1. Fractures of the femur Leeds 2005 AO Principles Course
David L Shaw
Module : Principles of operative management of common fractures

3. Fractures of the Femoral Shaft (AO 3.2)
Why should I fix the #?
How should I fix it ?
What complications can I expect ?

5. Paediatric fractures J Am Acad Orth Surg 1995 no3 See article Gallows
Hip Spica
Traction
J Am Acad Orth
Surg 1995 no3
J Am Acad Orth Surg 1995 no3

6. Why fix the # Save life Save limb Preserve function Poly trauma
Stabilisation with immediate rehabilitation

7. Choose a method ? Plating Ext fixn IM Nail
Rigid fixation Abs stability
LISS
LCP
Ext fixn
IM Nail
Consider absolute vs relative stability
Consider soft tissues and scars
Consider facilities and equipment
J Am Acad Orth Surg 1995 no3

8. Choose a method 2 Patient factors Facilities, time and polytrauma
Damage control orthopaedics
J Am Acad Orth Surg 1995 no3

9. “Get me a nail!”

10. Rods & Nails The truth is out there! When is a nail not a nail
Hollow – Slotted – Solid
Why nails fail
Effects of Reaming

11. Bones & Nails Hollow structures
Hollow bones for strength
Early nails were hollow & needed 3 point fixation

12. Kuntcher - Clover leaf nail
3 point fixation
Inserted open so no guide wire required

13. GK & AO – Slotted hollow nail
Allowed guide wire insertion
Flat sheet manufacture

14. Reaming to increase the contact area

15. Lets talk about stiffness

16. Bending Stiffness Second Moment of Inertia (I)
Tube
I=(Ro4 – Ri4) * ¶/4
 Radius cubed

17. Hollow structures are relatively strong for the volume of material
For a given increase in radius torsional and bending stiffness go up to the fourth power
Torsional stiffness roughly 2x inc vs bending as radius
At physiological loads torsional deformation more clinically evident

18. Slotted nails especially are weak in torsion

19. The advantage of “Unreamed”
The advantage of Solid
Solid Ti nails are strong enough at diameters small enough to be inserted without reaming
Not possible with SS nails
Expensive

20. “You be the Judge”

21. For unreamed Healing 170 # Equivalent healing time (19/52)
55mins quicker
= delayed unions
Reynders Injury 2000

22. For unreamed General Results 164# retrospective series
93% union rate with UFN
AO type C healed at 6.2mo (ave)
UFN “healing rates comparable with historical standards”
Herscovici JOT 2000

23. For unreamed Intramedullary pressure Clinical trial 38 pts
5x increased pressure in reamed group
Pressure correlated with fat extravasation
Berger JOT 1997

24. For unreamed Poly Trauma Femur # in polytrauma pts managed by;
Early Total Care
Intermediate Stabilisation
“Damage Control Surgery”
“A significant reduction in the incidence of complications was found ..regardless of the type of fixation”
Garapati & Krettek J of T 2002

25. Against unreamed method
Healing
147#
6 weeks longer to heal
Giannoudis Injury 1997
172#
4 weeks longer to heal
More “technical complications”
Tornetta JOT 2000

26. Against unreamed method
Stimulation of the inflammatory system
IL6, CD11b, s-ICAM-1, E-selectin & elastase
Reamed vs Unreamed
Evidence of a “second hit” to the immune system
No difference reamed vs unreamed
Giannoudis JBJS(B) 1999
If you don’t ream you still get a second hit to the immune system

27. Against unreamed method
Complications
100 randomised pts
2x iatrogenic comminution in unreamed
Reaming was “required” in the unreamed group in 3
Shepherd J Orthop Trauma 2001

28. For unreamed Quicker Simpler Less equipment Equivalent healing rate
Less fat embolus
Less H-O
Lower immune “hit”

29. For reamed Faster union Fewer implant related complications
Lung injury not directly & only caused by reaming
“Second hit” not specifically caused by reaming

31. It’s all about technique

32. Solid nails are implants
Reaming is a technique
Solid nails are implants

33. Solid nail ?
Who would put a 9mm nail in this pt!

34. Summary & “Verdict” Reaming is a technique
Solid vs Slotted vs Cannulated
is a design / manufacturing process

35. “I always do reamed nails”

36. Solid
Hollow
Reamed
Unreamed

37. Solid
Reamed
Hollow
Unreamed

38. Solid
Reamed
Hollow
Unreamed

39. Solid
Reamed
Hollow
Unreamed

40. Solid
Reamed
Hollow
Unreamed

41. Summary
Chose the smallest nail which is strong enough for the patient and his/her injury
Ream if necessary to put the appropriate size of nail in for the patient & injury
Don’t confuse implants with technique

42. Other peoples’ complications
General complications
Specific # related comlpications
Malunion

43. Cambell’s Operative Orthopaedics
“Malunions after closed treatment are the rule”

44. Malrotation > 10 degrees in 8-19% of fractures JBJS 75 (B) 799-803
JBJS 66 (A)

45. Cambell’s Operative Orthopaedics
“..become significant only if they result in
shortening of more than 2.5 cm
angulated more than 10 degrees
internally or externally rotated to the point that the knee cannot be aligned with forward motion during gait.”

46. ? How much rotation ? External rotation less well compensated
than internal
15 degree limit
Based on functional assessments and FPA
Nijmegen group: Injury

47. Malunion > 2.5 cm shortening > 10° angular deformity
>15° rotation deformity

48. Malunion > 2.5 cm shortening > 10° angular deformity
Rotation that the pt can see !

49. Fractures of the Femoral Shaft (AO 3.2)
Why should I fix the #?
Damage control
Restore function
How should I fix it ?
For the fracture / for the patient
What complications can I expect
Length , Rotation the pt can see