Flexible medullary nailing of tibial shaft fractures

Fifty-two tibial shaft fractures in 50 patients were treated with flexible medullary nails (Ender type). In 32 cases the fracture was closed and in the remaining 28 cases the fracture was open. Forty-eight of the 52 fractures united in an average time of 16.8 weeks and there were no cases of deep infection or osteomyelitis. Nonunion in four patients required a secondary procedure to obtain union. Flexible medullary nailing is an excellent method for fixation of tibial shaft fractures because it combines the benefits of closed nailing and functional bracing while minimizing the disadvantages of each. Three-point fixation within the medullary canal maintains length alignment and avoids rotational problems. Nailing is done by closed methods without reaming. The technique allows early weight-bearing in a patellar tendon bearing cast or functional brace. Dynamic controlled motion at the fracture site leads to early callus formation which is biomechanically and biologically favorable. The procedure is relatively easy to perform, short in duration, and requires little specialized equipment. Flexible medullary nailing is an alternative treatment modality for selected open and closed displaced tibial shaft fractures.     

Intramedullary infections treated with antibiotic cement rods: preliminary results in nine cases

The treatment of intramedullary infections after nailing usually includes removal of the rod, debridement of the canal, and, in many cases, insertion of antibiotic-impregnated cement beads. These beads offer no mechanical support and are difficult to remove if left in place for more than 2 weeks. We present an alternative for filling the medullary canal's noncollapsible dead space with an antibiotic-impregnated cement rod. This rod can be custom-made at the time of surgery, using different diameter chest tubes as molds and embedding a 3-mm beaded guidewire within the cement. The smooth molded surface of this nail makes extraction of the cement rod relatively easy. The cement rod also provides some limited temporary support to the fracture or nonunion site while the infection is being treated. After 6 weeks, the rod can be removed and replaced with a definitive metal intramedullary nail, with or without bone grafting to treat the previously infected fracture or nonunion site. We retrospectively reviewed nine cases of intramedullary infection treated with antibiotic-impregnated molded cement rods. These included six femora, two tibiae, and one humerus. The cause of infection was lengthening or transport over nail in six cases, fixator-augmented nailing of osteotomies in two, and fracture fixation in one. The follow-up period after surgery ranged from 38 to 48 months. No recurrent infection occurred during this follow-up period, and no patient required antibiotics after the rod was removed. In all cases, the canal cultures were negative after rod removal. The cement rod was removed between 29 and 753 days after implantation. Fracture of the rod occurred in one case in which the rod was left in place for more than 1 year. We conclude that this method is a relatively simple and inexpensive alternative for the treatment of intramedullary infections.     

闭合复位交锁髓内钉内固定治疗股骨干骨折

目的 总结在无空心髓腔软钻的情况下采用闭合复位交锁髓内钉内固定术治疗股骨干骨折的方法及优点.方法 2006年1月-2007年6月,收治24例股骨干闭合骨折患者.男14例,女10例;年龄18～63岁,平均38.3岁.左侧7例,右侧17例.病程3～20 d,平均7.6 d.AO分型A型5例,B型6例,C1型7例,C2型2例,C3型4例.术中对断端均不予切开,透视指导下闭合复位,顺行扩髓并植入髓内钉.结果 手术时间100～170 min,平均128_3 mm1例输血400 mL,余患者均未输血.20例获随访6～24个月,平均13.1个月.术后6～12周X线片可见大量骨痂生长.术后15～30周,平均22.2周去拐行走.伸膝均达0°;屈膝120～170.,平均145.5°.无感染及内固定物断裂.术后出现骨化性肌炎伴屈髋受限、疼痛1例,口服非甾体类消炎镇痛药后症状消失;无症状骨化性肌炎2例,未行特殊处理.结论 闭合复位交锁髓内钉内固定治疗股骨干骨折具有保护断端血供、中心固定、固定强度高等优点;在无空心髓腔软钻情况下,需要特殊的手术操作程序.     

