urag ing

re su lts w ith such a tech n iqu e . H o w eve r , the eva lua tion ofclo sed na iling as a rou tin e p rocedu re

has no t b een po ssib le fo r lack of com p ara tive stu d ie s on se lected se r ies trea ted b y o th er

m e t h o d s .

In this repo rt an a ttem pt is m ade to as ses s th e v alu e o f p rim ary c losed in tram edu lla ry

na iling of fem ora l sh aft frac tu res , a s com pared w ith o rd in ary o pen in tram ed u lla ry n ailin g and

w ith co nse rva tive treatm en t.

M A T E R I A L

T he serie s com prise s 1 54 p atien ts w ith 1 5 6 frac tu re s o f th e fem o ra l sh aft treated a t the

C lin ic fo r O rtho paed ic s an d T rau m a to log y , U n ive rsity o f H e lsin k i, du ring a th ree and a h alf

y ear pe riod (M arch 1 , 196 3 , to A ug ust 30 , 19 66). O u t o f th e en tire ser ie s , I 1 8 frac tu re s w ere

treated b y in tram ed u lla ry na iling . In f ifty -fou r o f th ese the na iling w as do ne by a c losed

techn ique w ithou t expo sing the frac tu re site , and u sing an im age in tens ifie r. In six ty -fou r

frac tu re s the trad ition al re tro g rad e na iling tech n iqu e w ith op en reduc tion of th e frac tu re w as

u sed (S tree t 19 51).

T h e re rem ain ed th ir ty -e igh t con se rv ativ ely trea ted fem ora l sha ft frac tu re s . T h is co n tro l

g roup w as se lec ted o u t o f th e co nse rva tive ly treated fem ora l fractu re se rie s o f the C lin ic d u ring

the co rre spo nd in g p eriod , an d in c lu ded on ly frac tu res w hich , on acco un t o f locatio n and type ,

w ou ld have been tech n ica lly su itab le fo r in tram edu llary n ailin g .

V O L . 51 B

NO . 2,

M AY

1969 313


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31 4

R O K K A N E N , P . S L A T IS A N D E . V A N K K A

A ge-T he age of th e pa tien ts rang ed fro m fou rteen to e ig h ty yea rs . T h e m ean o f th e pa tien ts

treated by c losed and open na ilin g w as th irty -six yea rs and th ir ty -fo u r y ea rs re spec tive ly . In

th e co nse rv a tiv e ly treated g ro up , as w e ll a s in th e to ta l se rie s , th e m ean ag e w as th irty -fiv e

years . N ine p a tien ts w ere und er s ix teen yea rs o ld , f if ty -f ive w ere aged six teen to tw en ty -fou r ,

seven ty -seven w ere aged tw en ty -f ive to six ty -fou r and th ir teen w ere ov er six ty -f ive years o ld .

T he re w ere m o re m en than w om en in the ser ie s , th e ra tio b ein g 2 4 : I .

M echan ism of in ju ry -T ra ffic acc iden ts w ere the cause in 7 8 p er cen t, ind ustr ial accid en ts in

I 2 pe r cen t an d do m estic accid en ts in 10 pe r cen t. T h e seve rity o f the frac tu re in the d iffe ren t

treatm en t g rou ps is sh ow n in T ab le I . T he th ree g rou ps w ere ro ugh ly com p arab le in resp ect

TABLE I

S E V E R IT Y O F T H E F R A C T U R E S IN T H E D IF F E R E N T T R E A T M E N T G R ou P s*

M e t h o d of t rea tmen t

S everity o f frac tu re C losed O pen c nse t

in tra m edullary in tra m edullary

iv e

n ai l in g

na iling ea

en

p er ce n t) (p e r ce n t) p er ce n t

D i sp l a c e m e n t

Nil.

. .

2 2 3

Sligh t . . 89 74 7 9

Severe

. .

9 24 18

C o m m i n u t i o n

N il .

. .

46 45 37

Sl igh t . . 46 45 37

Severe . . 8 10 26

W o u n d

N il . . . 85 86 63

Slight

. .

13

11 29

Severe . . 2 3 8

N um ber o f frac tu res 54 62 * 38

N u m ber of pa tien ts 54 60 38

* T w o d eath s e xclu d ed .

of d eg ree o f d isp lacem en t, co m m in u tion an d o ccurren ce o f co m plica ting w o und s. In the

conse rva tive ly trea ted g roup , h ow ev e r, the re w as a s ligh t p rep ond erance o fseve re com m inu tio n .

C om pou nd frac tu res accou n ted fo r 2 1 p er cen t o f the en tire ser ie s .

S ite o f frac tu re-In 79 pe r cen t the frac tu re w as lo ca ted in the m idd le th ird o f th e fem oral

shaft, in 13 p er cen t in th e upp erm o st th ird and in 8 pe r cen t in th e low est th ird .

S eve re in ju r ies to o the r pa rts o f the bod y w ere reco rded in 57 pe r cen t o f the pa tien ts

trea ted by c losed n a iling , in 52 p e r cen t o f tho se trea ted by op en na iling and in 3 6 pe r cen t o f

the conse rva tive ly treated cases.

M E T H O D S

C losed in tram ed u lla ry na iling -T h is w as do ne u nde r g en era l anaesthesia w ith the p atien t in

th e la te ra l pos ition o n a fractu re tab le (F ig . 1 ) , u sin g the fo llo w in g tech n iqu e . B e fo re sk in

cleansin g an d d rap in g , the frac tu re is red uced w ith th e aid o f the im age in ten sifie r , the red uc tion

m anoeu vre b ein g repea ted b y the ass is tan t u n til he can easily m a in ta in an ap propriate redu c tio n .

