under the age of thirty years and thirty-four had multiple injuries. Sixty-nine fractures were nailed ... War ii German surgeons used the technique on a large scale and the results, particularly with femoral ..... in eighty-nine patients pro- ceeded.
CLOSED
KUNTSCHER
NAILING A
SERIES
OF
A.
From
One
the
hundred
patients vehicle
Department
and two fractures
were internally accidents; ten
Complications
during
and 77 per cent
ofthose
infections. The detail, range early
in
results
100
ROTHWELL,
of
Orthopaedic
ofthe
injuries. were nailed and
after
are discussed
C.
femoral
shaft,
returned
to work
it is concluded
1 940
KUntscher first described nail for fixation of fractures (K#{252}ntscher 1940). He used a closed fluoroscopic control. During World surgeons
used
the
technique
on
particularly with femoral shaft impressive that the method rapidly throughout the world (Watson-Jones
with
open
method
used
(Watson-Jones The
with
site
technical
for
and
the
four
fractures,
technique
left hospital
months.
scale
and
There
in 100
equipment
careful
the
to five
age
range
was
were
under
patients twenty-nine
from
age
weeks or bone
attention
to
include the wide to the knee, the
follow-up
period
ranges
years. MATERIAL
thirteen
the
four
no wound
and
fractures;
months
is described.
within
were
CLINICAL The
the
fractures, were so gained popularity et al. 1950; Bick
nine
to ninety-two of
thirty;
years.
but
seventy-one
seventy-five
were
male
and
female.
Sixty-eight fourteen
fractures
from
the
resulted
other
from
trauma
surgeons
and
in the paper
A. G. Rothwell. C. B. Fitzpatrick,
nailing
1972;
have
presents
F.R.A.C.S.. F.R.C.S.(Ed.),
the not
and
motor
vehicle
eighteen
accidents.
were
classified
as
is practised
it was
rapidly
the
treatment
two-quarters the
Senior
first
Lecturer F.R.A.C.S.
patients
Fracture
of tibia
9
Fracture
Fracture
of pelvis
8
Dislocation
of hip
1
7
Dislocation
of shoulder
1
7
Rupture
6
Brachial plexus (permanent)
knee
of forearm head
Fracture maxilla
injury
of mandible
around
the
ankle
2
of urethra
1 lesion 1
or 4
Abdominal
widely
injury
Crushed
chest
1
3
*Requiring
postponement
pathological
fractures.
osteoporosis.
five
of operation
by
at least
24 hours
relatively
nailing
accepted of
in thirty-five
potential
in
K#{252}ntscher
injuries
be image
been
closed
is now
middle
x-ray
Associated
Fracture/soft tissue injury around the
and a fracture table with access to the has eliminated the originally associated
Nevertheless,
technique
in June
mobile
dangers
Dunedin
should
I.
the
intensifier,
and
fracture,
Table
*Closed
monitor, traction
image
closed
in
introduced
This
the operative
shaft
from
Fractures
technique.
recognised
fractures
pathological
patients
the correct
1950).
of
difficulties of
504
ci a!.
closed
centres.
of the
a television efficient
advantages
the
exposure
development
intensifier with that combines
few
and
femoral
the high incidence of reported complications, such as failure to reduce the fracture, jamming of the nail, splitting of the distal fragment and damage to arteries and nerves, as well as high radiation exposure, prompted leading surgeons in Britain and America to declare that closed nailing was dangerous and that, when intramedullary nailing was indicated, the
the
Dunedin
1950
By
with
eighteen
Fifty-eight
that,
Otago,
Sixty-eight fractures resulted from motor were under the age of thirty years and
in less than
the use of the of long bones technique with War ii German
a large
results,
fracture
including
of
closed nailing is a straightforward procedure with few complications. Advantages offractures that can be nailed, the short hospitalisation, the rapid return offunction return to work and the absence of infection.
clover-leaf
1968).
University
on the day of the accident few.
FRACTURES
FITZPATRICK
K#{252}ntscher nailing. Seventy-five patients
were
and
B.