Closed femoral intramedullary nailing in the lateral decubitus position with the aid of intraoperative skeletal traction

The closed intramedullary nailing is the treatment of choice for femoral diaphyseal fractures. These procedures typically have been performed on a fracture table with either supine or lateral position. However, the use of a fracture table has a lot of disadvantages compared to a lateral position on radiolucent routine table. We reviewed one hundred and twenty-eight patients with femur fractures between 2005 and 2009, who were treated with closed femoral intramedullary nailing in lateral decubitus position on radiolucent routine table. Indirect reduction was facilitated by the aid of intraoperative skeletal traction. Clinical and radiologic results were evaluated. There were no rotational or length malreductions that required surgical revision. There were no injuries to the perineum or contralateral leg, nerve palsies, or fracture table–related complications. There were three cases of non-union and two cases of interlocking screw loosening. Lateral decubitus position obviates the need for fracture table, making it easier to establish an entry point for an intramedullary device. Closed femoral intramedullary nailing in lateral decubitus position with the aid of intraoperative skeletal traction is safe and an effective technique with a low incidence of complications compared to the use of fracture table.     

闭合复位带锁髓内钉适宜治疗合并桡神经损伤的肱骨干骨折吗?

目的探讨肱骨干骨折合并的桡神经损伤是否会因为带锁髓内钉置入时的闭合复位操作而导致神经损伤的加重。方法2002年1月～2005年1月手术治疗的353例肱骨干骨折患者中,63例术前合并桡神经损伤。对此63例患者的体检、手术记录、X线片及治疗结果进行回顾性分析。11例行闭合复位带锁髓内钉固定；52例行切开复位内固定术及桡神经探查术,应用PEMS 3．1版本的卡方检验对11例行闭合复位带锁髓内钉固定术的患者与19例可以采用带锁髓内钉固定但行切开复位内固定术及桡神经探查术的患者桡神经恢复情况进行统计学分析。结果52例行切开复位内固定术及桡神经探查术的患者中,9例(17．3%)桡神经被骨折端嵌压,其余43例均为桡神经挫伤。63例患者中,除2例外,桡神经损伤均于术后2～12周(平均8周)自行恢复。所有患者术后3～4个月获骨性愈合。闭合复位带锁髓内钉术与切开复位内固定及神经探查术对肱骨干骨折合并桡神经损伤患者的影响差异无显著性意义(P=0．3931)。结论闭合复位带锁髓内钉固定治疗合并桡神经损伤的肱骨干骨折患者是适宜的。     

逆行和顺行置髓内钉治疗股骨干骨折的疗效比较

目的比较逆行和顺行置髓内钉治疗股骨干骨折的临床疗效。方法将57例股骨干骨折患者按置钉方式的不同分为对照组(经大转子顺行置髓内钉治疗,25例)和观察组(经股骨髁逆行置髓内钉治疗,32例)。比较两组术中透视次数、手术时间、术中出血量、骨折愈合时间、术后6个月Harris评分。结果患者均获得随访,时间7~12个月。手术时间、术中出血量观察组明显短(少)于对照组(P<0.05);术中透视次数、骨折愈合时间以及术后6个月Harris评分两组比较差异均无统计学意义(P>0.05)。结论逆行和顺行置髓内钉治疗股骨干骨折均能取得满意的临床疗效,但逆行置髓内钉具有手术操作简单、无需使用牵引床、手术时间短、术中出血量少等优点,更利于基层医院使用。     

The case for an open approach to tibial nailing

Medullary nailing of the tibia without exposing the fracture site is a technically possible procedure. In order to test if it is a superior method to open nailing, a retrospective study of 55 cases was undertaken; 35 had been nailed by the closed technique and 20 by open operation.

All fractures united. Knee movements were full unless there had also been other injuries. Complications were common; infection occurred in 20 per cent of open nailings and in 31 per cent of closed nailings. Twenty per cent of the tibias showed rotational deformities and 9 per cent of patients developed peroneal nerve palsy. Complications occurred less frequently in cases operated on by an open technique. It is suggested that opening the fracture site may reduce the complication rate.     

Indications and results of operative treatment of femoral shaft fractures in children.

