Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients.

BACKGROUND: From 1989 to 1997, 1507 fractures of the shaft of the femur were treated with intramedullary nailing at The R Adams Cowley Shock Trauma Center. Fifty-nine (4 percent) of those fractures were treated with early external fixation followed by planned conversion to intramedullary nail fixation. This two-stage stabilization protocol was selected for patients who were critically ill and poor candidates for an immediate intramedullary procedure or who required expedient femoral fixation followed by repair of an ipsilateral vascular injury. The purpose of the current investigation was to determine whether this protocol is an appropriate alternative for the management of fractures of the femur in patients who are poor candidates for immediate intramedullary nailing. METHODS: Fifty-four multiply injured patients with a total of fifty-nine fractures of the shaft of the femur treated with external fixation followed by planned conversion to intramedullary nail fixation were evaluated in a retrospective review to gather demographic, injury, management, and fracture-healing data for analysis. RESULTS: The average Injury Severity Score for the fifty-four patients was 29 (range, 13 to 43); the average Glasgow Coma Scale score was 11 (range, 3 to 15). Most patients (forty-four) had additional orthopaedic injuries (average, three; range, zero to eight), and associated injuries such as severe brain injury, solid-organ rupture, chest trauma, and aortic tears were common. Forty fractures were closed, and nineteen fractures were open. According to the system of Gustilo and Anderson, three of the open fractures were type II, eight were type IIIA, and eight were type IIIC. Intramedullary nailing was delayed secondary to medical instability in forty-six patients and secondary to vascular injury in eight. All fractures of the shaft of the femur were stabilized with a unilateral external fixator within the first twenty-four hours after the injury; the average duration of the procedure was thirty minutes. The duration of external fixation averaged seven days (range, one to forty-nine days) before the fixation with the static interlocked intramedullary nail. Forty-nine of the nailing procedures were antegrade, and ten were retrograde. For fifty-five of the fifty-nine fractures, the external fixation was converted to intramedullary nail fixation in a one-stage procedure. The other four fractures were associated with draining pin sites, and skeletal traction to allow pin-site healing was used for an average of ten days (range, eight to fifteen days) after fixator removal and before intramedullary nailing. Follow-up averaged twelve months (range, six to eighty-seven months). Of the fifty-eight fractures available for follow-up until union, fifty-six (97 percent) healed within six months. There were three major complications: one patient died from a pulmonary embolism before union, one patient had a refractory infected nonunion, and one patient had a nonunion with nail failure, which was successfully treated with retrograde exchange nailing. The infection rate was 1.7 percent. Four other patients required a minor reoperation: two were managed with manipulation under anesthesia because of knee stiffness, and two underwent derotation and relocking of the nail because of rotational malalignment. The rate of unplanned reoperations was 11 percent. The average range of motion of the knee was 107 degrees (range, 60 to 140 degrees). CONCLUSIONS: We concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients.

Intramedullary nailing of the femur: reamed versus nonreamed.

All intramedullary nailing creates some loss of endosteal blood supply and an increase in intramedullary pressure, resulting in marrow embolization. In laboratory studies, both reamed and nonreamed intramedullary nailing have led to alteration in selected pulmonary variables. This effect, although transient, appeared more pronounced with reamed techniques than with nonreamed techniques. Concern about the systemic pulmonary effects of reamed intramedullary nailing has led to an increase in the use of nonreamed nailing. The authors of most clinical studies have reported that reamed intramedullary nailing has not been associated with a concomitant increase in pulmonary complications in multiply injured patients, although this point is still controversial. Femoral shaft fractures treated with nonreamed nailing have been shown to have slightly higher rates of delayed union and nonunion compared with those treated with reamed nails. Reamed interlocking intramedullary fixation remains the treatment of choice for femoral shaft fractures in adults. Further study is required to determine whether an identifiable subgroup of trauma patients is adversely affected by intramedullary reaming, which would suggest the need for alternative fixation techniques.

