closed kuntscher nailing of femoral shaft fractures - Bone & Joint

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.

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