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Femoral Intramedullary Nailing: Comparison of Fracture-Table and Manual Traction

A Prospective, Randomized Study

Investigation performed at the University of Toronto Orthopaedic Trauma Research Group, Toronto, Ontario, Canada

David J.G. Stephen, MD, BSc, FRCS(C)
Hans J. Kreder, MD, MPH, FRCS(C)
Lisa B. Conlan
Division of Orthopaedic Surgery (D.J.G.S., H.J.K., and L.B.C.) and Department of Health Policy Management and Evaluation (H.J.K.), University of Toronto, Sunnybrook and Women's College Health Sciences Centre, MG 365, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. E-mail address for H.J. Kreder: kreder{at}rogers.com

Emil H. Schemitsch, MD, FRCS(C)
Michael D. McKee, MD, FRCS(C)
Lisa Wild, RN
Department of Orthopaedic Surgery, St. Michael's Hospital, 30 Bond Street Toronto, ON M5B 1W8, Canada

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the Canadian Orthopaedic Foundation and Smith and Nephew Richards. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: The purpose of this study was to compare manual traction and fracture-table traction for the reduction and nailing of femoral shaft fractures. We evaluated the quality of the reduction, operative time, complications, and functional status of the patient.

Methods: Eighty-seven consecutive adult patients with a unilateral fracture of the femoral diaphysis that did not extend into the knee joint or proximal to the lesser trochanter were enrolled in the study. Patients who were transferred to our institution more than forty-eight hours after injury; those with multiple-system injuries, injury to the ipsilateral lower extremity, or pathological fracture; and those who were unable or unwilling to provide consent or to return for follow-up were excluded. Forty-five patients were randomized to manual traction and forty-two, to fracture-table traction; all were treated in the supine position. The number of surgical assistants, operative and fluoroscopy time, complications, functional scores, and other outcomes were recorded.

Results: There were no significant differences between the groups with respect to age, gender, Glasgow Coma Score, Injury Severity Score, side or mechanism of injury, fracture type, or time from injury to treatment. Internal malrotation was significantly more common when the fracture table had been used: twelve (29%) of the forty-two femora were internally rotated by >10° compared with three (7%) of the forty-five treated with manual traction (p = 0.007). Total operative time, from the beginning of the patient positioning to the completion of the skin closure, was decreased from a mean of 139 minutes (range, 100 to 212 minutes) when the fracture table was used to a mean of 119 minutes (range, sixty-five to 180 minutes) when manual traction was used (p = 0.033). There was no significant difference between the two treatment groups with regard to the number of assistants per case (mean two; range, zero to three), fluoroscopy time, other complications including femoral shortening or lengthening, or functional status of the patient at one year.

Conclusions: Compared with fracture-table traction with the patient in a supine position, manual traction for intramedullary nailing of isolated fractures of the femoral shaft is an effective technique that decreases operative time and improves the quality of the reduction.

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