Immediate weight-bearing after treatment of a comminuted fracture of the femoral shaft with a statically locked intramedullary nail.

BACKGROUND: The purpose of this two-part investigation was to test the feasibility, safety, and efficacy of immediate weight-bearing after treatment of fractures of the shaft of the femur with a statically locked intramedullary nail. METHODS: In the first part of the investigation, a biomechanical study was performed to determine the fatigue strength of eleven different statically locked intramedullary nail constructs. Segmentally comminuted midisthmal fractures were simulated with use of sections of polyvinyl chloride pipe; each construct was cyclically loaded in compression with use of physiologically relevant loads in a materials testing machine at eight hertz. The fatigue tests were conducted according to the so-called staircase method, and the construct was considered to have run out (exceeded its anticipated service life) if it had not failed after 500,000 cycles. In the second part of the study, a clinical investigation of immediate weight-bearing after treatment of comminuted fractures of the femoral shaft with a Russell-Taylor (RT-2) construct was performed. Complete follow-up data were available for twenty-eight of the thirty-five patients (thirty-six fractures) entered into the study. RESULTS: In Part I of the study, two constructs, a statically locked twelve-millimeter-diameter Russell-Taylor femoral nail with two distal locking screws (RT-2) and a statically locked twelve-millimeter-diameter Zimmer femoral nail with two distal locking screws (Z-2), had significantly higher mean fatigue strengths (2171 and 2113 newtons, respectively) than all other constructs tested (p<0.001), but the strengths of these two constructs were not significantly different from each other. Constructs with only one distal locking screw demonstrated significantly lower (p<0.05) fatigue strengths than the two-screw constructs. These results suggest that full weight-bearing during the weeks immediately after insertion of the nail may be possible, even for patients who have a comminuted fracture of the femoral shaft. In Part II of the study, twenty-six of the twenty-eight patients were bearing full weight on the fractured limb or limbs at the six-week follow-up visit. All fractures united; only one of these needed an additional procedure (the removal of the screws five months after the insertion of the nail) to stimulate union. No loss of fixation, such as back-out or breakage of a locking screw or breakage or bending of the intramedullary nail, occurred. CONCLUSIONS: We concluded from this two-part investigation that immediate weight-bearing after stabilization of a comminuted fracture of the femoral shaft with a statically locked intramedullary nail is safe when the construct has a relatively high fatigue strength. Immediate weight-bearing after stabilization of a fracture of the femoral shaft permits patients who have multiple fractures of the extremity to walk and to participate in physical therapy earlier, possibly decreasing the duration of the hospital stay or reducing the need for prolonged rehabilitation on an inpatient basis.

Early fracture fixation may be "just fine" after head injury: no difference in central nervous system outcomes.

BACKGROUND: Recent reports suggest that early fracture fixation worsens central nervous system (CNS) outcomes. We compared discharge Glasgow Coma Scale (GCS) scores, CNS complications, and mortality of severely injured adults with head injuries and pelvic/lower extremity fractures treated with early versus delayed fixation. METHODS: Using trauma registry data, records meeting preselected inclusion criteria from the years 1991 to 1995 were examined. We identified 171 patients aged 14 to 65 years (mean age, 32.7 years) with head injuries and fractures who underwent early fixation (< or = 24 hours after admission) (n = 147) versus delayed fixation (> 24 hours after admission) (n = 24). RESULTS: Patients were severely injured, with a mean admission GCS score of 9.1, Revised Trauma Score of 6.2, Injury Severity Score of 38, median intensive care unit length of stay of 16.5 days, and hospital length of stay of 23 days. No differences between groups were found by age, admission GCS score, Injury Severity Score, Revised Trauma Score, intensive care unit length of stay, hospital length of stay, shock, vasopressors, major nonorthopedic operative procedures, total intravenous fluids or blood products, or mortality rates. In survivors, no differences in discharge GCS scores or CNS complications were found. CONCLUSION: We found no evidence to suggest that early fracture fixation negatively influences CNS outcomes or mortality.

