The Journal of Bone and Joint Surgery, Vol 70, Issue 10 1441-1452, Copyright © 1988 by Journal of Bone and Joint Surgery, Inc
Intramedullary nailing of femoral shaft fractures. Part I: Decision-making errors with interlocking fixation
RJ Brumback, JP Reilly, A Poka, RP Lakatos, GH Bathon and AR Burgess
Shock Trauma Center, Maryland Institute for Emergency Medical Services Systems, Baltimore 21201.
Dynamic intramedullary fixation depends on the configuration of the
fracture for postoperative stability. Unanticipated loss of reduction of
the fracture after dynamic intramedullary nailing of the femur may result
from errors in surgical decision-making, specifically the failure to insert
both proximal and distal interlocking screws. Of 133 dynamic femoral
intramedullary nailings that were performed after interlocking techniques
became routinely available, fourteen (10.5 per cent) were complicated by
loss of postoperative fixation and reduction. Thirteen of the fourteen
femora shortened an average of 2.0 centimeters; the remaining femur
shortened slightly, with clinical loss of rotational stability. Eight of
fourteen patients elected some form of surgical revision, most commonly
closed osteoclasis with restoration of femoral length, followed by the
insertion of a statically locked nail. Errors in surgical judgment were
attributed to inadequate preoperative analysis of the pattern of the
fracture; undetected intraoperative comminution during reaming or insertion
of the nail, or both; or postoperative failure to recognize an increase in
comminution and instability of the fracture. We suggest using high-quality
preoperative radiographs to detect non-displaced comminution of the major
fracture fragments. Any increase in comminution of the fracture that occurs
with reaming of the canal or insertion of the nail is an indication for
static interlocking fixation. Radiographs that are made immediately
postoperatively should be analyzed while the patient is under anesthesia,
and any previously undetected instability of the fracture should be treated
by static interlocking fixation. Dynamic intramedullary stabilization of
the femur should be reserved for transverse or short oblique fractures at
the femoral isthmus that have type-I or type-II comminution.
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