Retrograde intramedullary nailing of femoral diaphyseal fractures caused by low-velocity gunshots.

The purpose of this study was to evaluate the results of retrograde intramedullary nailing of femoral diaphyseal fractures caused by low-velocity gunshots. Seventy-three patients (68 men and 5 women) with 74 femoral diaphyseal fractures caused by gunshots were treated with reamed, retrograde, statically locked intramedullary nailing. The main outcome measures were fracture union, the need for additional operations, shortening, angular deformity, postoperative knee range of motion, and complication rate. Twenty-nine patients sustained additional injuries. During initial treatment, 18 patients underwent further orthopedic and nonorthopedic elective procedures. Three patients had fasciotomies for compartment syndrome. At follow-up, 3 patients had shortening >10 mm (range, 12-18 mm) and 1 had angulation >10 degrees (13 degrees recurvatum). Four patients underwent surgeries after discharge. Complications included 1 case of heterotopic bone formation, 1 hypertrophic nonunion that went on to union after dynamization, 2 postoperative positive blood cultures, and 1 wound dehiscence. There were no cases of septic arthritis. Our data indicate that there is a low incidence of shortening, angular deformity, complication, and infection rates following treatment of femoral gunshot diaphyseal fractures with a retrograde nail. This study demonstrates that this is an acceptable alternative for the treatment of these injuries.

A retrospective review of high-energy femoral neck-shaft fractures.

OBJECTIVES: To determine the incidence of femoral neck fractures with high-energy shaft fractures and to determine whether there was a correlation of neck fractures with antegrade or retrograde intramedullary nailing. We also evaluated the timing of diagnosis and the treatment options and outcomes. DESIGN AND SETTING: A retrospective review of patients with femoral shaft fractures treated at 8 level 1 trauma centers from 2001 to 2005. Two thousand eight hundred ninety-seven fractures were identified, and 89 patients had 91 femoral neck-shaft combinations (3.2%). PATIENTS: Average age: 36 years (15-72 years) and average Injury Severity Score: 18 (9-66). Seventy-eight patients had associated injuries; 67 of 91 femoral neck fractures were discovered before nailing. RESULTS: There were 24 missed femoral neck fractures, 11 discovered intraoperatively and 13 postoperatively. Of these 24 patients, 15 had retrograde fixation and 9 had antegrade femoral shaft fixation. There was a high rate of open femur fractures (34%) and an increased incidence of associated injuries (88%) with neck-shaft combinations. In 12 of 67 patients with a preoperative computed tomography scan, the scan did not demonstrate a femoral neck fracture. CONCLUSIONS: This study found a similar rate of neck-shaft combinations (3.2%), a higher rate of open fractures, and increased incidence of associated injuries compared with the literature. Most importantly, our data indicate that even with a negative preoperative computed tomography scan, a femoral neck fracture can be present. A trend also indicated more missed femoral neck fractures with retrograde nailing, which may be attributed to less fluoroscopic imaging of the hip with this technique. Patients with femoral shaft fractures should have good quality radiographs after femoral nailing to minimize the risk of missed femoral neck fractures.