Biomechanical comparison of fixation of type-I fractures of the lateral tibial plateau. Is the antiglide screw effective?

Type-I fractures of the lateral tibial plateau were simulated by osteotomy in 18 pairs of unembalmed cadaver tibiae. One fracture of each pair was fixed with two lag screws whereas the contralateral site was stabilised with three lag screws, or two lag screws plus an antiglide screw. The lateral plateau was displaced downwards using a servohydraulic materials testing machine and the resulting force and articular surface gap were recorded. Yield load was defined as the maximum load needed to create a 2.0 mm articular offset at the fracture line. The yield loads of the three-lag-screw (307 +/- 240 N) and antiglide constructs (342 +/- 249 N) were not significantly different from their two-screw control constructs (231 +/- 227 and 289 +/- 245 N, respectively). We concluded that adding an antiglide screw or a third lag screw did not provide any biomechanical advantage in stabilising these fractures.

Mortality in patients with bilateral femoral fractures.

OBJECTIVES: To determine and compare the mortality rates of patients with bilateral versus unilateral femoral fractures and to determine the contribution of the femoral fracture to, and identify risk factors for, such mortality. STUDY DESIGN: Retrospective analysis using trauma registry data on consecutive blunt trauma patients with unilateral (800 patients, group I) or bilateral (eighty-five patients, group II) femoral fractures. METHODS: Univariate data analysis was performed to compare the groups' ages, Injury Severity Scores, Glasgow Coma Scale values, mortality, and the presence of adult respiratory distress syndrome (ARDS). Logistic regression analysis was performed to determine variables statistically associated with mortality. RESULTS: Group II patients had a significantly higher Injury Severity Score (30.2 versus 24.5, p < 0.001), lower Glasgow Coma Scale value (12.3 versus 13.1, p = 0.05), higher mortality rate (25.9 vs 11.7%, p < 0.001), and higher incidence of ARDS (15.7 versus 7.27%, p = 0.014) than group I patients. Group II patients also had significantly more closed head injuries, open skull fractures, intraabdominal injuries requiring surgical intervention, and pelvic fractures; the rates of thoracic injury were similar. Regression analysis of variables evident on admission revealed a significant correlation between bilateral femoral fractures and death; however, other factors (shock, closed head injury, and thoracic injury) had much stronger correlations with mortality. CONCLUSIONS: Patients with bilateral femoral fractures have a significantly higher risk of death, ARDS, and associated injuries than patients with unilateral femoral fractures. This increase in mortality is more closely related to associated injuries and physiologic parameters than to the presence of bilateral femoral fractures. The presence of bilateral femoral fractures should alert the clinician to the likelihood of associated injuries, a higher Injury Severity Score, and the potential for a more serious prognosis.

Biomechanical evaluation of transverse acetabular fracture fixation.

The purpose of this two-part biomechanical study was to evaluate various fixation methods for transverse acetabular fractures in a synthetic pelvic model. In Part 1, 40 transverse acetabular fractures were repaired with anterior column plating using 10-hole curved reconstructions plates with one of four screw configurations to evaluate the effect of screw placement and number on fracture fixation stiffness. In Part 2, 36 transverse acetabular fractures were repaired with one of six fixation methods using combinations of contoured plates and column screws to stabilize the anterior column, the posterior column, or both. Each repaired acetabulum was loaded via a hemiarthroplasty in a direction consistent with stance phase. Fixation stiffness was measured from the force-displacement curve for each construct. In Part 1, there was no significant difference in fixation stiffness afforded by any of the constructs. However, the stiffest construct resulted from two screws on each side of the fracture site: one placed as close to the fracture site as allowed (one empty screw hole adjacent to the fracture) and the second at the end of the plate. In Part 2, the constructs that concomitantly stabilized anterior and posterior columns were significantly stiffer than were those addressing either the anterior or posterior column alone, regardless of the number of plates applied. The stiffest construct combined a posterior column plate with an anterior column screw. Because no significant change in stiffness occurred with the addition of a third set of screws, two screws on each side of the fracture site appear to provide sufficient stability with acetabular plating. Concurrent fixation of anterior and posterior columns of transverse acetabular fractures provides the greatest resistance to postoperative loss of reduction in this model.

