Chapter 52: Femoral Shaft Fractures

Sean E. Nork

Chapter Outline

Introduction to Femoral Shaft Fractures

The evaluation and management of patients with femoral shaft fractures continue to evolve on the basis of the improved understanding of the local anatomy, impact of treatment, and biomechanics of fixation techniques. Starting with the introduction of intramedullary nailing by Kuntscher165167 during the years surrounding and after World War II, patient survival and outcomes have continued to improve. Improved prevention and management of fracture shortening, angulation, infection, and nonunion have made intramedullary nailing the primary treatment for most femoral shaft fractures. Patient mortality and morbidity from pulmonary dysfunction, open wounds, and the frequently associated multiple other injuries have continued to improve with a better understanding of nailing techniques. 
Femoral nailing has advanced continuously over the past 70 years. The transition from open nailing techniques to closed techniques using a remote entry site at the proximal femur paralleled the availability of image intensification. Intramedullary reaming allowed placement of larger implants, allowing improved rotational control and resistance to bending. The introduction and increased popularity of interlocking nails allowed for improved rotational control, better maintenance of femoral length, early weight bearing, the use of smaller implants, and improved control of comminuted and segmental fractures. Biomechanical improvements in nail designs and instrumentation have further expanded the indications for nailing. Cephalomedullary nails and retrograde nails have seen similar improvements in design and instrumentation, increasing the ease of insertion and further expanding the use of nailing techniques for some particularly difficult fractures (Fig. 52-1). More recently, alternative antegrade intramedullary nail starting points have been introduced. This includes starting points at, medial to, and lateral to the tip of the greater trochanter. Trochanteric nails appear to offer increased ease of nail placement without detriment in healing or outcomes.12,254,284 
Figure 52-1
A segmentally comminuted femoral shaft fracture occurred in this 26-year-old female after a fall from height (A, B, C).
 
Despite the complexity of the injury, current nail designs and the techniques of intramedullary nailing make stabilization of this injury possible (D, E). (Case compliments of Daphne Beingessner, MD, Harborview Medical Center, Seattle, WA.)
Despite the complexity of the injury, current nail designs and the techniques of intramedullary nailing make stabilization of this injury possible (D, E). (Case compliments of Daphne Beingessner, MD, Harborview Medical Center, Seattle, WA.)
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Figure 52-1
A segmentally comminuted femoral shaft fracture occurred in this 26-year-old female after a fall from height (A, B, C).
Despite the complexity of the injury, current nail designs and the techniques of intramedullary nailing make stabilization of this injury possible (D, E). (Case compliments of Daphne Beingessner, MD, Harborview Medical Center, Seattle, WA.)
Despite the complexity of the injury, current nail designs and the techniques of intramedullary nailing make stabilization of this injury possible (D, E). (Case compliments of Daphne Beingessner, MD, Harborview Medical Center, Seattle, WA.)
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Over the past 25 years, an improved understanding of the impact and timing of different techniques of femoral stabilization has been gained. The impact of early femoral stabilization was defined in the landmark prospective and randomized study by Bone et al.31 The beneficial effects of stabilization within 24 hours in the multiply injured patient included decreased pulmonary complications and shortened hospital stay. The ill effects of femoral reaming in the multiply injured patient were largely discounted after the comparative study of Bosse et al.33 In this study, mortality and pulmonary dysfunction did not increase with the use of reamed intramedullary nailing compared with plate fixation in the multiply injured patient with thoracic trauma. More recently, several prospective and randomized studies have shown improved rates of union with a reamed technique compared with unreamed nail insertions.54,67,312 
Although the clinical results using current techniques and implants for intramedullary nailing are uniformly positive, there continues to be numerous unanswered questions in the management of patients with femoral shaft fractures. Intense debate continues regarding the optimal timing of surgical stabilization, especially in patients with multiple injuries, associated thoracic trauma, or associated head injuries. Similarly, the ideal starting point, amount of reaming, and type of nail all continue to be sources of discussion and further investigation. Because of the general expectation of success in every patient treated with intramedullary nailing, the management of complications must be met with knowledge and planning. 

