Femoral Shaft Fractures

1. Introduction
Singer et al studied 15 000 fractures in adults attending The Edinburgh
Royal infirmary 1992-1993. (Singer)
The incidence of femoral diaphyseal fractures found by Singer et al is
shown in table 1.
Table 1. The incidence of femoral diaphyseal fracture per 10000 population.
Age (Yr)
Male
Female
15-19
3.55
0.57
20-24
3.56
0.88
25-29
1.64
0.64
30-34
3.73
0.18
35-39
0.39
0.20
40-44
0.57
0.37
45-49
0.72
0.47
50-54
0.76
1.2
55-59
0.27
0.25
60-64
0.00
1.01
65-69
0.00
1.81
70-74
2.3
3.15
75-79
0.58
3.74
80-84
4.11
10.7
85-89
2.76
16.39
90-94
0.00
37.14

Similar figures in Stockholm were found in 1986 by Hedlund et

al. (Hedlund) Femoral shaft fractures occur in a bimodal distribution. They are
either high-energy injuries in young men or low-energy injuries in elderly
women. (Singer, Taylor, Kolmert, Hedlund) The two distinct patient population
groups need to be considered individually when comparing mechanism of
injury, treatment, complications and outcome.
Several options exist for the treatment of femoral shaft fractures. Nonoperative, including skeletal traction and cast bracing. Operative, including
plate osteosynthesis, external fixation and intramedullary nailing. In the last
ten years the indications for femoral nailing have broadened. Intramedullary

nailing has thus become the most common form of treatment.

Intramedullary nailing has helped improve the outcome following open and
closed fractures. Complication rates following intramedullary nailing are
quoted at 15-19 % (Alho, Hammacher, Braten). These figures however refer to
studies predominantly of femoral shaft fractures in the younger patient.
Complication rates as high as 45-60% (Bouchard, Boyd, Salimen) have been
reported for Femoral shaft fractures in patients older than 65years, with a
peri-operative mortality approaching 20% in the older patient. (Bouchard,
Boyd)

2. Mechanism of injury and fracture patterns

Taylor et al in 1994 clearly showed the bimodal distribution of age and
mechanism of injury causing femoral shaft fractures. Outcome has been
shown to be dependent on the mechanism of injury. (Taylor)
High-energy injuries.

Young adults normally fracture their femurs in high-energy accidents

involving motorcycles and pedestrian vehicle accidents. Motorcycle and
pedestrian injuries are associated with a higher incidence of associated
injuries than falls. (Taylor)

Medical and engineering studies of 1074 car

accidents involving 2520 vehicle occupants have shown: The incidence of

femoral fractures in car occupants is 1.7% and 0.8% for front and rear seat
passengers respectively.
The incidence of femoral shaft fracture was not significantly different in
unrestrained drivers, but the associated injuries were more severe
The mean velocity change during the collision required to fracture a
femur is 42km/h (26 mph). There is a higher incidence of femoral shaft
fractures when velocity change was greater than 48km/h (30 mph).

 Estimates of forces needed to fracture a femur were higher than those

found in cadaver studies.
Frontal impacts caused the majority of femoral fractures. Rear impacts
were never associated with femoral shaft fracture.
Side impact collisions causing femoral shaft fractures, involved severe
intrusion into the car body, over 0.4m (16 inches) in all
instances. (Rastogi)
Like most bones the femur fails under tensile strain. The commonest
mechanism of injury is bending load causing a transverse fracture. It has
been estimated that 250 Nm of bending moment is required to fracture a
normal adult femur. (Kyle)
The incidence of femoral fractures following low velocity gun shot wounds
is increasing in urban centers. (Levy, Wright)
Low-energy injuries

Low energy injuries tend to occur in the elderly female population. They
account for between 25% and 56% of femoral fractures, depending on the
resident population age profile. (Moran)The majority of these fractures are
closed and not associated with significant concomitant injuries. Despite the
fact that these are low-energy fractures with no associated injuries. These
fractures have a high incidence of treatment complications. This is quoted
at 45-60% with a peri-operative mortality approaching 20% at six
months. (Bouchard, Boyd, Moran, Salimen)
Salimen et al studied 201 acute fresh fractures of the femoral shaft
admitted over a 10-year period, 50 (25%) patients had fractures caused by
low energy trauma. The mean age of the low energy group was 65 years.
Two thirds of the patients had at least one local or general factor
weakening the mechanical strength of the bone. These include; diabetes
mellitus, chronic alcohol use, previous major fracture and neuromuscular

disorders. The most frequent site and pattern was spiral mid shaft femoral
fractures accounting for 2/3 rds of the fractures. (Salimen)
Stress fractures

These occur in athletes and military recruits following an increase in

training intensity. In a study of Seventy-one athletes with 74 stress injuries
to the femur forty-three were females (27 yrs) and 28 were males (31 yrs).
Running was the most common activity at the time of injury (89%) followed
by triathlon (5%) and aerobic dance (5%). Thirty per cent of the runners
had increased their training duration immediately prior to their first
symptom. Anterior thigh pain was the most frequent site of exerciseinduced pain (46%) followed by hip pain (27%) and groin pain
(8%). (Clement) Stress fractures of the femoral condyles are uncommon, but
should be included in the differential of knee pain. During the clinical
examination, when asked to hop on the affected limb, 70% of the patients
had pain reproduced in the hip, groin or anterior thigh.
Plain radiographs are reported as being abnormal in only 24% of cases.
Radioisotope scans have been shown to be the most sensitive tests for
early detection of these injuries. The mean time to diagnosis and recovery
has been quoted as 6.6 and 10.4 weeks respectively. (Clement) The literature
on femoral stress fractures is limited and suggests that this is a rare injury.
Femoral stress fractures account for 3.8%- 7.2% of all stress
fractures. (Matheson, Hulkko) An isolated prospective study of military recruits
by Milgrom et al in Israel, reported tibial (51.2%) and femoral (29.8%)
stress fractures to be more common than stress fractures of the feet
(8.7%). (Milgrom) Milgrom et al actively looked for signs and symptoms
suggestive of a stress fracture. All suspected stress fractures were
confirmed on bone scan. It should be noted that 69% of the femoral stress
fractures in this study were asymptomatic. They were picked up incidentally

on bone scan. The clinical importance of this finding is borne out in case
reports of displaced stress fractures of the femur in athletes. (Luchini,
Clement)

Displaced stress fractures of the femur do occur, albeit rarely. In

case studies of displaced stress fractures of the femoral shaft, the duration
of symptoms prior to diagnosis has been 2-6 weeks. Most displaced stress
fractures of the femoral shaft required surgical repair. (Visuri)
Femoral shaft stress fractures have excellent healing potential when
diagnosed early and treated conservatively.
Classification

There is no universally accepted classification system for femoral shaft

fractures. The factors affecting outcome include age of patient, energy of
injury, open or closed fracture, comminution, anatomical position and the
associated injuries. As such there are three classification systems of
importance.
Anatomical classification systems refer to proximal, mid-shaft and distal
femoral fractures. Distal femoral fractures are further sub classified into:
supracondylar fractures, which are within 9cm of the distal femoral articular
surface. The most widely used anatomical classification system of distal
femoral fractures is the AO/ ASIF system.
AO DIAGRAM
It is important to distinguish Supracondylar fractures from femoral shaft
fractures as treatment, complications and outcome varies.
Winquist et al classification
Winquist et al 1980 devised a fracture classification based primarily on the
fracture pattern and its degree of stability, however it is now used more
widely to define the degree of comminution. Segmental fractures are a
double level fracture of the femoral shaft. The fracture pattern at each level

must be studied in terms of its own individual stability to determine

appropriate treatment.
I

Very small fragment, not affecting fracture stability

II

At least 50% cortical contact, preventing translation and shortening.

III

Less than 50% cortical contact, or poor purchase of nail on cortex

i.e. Proximal or distal femoral fractures

IV

Circumferential loss of stable cortical contact. (Winquist)

Open fractures are generally classified using the Gustillo-Anderson

classification. The fracture should be graded at the time of debridement.
The Gustillo Anderson classification of open injuries
I.

The wound is less than 1cm long. It is usually a moderately clean

puncture, through which a spike of bone has pierced the skin. There
is little soft-tissue damage and no sign of crushing injury. The fracture
is usually simple, transverse, or short oblique, with little comminution.

II.

The laceration is more than 1 cm long, and there is no extensive

soft-tissue damage, flap, or avulsion. There is slight or moderate
crushing injury, moderate comminution of the fracture, and moderate
contamination.

III.

These are characterized by extensive damage to soft-tissues,

including muscles, skin, and neurovascular structures, and a high
degree of contamination. The fracture is often caused by high
velocity trauma, resulting in a great deal of comminution and
instability.
III A Soft tissue coverage of the fractured bone is adequate
III B Extensive injury to, or loss of soft tissue, with periosteal
stripping and exposure of bone, massive contamination, and severe
comminution of the fracture. After debridement and irrigation a local
or free flap is needed for coverage.

III C Any open fracture that is associated with an arterial injury that
must be repaired, regardless of the degree of soft tissue
injury. (Gustillo)
There is some degree of inter-observer discrepancy when applying the
Gustillo-Anderson classification. As demonstrated in tibial fractures where
the average agreement was only 60%, however this has not been formally
studied in femoral shaft fractures to date. (Brumback)

1. Clinical problems and presentation

The diagnosis of femoral shaft fractures is generally straightforward.
Nevertheless there are recorded cases of delayed diagnosis. It should also
be borne in mind that stress fractures might be asymptomatic.
Assesment of the associated injuries at the time of presentation is of
particular importance.
Vascular injury

Vascular injury following femoral shaft fracture is rare. The incidence is

quoted as 0.7-2% of all femoral shaft fractures. (Howard, Kluger,
Barr)

Penetrating injury is the leading cause of vascular injury in the USA.