Treatment of humeral fractures by closed reduction and retrograde intramedullary Ender nails.

A retrospective review of 94 humeral shaft fractures stabilized with retrograde Ender nails was performed to determine the safety and efficacy of this technique. Follow-up averaged 71 weeks. Eighty-six (91.5%) healed with no additional intervention (average: 14 weeks). There were eight (8.5%) nonunions. The functional results were good in 74 (81%), fair in 12 (13%), and poor in 5 (6%). There was one radial nerve palsy secondary to the operative procedure. The reoperation rate, including the repair of nonunions, was 19%. We conclude that intramedullary Ender nail fixation is a relatively simple and quick procedure, especially for the multiply injured patient, that adequately stabilizes most humeral fractures, yielding overall good results.

Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated either with intramedullary nailing with reaming or with a plate. A comparative study.

Multiply injured patients (an Injury Severity Score of 17 points or more) who were admitted to one of two level-I regional trauma centers between 1983 and 1994 because of a fracture of the femoral shaft with a thoracic injury (an Abbreviated Injury Scale score of 2 points or more) or without a thoracic injury were studied retrospectively. The patient populations and the protocols for the treatment of trauma were similar at the two centers; however, the centers differed with regard to the technique that was used for acute stabilization of the fracture of the femoral shaft. At Center I intramedullary nailing with reaming was used in 217 (95 per cent) of the 229 patients, whereas at Center II a plate was used in 206 (92 per cent) of the 224 patients. This difference was used to investigate the effect of acute femoral reaming on the occurrence of adult respiratory distress syndrome in multiply injured patients who had a chest injury. Three groups of patients were evaluated: those who had both a fracture of the femur and a thoracic injury, those who had a fracture of the femur but no thoracic injury, and those who had a thoracic injury without a fracture of the femur or the tibia. The third group was studied at each center to determine if there was a difference between the institutions with regard to the rate of adult respiratory distress syndrome. Patients who had diabetes, chronic obstructive pulmonary disease, asthma, hepatic or renal failure, or an immunosuppressive condition were excluded from the study. The records were abstracted to determine the Injury Severity Score, Abbreviated Injury Scale score, and Glasgow Coma Score for each patient. Requirements for fluid resuscitation were calculated for the first twenty-four hours; these included the number of units of packed red blood cells, fresh-frozen plasma, and platelets that were transfused and the volume of crystalloid that was used. The duration of intubation, the duration of hospitalization, and the occurence of adverse outcomes (death, multiple organ failure, adult respiratory distress syndrome, pneumonia, and pulmonary embolism) were determined for each patient. The groups of patients were analyzed as a whole and then were stratified into subgroups (according to whether or not they had a thoracic injury and whether the Injury Severity Score was less than 30 points or 30 points or more) to determine if the type of fixation of the femoral fracture affected the rate of adult respiratory distress syndrome or mortality. Logistic regression models were used to analyze the data. The over-all occurrence of adult respiratory distress syndrome in the 453 patients who had a femoral fracture was only 2 per cent (ten patients). The rates of adult respiratory distress syndrome for the patients who had a thoracic injury but no femoral fracture (eight [6 per cent] of 129 patients at Center I, compared with ten [8 per cent] of 125 patients at Center II) did not differ between centers, suggesting that the institutions were comparable in their treatment of multiply injured patients. The occurrence of adult respiratory distress syndrome in the patients who had a femoral fracture without a thoracic injury did not differ substantially according to whether the fracture had been treated with a nail (118 patients) or a plate (114 patients). Likewise, the frequency of adult respiratory distress syndrome, pneumonia, pulmonary embolism, failure of multiple organs, or death for the patients who had a femoral fracture and a thoracic injury was similar regardless of whether nailing with reaming (117 patients) or a plate (104 patients) had been used. The use of intramedullary nailing with reaming for acute stabilization of fractures of the femur in multiply injured patients who have a thoracic injury without a major comorbid disease does not appear to increase the occurrence of adult respiratory distress syndrome, pulmonary embolism, failure of multiple organs, pneumonia, or death.