In the literature a number of risks due to operative treatment of femoral shaft fracture in children have been reported and justification for such treatment has been thrown into doubt. In our patient series 35 out of 191 children (18%) with femoral shaft fracture were treated by operation, 18 by intramedullary nailing, 16 by other means of osteosynthesis and one crushed extremity by primary amputation. No infections occurred. Nineteen patients of these were re-examined 4.5 to 13.9 years later. Eleven of them had no subjective complaints. Weakness of the fractured limb was suffered by 2 in normal life and by an additional 6 patients in hard exercise. Muscle atrophy of the thigh, more than 2 cm in circumference, was found in 9 patients. Mean longitudinal overgrowth of the fractured femur treated by operation was 9.8 mm corresponding to 10.7 mm in 52 patients treated by traction and casting. Overgrowth of 7.2 mm in intramedullary nailed patients was significantly less (P less than 0.001) than 13.5 mm in those treated by other means of osteosynthesis. A rigid fixation of the fracture partly prevented later spontaneous correction of angulation. Based on the results gained by previous author and from this study a list of indications for osteosynthesis of femoral shaft fracture in children is considered.     

Interlocking nailing of femoral shaft fractures with an extremely narrow medullary canal is associated with iatrogenic fractures

IntroductionControversy exists regarding the use of reamed interlocking nailing in femoral shafts with extremely narrow medullary canals (diameter ≤ 9 mm). The aims of this study were to (1) investigate the association of age and sex on femoral canal diameter in patients with a simple femoral shaft fracture and (2) compare the outcomes and complications of interlocking nailing between wide and extremely narrow intramedullary canals.Patients and methodsFor the purposes of this retrospective cohort study, consecutive patients with simple femoral shaft fractures were recruited between January 2009 and December 2016. The patient demographic data were analyzed. Then, fractures treated with interlocking nailing were divided into the wide group (canal diameter > 9 mm) and narrow group. The primary outcome was union rate, and the secondary outcomes were complications such as thermal necrosis, fat embolism syndrome, iatrogenic fracture, and implant failure.ResultsThis study included 340 femoral shaft fractures. The average canal diameter was 9.97 ± 1.79 mm, with significantly wider canals in men than in women. Overall, 289 of the patients had undergone interlocking nail fixation, and a similar union rate and complications were noted between the wide canal and narrow canal groups, with the exception of the incidence of iatrogenic fracture.ConclusionsFemoral shaft fractures associated with extremely narrow medullary canals are more common in women than in men. There was a similar union rate found when using interlocking nailing in a femoral shaft fracture in cases with extremely narrow and wider canals. Iatrogenic fracture is the only significant risk when using interlocking nailing in femoral shafts with extremely narrow canals.     

非扩髓闭合交锁髓内钉治疗股骨干骨折

目的　观察与分析闭合非扩髓交锁髓内钉技术治疗股骨干骨折的临床疗效与优点。方法　应用闭合非扩髓交锁髓内钉技术治疗新鲜股骨干骨折 2 83例。 2 83例患者均进行了 1次以上随访 ,随访时间为 3个月～ 4年 (平均随访时间 30个月 )。结果　骨折愈合时间 9～ 15周 ,平均 12周。术后3个月时 ,膝关节伸屈活动已与伤前相仿 ,无一例发生感染 ,无患肢疼痛、肿胀或关节僵硬等并发症。2 4例C型骨折中有 3例患肢短缩 1cm ,2例患肢轻度内翻 ,但成角 <7° ,1例交锁髓内钉在远端交锁螺钉孔处发生断裂。结论　闭合非扩髓交锁髓内钉内固定手术创伤小、保留了骨折处的血肿、不剥离骨折周围软组织、较少破坏骨内膜血供 ,为骨折愈合提供了良好的条件。同时 ,可进行早期功能锻炼 ,从而可防止关节肿胀、僵硬等骨折并发症发生 ,是目前治疗股骨干骨折较为理想的方法     

Fractures of the femur treated by intramedullary nailing using the fluted rod. A report of 193 consecutive cases.

One hundred ninety-three of 196 acute nonpathologic femoral shaft fractures were treated consecutively with intramedullary nailing using the fluted rod. Closed intramedullary nailing was used in 126 fractures, and an open technique was used in 67. This series includes 58 open fractures and 104 comminuted fractures. All fractures treated with the fluted rod united. Complications included three superficial infections (1.5%). Malrotation greater than 20 degrees was noted in six patients (3.1%). Significant shortening (5 cm), which required treatment, occurred in one patient. After initial resuscitation and evaluation, routine treatment included preoperative traction and a first-generation cephalosporin followed by accurate reduction and nailing of the fracture. The results of this series suggest that the fluted rod may be ideal for the treatment of most femoral shaft fractures.     