Assessment of Femoral Shaft Fractures

Mechanisms of Injury for Femoral Shaft Fractures

Femoral shaft fractures are observed across all age groups and are attributable to a variety of mechanisms.13,22,74,266,267 There tends to be an age- and gender-related bimodal distribution of fractures with injuries occurring most frequently in young males after high-energy trauma and in elderly females after falls from standing. The mechanisms in young patients tend to be motor vehicle crashes, motorcycle crashes, pedestrians struck by vehicles, or falls from height. The relative distribution of these fractures depends on multiple factors including the geographic location (urban vs. rural) and country of study. In a review of 515 patients with 551 femoral shaft fractures in a typical urban US city, the average age was 27.2 years and 70% were males. The mechanisms of injury were motor vehicle crashes in 78%, motorcycle crashes in 9%, pedestrians struck in 4%, falls from height in 3%, gunshot wounds in 2%, and other miscellaneous mechanisms in 3%. Open fractures were identified in 16%, and the distribution of fracture comminution according to the scheme of Winquist–Hansen was relatively uniform among types 0, 1, 2, 3, and 4. The fracture patterns that could be identified were oblique in 51%, transverse in 29%, comminuted in 14%, and spiral in 6%.337 In a very different study, the incidence of femoral shaft fractures in skeletally mature patients was estimated by Salminen et al.267 in a semiurban county in Finland reviewed over a 10-year period. The incidence of femoral shaft fractures was 9.9 per 100,000 person-years. The bimodal distribution of young males (between the ages of 15 and 25 years) and elderly females (>75 years) was confirmed. Most of these fractures (75%) were attributable to high-energy mechanisms, with the majority being road traffic accidents. The fracture configuration was either transverse or oblique in 77%.267 The application of these data points to patients injured in North America may be difficult; no patients in this series from Finland sustained a fracture caused by a gunshot. Fractures secondary to low-energy trauma tend to occur more commonly in older female patients. In a review of 50 femoral shaft fractures caused by low-energy mechanisms, Salminen et al.266 identified only 13 patients who were younger than 60 years. All fractures were closed, and none were associated with significant other injuries. The fracture was spiral in 29 patients, oblique in 11 patients, and transverse in 10 patients. Chronic disease and osteopenia were commonly identified as contributing to the occurrence of these fractures.266 

Associated Injuries with Femoral Shaft Fractures

Numerous associated injuries occur in conjunction with fractures of the femoral shaft and are more commonly observed in young patients after high-energy traumatic injuries. Ipsilateral femoral fractures can occur at the femoral neck, intertrochanteric, and distal femoral articular locations and will be discussed in detail later in this chapter. Other associated musculoskeletal injuries commonly observed are patellar fractures, tibial fractures, acetabular fractures, and pelvic ring injuries. Soft tissue trauma to the knee occurs commonly with femoral shaft fractures and requires a careful physical examination and further radiologic studies. Associated abdominal, thoracic, and/or head trauma related to the mechanism requires evaluation by a team of physicians. The identification and treatment of these associated injuries will be discussed in further detail later in this chapter. 