Experience in Europe shows blunt trauma to be leading cause of vessel

injuries.
Lower extremity vascular injuries are rare and easy to miss, especially
when encountered in hypotensive patients with multiple injuries. (Kluger,
Barr)

In a study by Kluger et al 1994 of 765 consecutive patients with closed

midshaft fractures 10 (1.3%) had an acute vascular injury. In 3 out of 10

patients with an acute vascular injury dorsalis pedis and posterior tibial
pulses were present initially. The pulses disappeared early in the course of
initial resuscitation and treatment. Thus the presence of peripheral pulses

does not exclude vascular injury. Fracture configuration was the same in
the group with and without vascular injury.
Active bleeding, expanding haematoma and bruit, or a thrill over an injured
vessel are absolute indications for angiography or surgical exploration. Of
the 765 patients reviewed 31 patients had an angiogram. Eleven were on
the grounds of loss of pulse, of these 11 patients with no palpable pulse 9
had a positive angiogram for vascular injury. Twenty patients had an
angiogram for large haematoma, only 1 of these had a positive angiogram
for vascular injury. Of the 765 patients, 734 had no clear indication for an
angiogram, of these only 1(0.1%) presented late, with an AV fistula. (Kluger)
The important message is repeated examination and a high index of
suspicion.
Nerve injury

Primary nerve injury following femoral shaft fracture is rare. Isolated case
reports exist in the literature. (Spiegel) Most nerve injuries are traction injuries
associated with operative treatment of femoral shaft fractures. (See
complications)

(Brumback)

Clawson et al 1960 reviewed the late

consequences of sciatic nerve injury from various aetiologies. They found it

was generally true that good neurological recovery and good function went
together. Although on occasion there were remarkable exceptions. One
third of patients showed vasomotor and trophic disorders. Pressure sores
were the most serious consequence of sciatic nerve injury and at some
time or other were present in 14% of patients. The cause of the pressure
sores was deformity rather than insensibility. Of note when amputation was
performed for fixed deformity with secondary ulceration the result was
satisfactory. When it was done for pain there was no relief. Amputation is
therefore avoidable provided that vigorous steps are taken to prevent or
correct deformity; it should not be done for pain relief. (Clawson) Kline et al

1989 reported on sciatic nerve injuries over a 24-year period. Regardless of

the mechanism of injury, patients treated conservatively because of partial
deficit and/or improvement in function had a slightly greater than 80%
chance of useful function in their tibial division distribution and
approximately 60% chance of ultimately regaining useful peroneal
distribution function. In surgically treated patients, recovery of useful
function was greatest after neurolysis if associated with a positive nerve
action potential, intermediate after suture, and less likely after nerve
grafting. Recovery in the tibial nerve far exceeded that in the peroneal
innervated structures. Femoral shaft fractures most commonly caused
traction injuries at the thigh level. Injuries at thigh level had a slightly better
prognosis compared to those in the buttock region. (Kline)
Ipsilateral femoral neck fracture

The incidence of ipsilateral intracapsular femoral neck fracture with

concomitant femoral shaft fractures ranges from 2.5%-5%. A delay in
diagnosis of the femoral neck fracture is quoted as 19% - 30%. (Swiontkowski,
Alho) This

delay is usually due to inadequate initial Radiographs. Avascular

necrosis of the femoral head complicating this injury occurs in 3%-5% of

reported cases. (Swiontkowski, Alho) The incidence of avascular necrosis is
less than that reported for age related isolated femoral neck fractures,
where it is reported to be 10%. (Gerber) Chapman has attributed this to the
majority of energy being dissipated in the femoral shaft
fracture. (Chapman) Alternatively this incidence may be erroneously low as
greater than 60% of cases have less than 1 year follow up, and avascular
necrosis can occur up to 3 years post injury. The true incidence of
avascular necrosis of the femoral head in these injuries therefore probably
approaches 10-15%. (Swiontkowski)

Most authors agree that rigid internal fixation of both fractures is indicated.
The argument exists as to which fractures treatment should take priority.
Alho et al in a meta-analysis of 659 cases of concurrent ipsilateral fractures
of the hip and femoral shaft made a general observation that complications
and reduced function resulted from the shaft fracture component. In
addition the low incidence of avascular necrosis of the femoral head
suggests outcome depends on the treatment of the femoral shaft
fracture. (Alho) However Swiontkowski et al in1987 has made the point that,
the complication of symptomatic avascular necrosis of the femoral head is
much harder to deal with than mal/non union of the femoral shaft. As such
the neck fracture deserves priority in treatment. (Swiontkowski)
Intertrochanteric (extracapsular) fractures account for 28% of ipsilateral hip
fractures, they do not pose as much of a diagnostic dilemma and are not
associated with the above complications of avascular necrosis and nonunion. (Alho)
Ipsilateral knee injury

Ipsilateral knee injury is easily missed during initial treatment of the femoral
shaft fracture. The reported incidence of ipsilateral knee ligament injury
with femoral shaft fracture is between 17% and 52%. (Moore, De Campos,
Vangsness)

This wide variation in frequency is caused by several factors;

Variations in recording the incidence due to an increased awareness of

ligament injuries currently as opposed to historically.

Data gathered acutely as opposed to chronically is more likely to miss

the diagnosis, as examination of the knee is difficult in the acute setting.

Variations in the mechanism of injury. High-energy injuries are more

likely to be associated with ligamentous injury.

Arthroscopic evidence of ipsilateral knee injury following midshaft femoral

fractures is common reported as 55%(22/40) by De Campos et al 1993. (De

Campos) Blacksin

et al 1998 reported MRI derangements of the knee

associated with femoral shaft fractures. Blacksin reported a meniscal injury

rate of 27%, with the posterior horn of the medial meniscus most frequently
torn. The most frequent site of ligamentous injury was the medial collateral
ligament (38%). (Blacksin) The presence of an intra-articular lesion does not
imply progression to a symptomatic or degenerative problem or exclude its
pre morbid presence. It should be borne in mind that in cadaver studies
meniscal abnormalities are seen in 8%-57% of knees with little or no
correlation with symptoms on history. (Fahmy)
In Arthroscopic studies of the knee very little correlation exists between
ligamentous laxity and meniscal pathology. Knee effusion was associated
with a high incidence knee pathology 13 out of 40 (54%), however the
absence of a knee effusion did not rule out significant intra articular
pathology, 11 out of 40 (28%). (De Campos)
Table 2. Ipsilateral knee injury
De Campos 1994
Arthroscopy
Number patients
40
Total abnormal
22 (55%)
PCL
3 (7.5%)
ACL
13 (32.5%)
LCL
5 (12.5%)
MCL
11 (27.5%)
A- scope ACL
2 complete 19 partial
A- scope PCL
1 complete
Total meniscus
22 (55%) knees
Lateral meniscus
13 (33%)
Medial meniscus
13 (33%)
Bone bruise

Blacksin 1998 MRI

34
34 (100%)+
7 (21%)
2 (6%)
2 (6%)
13 (38%)

9 (27%)
6 (18%)
4 (12%)
32%
1 (3%) occult tibial plateau
fracture

+Magnetic resonance imaging of the ipsilateral knee was performed on

patients with closed femoral shaft fractures, fixed with intramedullary
nailing. Only knees with an effusion or clinical abnormality on examination
under anaesthesia were included in this study.

Ipsilateral Tibial fractures

Ipsilateral tibial and femoral shaft fractures the floating knee are
uncommon. These complex injuries are associated with a high morbidity
and prolonged rehabilitation. Treatment is also associated with significant
complications. (See treatment and the floating knee )

2. Treatment
Choice of treatment

The current favoured treatment of femoral shaft fractures is with statically

locked reamed intramedullary nailing. Alternatives include: traction with or
without cast bracing, plate osteosynthesis and external fixation. These will
be dealt with in turn.
NON-OPERATIVE
In a study of 2805 femoral shaft fractures between 1989 and1992, 31%
were treated non-operatively; these were associated with a higher mortality
and morbidity.

(Fakhry) Traction,

with or without cast bracing yields

acceptable functional results. Union of the fracture usually occurs within

thirteen to fifteen weeks with most non-operative forms of treatment.
Common sequelae included shortening, malrotation and contractures of the
knee.
Table3. Non-operative management of femoral shaft fractures
Hardy 1983 Cast
Suman 1981 Cast
bracing
bracing
Fractures
108
117
Patients
106
117
Infection
29/106 (27%) skin
2 (1.7%) pressure
ulcers from cast
sores, 1 (0.8%) infected
Tibial pin track
Union
10-12 wks-22 (20%),
15 weeks (11-24)
12-16, wks-74 (69%),
16-24 wks-24 (22%)
Delayed
9 (8.3%)
union
Non- union
0
Shortening
> 2cm-11/92 (12%)
>2cm-15%
Rotation
>10 degrees-18/95

Buxton 1981 Perkins

traction
50
50
18 (36%) pin track
problems. No pressure
sores
47 (94%) clinical and
radiological union at 12
wks.

>2cm-3 (6%)
>10 degrees- 0

Angulation
>15 degrees
Re-fracture
Knee
movement

(20%)
>20 degrees- 4/95 (4%)
Varus/valgus-0
anterior bowing-2 (2%)
posterior bowing-1 (1%)
2 (2%)
<90 degrees flexion-3
(3%)
90-110 degrees-2
(2%), >110 degrees but
lacking last 10 degrees
flexion-16 (15%)

Varus/valgus-6 (5%)

(15 excluded), < 90

degrees-13/102 (13%),
90-120 degrees-28/102
(27%)

