im nail of femur
TRANSCRIPT
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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 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
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,
;-
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
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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 .
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 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
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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 ? 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 .
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
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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
T r a u m a ,
5 , 1 50 .
B O H L E R ,
L ., a nd
B O H L E R ,
J . (1 949): K U ntscher’s M edu llary N ailin g .
Jo u rn a l o fB o ,ze an d fo in t S u rg e ry ,
31-A ,
295 .
C H A R N L E Y , J ., a nd G U I N D Y , A . (1961 ): D elayed O p eration in th e O p en R ed u ctio n o f F ractures o f L on g B o nes .
J o u rn a l o fB on e
an d
J o in t S urge ry , 43-B , 664 .
D E N C K E R , H . (1964 ): E rro rs in T ec h n iq u e an d C om p lic ation s S p e cific to In tram ed u llary N a ilin g . A S tu d y
B ased o n
45 9 N ailed F em o ra l S h a ft F ra ctu res .
A c ta O rth op ae dic a
Sc and inav ic a , 35 , 164 .
D E N C K E R , H . ( 1965 ) :
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.
A cta C hiru rg ica S ca n d in av ica , 130 ,
1 7 3 .
G O T H M A N , L . (196 1): V ascu la r R eactions in E x perim en tal F ractu res . M icroang iograp h ic an d R ad io iso tope
S tud ies . A cta C h iru rg ica S c an d in av ica , S up p le m e n t 2 8 4 .
G R O V E S , E . W . H E Y ,
(191 8): U nun ited F rac tu re s,
w ith Sp ec ia l R efe rence to G unsho t In ju ries and the U se of
B on e G raftin g. B rit ish Jo u rn a l o f S u rg ery , 6 ,
203 .
K U N T S C H E R ,
G . (1 940): D ie M arkn age lu ng von K n ochen b rU chen . A rc h iv fu r k lin isch e C h fru rg ie , 2 00 , 443 .
K U N T S C H E R , G . B . 0 . (1 958): T he K U n tsch er M etho d of In tram ed ullary F ixation .
Jo u rn a l of B o n e an d
J o in t
Su rg ery , 40-A, 17 .
K U N T S C H E R ,
G . (195 9): D ie T ech n ik des A ufw eitens d er M a rk h {246}le . Ch i ru rg , 30 , 28 .
K U N T S C H E R , G .
(1964) : Prim {228}renochenhei lung .
L an g en b ecks
Ar c h iv
f {252}r
lin isch e C hiru rg ie , 3 0 8 , 4 5 2 .
K U N T S C H E R , G . (19 65): In tra m edu llary S urg ica l T echn iqu e an d Its P lace in O rth op aed ic Su rgery . M y P resen t
C oncep t . Jo u rn a l o fB o n e an d Jo in t S u rg e ry , 47-A , 809 .
K U N T S C H E R ,
G . (1967) :
P ra c tic e o fln tra m ed u lla ry N ailing .
S prin gfield , Illino is: C ha rle s
C . T h o m a s .
L A U R I T Z E N ,
G . K . (1949 ): M edu lla ry N ailing : a C lin ical and C ritical S tu dy . A cta C hiru rg ic a S c an d in av ic a ,
S u p p l em en t 147 .
L O i - I -E S, J . 0 . (195 3): C om p lica tio ns and E rrors
in
T ec hnic in M ed ullary N ailing fo r F ra ctu res of the F em ur.
C lin ic al O rth op ae dic s, 2 , 3 8 .
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
-
8/19/2019 IM Nail of Femur
11/11
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 ? 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.
Jou rn a l o fB on e a nd
Jo in t
Sur ge r y , 4 5- B, 9 6.
O ’B R IE N , J.
P . (1963 ) : F rac tu red Fem oral Shafts . A u stra l ian a n d Ne w Z ea lan d Jou rn a l o f S u rge ry , 33 , 91 .
P A L M E R , I. ( 1951 ) : O n the C om plications and T echn ica l P rob lem s of M edu lla ry N ailing . Ac ta
Ch iru rg ica
Sc and inav ic a , 101 ,
4 8 4 .
R E H M , J., and U E B I N G , D . (1 963): D ie B ehand lun g von F rak tu ren langer R {2 46}h renknoch en m it d em M arkn age l
na ch K fln tsch er.
A rch iv fu r o rth o p ad isc h e u n d U n fa ll-C h iru rg ie , 5 5 , 82 .
S C H E N K , R ., an d W I L L E N E G G E R , H . (196 4): Z u r H isto lo g ic der p rim {22 8}renK n ochenhe ilung . L a tige nbe ck s A rc h ly
f {252 } rlin is ch e C hiru rg ie , 3 08 , 4 40 .
S L A T I S ,
P ., and
R O K K A N E N ,
P . (19 65): T h e N orm al R ep a ir o f E xperim en ta l F rac tu res. A cta O rth op ae dic a
Sc and inav ic a ,
3 6 , 2 21 .
S L A T IS , P ., an d R O K K A N E N , P . (1967a): C lo sed In tram edu llary N ailing of T ib ia l Shaft F ractu res . Act a
O rtho pa ed ica S can din av ica ,
3 8 , 88 .
S L A T I S , P ., and
R O K K A N E N ,
P . (1 967b ): T he M in eral P hase in the R epa ir o f E xperim en ta l F ractu res . Anna les
C h iru rg ia e e t G y n a ec o lo g ia e F en n ia e , 56 ,
1 9 3 .
S M I T H , J. E . M . (1964 ): T he R esu lts o f E arly and D elayed In te rna l F ix ation of F rac tu res o f th e Sh aft o f the
F e m u r . Jo u rn a l o f B one an d Jo in t S u rg e ry , 46-B, 28.
S T R E E T , D . M . (19 51): O n e H und red Frac tu res o f the F em ur T rea ted by M eans of the D iam ond-shaped
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 .
T R U E T A , J. , and C A V A D I A S , A . X . ( 1955 ) : V ascu la r C hang es C au sed by the K {2 52} n tscher T ype o f N ailing . A n
E xp erim en ta l S tud y in the R abb it. Jo u rn a l o fB o ne an d J oin t S urg er y,
37-B ,
4 9 2 .
T R U E T A , J., an d C A V A D I A S , A . X . (196 4): A S tu d y of th e B lood S u p p ly of th e L on g B on e s . Su rg ery , G y nec o logy
a nd O bs te tri cs ,
1
1 8, 4 85 .
W I C K S T R O M ,
J., an d
C O R B A N ,
M . S . (196 7): In tram edu lla ry F ixa tio n fo r F rac tu res o f the Fem o ra l S haft. A
S tudy o f C om plica tio ns in 2 98 O p erations . Jo u rn a l o f T r a u m a , 7 , 5 51 .
M U L L E R , M . E ., A L L G O w E R , M ., an d
W I L L E N E G G E R ,
H . (196 5): Techn ique o f In te rn al Fixat ion of F rac t u res .
B erlin , H e ide lberg , N ew Y ork : Spring er-V erlag .
V O L .
51 B ,
NO .
2,
M AY
1969