The rationales of interlocking nailing of the femur, tibia, and humerus.

Interlocking nailing has been increasingly used to treat acute and chronic afflictions of long bones. Although the interlocking construct is similar, regardless of the anatomic area of application, the results and complications of this type of fixation in the femur, tibia, and humerus differ. This review compares the anatomy, biologic response to injury, and functional expectations of these 3 distinct long bones with respect to interlocking nailing. Final results seem related more closely to the bony anatomy and soft tissue injury than to any inherent success of interlocking techniques.

Fractures of the tibial plafond. Evolving treatment concepts for the pilon fracture.

Pilon fractures represent a most difficult challenge to the orthopedist. Assessment of the degree of energy causing the fracture and careful planning of the joint reconstruction will lead to acceptable results in most cases. High-energy pilon fractures should be treated with great care and respect because the risk of complications is high and the likelihood of a good functional ankle is less predictable. Detailed and individualized postoperative care coupled with a knowledge of salvage procedures, should complications develop, are needed to treat the full spectrum of pilon injuries.

Medical cost containment: analysis of dual orthopedic/radiology interpretation of X-rays in the trauma patient.

OBJECTIVE: The purpose of this study was to investigate the timing, accuracy, clinical impact, and cost of dual orthopedic and radiology interpretation of orthopedic trauma roentgenograms. DESIGN: The investigation was performed in a combined retrospective-prospective fashion. MATERIALS AND METHODS: Records of 25 retrospective and 25 prospective trauma patients with femoral fractures were reviewed and the radiology and orthopedic roentgenographic interpretations were compared in terms of four criteria: timing, accuracy, clinical impact, and cost. MEASUREMENTS AND MAIN RESULTS: The orthopedic surgeons documented reading 85% of 272 acute roentgenograms in the retrospective patients and 89% of 181 roentgenograms in the prospective patients. The orthopedist readings were immediate, 100% accurate, had significant impact on the patients' care, and incurred no additional cost. The radiologists read 59 and 75% of the retrospective and prospective roentgenograms, respectively. The accuracy rate was 94 and 96%, the time to reading averaged 7 and 4.6 days, and the estimated cost averaged $393 and $200 per patient, respectively. The radiologist readings had no impact on patient care. CONCLUSION: This study suggests that routine radiology consultation of musculoskeletal films read by the orthopedic surgeon is not required for the care of the acute trauma patient.

Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons.

The system of Gustilo and Anderson for the classification of open fractures is commonly used as a basis for treatment decisions and for comparison of the published results of treatment. The reliability of this classification system was tested on the basis of the responses of 245 orthopaedic surgeons to a survey. The respondents were asked to provide data about their age, type of practice, and type of training; the number of open fractures of the tibia that they treated each year; and their use of the Gustilo-Anderson classification system. They were also asked to classify twelve open fractures of the tibia on the basis of a series of videotaped case presentations. Each case presentation on the color videotape included demographic data on the patient, a history of the injury, the results of the physical examination, the appearance and dimensions of the open wound before the operation, preoperative radiographs, and selected portions of the operative débridement with narration. The level of agreement for the classification of each fracture was determined according to the largest percentage of observers who chose a single classification type. The average agreement among the observers for all twelve fractures was 60 percent. The over-all agreement for each fracture ranged from 42 to 94 percent. The average agreement in the subgroup of surgeons who were considered to have the least experience (residents and fellows) was 59 per cent (range, 33 to 94 percent).(ABSTRACT TRUNCATED AT 250 WORDS)

Immediate interlocking nailing of fractures of the femur caused by low- to mid-velocity gunshots.

