appropriately according to its destination in either the medial or lateral femoral condyle. The first nail is then inserted and passed down the medullary canal.
FEMORAL ENDER
NAILS
JOHAN
WALTERS,
SHAFF
FRACTURES
USING
A TROCHANTERIC
WILLIAM
From
Groote
SHEPHERD-WILSON,
Schuur
Hospital
use of intramedullary
as the
ideal
fractures.
form It was
nails
of internal not
until
is now fixation
the
last
widely
decade
1971
; Rascher
and
Ender
et al 1972; Clawson 1984).
and
use of multiple chanteric and
Rothwell
Simon-Weidner flexible nails subtrochanteric
for
nailing was popularity of and Hansen
1982;
(1970)
the
Winquist,
first reported
the
the fixation of intertrofractures by a medial
supracondylar approach. This was later extended to femoral shaft fractures by the same approach (Eriksson and Hovelius 1979; Pankovich, Goldflies and Pearson 1979; Muckle and Siddiqi 1982). We encountered a high incidence of postoperative knee problems, so we developed
a trochanteric
approach.
Our
method
can
be used
for a wide range of fractures of the femoral shaft, including simple, comminuted or segmental injuries extending from the subtrochanteric to the supracondylar regions (Fig. 1). The method is comparatively easy and quick and requires little specialised instrumentation.
PATIENTS, From June 106 femoral
MATERIALS
1984 to December shaft fractures
AND
METHODS
with
FCS(O)(SA),
W. Shepherd-Wilson,
Senior FRCS,
Consultant/Lecturer Associate
Professor
and
Head
of Trauma
Service 1. Lyons,
FRCS, Registrar R. Close, MB, ChB, Senior Registrar UniversityofCapeTown, DepartmentofOrthopaedicSurgery, School, Observatory 7925, Cape Town, Republic Correspondence
© 1989 British
should
be sent
to Dr J. Walters.
Editorial Society of Bone and Joint 0301-620X/90/l 196 $2.00 J Bone Joint Surg [Br] 1990; 72-B : 14-8.
14
Medical
Surgery
Africa.
nails
On
heavy
skeletal
traction
performed
on
was
patients
as soon
femoral
shaft
below
the
Groote
the
Schuur
patient
the
next
Hospital,
was
(9 kg) in a Thomas’
placed
splint.
available
in
Surgery
operating
list
was fit for anaesthesia. for operation were unacceptable and the desire to rehabilitate the
as possible. fractures
tip
at
admission
provided the patient The indications fracture alignment,
of the
We
treated greater
recorded
in this
details
way
trochanter
of all
from
75 mm
to 45 mm
above
the intercondylar notch as measured from the most proximal or distal extent of the fracture. The surgery was performed by seven specialists and 13 registrars with varying
surgical
expertise.
affication
of fractures.
A classification
based
on that
described by Pankovich et al (1979) and Tencer et al (1984) was adopted in order to rationalise the postoperative management Type A : Bicortical
(Fig. 2). contact.
oblique
with
fractures
Simple
bicortical
transverse
contact
tamed longitudinal and lateral stability. Type B : Unicortical contact. Fractures fragment and/or unicortical comminution longitudinal but not lateral stability. C: No cortical
fractures, nal or lateral
with
or
which with
short
main-
a butterfly maintaining
Comminuted or long oblique contact and thus no longitudi-
stability.
technique.
patient is placed in a ‘wind-swept’
maximally view ofthe
contact.
no cortical
fractured limb raised maximally ofSouth
CLOSE
Town
Ender
Town.
Operative J. Walters,
ofCape
Cape
Type
1986, 100 patients with were treated by internal
ROGER
fixation of femoral shaft fractures by a closed of 100 patients with 106 fractures, of which 88 was primary union in 85 fractures (96.6%) and in eight (9%). We discuss the principles of
fixation
shaft
or so that
benefit of closed prograde intramedullary acknowledged, adding fresh impetus to the this technique (B#{246}hler1968 ; Clawson, Smith Hansen
accepted
of femoral
LYONS,
the University
and
BY
APPROACH
TIMOTHY
We describe the use of Ender nails for the internal technique via the greater trochanter and report the treatment were reviewed 12 months or more after operation. There significant angulation, rotation or leg length discrepancy management which we have evolved. The
TREATED
Under
general
anaesthesia,
supine on an orthopaedic position, making the prominent. and the
The foot contralateral
traction trochanter
the tble of the
of the same side leg is depressed
is
(Fig. 3) to facilitate the lateral fluoroscopic proximal femur. The traction is applied either
through the existing skeletal via the boot of the orthopaedic The fracture is reduced THE
JOURNAL
traction pin and stirrup table. under image intensification. OF BONE
AND
JOINT
SURGERY
or
FEMORAL
SHAFT
FRACTURES
TREATED
BY ENDER
A simple transverse fracture (a) and a segmental and internal fixation by prograde Ender nails.