SHAFT
PATiENTS
Surgery,
operations
working
FEMORAL
CONSECUTIVE
G.
fixed by closed were compound.
thirty-four had multiple Sixty-nine fractures
OF
choice
was
by all
carcinoma.
for
in Orthopaedic
Thirty-five
injuries;
of the femoral shaft. 100 patients with 102
I). The for
Surgery j
The with
fractures presence
early
Department Dunedin.
pathological Paget’s
patients
of the of other
tibia.
group
disease had
fifty-one
pelvis
injuries
and
and was
patella
regarded
included three
ten with
significant predominated as a strong
with
senile
metastatic associated (Table indication
nailing.
New
of Orthopaedic Zealand.
THE
Surgery.
JOURNAL
OF
University
BONE
of Otago.
AND
JOINT
SURGERY
CLOSED Table
II.
Type
and
site
KUNTSCHER
NAILING
OF
of fracture
FEMORAL shaft
SHAFT
is reamed
using
In fractures into
Site
Type
the
across Transverse
53
Middle
third
78
17
Oblique Spiral
Proximal
9
12
third
23
Comminuted
Compound
Distal
10
fragment.
fracture; tt?
threaded
over lever
the for
across
the
nail,
which
must
site.
The
traction
type
of
fracture
and
proximal
limit
for nailing
one-quarter junction
with the distal three-quarters of the proximal three-quarters
was
its
site
are
accepted
shown
as the
in
Table
junction
11. The
of the
proximal
and the distal limit, with the distal one-quarter.
the
It was
decided
fracture
was
within
fourteen Blood
fit
to
enough,
at
very
on the
day
early
nailing.
of injury,
in
and
sixty-nine
all except
cases
one
were
of the
Multiple
nails
Operative
the
nailed
series
there
are
the Image
before
operation
is
Intensifier
are
operation
begun.
A
used
and,
when
Marquet
(Fig.
the patient
table
I ). The
and
patient
is
Philips
is positioned
had nails
where by
not
was
used
a spike
the
cutting solid
head
After
extension to a right
angle
the
regime and
58
89
of the
there
was who
fracture,
than
one
developed
millimetre
nail
manipulation
bent under
all in senile
is placed
on his side on a Marquet
the
with
the
fitting
boot
is kept
fractured
in the
rotation, system
way
A
is
reduced planes.
incising
the
short
incision splitting
femoral
60-B,
neck.
No.
the
traction,
in two
trochanter,
on
that is parallel to the floor. has complete access to the
flexed
gauge
around
The
cases
and
a closely leg
positioning
direct
is
manipulation,
checked
to be able
post
uninjured
Correct
position
It is essential
centre through
windlass.
support.
in some
the
the
is applied
and
special
on
to reduce
the
image
the
fracture
the
greater
skin. is the The
made
glutei femoral
4. NOVEMBER
proximal to expose neck
1978
patients
to the is then
the
tip
pyriform broached.
of fossa
The
at the
base
proximal
had
was
split
while
s splint
after
in thirteen
support. diagnosis
by finding three
suprapubic
Four
developed drainage,
nerve.
In one was
three
of a Po2
completely.
emboli,
were
weeks, by which
or an ipsilateral
all recovered
There
fractures.
union.
supported
it
four weeks.
eight
a clinical
operation;
six
weeks,
additional
ulnar
than
by to
fractures
no
hospital.
in less
of bony
requiring
taking
from
six
and
his knee
and
to twelve
was
was
were
flexion bend
pathological
at
patientt
and
active
hospital
with
for
of the
and
patient
a 9
straightened deaths
by
in hospital
osteoporosis.
clinically
to the femoral fracture than 2.5 centimetres.
detectable
but in only Five patients
two had marked (40 degrees) although when walking; both
deformities,
rotation apparent
Traction
and and
Twelve
with the T-piece
leg is flexed 90 degrees through the foot stirrup.
site.
side
perineum. to a strain
of the
fracture
before
VOL.
the
By applying
intensifier
of the
on
connected
out
critical. the
hip T-piece
table,
fractured applied
fracture
with
this
RESULTS
the perineum. The hip ofthe the centre post and traction
The foot itself is placed in neutral The mobile image intensification
used
palsy
with
in the which
exercises
home
femoral
retention
Fig. through around
those
evidence
anaesthesia.
patients
be
crutches
allowed
made
soon
may
could
from
pulmonary
urinary
shaft;
discharged
were
of mercury;
a transient
in the
reamers
the
more
then
In eight
non-fatal
be was
Early
a Thomas’
patient
by ten
was
55 millimetres had
pneumonia,
The patient
were
comminuted
was
to
using
was
radiological
either
syndrome
patients
the
was
cast-bracing
fat embolism
splint,
discharged
complications.