Varus/valgus-2/46 (4%)
4 (8%)
<120 degrees flexion-0

Several modifications of skeletal traction have been advocated to try and

improve outcome. For example Perkins traction with a split bed allowing
knee motion helped to reduce the incidence of knee stiffness. Nonoperative treatment requires close supervision of the healing fracture
configuration to ensure acceptable results. Several reports of the results of
traction achieved in the early 1970s exist; (Mooney et al 1970, Connolly et
al 1973; Brown and Preston 1975; Wardlaw 1977, Lesin et al 1977). There
is very little published data available from the last decade on treatment with
traction. Mooney et al 1970 in a prospective study of one hundred and fifty
patients with fractures of the distal part of the femur, treated with traction
and cast bracing, reported no non-unions or re-fractures and a mean
healing time of 14.5 weeks. (Mooney) Thomas et al 1981, in a comparative
study of 81 patients with fractures of the distal half of the femur, treated
with: 1.Traction 2. Traction followed by cast brace application at 5 to seven
weeks 3. Open reduction and intramedullary nailing. They found that
prolonged traction led to slower bony union and a prolonged hospital stay.
Traction and cast bracing averaged 7 weeks in hospital and 15 weeks to
union, no delayed union and no cases of deep infection. Intramedullary
nailing averaged 5 weeks in hospital and bony union at 13 weeks. However
this was associated with one case of deep infection which took 20 weeks to
unite, 3 sequestrectomies and 3 years of treatment. Traction with timely
hinged knee bracing provides a safe reliable method for the treatment of

distal femoral fractures, combining the advantages of non-operative

management with early mobilisation and knee movement. (Thomas)
OPERATIVE
The principles of anatomical reduction and rigid fixation of femoral shaft
fractures followed by early limb rehabilitation have gained widespread
acceptance.
Dissatisfaction with the results of non-operative treatment of femoral shaft
fractures, because of prolonged hospitalization, high costs, fracture
shortening, malunion, delayed union and joint stiffness has led to the
development of various operative techniques for the management of
femoral shaft fractures. In the last ten years intramedullary nail design and
insertion techniques have been pre-eminent especially in femoral shaft
fractures, with associated multiple injuries, including head injuries and
chest injuries.
PLATING
Plate osteosynthesis is an important technique in the treatment of femoral
shaft fractures. It is advantageous in situations where intramedullary nailing
is not ideal. These include:

Adult and paediatric polytrauma with concommitant head trauma or

pulmonary compromise

Ipsilateral femoral neck and shaft fractures

Open fracture with a vascular injury

Fracture location in the proximal or distal femoral shaft and excessively

narrow intramedullary canals

Where the equipment necessary for intramedullary nailing is not

available. (Rozbruch)

The principles of accurate reduction and rigid internal fixation of femoral

fractures with plates should be followed. Despite the improvements in
anatomical reduction, earlier mobilization, decreased pulmonary morbidity
and earlier discharge from hospital, plating has brought with it an array of
new complications. The problem of knee movement has not been
completely addressed. This is a bit skewed in that plating is more likely to
be used in the distal third (supracondylar) fractures where knee movement
is more likely to be affected. Malunion, infection, mechanical failure of
fixation, delayed union, non-union, re-fracture and re-operations are all
possible complications following plate fixation of femoral fractures. Accurate
open reduction and plate fixation requires considerable experience and
operative expertise to ensure satisfactory results. Recent evolution in
plating techniques has lead to the concepts of careful tissue dissection,
epiperiosteal exposure of bone, and indirect reduction of fractures to
minimize stripping and devascularization of bone fragments. Reduced soft
tissue dissection also leads to less quadriceps tethering and improved knee
range of motion. Reduction of the fracture to achieve anatomic alignment of
intra-articular fractures and optimal rather than maximal stability is the goal.
Routine bone grafting of the medial cortical defect as advocated in the
1980s (Loomer, Magerl, Ruedi) is no longer advocated. (Rozbruch) The greater
initial soft tissue dissection in those earlier series likely compromised the
biologic healing potential, then mandating a biologic stimulus for healing,
namely bone grafting. Plate construction and design has also evolved,
limited contact dynamic compression plates composed of pure titanium
provide improved tissue compatibility and improved blood supply to the
plated bone segment. Longer plates relative to the fracture length are
thought to be particularly important, increasing the lever arm of the plate.
Optimal use of screws through the plate as opposed to maximal use of
screws the length of the plate has also been suggested. The use of

unicortical screws at the plates periphery and multiple inter-fragmentary

lag screws outside of the plate have been abandoned. The latest study by
Rozbruch et al 1998 clearly shows the improvement in outcome with new
biological internal fixation. (Rozbruch) The improved figures for 1993-1994
surely also reflect the fact that plating requires experienced hands to
achieve acceptable outcomes.
Table 4. Plate osteosynthesis of femoral shaft fractures.
Rozbruch
Rozbruch 1982
1972-1973
Number fractures
25
30
Number patients
23
30
Age (years)
32.8 (12-64)
26.7 (14-58)
Open
8 (32%)
10 (33%)
Bone graft
4 (16%)
11 (30%)
Infection-deep
1 (4,8%)
1 (3.4%)
Union
4.9 months
4.98 months
Delayed union
3 (14.3%)
2 (6.9%)
Non- union
2 (9.5%)
1 (3.4%)
Implant failure
4 (19%)
3 (10.3)
Implant loosening
2 (9.5%)
0
Successes
13 (62%)
24 (84%)
Re operations
9 (43%)
9 (31%)

Rozbruch 19931994
25
23
49.5 (20-86)
3 (12%)
1 (4%)
1 (4.3%)
3.38 months
0
1 (4.3%)
1 (4.3%)
2 (8.7%)
20 (87%)
3 (13%)

Geissler 19801987
71
69
26 (8-88)
13 (18%)
41 (69%)
0
16 weeks (23-72)
0
2 (3%)
1 (1.4%)
0
66 (93%)
3 (4%)

EXTERNAL FIXATION
As the indications for closed locked intramedullary nails expand, indications
for external fixation diminish. In certain circumstances for instance the
unstable polytraumatized patient and unstable patients with head injuries,
external fixation allows for rapid rigid fixation. (Alonso) Operating time and
the ease of external fixator application in the polytrauma patient have been
cited as indications for external fixation. Volker et al 1995 in a study of 18
open femoral shaft fractures showed that, soft tissue debridement,
reduction, and application of external fixator took a mean time of 73
minutes. (Volker) Van den Bosche et al 1995 showed that it was safe to
stabilize fractures temporarily with external fixation and convert to
intramedullary nailing when the patients condition was stable. (Van Den
Bosch)

The external fixator is a useful adjunct to fractures about the knee

that include both the supracondylar area and the proximal tibia. Generally

external fixation is reserved for the more complex femoral fracture,

including severe comminution and open fractures with extensive soft tissue
injury and/or vascular injury. This selection bias is reflected in the relatively
high complication rates.
Table 5. External fixation of femoral shaft fractures
Volker 1995
Gottschalk 1985
(1985-1989)
(1981-1983)
Open
severely
comminuted
Fractures
Patients
Open
Pin tract
infection
Infection deep
Union
Delayed union
Non- union
Shortening
Rotation >15
degrees
Angulation >15
degrees
Re-fracture
Knee movement

18
18
18 (100%)
0

7
7
3 (43%)
1 (14%)

2 (11%)
5.5 months
(1.8-9.6)

0
6 months (4.5-8)

0
>2cm-1/15 (7%)
0

Alonso 1989
(1983-1986) 14
patients
temporary
external fixation
24
24
13 (54%)
3 (12.5%)

Murphy 1988
(1979-1986)
Complex
fractures

1 (4.2%)

2 (6%)^^^
4.8 months (2-9)

2 (8%)
1 (4%)

4 (13%)
0 caution, reoperation
> 2 cm- 5 (16%).
1 (3%)

>2cm-2 (8%)

All 7 (100%) had

almost full ROM

Average loss of
motion 56
degrees

34
34
26 (76%)^
6 (19%)

Valgus-1 (7%)
0
3 (20%)- flexion
deficit>10
degrees

Re-operations

8- converted to
dynamic
compression
plating or casting,
6 delayed
intramedullary
nailing.

Average ROM 91
degrees, <90
degrees 14
(44%)
4 (13%)

INTRAMEDULLARY NAILING
Closed intramedullary nailing has many theoretical and practical
advantages compared with other treatments for fractures of the femoral
shaft. It is the most commonly used treatment for femoral fractures.
Femoral nailing gives predictable realignment of bone, rapid healing and
early functional use of the limb. The advent of static locking to prevent
shortening and malrotation has extended the indications of intramedullary

nailing to severely comminuted fractures, subtrochanteric fractures and

supracondylar fractures. There is mounting evidence to show that early
intramedullary nailing of open fractures including Gustillo grade III, yields
acceptable results. (Rutter, Williams, Nicholas)
Closed intramedullary nailing should be attempted, but inadequate
reduction and eccentric reaming of comminuted fractures can lead to
inferior results. Open reduction during intramedullary nailing is
controversial. Some authors contend that open reduction is not associated
with a significant increase in complications, and therefore if a satisfactory
closed reduction cannot be obtained the fracture should be opened and
held reduced. (Winquist, Rokkanen, Leighton) Green et al 1987 tempered this, in
an article dealing with the consequences of chronic sepsis in the femur
following intramedullary nailing. The perceived benefits derived from open
reduction are rapidly lost in the presence of chronic deep infection. In his
study several of the patients referred with deep-seated infection were
initially closed injuries, which were opened to allow reduction. (Green) In a
comparative study by Rokkanen et al 1969, of open or closed
intramedullary nailing versus conservative management. They found both
early and late results of treatment were better after intramedullary nailing
than after conservative management. The difficult fractures in the older
patient benefited most from intramedullary nailing, whereas low energy
injuries in young people healed equally well regardless of the method of
treatment. (Rokkanen) Controversy exists over reamed versus unreamed
nailing. With improved implant technology, smaller diameter, closed
section, thicker walled nails are available. They theoretically could provide
adequate support to allow uncomplicated union. Smaller unreamed
intramedullary nailing has the theoretical advantages of less soft tissue and
bony trauma, lower intramedullary pressure and less fat embolism risk,
lower incidence of infection and shorter operating times. The theoretical

