Open intramedullary nailing in neglected femoral diaphyseal fractures

Introduction

Neglected femoral diaphyseal fractures are not uncommon in developing nations however there is a paucity of literature in this regard. Due to lack of effective traction, reduction or immobilisation these fractures are invariably associated with shortening and adjacent joint stiffness, presenting a challenging problem to the treating surgeon. The socioeconomic constraints in our society which result in patients seeking non-medical forms of treatment in the first place also warrant the need for an economically viable, simple effective form of treatment which can be carried out in a less advanced setup, gives reliable outcomes and allows early return to work.

Methods

Eleven patients with neglected or late presenting femoral diaphyseal fractures were considered for the study. All patients underwent open intramedullary nailing, bone grafting and manipulation of the knee under anaesthesia. Iliac crest graft was harvested when local callus did not suffice. All patients received a supervised regimen of physiotherapy. Patients were followed up clinically and with plain radiographs at 6 weeks and 3 months to assess union and at monthly intervals thereafter.

Results

The mean patient age was 28.8 years (15-48). The mean delay in presentation was 14 weeks (3-32 weeks). The mean shortening was 3.8 cm with four fractures showing signs of malunion. Five patients were given preoperative traction and bone resection was performed in only one patient. The mean hospital stay was 11 days (5-25 days). One patient was lost to follow up, of the remaining 10 patients all united at a mean of 11.9 weeks with 7 patients regaining full range of motion. The mean knee range of motion was 142.5°. There were no wound related or neurological complications. One patient had a patellar tendon rupture which was repaired and another required dynamisation and bone marrow injection for delayed union.

Conclusion

We conclude that the treatment of neglected femoral diaphyseal fractures with open intramedullary nailing and bone grafting followed by manipulation of the knee with preoperative traction in selected cases is a satisfactory method of treatment showing reliable bony union however knee mobilisation should be undertaken with caution.