A lm ost p erfec t a lign m en t o f th e frag m en ts is the k ey to success fu l clo sed in tram ed u lla ry

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


3/11

,

;-

F I G . I F I G . 2

C lo sed in tram edu lla ry na iling of fem ora l sha ft frac tu re s . T he an aesth etised p atien t is p laced in the la te ra l

pos it ion

on a fra ctu re ta b le (F ig . I ). R ed u ction of th e fr actu re is a ch ieve d w ith th e a id o f an im ag e in te n sifie r

m o u n ted o n a C -arc h , a llo w in g c on tro l in tw o p lan es. T h e op e rat ion are a is d rap ed , lea v in g o n ly a n arr ow b are

a rea a t th e tip o f the tro chan ter (F ig . 2 ). T h e in troduc tion o fth e gu id e w ire , th e in tram ed u lla ry ream ers and the

na il is con du cte d w ith ou t e xpo sin g the fractu re site a nd w ith th e aid of the im a ge in te nsifier .

C L O S E D O R O P E N IN T R A M E D U L L A R Y N A IL IN G O F F E M O R A L S H A F T F R A C T U R E S ?

31 5

V O L .

51 B ,

NO . 2, MA Y 1969

na iling , th e pa rt p layed by the assis tan t du ring the in trodu c tio n of th e in stru m en ts be ing of

the u tm ost im portance. T he p atien t is ca refu lly d raped , leav in g on ly a na rrow area expo sed

in the trochan te r ic reg ion (F ig . 2 ).

T h ro u gh a m usc le -sp litting in cis io n fiv e to e igh t cen tim etre s in leng th the m edu lla ry can al

is en te red a lon g the m ed ia l su rface o f the g rea ter tro ch an ter . A gu ide w ire is m an ipu la ted

Fio. 3 FIG 4 FIG 5

A 25-year-o ld m an su sta ined a com p ou nd , severe ly d isp la ced fra cture o f th e fem ora l sh aft in a traffic a ccid ent

(F ig . 3 ). C losed in tram edu lla ry na iling w as d one on the six th day after the frac tu re . S ix w eeks la ter ca llu s

h ad de velo pe d

a ro u n d th e fra ctu re (F ig . 4 ). W alk in g w ith o u t a s tic k w as rec ord ed tw e n ty w eek s a fte r th e

opera t ion a n d th e p a tien t r etu rn ed to w or k as a m e ch a n ic tw en ty- fou r w ee k s a fter th e a ccid en t. T h e r ad iogr ap h

in F igu r e 5 sho w s the re su lt eig h teen m on ths af te r th e op era tion . T h e na il h a s b een rem oved .

th roug h the m ed u lla ry can al ac ross the frac tu re in to the d ista l fragm en t r igh t d ow n to th e

leve l o f th e base o f the p a tella . A lo ng the gu id e w ire f lex ib le ream ers a re in trod uced in to

the m edu lla ry can al, w h ich is en larged succes sive ly up to a d iam ete r o f I 1 -16 m illim e tre s .

T he d iam e te r o f the c love r-lea fed na il sh ou ld be 05 m illim e tre le ss than the inn er d iam e ter

o f th e m edu lla ry cana l. T he d istance fro m th e tip o f th e g reate r trochan te r to th e u ppe r m arg in

o f the pa tella is m easu red , an d a na il o f approp ria te leng th an d w id th is in tro duced a long the


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31 6 i. R O K K A N E N , P . SL A T IS A N D E . V A N K K A

gu ide w ire in to the m edu lla ry can al. T h e na il is tapp ed dow n the line and sh ou ld en te r the

cav ity w ith ou t d iff icu lty , adv an c ing read ily w ith eve ry b low of the h am m er. T he p osition of

th e fractu re site and of a ll in s trum en ts in trod uced in to the m edu lla ry cana l sho u ld frequ en tly

be checked in tw o p lan es w ith th e im age in ten sifie r . A fte r th e na il ha s been driven hom e ,

p lain rad io g rap hs a re tak en of the en tire fem ur, in clu d ing bo th the frac tu re s ite and bo th

en ds o f the na il. T he w o und is c losed in lay ers and th e pa tien t lif ted in to bed w ith the leg

eleva ted on p illo w s (F igs 3 to 5 ).

O p en in tram ed u lla ry na iling -O pen na iling w as d on e b y the re trog rade tech n iqu e (S tree t 195 1).

T he av e rage size o f the n ails u sed in th is se rie s w as 1 2 m illim e tre s .

P o st-o pe ra tive ca re -A fte r c lo sed o r open in tram edu lla ry n ailin g the pa tien ts w ere a llow ed to

m ove freely in bed and a few day s late r w ere en co urag ed to w a lk w ith c ru tches. L eg e leva tion

an d kn ee exe rc ise s w ere sta rted d uring the firs t w eek a fter ope ra tio n . P a rtia l w eig h t-b earing

w as allo w ed in su itab le transve rse fractu re s w ith in a few w eek s a fter the o pe ra tion , bu t fu ll

w e igh t-b ea ring w as no t pe rm itted un til th e rad iog raphs sh ow ed th at ca llu s fo rm a tion w as w e ll

ad vanced . T he ave rage tim e fo r fu ll w eig h t-bearing w as tw e lve w eek s a fte r clo sed n ailin g an d

fif teen w eeks afte r o pen na iling .

