LOCKED

NAILING

OF

COMMINUTED

FRACFURES

JENS

OLE

S#{216}JBJERG,

From

OF

THE

S#{216}REN EISKJAER,

the University

AND
FEMUR

FLEMMING

ofAarhus,

UNSTABLE

M0LLER-LARSEN

Denmark

Forty

comminuted
or unstable
fractures
of the femoral
shaft were treated by closed intramedullary
reaming
and locked nailing. Twenty-four
fractures
were severely comminuted,
and the other 16, in the distal
or proximal third of the shaft, were classified
as unstable.
At 12 to 30 months postoperatively
all the fractures
had healed. Three patients had lateral rotation
deformity
of 5#{176}
to 1O,
had shortening
of 1 to 2 cm and two had lengthening
of about 1 cm. There were
no infections
or delayed unions.
intramedullary
locked
nailing
can provide stability
in fractures
of the
femoral
shaft, irrespective
of the degree
ofcomminution
and the site of hjury.
The
shaft

treatment
has been

of comminuted
changed
by the

intramedullary
ceptable
results
yield

a high

fractures
introduction

nail. Conservative
but requires
a long
percentage

treatment
yields
hospital
stay and

acmay

(Montgomery

and

of malunion

Mooney
Operative

1981 ; Johnson,
treatment
with

infection

and

neither

Johnson
and Parker
rigid plating
has a high

eliminates

malunion

1984).
risk of

nor

allows

early
weight-bearing
(Magerl
et al 1979 ; R#{252}ediand
L#{252}scher 1979). Conventional
closed
intramedullary
nailing does
not provide
rotational
or axial
stability
of
comminuted
and

fractures

lack

of fit

1980 ; Johnson
Andreassen

flexibility

et al 1984;

of the

(Winquist

and

and Schellmann

They

reported

rotational
and
series
reported

(1972)

that

and Kempf,

comminuted

Grosse

intramedullary
fractures
of the

method

gave

axial,

to the fracture
; both
of infection,
non-union

a prospective

reaming

series

fractures

and

a locked

of 40 consecutive
of the

femur

intramedullary

treated
Grosse-

years

S. Eiskjaer,

MD,

Department

of

University

ofAarhus,

Hospital,

1989

thirds

Senior

Orthopaedic

Randersvej

Surgery,

DK-8000
be

sent

1, DK-8200

Editorial

Society

Aarhus
to Dr

Aarhus
ofBone

030l-620X/90/1
199 $2.00
JBone Joint Surg [Br] 1990; 72-B : 23-5.

VOL. 72-B,

No. 1, JANUARY

Registrar

in eight
fractures
which
required
laxis

1990

Kommunehospital,

C, Denmark.
J. 0.

S#{248}jbjerg at Orthopaedic

N, Denmark.
and

Joint

Surgery

The

and

was

used

was
primary

fractures

were

classified

considered

for

1980): 16
or distal

unstable,

24 were

supine
position
a guide-wire

from

the

due to other
multiple
treatment.
Antibiotic

injuries,
prophy-

routinely.

All fractures

were

operated

on a fracture
was introduced

tip

of the

being

carefully

on with

table. After
into the

greater

the patient

trochanter,

checked

with

in a

closed
reduction,
medullary
canal

the

a image

point

of

intensifier.

Flexible
intramedullary
the diameter
ofthe canal

reamers
were used to increase
by 0.5 mm in a stepwise
manner

to

diameter

1 mm

distal

Registrar
Aarhus

15 to 83).

of the diaphysis

more

was

than

the

12 mm except

medullary

With
introduce

Registrar

Orthopaedic
should

British

Orthopaedic

Orthopaedic

F. M#{248}ller-Larsen, MD,

Correspondence

(range

grade
3 or 4, mostly
in the middle
and distal
thirds.
Eleven fractures
were open grade 1 or 2, none were open
grade 3. Thirty-two
fractures
(23 closed and 9 open) were
operated
on within the first 24 hours. The operative
delay

wider
J. 0. S#{248}jbjerg,
MD, Senior

METHODS

degree of comminution
(Winquist
and Hansen
were grade
1 or 2 but located
in the proximal

diameter

nail.

AND

A total of 37 consecutive
patients
with 40 comminuted
or unstable
fractures
of the femoral
shaft were operated
on in 1986 and early 1987.
There were 13 women and 24 men, median
age 31

insertion

or unstable

closed

this

bending
stability
low incidences

and malunion.
We report

Kempf

device
Hansen

M#{248}ller-Larsen, S#{248}jbjergand

Beck
(1985)
introduced
the locked
for the treatment
of comminuted

femur.

with

to the

fracture

1988).

