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A case of a complex distal humeral fracture is presented. The patient lacked sufficient bony architecture to allow for conventional reconstruction. A technique is described using an intramedullary plate to obtain bony stabilization and permit early range of motion exercises.
The authors demonstrate a group of 27 patients subjected to intramedullary osteosynthesis of the forearm by means of Kirschner wires, using closed surgery. They prefer the described method in patients suffering from multiple injuries who have devastated soft parts of the forearm and in unstable fractures in children. The authors draw attention to the fact that they have achieved very good results by the simple surgical method they described.
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Since the introduction of flexible intramedullary nails, the treatment of femoral shaft fractures in adolescents has been revolutionized and this has become the routine treatment in most units, with minimal complications. We report a rare complication of an ipsilateral fractured neck of femur in a fit and healthy 12-year-old girl 6 months after treatment of a traumatic fractured femoral shaft; this was treated effectively with cannulated screws and the patient was successfully discharged without any further complication.
A consecutive series of 378 patients with 381 acute adult femoral shaft fractures in previously intact femora admitted during a 10-year period was reviewed for the incidence of local complications including malunion. The majority, 282 fractures (74%), were caused by motor vehicle accidents. The median age of the patients was 28 years. The policy of management was internal fixation of the fracture on the day of admission. The method of treatment was intramedullary nailing (Küntscher or interlocking nailing) in 279 and plate fixation in 102 fractures. A local complication occurred in 90 patients (24%). Of these 90 cases 24 had malunion only while in the remaining 66 patients there was mechanical failure of fixation in 27, local infection in 20 (5.3% of the total), delayed union or nonunion in 15, and refracture in four patients. Concurrent injuries in the lower extremities were associated with a significantly increased frequency of delayed union, nonunion, and refracture. In 41 patients (11%) a total of 58 reoperations had to be undertaken because of local complications. There was an over-representation of plated fractures among those patients suffering a local complication classified as severe, 24 out of 37 (chi 2 = 30.3; p less than 0.001). Consequently, we now only exceptionally use plate fixation in the management of femoral shaft fractures.
Intramedullary nailing of the tibia has been used mainly in selected cases of fresh diaphyseal fractures and nonunions. However, with modern variations of the technique, the indications can be expanded considerably. Interlocking nailing has increased the number of fractures suitable for intramedullary fixation. With this technique or with other additional measures, intramedullary fixation can be used after correction osteotomies and for stabilization of metastases and pathologic fractures. When used on correct indications and in the absence of complications, intramedullary nailing is the method of choice for stabilization of the tibia. The advantages are short stay in hospital, short morbidity, early range of motion exercises, and weight-bearing without immobilization in plaster. A prerequisite, however, is that the surgeon be very familiar with the technique, and its indications and complications.
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OBJECTIVES: To compare the initial stability of the genucephalic (GSH) intramedullary nail and the 95-degree condylar compression screw and side plate (DCS) for distal femur fractures. DESIGN: Human cadaveric biomechanical study. PARTICIPANTS: Twelve matched pairs of fresh frozen human cadaveric femurs. INTERVENTION: Genucephalic intramedullary nail device (Smith and Nephew Richards, Memphis, TN, U.S.A.) and the 95-degree DCS device (Synthes USA, Paoli, PA, U.S.A.) were compared. Grouped or dispersed screw constructs were tested for each fracture fixation system with progressively more severe simulated fracture patterns. MAIN OUTCOME MEASUREMENT: Axial and torsional stiffness values. RESULTS: The DCS plate with the dispersed screw configuration had the greatest torsional stiffness (p < 0.0011). The GSH nail with the grouped screw configuration absorbed more energy (work) during axial loading compared with the plate constructs (p < 0.0007). There were no significant differences in axial or torsional stiffness within treatment groups for fracture patterns of increasing severity. CONCLUSIONS: Based on the authors' results, the selection of a GSH nail or a DCS plate should not be determined by the severity of the fracture. If a DCS plate construct is selected, the authors recommend a dispersed screw configuration, including the most proximal hole in the plate, to provide superior stiffness in torsional loading and equal stiffness in axial loading when compared with the GSH nail constructs. If a GSH nail is selected, the authors recommend a grouped screw configuration, which absorbed more energy during axial loading compared with the DCS plate constructs and the nail with the dispersed screw configuration.
Closed tibial shaft fractures are common injuries that remain challenging to treat because of the wide spectrum of fracture patterns and soft-tissue injuries. Understanding the indications for surgical and nonsurgical treatment of these fractures is essential for good outcomes. Although cast treatment of stable tibial shaft fractures has traditionally been successful and continues to be widely used, recent clinical studies have shown that intramedullary nails may be more advantageous for fracture healing and function than casting. Surgical treatment (intramedullary nailing, plate fixation, or external fixation) of closed tibial shaft fractures varies depending on multiple factors. Metaphyseal fractures are well suited for plates, although newer intramedullary nail designs provide the option of intramedullary nailing of proximal or distal metaphyseal tibia-fibula fractures. External fixators are well suited for skeletally immature patients with unstable fracture patterns or for patients with unacceptably small intramedullary canals. Interlocking intramedullary nails are the treatment of choice for most unstable tibia-fibula shaft fractures.