In all bu t on e case c losed in tram edu lla ry na iling w as don e w ith in th ree w eek s a fte r the

in ju ry , the m ean in terva l b etw een acc id en t and n ailin g be in g seven days. U su ally c losed

fractu re s w ere o pe ra ted upo n ea rly , w he reas in open frac tu re s th e o pe ra tion

w as

postponed

un til the w oun d had hea led . In tw o pa tien ts w ith ex ten sive so ft-tissue in ju rie s an d d en ud ed

bo ne fragm en ts th e op era tion w as d one o n th e day of the acc iden t a f ter approp ria te

resusci ta t ion .

In f ifty -six o u t o f six ty -fou r fractu re s op en in tram ed u lla ry na iling w as p e rfo rm ed w ith in

th ree w eeks, bu t in th e o th e r e igh t ca se s the ope ratio n had to be postp oned on accoun t o f

seve re co ncom itan t in ju r ie s to o th er pa rts o f th e bod y . T he m ean tim e b etw een th e acc iden t

and the op era tion in th is g roup w as ten days .

C on se rva tive freatm en t-W h en conserva tive trea tm en t w as em ploy ed the frac tu re w as redu ced

and reta ined b y b alanced trac tion o n a B {2 46} h le rfram e. In seve ra l p atien ts trac tion w as

sup p lem en ted by a p la ste r h ip sp ica . T he tim e o f im m obilisa tio n in the con se rva tive ly treated

g rou p rang ed fro m five to tw en ty -seven w eeks (m ean e igh teen w eek s) .

F o llow -up-A ll pa tien ts w ere fo llo w ed up un til the en d of trea tm en t. In add ition , a ll pa tien ts

w ere sum m on ed to a fo llow -u p exam in atio n on e to fo u r y ears a fte r th e acc iden t (ave rage 29

years) . T he end -resu lts w ere ob ta ined in 1 1 3 o u t o f I 52 cases (74 pe r cen t) .

R E S U L T S

In th e na iled frac tu re s the tim e to so lid u n io n cou ld n o t b e de te rm ined by ord ina ry c lin ical

m e tho ds, because in a ll p atien ts the frac tu re w as ren de red stab le by the heavy in tram ed u lla ry

na il. M oreove r , rad io lo g ical a sse ssm en t o f fractu re repa ir du ring the firs t m o n ths a fte r th e

op era tio n is

d ifficu lt an d incon clu sive . T he re fo re , fun ctio na l re su lts had to b e chosen as

c r ite r ia fo r the p rogre ss o f frac tu re hea ling -nam e ly the tim e elaps ing be tw een th e accid en t

and ab ility to w a lk w itho u t a stick , an d the in te rva l be tw een the acc iden t an d re tu rn to w ork .

In th e pa tien ts treated con se rva tiv ely u n ion w as asse ssed by tho rou gh c lin ica l exam in atio n

o f frac tu re stab ility sup p lem en ted by p la in rad iog raphs . T he tim e to un io n w as reco rded as

th e tim e to the d iscon tinuan ce o f im m obilisa tion .

T h e tim e e lapsin g b etw een the acc id en t an d ab ility to w a lk w ith ou t a stick is show n

grap h ically in F igu re 6 . F rom th is it em erges th at s ix m o n ths a f ter the in ju ry th e na iled

frac tu res d id b e tter than tho se treated con serva tive ly . C losed na iling seem ed to y ield b ette r

re su lts than open n a ilin g . T h e sam e trend pe rsis ted tw e lve m on th s a fte r the accid en t : by

tha t tim e a ll pa tien ts trea ted by c losed n ailin g w a lked w ith ou t a s tick , com pared w ith 96 pe r

cen t o f the pa tien ts trea ted b y open na iling and 8 1 pe r cen t o f the p a tien ts trea ted conserva tive ly .

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


5/11

63 -

TD -

C _ OS E D

N A IL IN G 4 9 C A S E S )

-

O PE N I NT RA ME DU LL AR Y

:

.... . ‘ LING 4 9 CASES)

SO

-

_

. ..r. r_ r

r

60-

PE R

C E N T

40 -

CS T

43

-

20

O

16 24 32

W E E K S

80-

I

3 2 4 0 48 52

W E E K S

20

F I G . 6

T he ea rly func tion al

resu lt a fte r fem ora l shaft f ractu re

in th ree se ries trea ted eithe r by c losed in tram edu lla ry

n ailing , b y o pe n in tram edu lla ry n ail ing o r b y c on serv a-

tiv e m eas ures .

T h e ab ility to w alk w ith ou t a s tick d uring

the first yea r a fte r the traum a is exp ressed in cum u la tive

percen tages.

F i G . 7

T h e tim e in ter val b etw e en th e a cc id e n t a n d retu rn to

w ork after fe m ora l sh aft fra ctu re in th ree ser ies tr eate d

either by c losed in tram edu lla ry na ilin g , b y op en in tra-

m edulla ry na iling o r by conserva tive m easures . R e tu rn

to w or k is e xp r esse d in c u m u lative p e rc en tag es .


31 7

V O L . 5 1 B ,

NO .

2, M AY 1969

H

....

i--I

.1

1 00 - C L O S E D IN TR A M E D U L LA R Y

N A IL IN G 4 4 C A S E S )

.

O PE N IN TR AM EO UL LA RY

N A IL IN G 44

C A S E S )

C O N S E R V A TIV E TR E A TM E N T

--

3 3 C A S E S )

F urthe r an aly sis o f the se f igu re s rev ea led tha t the bene fit o f clo sed in tram edu llary n ailin g

var ied acc ord ing to

the seve rity o f th e frac tu re and th e age of the pa tien t. T he m ost g ra tify ing

re su lts w ere o b ta ined in p atien ts o ve r th irty -f ive y ea rs o fage w ith seve re fractu re s o fthe fem ur;

th ese p atien ts w ere ab le to w a lk w itho u t a stick o n an av e rage five m on ths ea rlier th an th e

cor resp on din g gro up of p atie n ts tre ate d con servat ive ly (T ab le II) . It sh ou ld be no ted , in

c on tr ast ,

that

in y ou ng

peop le the re su lts o f trea tm en t w ere a lm o st the sam e w he the r trea tm en t

w as o pe ra tive o r con serva tive .