disadvantages are loss of mechanical strength and stability leading to

implant failure, higher rates of non-union or delayed union. Theoretically
they have advantages in open fractures, head injured patients and patients
with pulmonary compromise. Conflicting articles exist in the literature.
Boyer et al 1996 concluded smaller diameter nails had not been shown to
increase the rates of mal or non-union. (Boyer)Kropfl et al 1995 showed
superior results with unreamed smaller diameter nails compared with the
published results for reamed intramedullary nailing. Kropfl et al quoted nonunion figures of 0% and infection rates of 0%. (Kropfl) Hammacher et al 1998
was unable to confirm these findings in a multicenter experience of 129
unreamed intramedullary nails he quoted non-union figures of 5.1% and
infection rates of 2.9%. Of note in the Hammacher study 26% of the cases
were open fractures as opposed to 10% in the Kropfl study and open
reduction was performed more frequently in the Hammacher
series. (Hammacher) Tornetta et al 1997 in a prospective randomized study of
81 fractures concluded that reamed canal preparation led to faster healing
of distal fractures treated with statically locked intramedullary nails and that
their was no advantage to nail insertion without
reaming. (Tornetta) Clatworthy et al 1998 in a prospective randomised trial of
48 patients with 50 fractures, concluded that; reaming aids fracture healing
and suggested the use of reamed nails. (Clatworthy) The latest largest study
available to date by Wolinsky et al 1999 reporting on 551 femoral shaft
fractures treated with reamed intramedullary nails, reported 94% of
fractures healing after primary nailing, 4.7% needed a second procedure to
heal the fracture, 0.5% needed two procedures and 1% did not heal. Six
fractures (1%) became infected. All six fractures that became infected,
healed after adequate treatment and at follow up were infection free. Only 1
nail (0.2%) broke after 17 months, in a case with segmental bone loss and
non-union. Thirteen locking bolts broke with no effect on treatment or

outcome. Malunion was rare. All fractures healed with less than 10 degrees
of angulation in any plane. Careful attention must be paid to reduction and
nail placement when treating distal third fractures. (Wolinsky)
Table 6. Intramedullary nailing of femoral shaft fractures
Wolinsky
Braten 1995 Winquist
1999 (1986- (1982-1991)
1980 (19681996)
Reamed
1979)
Reamed
Comminuted
Fractures
551
120
245
Patients
515
116
Infection
3 (0.5%)
4 (3%)
(superficial)
Infection
3 (0.5%)
1 (0.8%)
1 (0.4%)
(deep)
Union
545 (99%)
100%
243 (99%)
Delayed union 29 (5%)
6 (5%)
Non- union
6 (1%)
0
2 (0.8%)
Shortening
5 noted on
>2cm-1
>2cm-7 (3%)
gait analysis (0.8%)
Rotation
None
> 15 degrees >10 degrees
requiring
23/116 (20%) 16 (7%)
correction
Angulation >
44/4180
2 (1%)
5-10 degrees
(11%)
Angulation >
0
1 (0.8%),
3 (1%)
10 degrees
Implant failure 1 (0.2%)
2 (1.6%)
Knee
N/A
Full ROM
<125 degrees
movement
6/201 (3%)
Re operation
29 (5%)
1 (0.8%)

Kropfl 1995
(1992-1993)
Unreamed
81
75
0

Hammacher
1998 (19941996)
Unreamed
129
122
2 (1.5%)

2 (1.5%)

81 (100%)
0
0
>2 cm-0

118 (91%)
4 (3%)
7 (5%)
N/A
>20 degrees
1/ 125 (1%)

7 (9%)

N/A

N/A

0
N/A

1 (0.8%) nail
N/A

9 (6.6%)

Open fractures
Several studies have shown that intramedullary nailing of open fractures is
safe if thorough debridement and irrigation are performed prior to
nailing. (Rutter, Williams, Grosse, Brumback, Van den Bossche) Controversy still
exists regarding the intramedullary nailing of grade III open
fractures. Below are various advocates of intramedullary nailing various
grades of open femoral fractures.

All grades: Rutter et al 1994, Grosse et al 1993

Grade I,II and IIIA: Van den Bossche 1995

Grade I, II and selected grade III: Brumback et al 1989,

Williams et al 1995

Gunshot wounds: Nicholas et al 1995, Levy et al 1993

Proponents of the more conservative approach of only nailing selected

grade III fractures cite the high incidence of local complications following
intramedullary nailing of open grade III B and III C fractures. They advocate
external fixation for grade IIIB and IIIC fractures.
Green et al 1991 reported a high incidence 55% (6/11) of infection for
grade III fractures versus a low incidence 4.5% (1/22) for grade I and II
femoral shaft fractures treated with intramedullary nailing. (Green) In a
prospective study by Grosse et al 1994, of 115 consecutive open fractures,
including 12 grade IIIB and 5 grade IIIC fractures treated with
intramedullary nailing, only 3 patients (2.6%) developed serious
infections. (Grosse) In a prospective randomized trial by Williams et al 1995,
forty-two patients with open femoral shaft fractures of all Gustillo-Anderson
grades, were randomized to primary nailing (at the time of initial
debridement) and delayed nailing (two to five days post initial
debridement). This included 4- grade IIIA, 3- grade IIIB and 2- grade IIIC
fractures in the primary nailing group. He reported an infection in 1 patient
(2.4%). This infection was in the group treated by delayed intramedullary
nailing, Gustillo-Anderson grade II. This patient was later found to be HIV
positive. (Williams) Further evidence to suggest the low complication rate of
intramedullary nailing in Gustillo-Anderson IIIB and IIIC is accruing, Rutter
et al 1994 reported 0% infection in 5- grade IIIB and 1- grade IIIC femoral
fracture treated with intramedullary nailing. (Rutter) Recent reports on the
use of intramedullary nailing for femoral shaft fractures caused by gunshots
also support the use intramedullary nailing in grade I to grade IIIC open
fractures. (Wright, Nicholas)
Although studies are starting to show that Intramedullary nailing produces
acceptable results in Gustillo-Anderson grade IIIC fractures, controversy
still exist about the optimal form of treatment for femoral fractures with
associated vascular injuries. Some authors believe that short term

temporary external fixation of severe open fractures followed by conversion

into an intramedullary nail can be done without increased risk of deep
infection. (Van den Bossche)
Table 7. Infection rates in open femoral shaft fractures.

Open
fractures
Infection
rate

Brumbac
k 1989
(nail)

Grosse
1991
(nail)

Green
1991
(mixed)*

Rutter
1994
(nail)

Williams
1995 (nail)

89

115

53

28

42

3 (3.4%)
(all IIIB)

3 (2.6%)

9 (16%)
(2 type
II, 7 type
III)

2 (7%)
(IIIB,II)

1 (2.4%)
(II) **

Van Den
Bossche
1995
(mixed)**
*
57

Total
(Mixed)

0 (0%)

18 (4.7%)

384

Table 8. Infection rates according to Gustillo grade of open femoral shaft fractures
Brumback 1989 Rutter 1994
Williams
Van Den
Total
(nail)
(nail)
1995 (nail) Bossche
(Mixed)
1995
(mixed)***
Open
89
28
42
57
216
fractures
Grade I
27 (30%)
10 (36%)
12 (29%)
18 (32%)
67
Grade II
16 (18%)
9 (32%)
16 (38%)
11 (19%)
52
Grade III
46 (52%)
9 (32%)
14 (33%)
28 (49%)
97
Grade III A
19 (21%)
3 (11%)
6 (14%)
21 (37%)
49
Grade III B
27 (30%)
5 (18%)
5 (12%)
5 (9%)
42
Grade III C
0 (0%)
1 (3%)
3 (7%)
2 (3%)
6
Infection
3 (3.4%)
2 (7%)
1 (2.4%) **
0 (0%)
6 (2.7%)
rate
Gustillo
I=0
I=0
I=0
I=0
I=0
grades
II=0
II=1(3.5%)
II=1(2.4%)
II=0
II=2 (4%)
III=3 (3.5%)
III=0
III=0
III=0
III=4 (4%)
IIIA=0
III=1 (3.5%)
IIIA=0
IIIA=0
IIIA=0
IIIB=3 (3.4%)
IIIA=0
IIIB=0
IIIB=0
IIIB=4 (10%)
IIIC=0
IIIB=1(3.5%)
IIIC=0
IIIC=0
IIIC=0
IIIC=0

* Forty-two had internal fixation, 1 external fixation, 10 Traction and cast

bracing.
** This patient was seropositive for the human immunodeficiency virus.
*** Twenty-six treated with plating, 11 intramedullary nailing, 20 external
fixation (External fixator used for all 7 IIIB and IIIC fractures, and 9 IIIA
fractures). The external fixator was routinely converted to internal fixation
on average 21 days after initial injury.

The Floating knee

Fraser et al 1978 reported on 222 cases of ipsilateral tibial and femoral
shaft fractures. They divided these into three groups; group 1 had operative
fixation of both fractures, group 2 had operative fixation of one fracture and
in, group 3 both fractures were treated non-operatively. They found the best
overall results in group 1 and the worst in group 3. The most alarming
finding was a 30% incidence of osteomyelitis in patients who had operative
fixation of both fractures. Other authors have reported figures of deep
infection of 7% and 10% among their patients treated operatively. (Karlstrom,
Fraser)

Group 3, the non-operative group, was associated with a 30% rate of

delayed union or non-union. Despite this high incidence of osteomyelitis in

the operative group, patients treated non-operatively had the worst
functional results. Fraser et al recommended intramedullary nailing of the
femoral fracture and the use of rigid external fixation or cast bracing in the
management of the tibial fracture, In an attempt to reduce the morbidity
associated with osteomyelitis. (Fraser) Karlstrom et al 1977 reporting on a
series of 32 cases in 31 patients noted, patients that had their femoral
fracture internally fixed had better outcomes than those that did
not. (Karlstrom) McAndrew et al 1988 reported long term follow up results on
29 out of 45 patients (64% follow up) with ipsilateral tibial and femoral
diaphyseal fractures. They also found improved outcome in, patients who
had intramedullary nailing of their femoral fracture. At follow up, a mean
time of 6.5 years the 29 patients were functioning well, all had returned to
work. Forty eight per cent were heavy labourers and 31% had sedentary
occupations. Seventeen patients (59%) limited their sporting
activities. (McAndrew)

Tourniquet
De Campos et al 1993 found no complication directly related to pneumatic
tourniquet use in knee arthroscopy following reamed intramedullary nailing
of femoral fractures. (De Campos)Pollack et al 1997 in a retrospective review
found that the use of a pneumatic tourniquet in patients with polytrauma
who have also undergone reamed intramedullary nailing is associated with
increased length of ventilator dependence and increased length of stay in
the intensive care. (Pollack) Moore et al 1987 described compartment
syndrome complicating surgical treatment of ipsilateral femur and ankle
fractures associated with pneumatic tourniquet usage. (Moore)

3. Complications
Deep infection

The long term sequelae and poor functional outcomes associated with
chronic sepsis are devastating. Green et al 1987 reporting on chronic
sepsis following intramedullary nailing observed: shortening (average
4.3cm), thigh atrophy and substantial limitation of knee movement (mean
knee flexion 68 degrees). Treatment varied, Green et al removed the nail
when radiographs demonstrated unattached, apparently nonviable, bone
sequestra at the fracture site requiring debridement. The nail was left in
place if it was stabilizing the fracture and not showing evidence of
sequestration. They found healing to be prolonged. Healing defined as the
ability to ambulate pain free without an external support. For patients in
whom the intramedullary nail was left in place, fracture healing occurred
between 19 months and 10 years. Excluding the 10-year case the average
time to fracture healing in the retained rod group was 33 months. In six
patients the intramedullary nail was removed as part of the debridement
and an external fixator used to provide stability and maintain length.