Klemm
and
nail

due

in the

PATIENTS

of the femoral
of the locked

of the

nail.

in five elderly

The

nail

patients

with

canals.

the nail in place a special

jig was used to
the proximal
diagonal
self-tapping
bolt. The

bolts

were

placed

the image
intensifier
described
by Thoresen
mobilised
on crutches
weight-bearing

was

percutaneously

with

the

aid

of

using
the free hand
technique
et al (1985).
The patients
were
after removal
of the drain, and full
allowed

when

callus

was

visible

on

the radiograph.
Ailpatients

were

reviewed

clinically

and

radiograph-

23

J. 0. S#{216}JBJERG,

24

S. EISKJAER,

F. M#{216}LLER-LARSEN

Table

ically until fully healed.

Final
follow-up
was at 12 to 30
months
postoperatively
(median
17 months)
except
for
one patient
who died after six months
from an unrelated
disease,

by which

time

the

femoral

fracture

had

16 patients

with

an isolated

fracture

defined
by the presence
of adequate
was 12 weeks
(range
10 to 22). One
remained

in

hospital

for

three

months

20 patients

with

multiple

Infection

Lengthening

1 cm

Shortening

1 cm to 2 cm

Knee

60

a mean

trauma
was

tolerate
fracture
The
I. There

In

cause delay in starting

rehabilitation.
complications
in our series are shown
were no cases of non-union
or infection,

in Table
and no

patient

complained

The

grade

4 fractures

or shortening

unit of 38 days
(range
14 to 80);
allowed
as soon as the patients
could

none

of

these

of

any

had healed
and

patients

did

significant
had

minor

All except
one
injury
regained

of the patients
with
excellent
movement

five

lengthening

malunion

with

rotation,
valgus
deformity
or anteroposterior
of between
5#{176}
and 10#{176}.
None
of these patients
complaints
in relation
to the malunion.
knee

femoral

pain.

with some

six fractures

the

lateral

angulation
had serious
no ipsilateral
of the knee.

Two patients
had only 60#{176}
of flexion at three months,
but
after
manipulation
and physiotherapy
both regained
flexion

to over

120#{176}.

All the fractures

proximally.
three
months
three patients

had

Two distal
respectively
the distal

a bursa ; these
bolts
distal
bolts did not

There

been

locked

bolts

backed
and had
bolts caused

were removed.
interfere
with

was no failures

of proximal

both

distally

and

out after
two and
to be removed.
In
localised
pain from
The problems
with
the fracture
healing.

proximal

nailing
reduction

as against
and rigid

internal
fixation
have been well documented
(Rokkanen,
Sl#{228}tisand Vankka
1969;
Magerl
et al 1979;
R#{252}ediand
L#{252}scher 1979;

Winquist

and

Hansen
et

1980;

Montgomery

al 1984).
The
main
and unstable
femoral

shaft fractures
are the preservation
of length,
alignment
and rotation.
Klemm
and Schellmann
(1972) and Kempf
et al (1985) introduced
the locking
technique,
using bolts
both
distal
and proximal
to the fracture
to extend
the
indications
for medullary
nailing.

In our series,
comminuted

and

24 of the fractures
the

others

5#{176}
to 10#{176}

Lateral

rotation

5#{176}
to 10#{176}

AP angulation

9#{176}

Medial

rotation

thirds

of the shaft.

treated
with sufficient
nailing.
Axial
and

In our

series,

five

fractures

were

were
unstable

grade
and

None

of them

rotational
bending

healed

or shortening
of between
1 and
femur
is a unique
complication
nailing,
caused
tion. Shortening
and
can

not to failure
of the
be avoided
by careful

fractures
especially
are goals

but
if
of

lengthening

Lengthening

of the

to locked

by over-correction
was due to failure

could

stability
by
stability
could

with

2 cm.

medullary

at the time of operato estimate

nail length

nail. Such
determination

length

discrepancy
of the length

of

the opposite
intact
femur,
and in bilateral
fractures
by
the use of equal length nails. We found that observation
of skin
intensifier

tension,
checks

the

rotation

position
were
the

of the patella
best methods

and angulation.

were

all due

nailing,
that
is, both
bolts
were
removed

fracture.
fractures
same

incidence

dynamic

distal
in an

and proximal
attempt
to

of malunion

as we

severe.