T h e in te rva l b etw een the acc iden t an d re tu rn to w o rk in 121 p atien ts is show n in F igu re

7.

In th is re s p e c t,

too , the pa tien ts trea ted b y in tram edu lla ry na iling d id be tte r th an th ose trea ted

co nse rv a tive ly . A g a in , c lo sed n ailin g ap peared sligh tly sup erio r to open na iling . T w e lve

m on th s af te r th e acc iden t 95 pe r cen t o f those treated b y c losed na iling , 89 pe r cen t o f

th ose treated b y open na iling an d 85 pe r cen t o f those treated con se rv ativ ely had re sum ed

work .*

T h e adv an tag es o f na iling w ere m ost ev iden t in pa tien ts o ve r th ir ty -f ive y ea rs o f age w ith

sev ere fractu re s , fo r the se pa tien ts retu rned to w ork on an ave rag e th ree m on ths earlie r than

th e co rre sp ond ing g ro up of pa tien ts trea ted conserva tive ly (T ab le III).

T he re w as no ap prec iab le d iffe rence in the resu lts af te r ea rly n ailin g (w ith in o ne w eek a fte r

the accid en t) com p ared w ith th ose o pe ra ted up on during th e seco nd and th ird w eeks (T ab le IV ).

A ll fractu re s un ited w ith in tw e lve m o n ths af te r the accid en t.

D u ra tion of h osp ital trea tm en t-In pa tien ts w ith on ly a fem oral frac tu re the s tay in h osp ita l

w as sh ortes t in the g ro up treated b y c losed n ailin g . T h is g ro up of pa tien ts stayed in ho sp ita l

fo r an ave rag e o f th ir ty -on e d ay s com pared w ith th ir ty -f ive d ay s fo r tho se trea ted by op en

na iling and seven ty -o ne days fo r tho se trea ted conse rva tive ly .

C O M P L IC A T IO N S A N D F A IL U R E S

T he co m plica tion s an d fa ilu re s a re sum m arised in T ab le V . T w o pa tien ts d ied . O ne w as

a fo rty -yea r-o ld w o m an w ho d ied of pu lm on ary em bo lism o n th e n in th day a fter op en n ailin g .

* M o st p atien ts w e re in d u stria l w o rk e rs, fo r w h o m a ccu rate in fo rm ation co u ld rea d ily b e ob ta in ed . T h e

fo llow in g th irty-on e cases w e re om itted : e igh t sc h oolc h ild re n , fifte en p atie n ts ov er s ixty-five y ear s of age or

pen sio ned for o the r unrela ted ca uses , thre e patie n ts

w ith an oth er m ore seve re in ju r y r estr ictin g w o rk in g cap acity

an d five p atie n ts for w h o m n o in for m a tio n co u ld b e ob ta in ed .


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3 1 8 i. R O K K A N E N , P . S L A T IS A N D E . V A N K K A

TABLE II

IN T E R V A L B E T W E E N A C C ID E N T A N D A B IL IT Y T O W A L K W IT H O U T A S T IC K

T h e tab le in c lu d es on ly fra ctu re s w ith sev ere d isp lace m e n t o r co m m in u t ion in p a tien ts of w o rk in g a ge

Interval be tw een a ccid en t a n d ab ili ty

A ge gro u p s to walk w ith ou t a stic k T o ta l n u m b e r

- -------------

: ofe a se s

In tram edu lla ry na iling C onserva tive trea tm en t

Pa tien ts under 3 5 years o f age 26 w eeks (1 5 cases) 29 w eeks (7 c ases) 22

Pa tien ts ov er 35 y ears o f age 33 w eeks (9 cases) 53 w eeks (7 cases) 16

TABLE III

IN T E R V A L B E T W E E N A C C ID E N T A N D R E T U R N T O W O R K

T h e tab le in c lu d es on ly fra ctu re s w ith sev ere d isp lace m e n t or co m m in u tion in p a tien ts o f w or k in g ag e

In te rva l b etw een ac cid en t a n d r etu rn to w or k

T ota l n u m ber

ge gr ou ps

- -- -

of ca ses

Intram edu llary nailin g C on se rvative

t r e a t me n t

P atien ts und er 35 years o f age 36 w eeks (1

5

cases ) 37 w eeks (7 cases ) 22

Pa tien ts ov er 35 years o f ag e 4 3 w eeks (9 cases)

55

w eeks (7 c ases) 16

TABLE 1V

IN T E R V A L B E T W E E N A C C ID E N T A N D R E T U R N T O W O R K A F T E R E A R L Y A N D D E L A Y E D N A IL IN G O F

F E M O R A L S H A F T F R A C T U R E S

In ter val b e tw e en a cc id e n t an d re tu rn to w ork

M ethod of trea tm ent . . .

Nall lng

perfo rmed

w ith in N ailin g

perfo rmed

7 to 21

6

d ays a fte r th e fracture d a ys a fter th e frac tu r e

C lo sed or open in tram edu lla ry na ilin g 32 w eeks (3 9 cases ) I 30 w eek s (49 c ase s)

TABLE V

C O M P L IC A T IO N S IN

I 54

C A S E S W IT H F R A C T U R E S O F T H E F E M O R A L S H A F T

M eth od of t r e a t me n t

C o m p lica tio n in tra a ry C o nserv ative T ota l P er cen t

na ilin g na ilin g (38

____ ___ ____ ____ ___ ____ ____ ___ ____ _ 54 cases )

(6 2 ca ses ) cases

D eath . . . . . . .