Postoperative
the Once
weight-bearing
usually had
ends.
fragment
of patients
patients
to full
not
incision
hand
operation
He
were
weight-bearing
progressing
one
cent
9-15).
reduction;
bone
brazed
to walk
leg.
cent
remaining
Partial
allowed
per
per
average
could
which static quadriceps
begun.
injured
the (range
once.
from
were
second
the
distal
After
he was
through
of less
under
in relation
reamers.
occurred
release
exercises
fracture
prevented
was
the
this
the
unsatisfactory
single-piece
reduction
bone,
a small
of bone
with
to ten days during
tibial
nail
patients.
between
management.
time
fracture
home
ofthe
a guide
K#{252}ntscher the
1 1 millimetres
patients
interposed
used for seven
patients
the
hammered
cortical
only
through
problems
nail;
encouraged.
to ream
in two
Postoperative
Most
of the
across
positioning
is
provides
passage
in position
nail
A nail
this
is advanced
correct
In four
using
the
this
fragments.
the
wire
advanced
an unscrubbed
fragment;
the
we
cases
faulty
advancing
weeks
guide
decided
was
were
overcome
On
facilitates
and
needed
two
fractured
weight
and
reduction
muscle
With checked
and for
the
bone.
be advanced
introduced
align
length,
to ensure
open
In two
and
the
by cortical
must
be necessary
proximal
is released
were
and
other
is then
the
correct
complications.
reduced
days.
gases
Portable
aim
nailed
thigh
With
be the
we
diameter
necessary.
METHOD
it may
into
limited
joint.
Because The
wire
stage the
fracture.
until
the reamer
A guide
guide
control
knee
reamers
one-third,
manipulation
wire
to the
hand
at this
manipulate
radiographic
12
third
distal
assistant useful
solid
of the proximal
the
505
FRACTURES
shortening
due
one was this greater had minor rotational deformity of lateral in neither was this these patients had
multiple injuries which prevented the use of traction after operation. Only five patients lacked full flexion of the knee at follow-up; the restriction ranged from 10 to 40 degrees. in all five there Ninety-one ceeded within but
had been fractures
uneventfully six months. their
fractures
associated injuries in eighty-nine
to clinical and in three patients were
united
ofthe patients
radiological union was by
one
knee. prounion delayed,
year.
Two
506
A.
fractures
required
bone
grafting
for
G.
ROTHWELL,
non-union
at
C.
one
and eighteen months respectively; one was in a leg flail from poliomyelitis, the other in a patient with multiple fractures, including a severe head injury. Six year
patients
with
pathological
fractures
died
before
union
B.
FITZPATRICK
immobilisation
(Nichols
1963;
Low
risk ofinfection. advantages of closed
for open nailing (B#{246}hler 1951; O’Brien infection
1969).
range 1963;
strom
and
late,
Rush
1970;
superficial or deep. Antibiotics were not routinely either during or after operation. Fifty-five of the K#{252}ntscher nails have so far
used
rates for closed nailing range from and Giebink 1967; B#{246}hler1968;
been
et a!. 1 97 1 ; Rascher et al. 1 972 ; Gherlinzoni et a!. 1975; Kwan and Ma 1975; Winquist et a!. 1977). Prolonged morbidity, long hospitalisation, multiple operations and often an unsatisfactory final outcome which may include
established. There were
removed,
no
because
minor
varies
with
Sixty-four
of the
accident; of these three months and two
had returned in addition were five further
of
infection,
early
the upper end of the The policy of removing the individual surgeon.
symptoms.
nails
cases
patients
43 per 77 per
were
cent cent
nail was causing asymptomatic
working
before
the
had returned to work by by four months. All but
to work by six months. to the three deaths in hospital there deaths during the follow-up period. All
were in the pathological unrelated to the operation.
group
and
the
deaths
Miller,
amputation, in
(Dencker 1974).
