J Christie

Closed intramedullary tibial nailing. Its use in closed and type I open fractures

We present the results of using the Grosse-Kempf interlocking nail in the management of 125 closed and type I open tibial fractures. The mean time to union was 16.7 weeks and no fracture required bone grafting. Mobilisation of the patient and the range of joint movement were better than with other methods of treating tibial fractures. There was a 1.6% incidence of infection; 40.8% of patients had knee pain and 26.4% needed to have the nail removed. Other complaints were minor. We suggest that closed intramedullary nailing with an interlocking nail system is an excellent method of treating closed and type I open tibial fractures.

Locked intramedullary nailing of open tibial fractures

We report the use of Grosse-Kempf reamed intramedullary nailing in the treatment of 41 Gustilo type II and III open tibial fractures. The union times and infection rates were similar to those previously reported for similar fractures treated by external skeletal fixation, but the incidence of malunion was less and fewer required bone grafting. The role of exchange nailing is discussed and a treatment protocol is presented for the management of delayed union and nonunion.

Compartment pressures after intramedullary nailing of the tibia

Intracompartmental pressures of 66 patients with 67 tibial fractures treated by intramedullary nailing were monitored. There was no difference in the pressures recorded between the different Tscherne fracture types, between open and closed fractures, between low energy and high energy injuries or between fractures dealt with early and those not treated until more than 24 hours after injury. The overall incidence of acute compartment syndrome was 1.5%. No patient developed any sequelae of compartment syndrome. We conclude that intramedullary nailing does not increase the incidence of acute compartment syndrome in tibial fractures and that delay does not reduce the risk of raised compartment pressures.

External fixation for type III open tibial fractures

An analysis of 51 type III open tibial fractures treated by external skeletal fixation is presented. The fractures are subdivided according to the classification of Gustilo, Mendoza and Williams (1984) into types IIIa, IIIb and IIIc. The different prognoses of these fracture subtypes is examined. The use of the Hoffmann and Hughes external fixators in the management of type III open tibial fractures is presented and it is suggested that the prognosis is independent of the type of fixator used.

REAMED OR UNREAMED NAILING FOR CLOSED TIBIAL FRACTURES

We performed a prospective, randomised study on 50 patients with Tscherne C1 tibial diaphyseal fractures comparing treatment with reamed and unreamed intramedullary nails. Our results show that reamed nailing is associated with a significantly lower time to union and a reduced requirement for a further operation. Unreamed nailing should not be used in the treatment of the common Tscherne C1 tibial fracture.

Open adult femoral shaft fracture treated by early intramedullary nailing

In two hospitals, 115 consecutive open femoral shaft fractures were treated by meticulous wound excision and early locked (97) or unlocked (18) intramedullary nailing. All the fractures united; union was delayed in four, three of which required bone grafting. The average range of knee flexion at follow-up was 134 degrees (60 to 148). Five patients had a final range of less than 120 degrees, but three of these improved after manipulation under general anaesthesia. Three patients developed staphylococcal infections and required further surgical treatment. All eventually healed.

Tibial fractures with bone loss treated by primary reamed intramedullary nailing

We reviewed the results of the treatment of 30 tibial fractures with minor to severe bone loss in 29 patients by early soft-tissue and bony debridement followed by primary locked intramedullary nailing. Subsequent definitive closure was obtained within the first 48 hours usually with a soft-tissue flap, and followed by bone-grafting procedures which were delayed for six to eight weeks after the primary surgery. The time to fracture union and the eventual functional outcome were related to the severity and extent of bone loss. Twenty-nine fractures were soundly united at a mean of 53.4 weeks, with delayed amputation in only one patient. Poor functional outcome and the occurrence of complications were usually due to a departure from the standard protocol for primary management. We conclude that the protocol produces satisfactory results in the management of these difficult fractures, and that intramedullary nailing offers considerable practical advantages over other methods of primary bone stabilisation.

Femoral neck fracture during closed medullary nailing: brief report

Closed intramedullary nailing of the femur is a complex technique but one that has considerable advantages. The choice of an appropriate point of entry into the proximal femur during introduction is vital, since an oblique insertion of the nail may lead to impaction of the implant and comminution of the proximal femoral fragment (Winquist, Hansen and Clawson 1984); this is particularly so in small patients with a narrow medullary canal. Femoral neck fracture also may occur and we report here on our experience of this complication. Material. Four femoral neck fractures have occurred during closed femoral nailing in 143 consecutive procedures ; three of these fractures occurred in somewhat slight female patients. The insertion ofthe medullary nail had been oblique in all four cases, the starting point for the nail being too far lateral in the trochanteric region. All four neck fractures were vertical, extracapsular inferiorly, and without significant mal-alignment; indeed, two were virtually undisplaced and the other two only slightly separated (Fig. 1). All had pre-operative pelvic radiographs of reasonable quality none of which revealed evidence of femoral neck fracture. Three of the patients also developed some comminution of the proximal femoral shaft during nail insertion, and in this series of 143 nailing procedures three other patients had proximal femoral shaft comminution but without femoral neck fracture. Three of the femoral neck fractures were treated by insertion of compression screws into the femoral head around the proximal end of the nail, and when there was proximal femoral comminution a statically locked medullary nail was used (Fig. 2). All these femoral neck fractures and proximal femoral comminutions have gone on to heal, so far without avascular necrosis, though not all have been followed up for two years. Discussion. KOntscher (1967) recommended that his nail should be inserted through the tip of the trochanter and more recently the trochanteric starting point has been used by Kempf, Gross and Lafforgue (1978). Winquist et al. (1984) found insertion through the tip of the trochanter to be associated with proximal femoral comminution in some patients but do not mention femoral neck fracture having occurred ; they now recommend introduction through the trochanteric fossa. We have found that it is important to establish the approximate point of entry by examining the pre-