-

2

-

2 l3

F at em bolism (no n-fa ta l)

. . .

I 3 1 5 32

O ste itis a t 1 2 m on th s

. . . .

1 - - I 06

In fec tio ns o f the w o und , less than 3 w eeks 2 2 1 5 3 {149}2

D eep venou s th rom bosis

. . . . 4 2 3 9 5 { 149} 8

N oticea b le po st-t rau m a tic sw e llin g 2 yea rs

later

. . . . . . .

3 1 2 6 38

N on-u n ion a t 12 m onths .

. . .

- - - - -

T H E JO 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


7/11

C L O S E D O R O P E N IN T R A M E D U L L A R Y N A IL IN G O F F E M O R A L S H A F T F R A C T U R E S ? 319

T he o th er w as an e igh teen -yea r-o ld m an w ho d ied from ren al fa ilu re on th e tw en ty -seco nd

day a fte r op en na iling and sim ultaneous repa ir o f the fem ora l a rte ry .

In on e case o ste itis o ccu rred a fte r clo sed in tram edu lla ry n a iling and still con tinued ,

w ith ou t a d ischa rg ing sin us, a s a low -grad e in fec tion a t tw e lve m o n ths. T h e frac tu re even tu a lly

un ited , and th e oste itis su bsid ed an d has no t recu rred . In fou r na iled pa tien ts an d in on e

conse rva tive ly trea ted com pou nd frac tu re, w o und in fec tion w as reco rded bu t it hea led in a ll

w ith in th ree w eeks and seem ing ly d id n o t h av e an y adve rse e ffect on the frac tu re rep air .

D eep veno us th rom bos is o f the leg occurred in n ine pa tien ts . A t fo llow -u p six pa tien ts

com p lain ed of m uch sw ellin g . in th ree , deep veno us th rom b osis had b een obse rved ea rlie r ,

an d in on e pa tien t th e sw ellin g w as caused by ex ten sive con stric tin g sca rs in th e th igh from

severe

prim ary so ft- tissue in ju ry .

In f ive case s no n-fa ta l fa t em b o lism w as o bse rv ed clin ica lly and ve rif ied b y sk in b io psy or

rad iog raph s o f th e chest. F a t em bo lism o ccu rred on an ave rage 24 d ay s afte r the in ju ry and

in va riab ly appea red be fo re the in tram edu lla ry na iling .

N o n ail b ro ke . O ne n ail, 1 1 m illim e tre s in d iam ete r , ben t a s a re su lt o f a fu rthe r in ju ry

an d h ad to be chang ed .

T h e m o st frequen t com p lain t in the na iled pa tien ts w as sligh t d isco m fo rt in th e

troch an ter ic reg io n a t the tip o f th e na il. O n enqu iry , on e pa tien t in th ree w as foun d to have

T A B L E V I

R A N G E O F K N E E M O V E M E N T A F T E R D IF F E R E N T

Mrr i- ioDS

OF

T R E A T M E N T O F F E M O R A L S H A F T F R A C T U R E S

F o llow -u p ex am in a tio n o f I 1 3 p a tien ts

C losed

O pe n C on se rvativ e

R esu l ts o f trea tm en t na ilin g na ilin g treatm ent

(p e r c en t) (p er ce n t) (p e r ce n t)

G o o d

. .

86 7 9 56

Fair . . 14 2 1 37

P o o r . .

-

- 7

N u m b e r

of case s 4 2 43 28

som e p ain in th is a rea , w h ich u sua lly subs ided a fter rem ova l o f th e na il. T h ere w as no

corre la tion b etw een th e sub jec tive co m pla in ts and the d eg ree o f p ro tru sion of the na il.

R esidua l d efo rm ity -A t fo llow -up the deg ree o fangu lar and ro ta tiona l d efo rm ity w as m easu red .

in

n o frac tu re treated by clo sed na iling d id the an gu la r d e fo rm ity exceed 10 d eg rees. S u ch

de fo rm ity w as, how eve r , obse rved in 2 pe r cen t o f the fractu re s trea ted b y open na iling an d

in 29 p e r cen t o f th ose trea ted conserva tive ly .

R o ta tiona l de fo rm ity exceed ing 1 0 degrees w as reco rd ed in 10 pe r cen t o f the fractu re s

trea ted by clo sed na iling , in 1 1 p er cen t o f the frac tu re s treated by o pen na iling and in 4 pe r

cen t o f the frac tu res trea ted con serva tive ly .

S h orten ing of th e lim b by m o re than 2 cen tim e tres w as obse rved in 3 pe r cen t o f the

frac tu res trea ted by clo sed na iling , in 4 pe r cen t o f tho se trea ted b y open na iling an d in 1 8 p er

cen t o f tho se trea ted con se rv ativ ely .

R esid ua l jo in t s tif fne ss-A t fo llo w -up the rang e of m ovem en t at the h ip , k nee, ank le an d

ta rsa l jo in ts w as m easu red and co m pared w ith the in tac t s ide . T he rang e of m ov em en t in the

hi p jo in t w as equ ally goo d in a ll trea tm en t g ro up s. In th e n ailed pa tien ts d iscom fort a t the

site o f the tip o f the na il w as com m on , bu t o n ly in on e case d id a p ro trud ing na il p reven t fu ll

range of m ovem en t a t the h ip .

V O L . 51 B , N O. 2, M AY 1969


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32 0 r’.