Fracture healing time in this group ranged from 14 months to 53 months

(average, 31 months). The twelve patients in this series of Green et al
required four surgical procedures on average, to obtain fracture union.
Green et al reported two cases of non-union, one in a case lost to follow up
after 1 year and the second in a wheel chair bound patient with a traumatic
through knee amputation. Eleven patients (91%) in this series were initially
managed by exposing the fracture site combined with retrograde nailing of
the proximal femur, either at the time of injury or shortly thereafter. The
septic outcome following placement of a femoral rod was especially tragic
for the six patients (50%) who started out with closed fractures. (Green)
Non-operative treatment has the least potential for deep infection. Hardy et
al reporting on 108 open and closed fractures and Moulton et al reporting
on 45 closed fractures, reported no deep bone infections. (Hardy,
Moulton)

Mooney et al 1970 in a personal communication with P W Brown

stated that in over 1000 documented cases treated non-operatively, there

were no non-unions or persistent infections, despite an approximately 30
per cent incidence of open fractures. (Mooney) Pressure areas and skin
ulcers vary from 0%- 27%, these however do not significantly contribute to
final outcome or deep infection. Traction pin sepsis can cause problems
with an incidence of 0-16%. (Hardy, Suman, Buxton)
Infection is frequently quoted as the major complication of plating femoral
shaft fractures. Ruedi et al 1989 has published the largest series with 131
femoral shaft fractures managed by compression plating. (Ruedi) His
infection rate was 6%, Loomer et al 1980 reported an infection rate of
7%. (Loomer) Geissler 1995 et al pointed out that most of the reported series
quoting infection rates around 5-7% following femoral shaft plating, were
prior to the routine use of preoperative antibiotics for all cases, not just
open fractures. Studies of cases routinely using prophylatic preoperative

antibiotics for all fractures quote 0%-3% as the incidence of

infection. (Geisler, Thompson, Magerl)
External fixation, pin tract sepsis occurs in 13%-19% of patients, deep
infection ranges from 4%-11%. (Volker, Alonso, Murphy) It should be borne in
mind however these studies involved small numbers and were of complex
comminuted open fractures. The incidence of infection following closed
intramedullary nailing of femoral fractures has been generally low, ranging
from 0-2% in published series. (Wolinsky, Braten, Murphy, Alho, Winquist, Kropfl,
Hammacher)

Sepsis following intramedullary nailing of open femoral nailing is

more variable occurring in 2%-5% of patients. (Brumback, Williams, Grosse,

Rutter) Treatment

of open fractures has a higher rate of infection overall,

irrespective of treatment method, deep infection occurred in 18 out of 384

open fractures (4.7%). (Brumback, Grosse, Green, Rutter, Williams, Van Den Bosche)
Compartment syndrome
Compartment syndrome is defined as an elevation of the interstitial
pressure in a closed osseofascial compartment that results in
microvascular compromise. The diagnosis of compartment syndrome
differs depending on the awareness and ability of the patient to co-operate.
In the awake patient, pain and the presence of tension and swelling of the
thigh raise the suspicion. The clinical examination includes pain on passive
stretching of the muscles of the thigh, decreased sensation, in the area of
the distribution of the nerves in the compartment involved, weakness of the
muscles and diminution or absence of distal pulses. Measurement of
compartment pressures in the awake patient is only an adjunctive
diagnostic role. In patients unable to co-operate with the physical
examination compartment pressures should be measured with little
hesitation in patients with tense swelling of the thigh. The critical threshold
of compartment pressure above which tissue is irreversibly damaged is

controversial. The overall clinical picture must help the physician decide the
critical threshold for each patient. Thirty millimeters of mercury has been
suggested as the low threshold at which the diagnosis of compartment
syndrome needs to be considered. Whitesides et al 1975 believed that
fasciotomy was indicated if tissue pressure rose within 10-30 mmHg of the
diastolic pressure i.e. 40-45 mmHg in a patient with a diastolic blood
pressure of 70 mmHg. (Whitesides) In borderline cases repeated
measurement should be obtained and a low threshold for the performance
of decompressive fasciotomy should be used. Compartment syndrome of
the thigh following femoral shaft fracture is uncommon. Scwartz et al 1989
identified 5 cases of compartment syndrome of the thigh in a period where
more than 370 patients had intramedullary nailing of the femur giving an
approximate incidence of 1%. (Schwartz) Tarlow et al 1986 reviewed the
orthopaedic literature and found no cases of compartment syndrome in
1,311 reported cases of femoral shaft fracture. (Tarlow) Schwarz et al 1989
reviewed 21 cases of compartment syndrome of the thigh. They identified
several risk factors for the development of compartment syndrome i.e.
systemic hypotension, vascular injury, high-energy blunt trauma, external
compression including the application of military anti shock trousers,
coagulopathy, multiple trauma and infusion of large volumes of fluid to
maintain systemic blood pressure. (Schwartz) It is difficult to correlate
outcome from compartment syndrome of the thigh as it rarely occurs as an
isolated injury. The diagnosis of compartment syndrome in the multiply
injured patient is at least a measure of the severity of the patients injuries
and portends a poor prognosis. Schwartz et al 1989 found a high mortality
rate of 47% associated with compartment syndrome of the thigh. Of the 9surviving patients with 10 compartment syndromes, 6 patients developed
local wound infections. In 6 of the 9 patients (7 compartment syndromes)
who survived there was no demonstrable sequel of compartment

syndrome. Two patients used crutches for persistent quadriceps and

hamstring muscle weakness, accompanied by sensory loss distal to the
knee and one patient who had an ipsilateral open fracture of the tibia had
decreased flexion of the knee. (Schwarz)
Compartment syndrome of the uninjured leg complicating intramedullary
nailing and the use of the hemi-lithotomy position has been
reported. (Anglen, Morrow, Dugdale, Carlson). The risk of compartment syndrome
complicating the use of the lithotomy and hemi-lithotomy position has been
previously noted in urologic, gynaecological, anaesthetic, and general
surgical literature following positioning in the lithotomy position for 6 to 10
hours. Dugdale et al 1989 reported two cases, which took of 5 hours 45
minutes and 6 hours respectively. Anglen et al 1994 reported two cases
taking 6 hours and 6 hours 15 minutes respectively. A special case is the
presence of bilateral femoral fractures. Carlson et al 1995 reported 2 cases
and Morrow et al 1994 reported one case of compartment syndrome
following intramedullary nailing of bilateral femoral fractures in all three
cases the duration in the hemilithotomy position was less than 3
hours. (Carlson, Morrow)
Delayed and non-union

Unfortunately different authors have used different definitions of delayed

union when reporting their findings. One definition of delayed healing is
healing taking longer than 6 months or requiring a second operation to
speed up healing. Delayed healing is still a problem in fractures treated
with plating occurring in 0%-7% of cases. (Rozbruch, Geissler, Ruedi) Delayed
healing is especially a concern in plated fractures due to the relatively high
incidence and the consequences of implant failure. In an attempt to
decrease the incidence of delayed and non-healing grafting of the medial
femoral defect was advocated. This decreased the rate of delayed/ non-

union. Lately however it has been suggested that with the new biological
methods of fixation involving less soft tissue dissection, grafting of the
medial femoral defect is not essential. (Rozbruch) Intramedullary nailing has a
lower incidence 3.4% (14/416) of delayed union and the consequences of
early implant failure are not as common. Static locking was considered a
risk for increased delayed and non-union, this has not been clearly shown
and routine dynamisation to prevent delayed union is no longer considered
necessary. Delayed healing is highest in external fixation 8%-13% this can
be explained partly on the basis of the complex fracture patterns treated
with external fixation. (Alonso, Murphy)
Alho et al defined non-union as any fracture not healed at 12 months, or
requiring a second operation to achieve healing. (Alho) Non-union rates
following plating vary from 1.3%- 6.9%; the highest value (6.9%) was in a
series with 100% comminution and an infection rate of
6.1%. (Ruedi) Intramedullary nailing has a very low reported non-union rate
around 1%. The majority of cases of non-union were in a study by
Hammacher et al 1998 all involving unreamed intramedullary nails. In
contrast Kropfl et al reported a 0% non-union rate in 81 fractures treated
with unreamed intramedullary nailing. The largest latest study by Wolinsky
et al 1999 on 551 cases treated with intramedullary nailing reported a nonunion rate of 6 cases (1%). Once again the varying definitions of non-union
complicate the matter Wolinsky et al did not include patients undergoing a
second procedure (nail dynamization or nail exchange) to attain healing in
their figures for non-union. These included 26 patients requiring one further
operation and the 3 cases requiring two further operations to achieve
union. Giving a comparable non-union rate for the Alho definition of 6.4%
(35/551). (Wolinsky) The importance of delayed and nonunion following
operative intervention is the risk of implant failure.