Open versus closed nailing of femoral fractures in the polytrauma patient

Thirty-four patients with severe multiple injuries underwent either open or closed nailing of 35 femoral fractures. Open nailing was performed in 17 femurs and closed nailing in 18 femurs. The average abbreviated injury score was 27 in both the open group (range: 17-45) and closed group (range: 22-36). Soft tissue injuries were present in eight (47%) cases in the open group compared to three (16%) in the closed group. The treatment protocol was similar in both groups. Intramedullary nailing was delayed an average of 11 days in the closed group. This was significantly different than the open group where the average time to nailing was less than 24 hours (p less than 0.001). Reamed nails were used in all cases except for two in the closed group. The median time to fracture healing was 5.0 months in the open group and 4.1 months in the closed group, with an average follow-up of 18 months in both groups. Two cases required reoperation (one nonunion and one shortening at the fracture site). Both these cases were in the open group. There were no superficial or deep infections in either group. Closed reamed intramedullary nailing is recommended for treatment of diaphyseal femur fractures in patients with severe coexistent injuries. Open nailing should be reserved for cases in which an adequate reduction cannot be achieved by closed methods.     

The use of Ender nails in femoral shaft fractures: what are the remaining indications?

The use of Ender nails for the treatment of femoral shaft fractures has been described as technically easier and less time consuming than current intramedullary nailing techniques. We reviewed our results with unlocked Ender nails in 26 stable and 17 unstable fracture patterns an average of 3-4 years after injury. Because of continued instability, 42% of the stable and 76% of the unstable groups required adjunctive stabilization in the form of skeletal traction, a cast, or an external fixator. Additionally, nail migration and shortening and loss of motion at the knee were seen in 14 fractures in each group. Although two thirds of the patients with stable fracture patterns obtained good or excellent results, no outcome in the unstable group was rated excellent and only 19% were considered good. We therefore recommend that rigid locked intramedullary nails be used in femoral diaphyseal injuries. The use of Ender nails should be limited to stable fracture patterns and locked with screws or wires. They may be particularly useful for fractures in femora with small medullary canals (less than or equal to 8 mm), fractures below noncemented femoral prostheses, and fractures in young children requiring intramedullary stabilization without injuring the physeal plates.     

New problems in old bones: closed nailing of the shaft of the femur

Closed medullary nailing is now established as a routine treatment of fractures of the shaft of the femur. However, the quality of the bone in elderly patients is such that serious technical difficulties may arise during the operation. Three typical cases illustrate the problems that may occur and point the lesson that closed nailing in the elderly ought not to be undertaken by the inexperienced surgeon.     

闭合与切开复位髓内钉治疗股骨中段粉碎骨折疗效比较

目的 比较闭合复位和切开复位交锁髓内钉治疗闭合性股骨中段粉碎性骨折的临床疗效.方法 2001年12月至2012年2月,应用交锁髓内钉治疗闭合性股骨中段粉碎性骨折150 例,其中男114 例,女36 例,年龄18～68 岁,平均35.3 岁.按Winquist-Hansen分类,Ⅰ型35 例,Ⅱ型38 例,Ⅲ型40 例,Ⅳ型37 例.闭合复位76 例（A组）,切开复位自体骨移植74 例（B组）.对两组手术时间、术中出血量、骨折愈合时间、远期疗效等指标进行比较.结果 7 例失访,143 例获得随访,时间为6～21个月,平均9.3个月,术后无切口感染、内固定松动、断裂等并发症,A组中股骨颈骨折1 例,延迟愈合3 例,骨不连1 例,相应治疗后均骨性愈合;B组中延迟愈合2 例,未作特殊处理自行愈合.A组的手术时间、术中出血量均少于B组,差异有统计学意义（P＜0.05）,两组的骨折愈合时间无明显差异,远期疗效按马元璋功能评定标准评定,A组：优39 例,良27 例,可7 例,优良率90.41%;B组：优32 例,良28 例,可10 例,优良率85.71%,经统计两组优良率差异有统计学意义（P＜0.05）.结论 闭合复位交锁髓内钉治疗股骨中段粉碎性骨折,具有手术创伤小、对骨折端及骨块的血运干扰小、不破坏骨折处的血肿、早期进行功能锻炼、远期疗效好等优点,是一种理想的手术方法.但需要掌握手术时机,严格按照程序操作,密切术后随访,定期行影像学检查,及时发现和治疗相关并发症,尽早恢复肢体功能.     