TYPE Bicortical
A Contact
TYPE Unicortical
HH Classification
B Contact
TYPE NoCortical
fracture
C Contact
NAILS
USING
(b) ofthe
femoral
If closed open
reduction
enlarged
correct
the
reduction
the
distal
dial
aspect
facilitate
VOL. 72-B, No.
lateral
position
1, JANUARY
of the
of
1990
limb depressed
to
of the
image cortex
intensifier perforation
short
and
of
nail
passed
the
fracture.
to be insinuated in the
condyle.
posterome-
The
is directed
into
next the
nail
lateral
to distraction
at the
introduced
depends
nails
medullary
for
canal
but
adequate
fracture
more
fixation.
site.
upon than
The
the
four
use
are
of
during introduction is imperative or penetration at the fracture site
the as can
be missed.
wound
is
Antibiotics At
completion
flexed through Postoperative ment
the
or lateral
inserted
the
a bone
appropriately
the medial
is then
femoral and
with
by using
bent
its tip ending
tendency
necessary
inserted.
fracture.
is
to just
medial
1 cm
condyle and subsequent nails are inserted into medial and lateral condyles. After the of the first nail, the traction is released to the
The
with the uninjured
fluoroscopy
nail
allows
introduced
rarely
only.
end
canal
then
of the
by
is exposed. near its tip
is selected
in either
fragment,
number
easily
its first
medullary
into
capacity
The ‘wind-swept’
The
Manual
The
ofnail
to its destination
minimise
3
and
condyle.
2 cm
to about
length
intensifier
femoral alternately introduction
Fig.
is not possible an additional limited is performed. Through an 8 to 10 cm
The
is similarly
K:Ic:EE2a
reduction
hole
the
down fractures.
by closed
and
femoral
shaft
treated
15
approach, the trochanteric bursa is used to broach the trochanter
according
of femoral
APPROACH
direct lateral An AO awl
image
2
shaft
reduction
nibbler.
Fig.
A TROCHANTERIC
washed are of the
out reserved operation,
and for
a suction ‘high the
knee
as full a range as possible. management. The postoperative
is determined
by the fracture
configuration.
drain
risk’
cases
is gently
manage-
J. WALTERS,
16
Type
A
The
fractured
pillow
(Fig.
4),
and
aiming
at
active
.
rubber immediately, knee
flexion
partial
limb
is elevated,
free,
leg
straight as possible.
is
on
a foam
is
started
physiotherapy
to 90#{176} as quickly
weight-bearing
W. SHEPHERD-WILSON,
started
leg
R. CLOSE
and
raising
Walking
when
T. LYONS,
with
control
is
achieved. Type
B
The
.
the same
immediate
as for
achieved,
a cast
stability
before
weight. Type C.’
In
postoperative
Type
A fractures,
brace
is applied
the
patient
management
is
leg
is
when
control
to lend
additional
lateral
allowed
to
partial
is
take
fr.
traction
view
of
the
is maintained
is as for Types complete,
a
allowed
but
up
loss
for
A and
cast
longitudinal
3 to 4 weeks,
B. When
brace
with
of
is
partial
but
the
physiotherapy
traction
applied
-
stability,
and
period
the
is
patient
Fig.
is Foam rubber postoperatively.
weight-bearing.
block
pillow
4
used
to
elevate
the
fractured
limb
RESULTS Of the 100 patients 64 with an abbreviated weeks
with
postoperatively
disrupted
with
fractures,
one
score
(AIS)
ofsepticaemia
compound
patients,
106 injury
pelvic
105
related
fracture.
fractures,
patient
were
died
six
30
to a severely
Ofthe
17
aged
of 41
6
lost
to
A.I.S.>18
25
follow-up;
______
A.I.S.50
DAYS
to the
injury
severity
and
number
of injuries
score (AIS).
U)
I-.
z
OF
MOTION
review
13 12 ii
1-9
three months to drainage,
There was complete bone union with the
range
as reflected
(96.6%
painless
presented some this responded
35
those
successful
a
--
28
21 days
35 days
of function
as shown
Duration
taking
-
Fig. 5
RANGE
failures
debridement lution of the the
0
or wide
27 days
the
third
operation. case of infection initial surgery,
and
the
u_
fixed
table,
additional
hospital
Two
further
-
25
Average blood loss was 150 ml, 250 ml) for closed reduction and
ofconcomitant
Union
< a-
fractures.
internally
the
tip frac-
and
for those with an AIS of 18 or less with an AIS over 18 (Fig. 5). union).
of
segmental
compound
reduced but
45 mm had
muscle interposition butterfly fragments. excluding time for
of 50 minutes. 1 30 ml (50 to
350
within
patients
93 were
reduction
being
from
trochanter notch.
Of all the
average
z
20
fracture
intercondylar tures
II-.
The of
were
resonails in
0
100’
110’
120’
0#{176} to 135#{176}.
movement only
140’
150’
was Fig.