This

nailing

cannot

provide

fracture.

in our

series,

despite

3 or 4

that

in the

of infection

open

medullary
(Magerl

THE

of

or plating

; no
the

were

view
stability

the

to a

dynamisation

we feel that
supports
increases
LUscher

JOURNAL

JOINT

AND

that

or delayed

et al 1979 ; R#{252}ediand

OF BONE

static

theirs

the

no non-union

in our series

reaming

with

but

sufficient
lack

; the

48 femoral
shaft
nailing),
had the

did,

et al (1985);

minor

locking
dynamise

supports

We had

recommended
by Kempf
can be omitted.
The lack of infection

with

positions

change.
were treated

more

comminuted
union

in these

Thoresen
et al (1985) reporting
(most treated
with dynamic

generally

and image
of checking

Our six cases

to fixation

alignment
did not subsequently
In our series all fractures

intramedullary
or open

and
Mooney
1981 ; Johnson
problems
in treating
comminuted

angulation

have been obtained

in the less comminuted
probably
not in the grade 3 and 4 fractures,
early
mobilisation
and weight-bearing
treatment.

correct

bolts.

DISCUSSION
of closed
treatment

1 failure,

Valgus

or distal

have been
conventional

malunion

The benefits
conservative

to 90

Malunion:

stay in the
weight-bearing
it.

movement

5 removed

domestic

had

Range

Distal bolt

callus
77 years

for

injuries

nailing

Non-union

reasons.

The

locked

comminuted
and
treated
by intra-

Number

5 to 25) after
at a median
time to union

radiographic
patient
aged

in 40
femur

of the

healed.

were discharged

from
hospital
on average
1 1 days
(range
operation
; full weight-bearing
was allowed
of 4.5 weeks
(range
2 to 6). The median

fractures

medullary

RESULTS
The

I. Complications

unstable

this

the view
the risk
1979;

SURGERY

LOCKED

NAILING

OF COMMINUTED

AND

UNSTABLE

FRACTURES

trochanteric
wire, and

had

lateral

OF THE

region
during
no proximal

or anterior

more

extensive

the nail.
The

the insertion
complications.

portal

is used,

reaming,

main

25

FEMUR

rather

drawback

of the guideHowever,
if a

then

than

we

recommend

forceful

of locked

insertion

medullary

of

nailing

is

the
experience
required
to perform
the
procedure
(Browner
1986).
There
are many
pitfalls
and
in our
opinion
the method
should
be reserved
for surgeons
who
are experienced
most cases were

Conclusions.

with
medullary
nailing.
In
operated
on by the two senior

We

recommend

closed

our series
surgeons.
medullary

locked

nailing
for the treatment
of all comminuted
fractures
of
the femoral
shaft,
and
feel that
dynamisation
of the
fracture
six weeks postoperatively
is unnecessary.
Reduction and reaming
should
be a closed
procedure,
and it

:.

seems

that

No benefits
commercial
article.

reaming
in any
party

should

be minimised.

form have been

related
directly

received
or will be received
or indirectly
to the subject

from a
of this

REFERENCES
Browner
BD.
KOntscher
Christie

Fig.

1984).

We

did

not

intend

to achieve

anatomical
reduction,
but only correct
alignment.
fractures
healed
and incorporated
the displaced
ments
in the callus (Fig.
1).

nailing
tions.

All our
frag-

minimise
reaming,
using
a 12 mm nail in most
cases.
Despite
this we had no nail failures.
M#{248}ller-Larsen et al
(1988) found only a slight gain in rigidity
after increasing
the nail diameter
to 14 mm.
Locking
of the intramedullary

important
Christie
femoral
point,

to
and

rigid than
a proper

requires

that

such
reported

the

flexible
nail is

as jamming.
four cases

of

neck fractures
due to the use of a lateral
starting
and Johnson
et at (1987)
stress
the importance
of

select
the
intensifier

VOL.

nail

the original
cloverleaf
entry
point
for the

avoid
complications
Court-Brown
(1988)

posterior
placement
the anterior
cortex.

72-B,

of the start to reduce

the stress
We also have found
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appropriate
that
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Trauma

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K, Schellmaim
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an

Reaming
of the
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destroys
the
medullary
blood supply
and weakens
the cortex
(Kessler
et al 1986), but despite
this, non-union
and refracture
are
rare after reaming
and closed
nailing
(Winquist,
Hansen
and Clawson
1984 ; Kempf
et al 1985 ; Thoresen
et al
1985 ; Johnson,
Tencer
and Sherman
1987). We tried to

nail itselfis
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(a), treated
by closed
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(b). At 22 months
the
fracture
has healed
(c) and the functional
result
is excellent.

Johnson

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