R O K K A N E N , P . S L A T IS A N D E . V A N K K A

R esidu a l stif fne ss o f the kn ee w as m a in ly encoun te red a fte r frac tu re s trea ted con serva tive ly ;

the range o f m ovem en t w as de fin itely be tte r a f ter frac tu res trea ted b y na iling (T ab le V l)* . A

g o o d rang e w as thu s ob tain ed in 86 p e r cen t af te r c losed n ailin g , in 7 9 pe r cen t a f ter op en

na iling an d in 56 p er cen t af te r con se rv ativ e trea tm en t. In no lim b trea ted by na iling w as th e

ran ge of m ovem en t le ss than 90 deg rees, w h ereas in the co nse rv a tive ly trea ted cases the range

of

m ov em en t w as po or in 7 pe r cen t.

T h ere w as no d isce rn ib le d iffe ren ce in th e ran ge of m o vem en t at th e ank le o r tarsa l jo in ts

be tw een the d iffe ren t trea tm en t g roup s.

D I S C U S S I O N

O pera tive red uc tion and in te rna l f ixa tion of a frac tu re o f a lon g bo ne inva riab ly a ffec ts

the vascu la ris atio n of th e fractu re a rea . T he advan tag es o f a stab le red uc tion m ust th ere fo re

be w e igh ed aga inst the kno w ledg e th at an im p a ired b lood supp ly afte r ex posu re o f the fractu re

m ay resu lt in de fic ien t n u tr ition o f the o steogen ic ce lls and subseq uen t de layed un ion .

E xpe rim en ts h av e sho w n (G { 246 }thm an 19 61 , T rue ta and C avad ia s 1 955 , 1 964 ) tha t th e inne r

two-th irds

o f

the co rtex is nou rish ed b y bran ch es from the m edu lla ry a rte r ies , w he reas th e

o u te r th ird o f th e co rtex ob ta ins its b lo od sup p ly from the pe rio steal vesse ls . S ev erance o f

th e m edu lla ry vessels d oes no t resu lt in nu tr itiona l chang es in th e co rtex , becau se reactiv e

ac tiva tion of the pe rio s tea l v essels com p ensa te s fo r the sev ered m ed u lla ry sy stem (G { 246 }th m an

1961).

In an im a ls and in m an frac tu re h ea ling a fte r in tram edu lla ry na iling is basica lly b ro ugh t

ab ou t by pro lifera tion of th e inn er laye r o f the pe rio steum and sub seq uen t fo rm a tion o f an

en shea th ing ca llu s m ass a roun d th e b ro ken b one end s. T he prog re ss o f h ealin g thu s la rge ly

re sem ble s frac tu re repa ir du ring norm a l con d ition s (S l {22 8} tisn d R okk an en 1 965 , 19 67b ). T he

m ore s tab le the fractu re is ren de red a fter n ailin g th e le ss p rono unced w ill be the p e rio s tea l

reac tion (G {2 46} thm an 19 61). Indeed , K {2 52} n tsche r (19 64) cla im ed tha t if the f ixa tion w as rig id

th e p rocess o f rep air w as con ve rted in to d irect bon e fo rm a tion be tw een th e frag m en ts . T h is

co rre spon ds to the so -ca lled p rim ary ca llu s obse rved a fte r os teo syn th es is w ith com press ion

dev ice s (S ch en k and W illenegg er 19 64).

T h us, th eo re tica lly , c lo sed in tram edu lla ry n ailin g is p re fe rab le to o pen in tram edu llary

n ailin g , becau se by a c lo sed tech n iqu e the pe rio s tea l b lo od sup p ly is p re served , an d

revascu la r isatio n o f th e frac tu re a rea can occu r w ith in a rea son ab le tim e . F u rthe r , if

in tram edu llary na ils o f ap propria te size a re used , stab le fix atio n can be ach iev ed , w h ich m akes

ea rly m ob ilisa tio n of the frac tu red lim b po ssib le .

it em erg es fro m the pre sen t se rie s tha t in fem o ra l sha ft fractu re s bo th th e ea rly an d la te

re su lts o f trea tm en t w ere be tte r a fte r in tram edu llary n a ilin g th an a fter conserva tive treatm en t.

I t is in te re sting tha t it w as the d iff icu lt fractu re s in the o lde r pa tien ts th at b en e fited m o st fro m

in tram ed u lla ry na iling , w h ereas low -en ergy in ju r ie s in yo ung peop le healed equ ally w e ll

rega rd le ss o f the m e tho d o f trea tm en t.

I t is o bv io us tha t th e f irs t repo rts o f the re su lts o f in tram ed u lla ry na iling of the fem ur

sho u ld no t b e co m p ared w ith recen t reports . In the beg in n ing unsu itab le na ils and fau lty

eq u ipm en t caused nu m ero us techn ica l d iff icu ltie s an d led to fa ilu re s am ou n ting , in so m e

se ries , to 14 pe r cen t o f the na iled cases (D encke r 196 4). M o dern flex ib le d rills an d a

co m ple te asso rtm en t o f n ails are im p era tive fo r su ccessfu l in tram edu llary n ailin g . F ew

m eth ods o f osteosyn th esis are so liab le to techn ica l fa ilu re from fau lty equ ip m en t.

C o rre spo nd in g ly , an app ro priate se t o f in stru m en ts and a h igh qua lity im ag e in tensif ier m ake

clo sed in tram edu lla ry na iling of the fem u r an exp ed ien t su rg ical p ro cedu re . M e ta l fatig ue

and na il b reak ag e shou ld n o lon ge r com p licate the la te cou rse o f frac tu re hea ling , as is ev iden t

fro m the p re sen t se rie s w h ere , in 1 18 na iled frac tu re s , on ly o ne na il b en t.