6. Twenty-six but
130’
RANGE
four
Range
6
of knee movement
THE
JOURNAL
at final follow-up.
OF BONE
AND
JOINT
SURGERY
FEMORAL
had
angulation
discrepancy with Type
SHAFT
or rotation
FRACTURES
in excess
of over 10 mm occurred C fractures. One femur
TREATED
of
10#{176}. Leg
BY ENDER
length
in four patients, was 15 mm long,
all due
to the interposition ofa bony fragment and the remaining three were 25, 30, and 45 mm short respectively. There was trochanteric discomfort in 21 patients: 1 3 settled spontaneously, requiring no further treatment, seven responded one settled after
to the injection
removal oflocal
of protruding anaesthetic
and
NAILS
USING
A TROCHANTERIC
morbidity and thus providing systems.
APPROACH
greatly reduced an attractive
Radiographic
review
17
the problem alternative
showed
of the femur was the position fixation, in contrast to reported chanteric and intertrochanteric
that
of shortening, to locking nail the
attained experience fractures.
final at
position
the time of with subtroGreat care
nails and steroid.
DISCUSSION Until 1982, the use of Ender nails was largely confined to intertrochanteric and subtrochanteric fractures (BOhler 1972; Kuderna, B#{246}hlerand Collon 1976; Corzatt and Bosch 1978 ; Chapman et al 1981 ; Hall and Ainscow 1981), although a few papers reported their use for the fixation ofshaft and Hovelius
fractures (Pankovich 1979; Muckle and
pathological
fractures
(Katzner
et al 1976).
Fig. Ender
nails
bent
et al 1979 ; Eriksson Siddiqi 1982), and
7
to conform
to their
destination. Fig.
was and
Our experience unsatisfactory nail protrusion
to change to the trochanteric details emerged during our
approach. experience.
Some
Before operation. Skeletal traction of necessary to overcome any tendency (Winquist traction injury baum,
et al
Partridge oblique
with the medial condylar approach because postoperative knee stiffness were very real problems; this led us
1984).
This
at
is
should of the
therefore proximal varus, valgus, time of insertion fracture,
unnecessary and decreases the risk of perineal (Hofmann, Jones and Schoenvogel 1982; LindenFleming and Smith 1982). The narrowest diame-
crossed
femoral canal in the AP and lateral projections radiographs are measured. This gives a rough idea as to the number of nails that the femoral canal can be expected to accommodate.
After
At operation.
commonsense
to contour
the
nail
to suit
its
knee
operation. should
as possible. empirically
should the
site,
Once
be flexed
Postoperative to suit each approach
VOL.
72-B. No. 1, JANUARY
1990
significantly
long
increase
it is finally
have been as full a range
tendon
and
first
‘driven
applied, the of movement was a
devised flexible
resulted from either proof the bursa. The incidence that nails were buried within
the trochanter and by modifying proximal mini-Hardinge type medius
as the
is advised.
trochanter.
not
a
as soon
before
management type of fracture;
Nordstrom
did
to
and
dressings
Trochanteric discomfort truding nails or disturbance was minimised by ensuring
This
stability
be released
through
destination ; a nail passing into the medial femoral condyle must be the shape of an elongated S (Fig. 7). Late in our series, fractures with butterfly fragments (Type B) and comminuted fractures (Type C) were sometimes treated by open reduction and the application of Partridge bands (Fig. 8) (H#{228}gglund, Lidgren and 1982).
adding
be taken to assess the rotational position and the distal fragments and to correct anterior and posterior angulation at the ofeach nail. Ifthere is distraction at the
traction
nail has home’.
ters ofthe ofstandard
It is important
bands
important
least 9 kg to shortening excessive operative
makes
cerclage fracture.
8
entering
the approach to a more of incision in the gluteus the
bone
near
the
tip of the
18
J. WALTERS,
We
range are
have
highly
that other
authors
Mesdames
method
and
since
of fixation
to a wide
Segmental
fractures
levels.
torsion
of the
loose
fragment
We were surprised by the versatility finding that it provided a solution
fractures by any
this
types
suitable
eliminated. technique,
The
applied
of fracture
W. SHEPHERD-WILSON,
would
have
been
difficult
would
and the Medical
like
van
to thank
Eyssen
and
Michael
Vera
is
of the to many
for the
for secretarial
G, Lid;ren L, Nordstrom B. Intramedullary Ender nailing with Parnham’s modified band in the treatment of subtrochanteric fractures : report offour cases. Acta Orthop Trauma Surg l982;lOO:13l-3. combined
to fix internally
Wyeth
Barrow
Hall G, Ainscow DAP. Comparison nailing for intertrochanteric 1981 ;63-B:24-8.
artwork,
party
related
directly
or indirectly
to the subject
of
Kuderna
H, B#{246}hlerN, Colon subtrochanteric fractures Joint Surg [Am] l976;58-A
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Fleming with closed
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AND
JOINT
and twenty
SURGERY