Intramedullary forearm nailing

Nailing of the forearm, beginning with Sch?ne, antedated nailing of the femur and tibia. Its slower development appears due to anatomic problems with the radius, the interdependence of the two bones, and the strong torque loads from the pronators and supinators. Kirschner wires, threaded Steinman pins, Küntscher U nails, and Rush pins were investigated extensively on fracture services before 1954 when a square-shaped nail to improve stability and fracture healing was designed. A broaching point, allowing some bite of the corners into the circumference of a reamed canal, provided better control of torque loads. Closed nailing has many advantages, including early union, low incidence of infection, small scars, less blood loss, and, frequently, relatively short operating time with minimal surgical trauma. Complications and pitfalls during surgery relate mainly to improper nail size and reaming technique. Open fractures led to the highest number of infections, and in highly comminuted fractures nonunion was occasionally seen. In a series of 137 nailed fractures, the nonunion rate was 7%. While the compression plates may give a slightly lower nonunion rate than nailing, the incidence was more than offset by the greater incidence of refractures and disfiguring scars.     

Closed Ender nailing of femoral-shaft fractures.

Closed Ender nailing was used in sixty fractures of the femoral shaft. Follow-up examination in fifty-two cases is reported. There were only two failures of the method, both in fractures with supracondylar extension. Simple transverse and short oblique fractures and those with unicortical comminution were shown to be stable after nailing, while long oblique fractures and lesions with bicortical comminution had a tendency to shorten and often required cerclage wiring, cast-bracing, or traction. The average hospital stay was 23.7 days. The operations were simple and quick. There was one case of osteomyelitis, one of clinically apparent thrombophlebitis, and one of fat-embolism syndrome in a patient with multiple fractures and multisystem injuries. There were no cases of breakage of the nail, delayed union, or non-union. In most cases knee motion returned to the preinjury level, although in five knees removal of the nails was necessary. The two failures of nailing which required plate fixation occurred in fractures extending into the supracondylar region. Therefore, these fractures are not suitable for Ender nailing.     

Biomechanical factors affecting fracture stability and femoral bursting in closed intramedullary nailing of femoral shaft fractures, with illustrative case presentations

Closed intramedullary nailing is an accepted method of treatment for femoral shaft fractures. Technical complications of the procedure include fracture instability, which may result in proximal nail migration, malrotation, delayed union, and occasionally femoral bursting during insertion of the nail, sometimes leading to fracture instability as well as shortening. This study defines the effect of starting hole position, fracture component length, reamed diameter, and nail type on the potential for femoral bursting and fracture instability. The most significant factor in the proximal femoral component was found to be the position of the starting hole. Anterior displacement by greater than 6 mm from the neutral axis of the medullary canal consistently caused high hoop stresses at the level of the fracture, which resulted in bursting of the proximal femoral component by lifting off the anterior cortex. Hoop stresses at the level of the fracture were less sensitive to lateral or medial placement of the starting hole. Distally, fracture stability was governed by femoral component length and reamed diameter. In the proximal and distal components, fracture stability and the potential for bursting were influenced by the particular nail used. This was due to significant differences in mechanical geometric properties between nails of different manufacturers. Case reports are presented to illustrate these biomechanical principles as they apply to clinical situations.     

旋入式自锁髓内钉的研制及临床研究

目的　为临床治疗长骨干骨折提供快捷、有效的治疗方法。设计一种组合式髓内钉———旋入式自锁髓内钉 (旋入钉 ) ,方法　旋入钉是以旋转进钉、髓内填充式纵向交锁为设计特点的髓内固定系统 ,其结构由主钉和锁针组成 ,1994年 6月至2 0 0 0年 6月已应用该钉治疗长骨干骨折共 98例、 10 4侧骨折。采用闭合复位固定 36例 ,占 36 % ;6个月以上随访 6 4例。结果　骨折全部愈合 ,平均愈合时间 16周 ,半年内骨折愈合率 95 % ,畸形愈合 2 % ,感染 2 % ,功能恢复优良率 94 6 % ,无继发骨折短缩分离和金属断裂发生。结论　旋入钉具备轴向加压、抗短缩、抗分离和抗扭转的功能 ,其结构简单 ,手术操作简便、创伤小 ,疗效可靠 ,具有广泛的适应证及临床应用前景 ,尤其是手术可以不需X线设备