6

G rad ing o f m ob ility a t knee-G ood= F ull ex tension ; loss o f flex io n less than 1 0 d egrees. Fa ir= A ny loss o f

ex tens ion ; lo ss o f flex ion of 1 0 to 5 0 d egr ees . P oor = L o ss o f m ore th an 1 0 d egr ees of exten s ion ; r an ge o f

flex io n -ex ten sion les s th an 90 degrees .



9/11


32 1

A lthou gh th e d iffe ren ces be tw een re su lts a fte r op en an d c lo sed na iling a re no t v ery g rea t,

w e p refe r c losed n ailing . I t is le ss trau m a tic and hence be tte r to le ra ted by the pa tien t, and in

m os t in sta nce s it is an eas ier su rg ica l p ro ced ure than o pen reduc tion and na iling . If redu ctio n

proves

d ifficu lt, ho w eve r , ow ing to sh orten in g or in te rpo sed tissue , fo rc ib le attem p ts a t

reduc tion sh ou ld be avo id ed . In such cases tim e is sav ed and tis sue dam age redu ced if the

frac tu re is exp osed and n ailed by the o pen m e thod .

In the w h o le ser ie s the re w as no n on-un io n a t tw elv e m o n ths a f ter the frac tu re . S im ila r

resu lts have been rep orted by B {2 46} h le r1 965 ). B u t sev era l au tho rs have rep orted a h igh in cid ence

of

de layed un ion , the fig u res v ary in g from 43 pe r cen t to 25 pe r cen t (P a lm er 195 1

,

Charn ley

and G u indy 19 61 , O ’B rien 1 963 , D encke r 1 965 , W ick stro m an d C orban 1 967 ). In ou r se rie s

the re w as no ev id en ce to sug gest th at na iling d elays un io n . N e ithe r d id na iling in any w ay

prom o te un io n o f th e b roken bon e ends, a s jud ged from the rad iog raphs . in our op in ion ,

the go od resu lts o f in tram edu lla ry n a ilin g of the fem oral sha ft a re b ecause o f the g ood vascu la r

c ond i t ions

th rou gho u t th e d eep -sea ted bon e , w h ich favou r abu ndan t ing row th o f cap illa r ies

in to the frac tu re a rea in a w id e va rie ty o f pa tho log ica l con d ition s c rea ted eith er by the frac tu re

o r by su rg ica l in te rven tion . In tram edu lla ry na iling o f a sup erfic ia l bon e , such as the tib ia,

ha s no t g iven su ch go od resu lts (S l {2 28} tisnd R okk an en 196 7a ).

O ste itis occu rred in th is se rie s in o ne case . T he in fec tion even tu ally sub sided w ith ou t

any recu rren ces du ring the fou r-year fo llow -up pe riod . In ano th er fiv e cases w o und in fec tio n

w as reco rd ed . T hu s th e in cid en ce of deep in fec tion w as 0 6 p e r cen t and th e o ve ra ll ra te o f

in fec tion 38 pe r cen t. T hese fig u res a re low er than th ose repo rted recen tly by o the r au tho rs ,

acco rd ing to w ho m th e rate o f deep in fec tion a fte r in tram ed u lla ry na iling ran ges from I to

1

1 pe r cen t (B {24 6}h ler 19 51 , O ’B rien 196 3 , D en cke r 196 5 , W icks trom

et a l.

1967).

O p in ion s d ive rge rega rd ing th e p rop er tim e fo r in tram ed u lla ry na iling . C h arn ley an d

G u indy (19 61) rep orted th at in th eir expe rien ce d elayed fix atio n of the frac tu re low ered the

incid en ce o f de layed un io n from 25 pe r cen t to 7 p er cen t. S im ilar ly , S m ith (19 64) rep orted

an in c id ence of d elayed u n ion o f on ly 08 pe r cen t w hen the ope ratio n w as po stpo ned to the

s ec ond

w eek a fte r the acc id en t o r la ter . A n aly sis o f th e p re sen t se rie s , ho w eve r , d oes no t rev eal

an y c lea r d iffe rence b etw een ear ly an d de lay ed fixa tion of the frac tu re .

W hich ty pes o f fem ora l sha ft fractu re s shou ld then be trea ted by in tram ed u lla ry na iling ?

M ost su rg eons ag ree tha t the tran sve rse an d short o b liqu e fractu re s a re w e ll su ited fo r

in tram ed u lla ry n ailin g (B {2 46} h le r a nd B {2 46} h le r 194 9 ; B {24 6} h le r 1 9 51 ; K {2 52} n tsche r 196 5 ; M ulle r,

A llg ow er and W illeneg ge r 19 65 ; W ickstrom e t a . 19 67). W e ag ree w ith th is , bu t in our

op in ion th e c losed tech n iqu e o fn ailin g a llow s a broaden ing ofthe in d icatio ns fo r in tram edu lla ry

osteosy n thesis o f fem o ra l sh a ft frac tu re s . In ou r exp erience, s ligh t com m inu tion o f the

fractu re is no con tra -in d icatio n to c losed in tram ed u lla ry n ailin g , p rov ided th at n ails o f an

approp ria te size are used . In frac tu re s w ith seve re co m m in u tion conse rva tive trea tm en t is

usua lly re so rted to , supp lem en ted , if n ecessa ry , by bon e g ra f ting . H o w eve r , in these cases too ,

recen t exp eriences w ith c losed in tram ed u lla ry na iling have been en co urag ing . W e have been

fo rced to ad op t rath er b road in d icatio ns b y the fact th a t in ou r se rie s o ve r 70 pe r cen t are

tra ffic accid en t v ic tim s, w ith m u ltip le in ju rie s in tw o p atien ts ou t o f th ree . In th ese th e p lan

of

treatm en t a s a w ho le m ay ca ll fo r in te rn al fix atio n o f the fem ora l frac tu re : th is is th e case

in seve re b ra in in ju r ie s , m u ltip le in ju rie s to bo th lo w er ex trem itie s and in pa tien ts w ith

sim u ltaneous trau m a tic p arap leg ia , in w hich nu rsin g prob lem s are g rea tly red uced b y in terna l

f ixa tion of the fem oral fractu re and avo id ance of tractio n -susp en sion d ev ices.