Any
technique
The
0 to 3 per cent (Gross Cloke 1970; Clawson
all too
frequently
osteomyelitis
Corban
Miller, which
1970;
1974).
secondary
and
1971;
Couk
Richard
of events with
Wickstrom
Kostuik
and
and
sequence
patients
1965:
1968;
Carpenter
Kovacs
is the
described
land
1967;
from 1 to 1 1 per cent Dencker 1965; Wick-
or
was
Corban
ci a!.
Rokkanen
This is one of the most important nailing. Reported rates of deep
1967;
Kovacs minimises
MacAus-
and the
Richard risk of
were
DISCUSSION As
shown
in several
other
series
1967; B#{246}hler1968; Clawson, Rascher et a!. 1 972 ; Gherlinzoni, 1975; Kwan and Ma 1975; Clawson 1 977) intramedullary fractures
may
conventional
open and
have methods
(Gross
1967;
(K#{252}ntscher
al. 1 97 1 ; Rascher et a!. I 972; must be emphasised that essential and careful attention patient closed Short hospital,
as a safe and pitfalls B#{246}hler 1968;
1967;
Rascher supported
Rokkanen,
procedure are well Clawsonet
Gherlinzoni et a!. 1 975). It the correct equipment is to the positioning of the
on the table is mandatory. nailing are as follows: hospital stay. The short which is a feature of other
Giebink
Giebink
distinct advantages over more of conservative treatment or over
nailing. It is now established the technical requirements
documented
and
Smith and Hansen 1971; Vasciaves and Murena Winquist, Hansen and nailing of femoral shaft
The period reports
Sl#{228}tisand
et a!. 1972; Gherlinzoni in the present series.
advantages
of
of time in (Gross and
Vankka
1969;
et a!. 1975) is further The rapid turnover has
made a big difference to the availability as well as having clear economic and
of hospital social benefits
beds for
the patients. Rapid recovery ofknee function. Flexion of the knee to a right angle was required before the patient was allowed up on crutches. The fact that 58 per cent of patients had been discharged within four weeks shows how quickly this with
range was associated
bone
Rascher when
attained. Only five patients, of the joint, failed to regain
Similar
movement.
nailing,
usually injuries
because
(Nichols the
results of
muscle
1963;
et al. 1 972), knee may
are
less
likely
after
all full
and adherence to et a!. 1969; Rush 1970;
scarring
Rokkanen or after become
conservative stiff from
treatment prolonged
Fig.
Fig. 3
Fig. 2
open
4
Figure 2-A thirty-six-year-old fireman sustained this grossly comminuted fracture ofthe left femur in a fall from a ladder. Figures 3 and 4-The appearance one year later. The fracture is soundly united with I centimetre of residual shortening. A cast brace was worn for four
months
following
nailing;
resuming
THE
the
full
patient
duties
JOURNAL
then
at five
OF
BONE
returned
to light
duties.
months.
AND
JOINT
SURGERY
CLOSED
KONTSCHER
NAILING
OF
FEMORAL
SHAFT
507
FRACTURES
Greater stability of the fracture, rapid to the knee and early mobilisation contributing factors. Comparison In several reporting Early
with other closed nailing series respects this series differs from closed nailing.
nailing.
series
return of function are undoubtedly
The
was
to
whenever
nail
policy the
this
possible;
fractures. patients;
We other
Guindy
(1961),
reported fixation
that than
achieved surgeons, Lam
established
fracture
on
applied this
(1964)
very the even
objective including and
others
early
in this
day of injury to compound in sixty-nine Charnley and
Smith
(1964),
union was slower with immediate if it was done a few days later.
have
internal But in our
series, with early fixation, there were only two cases of non-union and three of delayed union. Rush ( 1 970) also found that delaying internal fixation did not significantly improve the rate of fracture union; moreover delay was associated
reported Miller
that Fig. 5
Fig. 6
infection
but close
retains
Stabilisation widely
of
best
that
1951
et al.