Implant failure

Implant failure is a significant problem following plating of the femoral shaft

occurring in 1%-11% of cases (35/417=8.4%). (Rozbruch, Geissler, Magerl,
Loomer, Ruedi, Thompson) Ruedi

et al 1979 noticed a large decrease in the

incidence of implant failure following routine bone grafting of the medial

femoral defect. (Ruedi) When looking closely at the figures of Rozbruch et al
the incidence of implant failure in 1972 prior to routine bone grafting was
19%, following increased bone grafting of the medial femoral defect in 1982
he quoted an implant failure rate of 10%, in 1993 with the advent of
biological fixation, and less grafting of the medial defect he quoted an
implant failure rate of 4%. Implant failure is rare following intramedullary
nailing. It is common for locking screws to fail, but this is not associated
with any significant clinical consequence. Franklin et al studying reports of
intramedullary nailing after 1980 found 7 cases in 1268 nails
(0.5%). (Franklin) Alho et al reported an implant failure incidence of 3%
following intramedullary nailing, this was a study of only comminuted
fractures i.e. increasing the time to healing and placing increased
mechanical stress on the nail. (Alho)
Malunion

Varus or valgus angulation less than 10 degrees does not lead to clinical
deformity or limitation. The exact amount of malalignment acceptable to
prevent future degenerative arthritis is not positively known. (See arthritis)
In the earlier studies of non-operative treatment malunion was reported if it
measured greater than 15 degrees. In the operative treatment group
angulation greater than 5 degrees was considered significant.
Kootstra et al 1973 assessed patients with external rotation deformity of 20
degrees and found 8 out of 23 patients (35%) were symptomatic. Braten et
al 1995 in a study of 116 patients found rotational differences less than 15

degrees were not associated with any significant symptoms, whereas

almost half the patients with greater than 15 degrees were troubled by this
condition. (Braten)
Arthritis

Relatively little information is available about the effect of angular

malalignment following a femoral fracture on the development of
degenerative arthritis in the hip, knee or ankle. The concern is that
abnormal forces may lead to degenerate arthritis. At present there is no
data to support the position that malalignment always leads to degenerate
arthritis. Kettelkamp et al 1988 discussed degenerative arthritis of the knee
secondary to fracture malunion. They studied 15 knees in 14 patients who
developed unicompartmental degenerative arthritis of the knee after
angular malunion of femoral or tibial fractures. Average interval from
fracture presentation to presentation for care of degenerative arthritis of the
knee was 31.7 (10-60) years. They found that, the knee was more tolerant
of increased valgus force than increased varus force. Nine femoral
fractures had varus angulation of 3 to 25 degrees (average12.4 degrees),
and all developed degenerative genu varum in an average of 28.7 years
(range, 10-49 years). The medial plateau force was calculated to be 1.87
times more than the medial plateau force of the uninjured extremity. Two
femoral fractures had valgus angulation of 8 and 14 degrees respectively
and developed genu valgum in 60 and 37 years respectively. The lateral
plateau force averaged 1.78 times more on the fractured side than on the
normal extremity. (Kettelkamp) Egund et al 1982 studied 62 distal femoral
fractures, treated non-surgically in 35 and surgically in 27 cases. They
evaluated angulation and displacement of the fracture in relation to the
development of gonarthrosis. Unfortunately their study has a short follow
up time of 2- 10 years. As would be expected gonarthosis developed more

commonly in displaced intercondylar fractures with a diastasis or planar

difference in the articular surface exceeding 3 mm. There seemed to be
less connection between angular deformity and gonarthrosis. Gonarthosis
was mostly confined to the patello- femoral articulation. Arthrosis of the
tibio-femoral articulation was rarely seen. (Egund)
Table 9. Incidence of arthritis following Supracondylar fractures. Egund et al

Number
Gonarthrosis

Undisplaced
Supracondylar

Displaced
Unicondylar

Undisplaced
Intercondylar

9
1 (11%)

10
2 (20%)

17
1 (9%)

Displaced
intercondylar
(diastasis)
18
10 (55%)

Volpin et al studied degenerative arthritis of the knee following 31 intraarticular fractures of the knee, including 3 undisplaced and 7 comminuted
displaced distal femoral fractures. Their follow up was from 6 to 22 years
(average 14). Six of the 10 femoral fractures were treated conservatively
and 4 surgically. They found no significant differences between results after
surgical or conservative treatment. Patients who had early active and
passive knee movement did better. There was no significant correlation
between degeneration and the initial mechanism of injury, nor with the type
and localisation of the fracture except that fractures caused by great
violence were more susceptible. Degenerative changes developed mainly
within the first six to eight years after initial injury. Later deterioration
seemed to be rare; it seems that if signs and symptoms of degenerative
arthritis have not developed by 10 years they are unlikely to appear later.
The probability of degenerative change increased significantly with greater
age at time of injury (older than 45 years). Radiological changes of severe
degenerative arthritis are of little significance unless they are correlated
with clinical signs. A number of patients in this study had very good knee
function with marked radiographic change. (Volpin)

The main factors in preventing degenerative changes in surrounding joints

appears to be the early restoration of joint congruity, realignment to the
normal anatomical axis, joint stability and early movement.
Shortening

Leg length inequality of 1cm or more is found in 7% (4%-8%) of the normal

adult population. This incidence in the normal adult population is thought to
be due to out of phase growth. (Giles)Patients with shortening of 1cm have a
normal gait and most patients with less than 2 cm shortening have a
normal gait and are free of symptoms. Shortening is most common in
severely comminuted fractures. With the advent of statically locked
intramedullary nailing the incidence and severity of shortening has
significantly reduced. In a meta analysis of 655 fractures treated by
intramedullary nailing, shortening greater than 2 cm was present in 19
fractures (3.4%). (Braten, Murphy, Alho, Winquist, Kropf) Of those 19, 16 were in
two large studies of only comminuted fractures including 368
fractures. (Alho, Winquist) As opposed to studies where approximately only
55-60% of fractures are comminuted only 3 out of 287 (1%) fractures had
shortening greater than 2cm. (Braten, Murphy, Kropfl) This problem of
shortening in comminuted fractures has been further addressed by
increased use of static locking. Non-operative treatment had the highest
incidence of shortening 12%, greater than 2 cm, in a meta analysis of 259
fractures. (Hardy, Suman, Buxton) External fixation also has a high incidence of
shortening, this in part is due to the complex nature of fractures treated with
external fixation. Gibson et al 1983 reported the influence on the spine of
leg length discrepancy after femoral fracture. Forty patients with acquired
leg length discrepancy of at least 1.5 cm, as a result of femoral shaft
fractures sustained after skeletal maturity but below 21 years of age were
studied. Patients with painful joints of the lower limb were excluded leaving

fifteen patients. During the ten year period between fracture and review
only one patient had worn a shoe raise for a short period of time. Follow up
at least ten years later of these fifteen patients showed that in this group
acquired leg length discrepancy produced little permanent structural
abnormality in the lumbar spine and no degenerative change in the 10 year
period after the fracture that led to shortening. No patient complained of low
back pain nor had any had significant back pain during the previous ten
years. The patients were still young adults at the time of examination and it
is possible that structural or degenerative changes would
develop. (Gibson) Leg length inequality and the development of chronic low
back pain is controversial. Giles et al 1981 studied low back pain and limb
length inequality in 217 patients. They found the percentage of control
cases with 10 mm or more leg length inequality was 8 %, whereas the
percentage of chronic low-back-pain patients with 10 mm or more leg
length inequality was 18.3%. They presented this as evidence of the
importance of limb length inequality, as an aetiological factor in the
production of low-back pain. Only 4 out of the 217 patients having a leg
length inequality of greater than 9 mm had previously broken a femur or
tibia. Clinical and radiological follow up showed that postural scoliosis did
become structural with increasing age. Correction of limb inequality with a
shoe raise resulted in a variable correction of the scoliosis. This was age
related. A proportion of patients symptoms improved with a shoe raise
alone. The authors suggested that shoe raise therapy plus manipulation
might result in quicker remission of symptoms. (Giles)
Reoperation to achieve healing
Reoperation to achieve healing excluding implant removal and treatment
for infection. Rozbruch et al showed a dramatic reduction in reoperation on
fractures treated with plating reducing from 43% in the 1970s to 13% in the
1990s. This reflects the evolution in plating techniques and improved

outcome as experience is gained in a particular technique. Similar trends

are seen in the intramedullary nailed group where the overall rate of
reoperation on 1004 fractures was 51 (5%). (Wolinsky, Braten, Alho, Kropfl,
Hammacher)

Later studies in the 90s show much lower reoperation rates

approaching 1%. (Braten) This low reoperation rate following reamed

intramedullary nailing can be attributed to lower rates of mal/non-union,
routine static locking and less routine dynamization of intramedullary nails.
Knee movement

In the past 90 degrees of knee flexion has been considered an acceptable

result. The average range of motion required for sitting is 93 degrees, for
climbing stairs is 100 degrees, for tying shoes is 106 degrees and for
squatting to lift an object is 117 degrees. These figures are averages, so
minimal standards must be higher to express a desired functional result for
70-90% of the population. Expressed in convenient ranges:

125 degrees or more of flexion enable a patient to squat and carry on

most normal daily activities

110-124 degrees would permit shoe tying in most patients

100-109 degrees generally allows patients to handle stairs and sit

comfortably

Less than 100 degrees often means difficulty with sitting and significant
functional loss. (Laros & Spiegel)

The highest incidence of restricted knee movement less than120 degrees

is in the non-operative group, 18% (range 0- 40%). (Hardy, Suman, Buxton) Of
the non-operative treatment modalities Perkins traction has the lowest knee
morbidity with 0% having less than 120 degrees of knee flexion. (Buxton)
Intramedullary nailing has been shown to give a consistently good range of
knee movement with only 2% (range 0-3%) having less than 120 degrees
knee flexion. (Braten, Grosse, Winquist)In a retrospective comparative study by

Rowntree et al of 85 patients treated by three methods: 1. Open

intramedullary fixation, 2. Skeletal traction with early knee motion, 3.
Skeletal traction with immobile knee. The mean follow up was 5 years
(range 2-13.5 years). Thirty per cent of patients had minor knee symptoms.
In all cases knee flexion was more than 90 degrees, no statistically
significant difference could be demonstrated in the effect on final knee
function between intramedullary fixation and skeletal traction. (Rowntree)
Refracture