Signs and Symptoms of Femoral Shaft Fractures

In the conscious patient, the diagnosis of a femoral shaft fracture is usually obvious. However, a methodical extremity examination of all patients who sustain injuries from blunt and penetrating trauma should ensure that the diagnosis is timely and accurate. Patients usually have significant pain localized to the thigh. However, the presence of associated injuries or other fractures may be distracting, both for the patient and the examining physician. 
A complete history is an important part of the initial evaluation of the traumatized patient and can be obtained from the patient, family members, emergency personnel, or others. This includes determination of the injury mechanism, the time elapse from injury to presentation, the need for a prolonged extrication, the location of the accident, and any known associated injuries. The mechanism of injury is an important aspect of the history that may suggest the fracture location, fracture configuration, and associated soft tissue injury. The time from injury to presentation gives valuable information regarding the potential for extensive blood loss into the thigh, the overall condition of the patient, and the possibility of significant associated soft tissue injury such as substantial muscle crush that is occasionally seen with a prolonged extrication. The location of the accident may give information regarding the potential for specific organisms contaminating open fractures and the impact of the ambient temperature on the overall condition of the patient. The identification of any associated medical comorbidities is similarly an important aspect of the history. Although this information has little impact on the actual diagnosis of the femur fracture, it may determine the timing of treatment, type of fixation, and need for specialized evaluations. 
The physical examination can be difficult in a patient with a femur fracture. However, the examination should not be limited to sites of obvious pain and deformity. Advanced trauma life support protocols should be followed in the initial evaluation. The orthopedic examination should include visual inspection and palpation of all extremities, the pelvis, and the spine. In patients with a fractured femur, there is usually an obvious deformity with gross mobility at the thigh. The visual inspection should include a circumferential evaluation of the limb to look for associated open wounds, degloving injuries, bruising, and abrasions. The ipsilateral knee and hip should be examined to determine whether there are associated noncontiguous fractures or ligamentous injuries. A focused examination of the knee ligaments and associated soft tissues is mandatory, although this is frequently more accurate in the anesthetized patient at the conclusion of surgical stabilization of the femur fracture. The association between femur fractures and concomitant ligamentous and meniscal injuries of the ipsilateral knee is well documented.320 Investigators evaluated 47 patients with femoral shaft fractures with arthroscopy and an examination under anesthesia after femoral nailing. Ligamentous laxity was identified in 49% of patients, medial meniscal injuries in 26%, and lateral meniscal injuries in 28%. There appeared to be no relationship between a meniscal injury and the presence of ligamentous laxity.320 
Similarly, De Campos et al.79 studied 40 patients after femoral stabilization with an examination under anesthesia and knee arthroscopy. The physical examination revealed ligamentous laxity in 52.5% of patients. Subsequent arthroscopic examination identified partial (48%) and complete (5%) anterior cruciate ligament tears, and partial (5%) and complete (2.5%) posterior cruciate ligament tears, with lateral and medial meniscus tears in 20% and 12%, respectively. In total, 55% of patients had significant arthroscopic findings. A well-defined treatment protocol for these associated ligamentous findings identified on arthroscopic or physical examination has not currently been identified. In the majority of instances, surgical repair or reconstruction is not initially required. In general, the overall approach to these commonly observed ligamentous findings should parallel the management in a patient without an associated femoral shaft fracture. Although associated knee dislocations are uncommon, a cursory examination of the knee or an examination that is minimized because of the obvious fracture of the femoral shaft can leave the limb threatened because of vascular injury. The vascular status of the extremity is determined with palpation and/or Doppler examination of the distal pulses. Any discrepancy with the contralateral extremity requires further evaluation. Extremity traction and limb realignment to a more anatomical position may change the vascular examination. An expanding hematoma, a bruit, and obvious bleeding are all indicative of an associated vascular injury. Even the presence of normal pulses does not completely rule out the possibility of a vascular injury. In a study of 765 consecutive patients with closed femoral shaft fractures, Kluger et al.161 identified acute vascular injuries in 10 patients (1.6%). Normal pulses were identified in a minority of patients with angiographic evidence of vascular injury, emphasizing the need for continued and repeated evaluation in these patients. Further, in a study of blunt femoral fractures with an associated vascular injury, DiChristina et al.81 found that the arterial injury was segmental in 15% of injuries. The ankle-brachial index has been shown to be a sensitive test for identifying vascular injuries in a variety of blunt lower-extremity trauma, as well as knee dislocations, and is a simple objective measurement to supplement the physical examination. An ankle-brachial index (the Doppler systolic arterial pressure of the injured extremity divided by that of an uninvolved arm) of less than 0.90 has been found to have a high sensitivity and specificity for a major arterial injury of the lower extremity.147 
A well-documented extremity neurologic examination is performed in an awake and cooperative patient. Although injuries to the femoral and obturator nerves are uncommon after a fracture of the femur, sciatic nerve injury does occur. Accurate documentation of the sensory and motor function of the tibial and peroneal branches is therefore a necessity. 
Open wounds or abrasions on the leg are examined to determine the presence or absence of communication with the fracture. Even the smallest of wounds should be viewed with suspicion and any drainage of fat or blood from the leg should be considered as indicative of an open fracture until proved otherwise. Although lateral and anterolateral open wounds are seen most frequently, medial and posterior open wounds are not infrequent and are worrisome for associated vascular and neurologic injury, respectively. Open wounds should be gently irrigated and gross debris or foreign material removed. Sterile dressings are applied, and repeated examinations are avoided to minimize further contamination. If possible, the extruded bone ends should be reduced to minimize further desiccation, contamination, and pressure necrosis of the underlying skin and muscle. Comfort and hemostasis may also be facilitated. In penetrating injuries, the entry and exit locations should be determined and can be marked with radiopaque markers before obtaining radiographs. This can aid in the intraoperative search for foreign materials, debris, or missile components. 
The presence of a femur fracture has an impact on the hemodynamic status of the patient, largely because of the potential for blood loss into the surrounding soft tissues of the thigh. In a study of 53 patients with isolated femur fractures, Lieurance et al.179 found that 21 patients (40%) required blood transfusions averaging 2.5 units of packed red blood cells during their initial hospitalization. Preoperative hemorrhage as opposed to intraoperative blood loss was identified as a risk factor for blood transfusion. Interestingly, the fracture pattern did not correlate with blood loss or the need for transfusion. Although isolated femur fractures are associated with blood loss requiring transfusion, the association with hypotensive shock is less clear. Ostrum et al.224 found that patients with femoral shaft fractures frequently exhibited hemodynamic changes with blood loss; however, hypotension was not observed. As a result, the authors recommended that in patients with an isolated closed femoral shaft fracture with associated hypotensive shock, alternative sources of blood loss should be investigated. 
Associated injuries occur commonly in patients with femur fractures caused by a blunt mechanism. This includes ipsilateral femoral neck fractures,3,256,293 pelvis and acetabular fractures,210 hip dislocations,344 knee injuries, intercondylar distal femoral fractures,15,50 and ipsilateral distal lower-extremity injuries. Associated hip dislocations occur uncommonly, but this combination of injuries complicates the initial management. Closed reduction of the hip remains a priority to protect the femoral head blood supply. However, an associated femoral shaft fracture complicates the usual reduction measures and may necessitate placement of an external fixator or a percutaneous Schanz pin.344 Similarly, associated pelvic and acetabular fractures complicate both the initial evaluation and the subsequent management. 