variety
open
of
fractures.
advantage easy,
so that
of early skeletal
nailing traction
(B#{246}hler
1965;
Wickstrom
and
Corban
However,
this
present
and
fractures
are
nailing
1969).
fractures,
is
short
of comminution
K#{252}ntscher
others) show that adequate fixation achieved in a much wider variety of fractures, comminuted fractures, long spiral or oblique
1967; series
can be including fractures.
involving
the
proxi-
distal one-thirds of the shaft (Figs. 2 to 9). We that this is possible with the closed method the
because
femur
it or
( and
mal and believe
One
fixation
transverse
a minimum
to
; KUntscher
segmental
is usually
freezing plant sustained a heavy drum fell on to and lateral radiographic soundly united with no at twelve weeks.
of internal
mid-shaft
with
suited
Rokkanen
advantages
a greater
fractures
those
et a!. (1974). reduction
of infection, a finding Corban (1967) and by
scrutiny.
accepted
oblique
the
a higher incidence by Wickstrom and
Fig. 7
Figure 5-A twenty-one-year-old worker in a this transverse fracture of the distal shaft when his leg. Figures 6 and 7-The anteroposterior appearance one year later showing the fracture residual shortening. He returned to work
deserves
with
also
musculoperiosteal
is left
sheath
undisturbed
and
can
surrounding act
as an
“
the external
splint”.
Other more under
advantages. The surgical incision required is no than 10 centimetres long and is easily hidden, even a bikini. The absence of a scar, often an ugly one,
is greatly
appreciated
by
younger
patients,
particularly
women.
Open
nailing
work after Rokkanen
fractures et al.
still further; et a!. 1969; VOL.
60-B,
dramatically 1
of the femoral shaft 969). Closed nailing
this is borne Gherlinzoni No.
decreased
4. NOVEMBER
time
from
(Nichols 1963; can decrease it
out by other series et a!. 1975) as well 1978
lost
(Rokkanen as our
own.
Fig. 8 Fig. 9 Figure 8-An eighty-five-year-old man with severe osteoarthntis of both hips fell and sustained this long spiral fracture of the proximal shaft. Figure 9-Five months later the fracture is soundly united with 2.5 centimetres of shortening. He began taking weight one week after the accident and is still walking with elbow crutches three and a half years later.
is or
508
A.
distraction 1 97
1
then
)
devices need
not
skeletal
fragments contributed hospital
used.
traction was
1965;
(K#{252}ntscher be
If nailing
with
slight
employed.
This
significantly
to
G.
ROTHWELL,
Clawson
had
to
be
of
shortening
of early
the
B.
FITZPATRICK
it deferred
ci a!. deferred,
overdistraction policy
C.
is commonly until the
diminishes
the
(Dencker
Giebink
nailing length
1967;
1968;
of
those
careful sound
delay.
the
was
to determine
used
medullary
narrow
canal. the
segment
and
and
of appropriate
internal
fixation.
Hence
nail.
Unlike
Clawson a!.
et a!.
1975;
necessary 17
1 97
to ream
fixation
is offset
particularly
This and
of the
view
distal
be
and
used
nail
Ma
same
used
of
972;
Gherlinzoni
not
ci’
believe
it is of 1 4 to
of
more
of causing
segment
rigid
a fracture, ci a!.
(Rascher
1972).
Cloke
Furthermore,
additional
1967;
to a diameter
risk
for
diameter
do
up
(1975).
canal
of the
by B#{246}hler(1968),
as
reaming
then
advantage
higher
is supported
by Kwan
can
bone
possible
by the
1
we
the are
(K#{252}ntscher
1977)
cortical the
that
plus
series
average
et a!.
1 ; Rascher
believe
medullary
was
small
of with
operation
of the
surgeons
et al.
millimetres;
after
length
other
Winquist
we
a K#{252}ntscher the
1972;
patient
in this
width
a!.
ci
of the gases
and
B#{246}hler
cent incidence favourably
Furthermore
diameter the
Rascher
of blood measures.