Refracture of the femoral shaft is rare. The incidence varies from 2%

to10%. (Breederveldt) Theoretically, refracture can only be defined as such
when there has been consolidation of the primary fracture. For practical
reasons refracture is defined as any fracture in the same bone as the
primary fracture without adequate trauma and independent of the primary
fracture line or radiographic degree of consolidation. Breederveldt in a
retrospective study of 148 femoral shaft fractures presented 19 refractures,
mostly after plate fixation. (Breederveldt) Intramedullary nailing leads to less
reduction in cortical density than following plating. A mean cortical reduction
in bone density of 11% in the plated segment has been reported by
Terjesen et al 1985.(Terjesen) Braten et al 1992 reported a mean cortical
density reduction of 7 % in the proximal diaphysis, and 6% in the distal
diaphysis after reamed intramedullary nailing, only the proximal reduction
was statistically significant. (Braten) Intramedullary reaming reduces torsional
strength of the femur; even reaming to only 12mm reduces torsional
strength by 37.5%. There also appears to be a sharp transition between
femurs reamed to 14 mm and 15 mm respectively. A more reliable formula
is to try and keep reamed diameter divided by bone diameter (Rd/Bd) less
than 0.45. (Pratt)
Table 10. Meta-analysis of complications where information available in respective articles.
NonPlate 481
External
Intramedullar

operative 275
Hardy,
Suman,
Buxton

Rozbruch, Geissler,
Magerl,Loomer,Ruedi,Thomps
on

fixation 98
Volker,
Gottschalk
, Alonso,
Rooser,
Murphy

Infection
deep

1/275- (0.4%)
*, closer to 0
Hardy,
Suman,
Buxton

16/481- (3.3%) Rozbruch,

Geissler, Magerl, Loomer,
Ruedi,Thompson

8/98- (8%)
Volker,
Gottschalk,
Alonso,
Rooser,
Murphy

Delayed
union

9/108-(8.3%)
Hardy

14/206-(6.8%) Rozbruch, Ruedi

Nonunion

0/108-(0%) **
Hardy

8/274-(3%) Rozbruch, Geissler,

Loomer, Thompson

6/58-(10%)
Alonso,
Murphy
1/57(1.7%)**
Volker,
Alonso,
Rooser

Angulation

>15 degrees8/275 (3%)

Hardy,
Suman,
Buxton

>5 degrees-3/144-(2%) Magerl,

Thompson

>15
degrees3/33 (10%)
Volker,
Rooser

Rotation

>20 degrees
4/158 (2.5%)
hardy, Buxton

N/A

>15
degrees1/34 (3%)
Volker,
Murphy

Shortenin
g

>2cm- 30/259
(12%)
Hardy,Suman,
Buxton

> 2cm- 2/144 (1.4%) Magerl,

Thompson

Reoperation

N/A

40/368-(10.9%) Rozbruch,
Geissler, Ruedi, Thompson

>2cm- 8/93(8.6%)
Volker,
Gottschalk,
Alonso,
Rooser,
Murphy
4/34- (13%)
Murphy

Knee
movement

<120
degrees46/259 (18%)

<120 degrees- 5/215- (2.3%)

Geissler, Magerl, Thompson

<120
degrees12/39-

y nailing 1349
Wolinsky,
Braten,
Murphy, Alho,
Winquist,
Kropfl,
Hammacher
10/1349(0.74%)
Wolinsky,
Braten,
Murphy, Alho,
Winquist,
Kropfl,
Hammacher
14/416- (3.4%)
Braten,Murphy,
Hammacher
15/1349(1.1%) **
Wolinsky,
Braten,
Murphy, Alho,
Winquist,
Kropfl,
Hammacher
>5degrees60/906=
(6.6%),
>10 degrees
7/1029(0.68%)
Wolinsky,
Braten,
Murphy, Alho,
Winquist,
Kropfl
>15 degrees
23/473(4.8%), >20
degrees 6/535(1%)
Braten,Murphy,
Alho,Winquist,
Hammacher
>2cm- 19/655
(3%), Braten,
Murphy, Alho,
Winquist,
Kropfl
51/1004-(5%)
Wolinsky,
Braten, Alho,
Kropfl,
Hammacher
<120 degrees6/321(1.8%)
Braten,

Hardy,
Suman,
Buxton
Refracture

6/275 (2.2%)
Hardy,
Suman,
Buxton

Mortality

8/387- (2%) Geissler, Magerl,

Loomer, Ruedi, Thompson
6/251- (2.4%) Loomer, Ruedi,
Thompson

(30%)
Gottschalk,
Volker,
Rooser
0/18- (0%)
Volker

Winquist

2/54(3.7%)
Volker,
Murphy

14/564- (2.5%)
Kropfl,
Hammacher,
Alho, Braten

0/53- (0%)
Braten, Kropfl

*1 infected tibial pin tact with sequestrum

** Does not include fractures requiring additional procedures to heal.
** Alho definition includes cases requiring further operations to achieve
healing
Deep venous thrombosis

The true incidence of deep venous thrombosis following fractures of the

lower extremity is difficult to assess. Rokkanen et al 1969 reported deep
venous thrombosis in 5.8 % of cases.(Rokkanen) Braten et al 1995 reported
the incidence of clinical thromboembolic events to be 4.2%
(5/120). (Braten) Abelseth et al 1996 in a prospective study demonstrated
that the incidence of clinically occult deep venous thrombosis was 28% in
lower extremity fractures. He quoted an incidence of 40% (8/20) following
femoral shaft fracture. This was however a small study, actively looking for
venous thrombosis. Fortunately there are very few clinical episodes of
pulmonary emboli. (Abelseth) There is a concern that patients may develop
post phlebitic syndrome many years later with its associated morbidity.
Aitken et al 1987 was not able to demonstrate a significant incidence of
associated post phlebitic syndrome after femoral shaft fractures, however
their study included very small numbers. Most of the literature has
concentrated on tibial fractures. The postphlebitic limb syndrome takes a
long time to develop 13% at 3years, 35% at 9 years, 39% at 14 years.
Therefore patients who develop a deep venous thrombosis should be of be

cautious accepting compensation concluded in full and final assessment,

as the syndrome may take years to fully develop.

(Aitken)

Heterotopic ossification

Heterotopic ossification about the hip after intramedullary nailing of femoral

shaft fractures is rarely commented on. The incidence is seldom quoted in
articles on femoral shaft fractures. Mild to moderate heterotopic ossification
has been shown to be compatible with excellent function of the hip.
Brumback et al 1990 studied 100 consecutive patients with unilateral
femoral shaft fractures, in a prospective randomized trial to delineate the
incidence and factors predisposing to heterotopic ossification about the hip.
Twenty patients were excluded leaving 80 patients. In 32 (40%) no
heterotopic ossification developed, whereas mild ossification developed in
27 patients (34%). Moderate ossification developed in 12 patients (15%)
and severe ossification, in 9 patients (11%). They were unable to identify
any specific factors related to the patient, fracture, timing or type of
intramedullary nailing and development of heterotopic ossification. They
randomized the patients into two groups, in group 1, the operative incision
was irrigated with 250 milliliters of saline, and group 2 the operative incision
was irrigated with 3000 milliliters of normal saline with use of pulsatile
lavage. Irrigation with pulsatile lavage did reduce the amount of mild and
moderate heterotopic ossification. It did not however reduce the only
clinical significant ossification, namely severe heterotopic
ossification. (Brumback)
Nerve injury, complicating treatment

Pudendal nerve palsy is noted as an infrequent complication of traction,

compression following intramedullary nailing of the femoral shaft.
Presenting with numbness of the penis and scrotum or Labia and rarely

erectile dysfunction in men. When specifically looked for the incidence is as

much as 10%-17%. In a prospective study of 106 patients 10 (9%) (6 men,
4 women) had a pudendal nerve palsy. Only one of the men complained of
erectile dysfunction. The symptoms resolved completely in 9 out of 10
patients within 1-11 weeks (average 4 weeks). One man still complained of
altered sensation in the penis and scrotum at 6 months.
The duration of procedure did not predict onset of symptoms. Statistical
analysis revealed the magnitude of total traction forces for the duration of
the procedure was significantly higher in the group who developed a
pudendal nerve palsy. However some patients who received high
pressures for the duration of the procedure did not get palsies, similarly
some patients who received very low traction pressures for the duration
developed palsies. It is thought that the anatomy and thin post play an
important role. Hip adduction time should also be limited as much as
possible, i.e. relaxing traction and abducting the hip while closing the
wounds may reduce the incidence of these iatrogenic injuries. (Brumback)
Carlson et al 1995 has reported peroneal nerve palsy and compartment
syndrome in bilateral femoral fractures. This is a rare complication related
to patient positioning. Placing one of the fractured limbs in the
hemilithotomy position, usually the left leg. It is thought the posterior
angulation and or added mobility of the leg may stretch the peroneal nerve.
The calf supports all the weight of the leg, because the fractured femur
cannot provide support. (Carlson)

4. Outcome
-

Employment

Rokkanen et al 1969 comparing open and closed intramedullary nailing to

conservatively treated case, showed earlier return to normal function and

work with operative treatment. They showed the greatest benefit to be

gained with operative intervention was in the older age groups with
complicated fractures. Only a marginal benefit was derived with closed
versus open intramedullary nailing. They also showed a curious difference
of two weeks, in fractures treated within 6 days; interval for return to work
was 32 weeks (39 cases) as opposed to 30 weeks in 49 cases when the
nailing was performed 7 to 21 days post fracture. (Rokkanen) In a study by
Bednar et al 1993 of 47 patients with isolated femoral shaft fractures
treated by intramedullary nailing. Forty one patients were available for
analysis of function: 33 (80%) had returned to full time occupation in their
original occupation, 4 (10%) were working in other full time employment;
3(7%) were working part time and only 1 (2%) was disabled and unable to
return to work. (Bednar)
Benirschke et al 1993 reported on a subset of 56 patients out of 144
available for analysis (treated with closed locked intramedullary nailing).
They found at a minimum of 12 months follow up that 39% had some
limitation in ability to ambulate or stand and 9 % had to obtain new
employment or seek job modifications. (Benirschke)
Alho et al 1991 reported on 120 patients with 123 fractures treated with
intramedullary nailing, with a mean follow up of 20 months (range, 12-60
months). He found the working ability of 18(15%) patients was reduced at
follow up examination. Four patients (3%) had stopped their sports activity
and 31(26%) had various degrees of reduction of activity. (Alho)
Kropfl et aI 1995 documented a subset of patients with workers
compensation treated with plate osteosynthesis, all patients returned to
their preoperative level of activity within a mean period of 3.25
months. (Kropfl) Loomer et al 1980 reporting on 45 patients with 46 fractures
treated with plating stated that the average patient healed their fracture in 7

months, returned to work at 12 months and returned to sports activities at

15 months. (Loomer)
Table 11. Employment following femoral shaft fracture
Hardy 1983
Number patients
106
Age
77%<30 years
Treatment
Cast bracing
Open
16 (15%)
Comminuted
85 (79%)
Non operative
106 (100%)
Plating
External fixation
Intramedullary nailing
Follow up
% return to work
75 (71%)
Time to work
30 weeks (6.9 months)
~