A retrospective review of 39 fractures of the femur in 37 patients caused by low- and mid-velocity handgun missiles treated with static interlocking nailing within 18 h of injury was conducted to evaluate the efficacy, safety, and cost savings of immediate intramedullary nailing in these injuries. Patients were followed through union of the fracture with an average follow-up of 12.5 months. The average hospitalization was 8.5 days. All but two fractures healed in an average of 14 weeks (range 8-28). One delayed union was treated with exchange intramedullary nailing with reaming 5 months postinjury and progressed uneventfully to fracture union. One nonunion occurred, presenting with broken distal interlocking screws 18 months after injury, which was treated with an exchange intramedullary nailing with reaming. The nonunion healed within 4 months of this secondary procedure. There were no malunions of > 5 degrees angulation, no leg length discrepancies of > 1.0 cm, and no rotational malalignments noted. There was one (2.5%) infection that was successfully treated with nail removal, reaming of the canal, and reinsertion of a larger diameter nail. We conclude that immediate interlocking nailing of low- and mid-velocity gunshot fractures of the femur is an effective and safe treatment. Compared with previously published data on intramedullary nailing of femoral gunshot fractures, immediate intramedullary nailing resulted in a shorter hospital stay with a significant decrease in hospital expenses. Because the findings of this study indicate that early fixation in these injuries had no detrimental effect on the clinical results, we recommend immediate intramedullary nailing of gunshot fractures of the femur.

Pudendal nerve palsy complicating intramedullary nailing of the femur.

A prospective study of 106 patients who had static interlocking nailing of the shaft of the femur was performed to determine the relationship between the duration and magnitude of intraoperative traction and the development of a pudendal nerve palsy. A strain-gauge, mounted in the countertraction post, measured the magnitude of the perineal pressure over time. All nailings were performed with the patient in the supine position. Postoperatively, the patients were interviewed by one of us, who had been blinded from the results of the recordings of intraoperative pressure, for a history of erectile dysfunction and changes in labial, scrotal, or penile sensation. A light-touch sensory examination of the genitalia was performed on all patients. Ten patients (six men and four women) had a pudendal nerve palsy: nine had sensory changes only, and one complained of erectile dysfunction. The symptoms had resolved at the three-month follow-up evaluation in all patients except one man who complained of dysesthesia six months postoperatively. The patients in whom a palsy did not develop had been positioned on the fracture-table and the perineal post for an average of 2.6 hours (range, 1.4 to 5.2 hours) compared with an average of 2.8 hours (range, 2.0 to 4.3 hours) for those in whom a palsy did not develop (p = 0.15). The magnitude of the total traction forces averaged 34.9 kilogram-hours for the patients who did not have a palsy compared with 73.3 kilogram-hours for those who did (p < 0.03). Adduction of the hip, as well as manipulations for reduction of the fracture, significantly increased the traction forces.(ABSTRACT TRUNCATED AT 250 WORDS)

Functional evaluation of the shoulder after transfer of the vascularized latissimus dorsi muscle.

The function of the shoulder after removal of the vascularized latissimus dorsi muscle in seventeen patients was compared with the function of the shoulder in seventeen control subjects. Physical examination of the extremity and instrumented muscle-testing were used to evaluate both the patients and the control subjects, and the patients also completed a questionnaire. Thirteen patients rated the appearance of the donor extremity as good, and sixteen patients perceived no functional impairment of the donor extremity. The range of motion of both shoulders was symmetrical in eleven patients and fourteen control subjects. Manual muscle-testing showed normal strength of the latissimus dorsi bilaterally in seven patients and in thirteen control subjects. Nineteen instrumented isometric, isotonic, and isokinetic tests were performed to assess the strength of each shoulder of all of the patients and control subjects, and the results in these two groups were then compared. there was no statistically significant difference in the strength of the two shoulders between the patients and the control subjects, with the exception that the patients exhibited weakness in the amount of isokinetic torque during extension of the shoulder with the limb in a position of 60 degrees of flexion and at a speed of 60 degrees per second. On the basis of these findings, and because of the inherent inaccuracy of manual muscle-testing, we concluded that transfer of the vascularized latissimus dorsi muscle had little effect on the range of motion, muscular strength, and function of the donor shoulder in our patients.