Gross
1967;
8 per compares
resuscitation
Reaming
1965;
the
advocate
should be syndrome
Corban
1971;
intensive
monitoring prophylactic
in its
and
a!. 1975) but cases in this series
initial
operation embolism
K#{252}ntscher
ci’
that
the
1965;
Wickstrom ci a!.
Clawson
Gherlinzoni non-fatal
stay.
stated that risk of fat
(1970)
a cast
support
with
brace
unstable
fractures.
Pathological
fractures.
fractures and
were early
are
(K#{252}ntscher the
of
correction
of
was
relieved
per
cent)
the
bowing
was
10 and
during
the
easier
Paget’s
internal
to note
disease,
follow-up
that
in
significant and
The
of the nursing
after
achieved
1 1).
cent
patients
it is interesting
with
(Figs.
I 8 per
such
much
1 967).
patients
series
With
mobilisation
fixation two
in this
pathological.
high
bone
pain
mortality
period
is
(44
probably
inevitable.
CONCLUSiON
With
modern
and to details
become
We
The authors co-operation Photographic
wish to thank Professor in this project and for and Arts Departments.
show
believe
that
other
surgeons included
the
of
of
K#{252}ntscher nailing
results
nailing
of this
has the
of
also
Department, acknowledge
Orthopaedics
Related
Researh.
ofBone
and
other
series over
deserves
of
femoral
of the Orthopaedic in the series. We
scrupulous are few.
therefore
method
the
has
advantages
and
as
fractures
and
distinct
treatment
consideration
treatment
A. J. Alldred and the other allowing their patients to be University of Otago.
that
closed
methods
serious
closed
easier than formerly. With of technique, complications
safer
attention Figure 10-A seventy-eight-year-old retired medical practitioner with painful Pagets disease fell and sustained this midshaft transverse fracture of the right femur. Figure 1 1-Eighteen months later the fracture is soundly united. The bowing is corrected and his bone pain has disappeared.
equipment
choice
for
shaft.
Dunedin the help
Hospital. of the
staff
for
their of the
33-A,
670-678.
REFERENCES Bick,
E.
M.
( I 968)
Editorial
comment
B#{243}hler,J. (1 95 1) Results
in medullary
B#{243}hler, J. (1968)
intramedullary
Carpenter, 52-A,
E. B., 815-816.
Closed and
Couk,
D.
on
article
nailing nailing E.
( I 970)
by
G.
of ninety-five of the Complications
KUntscher. fresh femur.
Clinical fractures
Clinical of
of the
femur.
Orthopaedics
intramedullary
and Journal and
nailing
Related of
the
THE
Research. femur.
JOURNAL
1 2.
60,
Joint 60,
Journal
OF
Surgery, 5 1-67. of
BONE
Bone
AND
and
Joint
JOINT
Surgery,
SURGERY
CLOSED Charnley, 43-B,
J. , and Guindy, 664-671.
Clawson, 53-A,
D.
J.
Cloke,
K. , Smith, 68 1-692.
H.
(1970)
H.
Kostuik,
F.
Closed
P.,
and
fractures
130,
and
Giebink,
of the 173-184.
G.
Die
and
Related
Orthopaedics
shaft
Closed
Marknagelung
nailing
femoral
K#{252}ntscher, G. ( I 965) Intramedullary surgical 47-A, 809-8 18. KUntscher, G. ( 1 967) Practice of Intramedullary Kwan,
P. XII
V., and (1), 43-57.
Ma,
( 1 975)
F.
Closed
technique
place
Springfield.
nailing
nailing
Joint
in
52-B,
59 1-598. 53-B,
of
of the
J.
P.
Rascher, Surgery. Rokkanen,
P. J. J.,
Smith,
J. New
Nahigian, S. H., 54-A, 534-544.
, Sl#{225}tis,P.,
P.
treated
Rush,
( I 963) Rehabilitation ( 1 963) Fractured femoral
R.
J.
cases.