S U M M A R Y

1

.

A serie s o f I 54 p atien ts w ith 1 56 fem o ra l sh a ft frac tu res trea ted du ring a th ree an d a ha lf

y ear p eriod is rev iew ed . F ifty -fou r frac tu re s w ere treated by c losed in tram edu llary na iling ,

s ix ty -fo ur b y op en in tram edu lla ry na iling and th irty -e igh t by conserva tiv e

m et h o d s .

V O L . 51 B , NO . 2, M A Y 19 69


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32 2 P. R O K K A N E N , P . S L A T IS A N D E . V A N K K A

2 . A ll the p atien ts had fre sh frac tu re s o f a sim ilar deg ree o f seve rity . S even ty -e igh t pe r cen t

o f the fractu re s w ere su stain ed in tra ffic accid en ts , and 21 p er cen t w ere com p oun d .

3 . T he tech n iqu e o f c losed in tram edu lla ry na iling is d escr ibed in de ta il. T he im p ortan ce o f

a com ple te an d fau ltle ss a rm am en ta riu m and a h ig h -qua lity im ag e in tensif ie r is em p hasised .

4 . A ll frac tu re s u n ited w ith in tw elv e m on th s a fte r th e acc iden t.

5. T h e func tion al re su lts w ere asse ssed u pon the basis o f w a lk ing ab ility an d re tu rn to w ork .

N a iled frac tu re s d id b ette r than con serva tive ly trea ted on es , and c losed na iling w as sligh tly

sup erio r to open na iling . A t tw elv e m on th s af te r the in ju ry all pa tien ts trea ted by c losed

na iling w a lked w ith ou t a stick , co m pared w ith 9 6 pe r cen t o f th e case s trea ted b y o pen n ailin g

and 8 1 pe r cen t o f th e co nse rv a tive ly trea ted p atien ts . T he sam e trend w as no ted rega rd ing

re tu rn to w ork .

6 . T he b en e fit o f in tram edu lla ry na iling w as pa rtly depen den t o n the seve rity o f the frac tu re

an d the ag e of th e p a tien t. T h e m o st g ratify ing re su lts o f n ailin g w ere ob tain ed in pa tien ts

ove r th ir ty -five yea rs o f ag e w ith seve re fractu re s .

7 . O ste itis o ccu rred in one case trea ted by c losed n a ilin g , an d low g rade w oun d in fec tion s

in fiv e cases , rep re sen ting an ove rall in fectio n ra te o f 38 p er cen t.

8 .

S even ty -fou r pe r cen t o f th e pa tien ts w ere exam ined on e to fou r years a fte r the frac tu re .

T h ere w as less ang u la r d efo rm ity an d m ore ro ta tiona l de fo rm ity in the n ailed than in the

conse rva tive ly trea ted frac tu re s . T he tip o f the n a il gave slig h t d iscom fort in the trochan te r ic

area in o ne pa tien t in th ree . R es idua l jo in t s tiffne ss w as in frequ en t in the n ailed cases as

com p ared to the con se rv ativ ely trea ted ones.

9. T he ind ica tion s fo r clo sed in tram edu lla ry na iling o f fem oral sha ft fractu re s a re o u tlined .

W e are m uch in deb ted to th e fo rm er H ead of th is C lin ic , P ro fesso r K . E . K allio , under w ho se g u idance the

m ethod of c losed in tram edu lla ry na iling w as ado p ted an d d ev elop ed .

R E F E R E N C E S

B { 2 4 6 } H L E R , J . (1951): R esu lts in M edu llary N ailin g of N in ety -five F resh F ractures of th e F em ur. Jo u rn a l o f B one

an d Jo in t S u rge ry , 3 3 - A ,

670 .

B O H L E R , J.

( 1965 ) : P ercu taneous In te rn a l F ixa tion U tiliz ing the X -ray Im age A m plifie r. J ou r na l

of

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an d

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B ased o n

45 9 N ailed F em o ra l S h a ft F ra ctu res .

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S h aft F ra ctu re s of th e F em u r : A C om p a rat ive S tu d y of th e R e su lts o f V ariou s M eth o d s

of T rea tm en t in 1 ,003 C ases.

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G R O V E S , E . W . H E Y ,

(191 8): U nun ited F rac tu re s,

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in

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C L O S E D O R O P E N IN T R A M E D U L L A R Y N A IL IN G O F F E M O R A L S H A F T F R A C T U R E S ? 32 3

N I C H O L S , P . J . R . (1963) : R eh ab ilita tion afte r F rac tu res o f the Shaft o f the Fem ur.

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O ’B R IE N , J.

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Me dul la ry

N ail . Jo u rn a l o f B o n e a n d J o in t S u rg ery , 3 3 - A , 6 5 9 .

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1

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W I L L E N E G G E R ,

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B erlin , H e ide lberg , N ew Y ork : Spring er-V erlag .

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51 B ,

NO .

2,

M AY

1969

im nail of femur

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