Fifty femoral fractures in 47 patients were treated by the insertion of flexible intramedullary Ender rods and observed until fracture healing was complete. Both condylocephalic and trochanteric approaches were used with a preference for the latter when biomechanically feasible. The fractures ranged from the intertrochanteric-subtrochanteric junction to the supracondylar area of the femur. This technique can be used to treat fractures unsuited for conventional rods. The system is relatively uncomplicated, the technique atraumatic. Healing is generally rapid. There were no non-unions, infections, surgical deaths, or significant residual deformities.
A prospective study of closed intramedullary fixation of fractures of the shaft of the humerus, using Ender nails, was performed over a six-year period. Eighty-nine fractures in eighty-eight patients were treated with no immobilization postoperatively. Three patients were lost to follow-up. Eighty-five of the remaining eighty-six fractures healed, the average time to clinical union being 7.2 weeks. Non-union of one fracture occurred and there were no infections or malunions. Six of the nine preoperative and two postoperative radial-nerve palsies were lesions in continuity and healed spontaneously. The remaining three radial nerves that had been severed by a missile needed further attention. One of the nails backed out in eight patients, requiring revision in five. The average lack of complete extension of the elbow was 4 degrees and flexion of the elbow was 132 degrees. Abduction of the shoulder averaged 91 degrees; external rotation, 54 degrees; and internal rotation, 68 degrees. We conclude that closed intramedullary Ender nailing can be performed safely and effectively in selected fractures of the humeral shaft. However, only fractures that are recalcitrant to closed reduction and immobilization or fractures in the non-compliant patient should be considered for this form of operative treatment.
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A 5-year retrospective review of 83 patients with 98 metacarpal fractures was performed. Fractures of the thumb metacarpal were excluded. Ninety-six closed metacarpal fractures were reduced closed and fixed with flexible intramedullary fixation, using multiple 0.8-mm prebent rods. Two open metacarpal fractures were also fixed with this technique. Fractures amenable to flexible intramedullary fixation include short oblique and transverse fractures. Contraindications include long oblique and bicortical comminuted fractures. The average follow-up time was 9 months (range, 2 to 34 months) with 15 patients lost to follow-up examination. All fractures went on to heal. Three complications occurred: backing out of a rod in one case and bending of the rods after repeat trauma in two. There were no infections. Flexible intramedullary nailing of specific metacarpal fractures affords excellent results with a low complication rate. Proper selection of fractures and good surgical technique are necessary to avoid complications.
Intramedullary fixation is used increasingly to treat clavicular fractures. Anatomical variations in the clavicle of relevance to this procedure are analyzed. The length, diameters and curvature of the clavicle were measured in 196 specimens from the dissecting room. The calcium bone density was analyzed in 300 cross-sectional samples of 100 specimens. The thickness of cortical and medullary bone of 70 slices was analyzed from freshly plastinated clavicles with implants in place. The female clavicle was shorter, less curved, and had a lower concentration of calcium than the male clavicle. Measurement of cortical thickness showed a mean value of 1.05 +/- 0.23 mm at the most sternal measuring point, 2.05 +/- 0.29 mm at the midpoint of the clavicle, and 0.95 +/- 0.35 mm at the acromial end. The thinnest regions were the medial ventral cortex and the dorsal acromial cortex. These measurements explain clinical observations on nail perforation. The diameter of the medullary canal measured 6.7 +/- 2.6 mm at its narrowest part, so that reaming (i.e., predrilling the medullary canal) prior to 3.5 mm titanium nail insertion is not necessary. The main difficulties encountered when placing a nail are secondary to the S-curvature of the clavicle. In 80% of fractures, the break is located at the narrowest diameter of the medullary canal. Thus, the clavicle displays definite gender- and side-specific anatomical features in terms of length, diameter, curvature, and calcium concentration. These should be considered when performing intramedullary fixation.
Five patients with stress fractures of the proximal tibia adjacent to an arthritic knee joint were treated by resurfacing arthroplasty with intramedullary fixation of the fracture. All five fractures healed and limb realignment was achieved. The literature concerning proximal tibial stress fractures in relation to the arthritic knee and the management of this condition is reviewed.
Retrograde intramedullary fixation of proximal humerus fractures with flexible wires was evaluated in a prospectively documented study. Seventy-four fractures in 73 patients with unstable proximal humerus shaft or neck fractures were fixed with 3-11 flexible intramedullary wires. The age of the patients averaged 72 years (42 females, 31 males). In nine fractures additional implants (screws, cerclages) were used to fix dislocated fragments through an anterior approach to the shoulder. Complications associated with the procedure especially in osteoporotic bone were secondary loss of reduction (16%) and wire migration (21%) which lead to revision surgery in 14% of patients within 6 weeks. A minimum follow-up of 12 months (average 16.5 months) could be obtained in 61 patients (84%). According to the Neer- and Constant-scores 60% showed good or excellent results, 30% had a satisfactory and 10% had an unsatisfactory or poor result.--Retrograde intramedullary, flexible wire fixation can provide an overall satisfactory outcome in unstable proximal humerus fractures of the elderly. However, the high incidence of secondary wire dislocations especially in marked osteoporosis appears to be an unsolved problem of this treatment modality.