( 1 970) Zealand
and
Journal
after
Macys,
Vankka, ofBone
fractures
( 1 969)
E. and
Joint
Closed
The
results
of early
and
of femoral
Watson.Jones, Saal, 32-B, Wickstrom, Journal
R., Bonnin, J. G., King, T., Palmer, I., F., Trevor, D., and Le Vay, A. D. (1950) 694-729. J. , and Corban, M. S. ( 1 967) intramedullary ofTrauna. 7, 551-581.
Winquist,
R.
VOL.
60-B,
A.,
No.
Hansen,
4. NOVEMBER
S. T.,
and
1978
Clawson,
J.
51-B,
delayed
D. K. (1977)
shaft
and
or open
Surgery,
The KUntscher rod in the treatment Journal oJ Surgery, 4.0, 44- 52.
J. E. M. ( 1 964) 46-B, 28-31.
of the
shafts. Australian J. R., and Brown,
internal
of the
surgery.
shaft
fractures:
of
fixation
Smith, H., Medullary
of fractures
for fractures
of the
Closed
intramedullary
of the
shaft
J.,
0.
after femoral
femoral
Bone
shaft
question
Vaughan.Jackson, nailing of fractures
fixation
of
West
and
of Surgery, 33, of femoral-shaft
of femoral The
Joint
Surgery.
1 .003
shaft.
443-455.
of
Journal
Journal
Journal
nailing
Surgery,
cases.
Italian
Ada
Journal
of
Translated Bone
in
and
Joint
Clinical Surgery.
C. Thomas.
New Zealand Journal E. ( 1 972) Closed nailing
medullary 3 13-323.
Joint
I 57.
200,
Chirurgie.
fractures.
femur.
and
in
femoral
Pacific
S. J. ( 1 964) The place of delayed internal fixation in the treatment of fractures of the long bones. Journal 46-B, 393-397. MacAusland, W. R., Jun. ( 1 968) Treatment of sepsis after intramedullary nailing of fractures of the femur. Clinical Research, 60, 87-94. Miller, J. , Kovacs, A. , and Richard, L. ( 1 974) Infection complicating intramedullary nailing of the fractured femur. Surgery, 56-B, 205-206. Nichols,
and
Bone
of treatment
Lam,
O’Brien,
Bone
774-775.
methods
7,
of
Journal
femur.
Surgery,
Charles
shaft
Journal
in fractures
orthopaedic
Illinois:
of femoral
bones.
Surgery,
f#{252}rklinische
Archiv
its
of the
Trauma,
and
long
of various
and of
Bone
of
Joint
results
Journal of
and
Nailing.
intramedullary
fractures
and
of the
509
FRACTURES
nailing
reaming
femur.
Journal
von Knochenbr#{252}chen. ( I 968) 60, 5-12.
Research
of
ofBone
study
of the
SHAFT
intramedullary
reduction.
shaft.
FEMORAL
reduction
Journal
P. F. ( 1 975) 1, 1 1 7- 1 3 1. Blind
open
fractures. A comparative
of the
OF
1 ) Closed
femur
R. R. (1967)
(1940)
in the
( 1 97
S. T.
of femoral
fractures
NAILING
operation
Hansen,
Vasciaves, F., Murena, and Traumatologv,
J. (1 97 1) infected
K#{252}ntscher,
,
1 ) Delayed
nailing
Shaft Scandinavica,
Gherlinzoni, G., Orthopaedics Gross,
R.
( I 965)
Dencker, H. (hirurgica
( I 96
A.
KUNTSCHER
Joint
delayed
of the
femur.
Journal
nailing.JournalofBone
Joint
Orthopaedics Journal 45-B,
Bone
H.
of
of complications andJoint
Bone
with
and
Joint
and
Joint
conservatively Australia,,
and
J.,
Related
96-102.
operation.
Bone
Surgery,
and of
oJBone
Adams, J. C., Burrows, fifty years. Journal of
Association,
and
A comparison
versus
A study
Bone
Journal
of early
shaft.
of
Surgery,
91-102. fractures.
fractures?
Orthopaedic
Joint
Nicoll, and
Joint
in 298 Surgery.
and
Surgery.
E. A., Vom Surgery. operations. 59-B.
I 26.