Mira A J 1980
29
25.1 (16-64)
Mixed
6 (21%)
12 (41%)
19 (66%)
2 (7%)
8 ( 27%)
37.3 months (16-69)
*
7.5 months (3-19)
*

Bednar D A 1993
41
22
Nailing
9 (19%)
N/A
22 (100%)
34.5 months
33 (80%)
4 months
+

~ Seventy-five (71%) returned to work within 30 weeks, fourteen were

retired or unemployed. The other seventeen were either living in institutions
or attending a school or university where they were continuing their studies
by correspondence, or had abandoned their studies until the start of the
next academic year.
* This study was of patients who had returned to work. The only significant
difference in time of return to work was in simple proximal (5.4 months)
versus comminuted distal (7.8 months) and between treatment by open
reduction and internal fixation (5.3 months) versus a spica cast (8.2
months) (Mira)
+ Of the patients not returned to preinjury employment, 4 patients (10%)
were working full time in different employment, 3 (7%) were working part
time. Only 1 (2%) remained disabled at the time of follow up. (Bednar)
-

Daily living

Thigh muscle function after operative fixation of femoral shaft fractures

varies depending on the operative form of fixation. Studies where the
uninjured side is used as control need to be viewed with caution, as it has
been shown that extension power and flexion power in the uninjured leg

increase on average by between 11% and 17% after two years. Similarly in
a group of normal volunteers the average quadriceps strength between one
side and the other differed by 6%, with a standard deviation of 4%. This
suggests a significant mean variation from normal needs to be more than
10%. (Mira) Zdravkovic 1978 showed that closed intramedullary nailing
versus open intramedullary nailing resulted in better quadriceps
function. (Zdravkovic) Finsen et al 1993 reported no loss in knee extension
strength at least 23 months post intramedullary nailing, compared with a
12% reduction in knee extension strength of patients treated with plate
osteosynthesis. (Finsen) Hamstring power is also significantly reduced after
operative fixation of femoral fractures, this appears to be unaffected by the
type of operation. (Finsen)

5. Factors affecting outcome

Patients age

Published complications following intramedullary nailing are low. In 1988

Christie et al reported their results of intramedullary nailing of femoral
fractures. They reported 4 perioperative deaths, but stated that 3 of these
patients were elderly. In 1984, Winquist et al published a major study on
500 fractures treated with closed intramedullary nailing; the average age
was 30 years, with a wide range 10 to 92 years. The nonunion rate was low
0.9%. However, of the 4 nonunions, 3 of them occurred in patients older
than 60 years of age. Bouchard et al 1996 retrospectively reviewed the
outcome of 138 femoral shaft fractures in the elderly, average age 79
(range 65-98). Low velocity injuries caused 92% of the fractures, only 10%
had associated injuries. Concomitant musculoskeletal illnesses were found
in 62% of cases, cardiopulmonary disease in 44% of patients and
neuromuscular conditions in 22% of patients. Only 12 patients (9%) were in

perfect health. Treatment varied, 29 non-operative and 109 were treated

surgically. Sixty-three patients had complications related to the fracture or
the treatment for a complication rate of 46%. Twenty-eight patients died
within 6 months giving a perifracture mortality rate of 20%. Most deaths
occurred early in the first month. The age and mental status on admission
to hospital were the main determinants for patient survival. The number
and type of medical illnesses did not influence the survival of the patient
nor did the type of treatment. Ninety patients were able to ambulate on
average 16 days after admission to the hospital. Forty-eight patients (35%)
were unable to ambulate after the fracture and remained
bedridden. (Bouchard)
Mechanism of injury

High-energy injuries carry increased morbidity due to the higher incidence

of open fractures, higher incidence of associated injury, and higher
incidence of ipsilateral injuries. Taylor et al 1994 showed union time to be
affected by mechanism of injury irrespective of treatment. Motorcycle and
car accidents were the slowest to unite; taking 14.3 weeks to unite
compared with 11.1 weeks following falls. Motorcycle, car accidents and
lower third fractures had the worst knee flexion. Shortening was not
statistically affected by the initial mechanism, but was worst with
traction. (Taylor)
Treatment modality

Non-operative treatment by traction does not risk infection, but results in

longer hospitalization, slower ambulation, more angulation and a higher
frank non-union rate. Cast bracing shortens hospital stay and time to
ambulation, but has the highest incidence of limb shortening

Operative treatment offers significant benefits in terms of mortality and

morbidity in the critically ill multiply injured patient. (Fakhry)
Internal fixation with plate osteosynthesis is especially useful in proximal
and distal fractures where intramedullary nailing is less effective. Plating
provides rigid fixation and anatomic reduction, good motion, low risk of
shortening and angulation, but risks the highest incidence of infection and
implant failure.
External fixation in the adult is generally reserved for complex, high energy
injuries, prone to complications.
Closed reamed intramedullary nailing provides short hospitalization, early
ambulation and return to work, good maintenance of bone length, minimal
angulation and a high percentage of patients with good knee flexion, but
risks infection.
Timing of surgery

A number of studies have supported early aggressive surgical management

of the patient with multiple injuries and long bone fractures. A strong
relationship exists between early fixation of femoral fractures and reduction
in the number of days in the intensive care unit; the number of days in
hospital; and the rates of adult respiratory distress syndrome, pneumonia,
infection and death. (Charash, Bone, Johnson, Behrman) Studies in the 1960s and
1970s by Charnley, Guindy and Wilber, suggested that fractures operated
on early (0-6 days after fracture) compared with those operated on late
(more than 6 days) had a higher incidence of non-union, delayed union and
re-fracture. Modern day studies refute these claims and show no benefit
from delaying surgery. (Pahud) In fact to the contrary they show significant
benefit in early surgery (within 24-48 hours). The patient who has the most
to gain is the critically ill multiply injured patient. (Bone, Behrman)

In a prospective randomized study by Bone et al 1989 of 178 patients who

were randomized into an early fixation group (the first 24 hours) or a late
stabilization group (more than 48 hours after injury). They found that
delayed fixation greater than 48 hours, increased hospital stay and
intensive care stay by 5 and 10 days respectively. (Bone) Johnson et al 1985
documented a five fold increased incidence of adult respiratory distress
syndrome if internal fixation was delayed by 24 hours. (Johnson) Recent
literature has attempted to further break down who does, or does not
benefit from early surgical intervention. Pelias et al 1992 in a retrospective
study of 130 consecutive patients with major blunt chest injury showed that
patients with major chest injury and long bone fractures had a high
propensity toward pulmonary complications. They also failed to show any
significant improvement in the high pulmonary morbidity despite optimal
early operative fixation. (Pelias) Pape et al 1993 challenged the philosophy
of early fixation of femoral fractures using reamed intramedullary nails in
the multiply injured patient. Concluding that in the presence of a thoracic
injury, primary intramedullary nailing with reaming of the femur causes
additional pulmonary damage and may trigger the development of adult
respiratory distress syndrome. (Pape) Charash et al 1994 repeated the study
design of Pape et al with similarly sized groups of patients who had a
femoral fracture and a thoracic injury, and they reported contradictory
findings. Charash et al reported a 48% rate of pneumonia in twenty-five
patients who were managed with delayed fixation, compared with a 14%
rate of pneumonia in fifty-six patients who were managed with early
fixation. The overall rate of pulmonary complications (pneumonia, adult
respiratory distress syndrome, fat embolism, and pulmonary embolism)
was 56% in the patients who had delayed fixation, compared with 16% in
those who had early fixation. (Charash) These findings of lower pulmonary
morbidity following early fixation were supported by later retrospective

studies done by Van der Made et al 1996. (Van der Made) Bosse et al 1997
strongly supported early operative fixation of femoral fractures even in the
presence of major thoracic injury (Bosse) and Carlson et al 1998 concluded
that reamed intramedullary femoral fixation did not increase pulmonary
morbidity in chest injured patients.(Carlson)
Associated head injury
Intramedullary nailing of fractured femurs has not been shown to be
associated with any increase in neurological disability. (Mckee, Starr) Provided
careful attention to prevention of secondary insults to the brain is applied
during surgery, i.e. avoiding intraoperative hypoxia, hypotension and
maintaining adequate cerebral perfusion pressure. Townsend et al 1998,
showed patients having intramedullary nailing 0-2 hrs post admission, were
8 times more likely to become hypotensive during femur repair than
patients in the >24 hr group. He therefore suggested a short delay to allow
for adequate resuscitation and stabilization. (Townsend) Starr et al 1998
showed that delay in stabilization appeared to increase the risk of
pulmonary complications and that early fracture stabilization did not
increase the prevalence of CNS complications. (Starr)

6. Implant removal
Intramedullary nail removal is performed in 20% to 38% of fractures treated
with intramedullary nailing. The most common indication for removal is pain
(63%). The suggested time prior to removal is at least 18-24 months and it
is important to protect the femur from heavy load bearing (sporting
activities) for three months after removal. (Alho, Wolinsky, Breederveld) Braten et
al found an increased incidence of hip and knee pain in patients, where the
nail had not been removed; they also quote no re fracture in 47 femurs
after nail removal. (Braten) Miller et al 1992 reported on the removal of 60

intramedullary rods in 58 patients. All the fractures had healed at the time
of rod extraction. The implant was removed from 34 asymptomatic patients
(36 femurs). Twenty-four patients had preoperative symptoms attributed to
the to the femoral rod. Problems encountered after extraction were broken
rods in 5 femurs and 6 patients required further hospital care for
postoperative haematomas. There were no re fractures in this group. Miller
et al advised against rod removal in asymptomatic patients. (Miller)

7. References
See Separate sheets.