Intramedullary nailing of femoral shaft fractures. Part III: Long-term effects of static interlocking fixation.

The results of treatment of fractures of the femoral shaft with static interlocking nailing were reviewed retrospectively to determine the clinical importance of any stress-riser or stress-shielding properties of the nail. These properties, if relevant, would have been manifested by refracture of the femur, either through a hole used for a locking screw or through the original site of fracture after extraction of the device. Two hundred and fourteen fractures that had been treated with static interlocking nailing and that had healed without conversion to dynamic intramedullary fixation were divided into two groups. In Group I, which comprised 111 fractures, the static interlocking-fixation device was retained and in Group II, which comprised 103 fractures, the static interlocking-fixation device was removed during one operative procedure at an average of fourteen months after the injury. The average duration of follow-up was thirty months from the time of the original fixation in both groups. All patients in Group II were followed for a minimum of six months after removal of the nail. No femur in Group I, in which the static interlocked nail remained in situ, refractured. No femur in either group fractured through the proximal or the distal holes used for the locking screws. No locking screws or nails broke. One patient (1 per cent) in Group II had a refracture of the femoral shaft through the site of the original fracture six weeks after removal of the nail.(ABSTRACT TRUNCATED AT 250 WORDS)

Open tibial fractures: current orthopaedic management.

Treating the spectrum of bone and soft-tissue injuries that can accompany open fractures of the tibia requires experience and judgment. It appears that the non-reamed interlocking nail can safely and reproducibly stabilize most low-energy and selected high-energy open fractures of the leg. Severe open tibial fractures require a staged reconstructive protocol using external fixation as the method of bony stabilization. Differentiation between the requirements of individual injuries remains the key to successful treatment.

Interlocking intramedullary nailing for ipsilateral fractures of the femoral shaft and distal part of the femur.

A review of the data on 684 fractures of the femur that had been treated with intramedullary nailing led to the identification of twenty-three patients who had had a fracture of the shaft of the femur with an accompanying ipsilateral supracondylar fracture (twelve patients, group I) or a concomitant ipsilateral intercondylar fracture (eleven patients, group II). The group-I fractures had been treated with interlocking nailing without supplemental fixation. In group II, ten fractures were stabilized with interlocking nailing and supplemental screw fixation and one, with interlocking nailing and a supplemental plate and screws. The average time to union for all fractures was nineteen weeks (range, twelve to thirty-six weeks), and the average duration of clinical and radiographic follow-up was thirty months (range, nine to fifty-nine months). In group I, alignment of the femur was within 5 degrees of normal in ten of the twelve fractures. In group II, seven intra-articular fractures healed in anatomical alignment, three had slight articular displacement (1.0 to 3.0 millimeters), and one had displacement of more than 3.0 millimeters. The average range of motion of the knee at the most recent follow-up was 0 to 120 degrees in group I and 0 to 115 degrees in group II. Two patients (both in group II) needed a reoperation for a previously unrecognized fracture of a femoral condyle in the coronal plane; post-traumatic arthritis developed in both. No patient in either group had loss of fixation or failure of the implant. We concluded that ipsilateral diaphyseal, supracondylar, and intercondylar fractures of the femur can be adequately stabilized with interlocking nailing and supplemental intercondylar screw fixation. The presence of a fracture in the coronal plane of a femoral condyle (AO type-B3 and type-C3 injuries) is a relative contraindication to the use of this technique.