Imaging and Other Diagnostic Studies for Femoral Shaft Fractures

The radiographic evaluation begins with full-length anteroposterior (AP) and lateral radiographs of the entire femur. More information can be obtained if these are performed with the femur at length, preferably after traction is applied. Traction can be accomplished with either a Thomas splint or an appropriately placed distal femoral or proximal tibial traction pin. Ideally, the entire femur should be present on a single radiographic cassette. The radiographs should be critically evaluated to determine the fracture pattern, bone quality, presence of bone loss, associated comminution, presence of air in the soft tissues, and amount of shortening. An actual measurement of the angular deformities is probably of little use on the initial radiographs. The length of the femur can be estimated using digital films or with rulers appropriately corrected for magnification. Contralateral extremity femoral films in two planes are useful for determining the normal femoral bow and the normal femoral length. The diameter of the medullary canal at the isthmus can be measured as part of the preoperative plan if nailing is anticipated. The presence of osteopenia, metastases, or cortical irregularities in the region of the fracture or remote in the femur should be identified. 
Other radiographs that should remain a part of the routine evaluation include dedicated films of the hip and knee. Although an internal rotation radiograph of the hip is ideal for evaluation of the femoral neck, this may be difficult in a patient with a femoral shaft fracture. The knee radiographs should be reviewed to determine whether there is associated joint widening or associated fractures. If a computed tomography (CT) scan of the abdomen and/or pelvis is obtained for other reasons, this should be reviewed because it may provide evidence of injury to the ipsilateral acetabulum or femoral neck. To minimize the incidence of a missed femoral neck fracture in association with a fracture of the femoral shaft, a number of additional radiographic evaluations can be considered including an internal rotation plain radiograph of the hip, a fine-cut (2-mm) CT scan of the femoral neck, an intraoperative fluoroscopic lateral of the femoral neck, and postoperative hip radiographs after femoral stabilization.307 

Classification of Femoral Shaft Fractures

Femoral shaft fractures have been classified by the anatomical location, fracture morphology, degree of comminution, or combinations thereof. The fracture may be described as proximal third, middle third, or distal third in location, or at the junctions between these regions. In addition, fractures may be described on the basis of the location relative to the isthmus of the femoral canal. Infraisthmal fractures are important to identify if intramedullary nailing is planned. In these fractures, the nail will not assist with reduction of the fracture because the direction of the implant is determined by its contact fit with the endosteal surface of the femoral isthmus, which is located proximal to the fracture. Conversely, simple fracture patterns at the isthmus are predicted to reduce with placement of an appropriately sized medullary implant. Fractures are often further described on the basis of the fracture geometry as transverse, oblique, spiral, or comminuted. This may be useful for communication regarding the injury as well as understanding the mechanism that produced the fracture. 
Early intramedullary implants did not have interlocking capabilities. As a result, an appreciation for the amount of fracture comminution was especially important to recognize. As interlocking nails became available, predicting which injuries were likely to subsequently shorten and those patterns that had poor rotational control was an important part of the decision whether to place interlocking screws. In the Winquist and Hansen system,330,331 fracture comminution is categorized as from grade 0 to grade IV (Table 52-1) based on the percentage of intact femoral shaft at the fracture site (Fig. 52-2). Grade 0 fractures have no associated comminution. Grade I fractures have a small chip or fragment of comminution. Grade II fractures have a small butterfly fragment, but at least 50% of the cortex remains intact. Grade III fractures have a larger butterfly fragment with minimal cortical abutment predicted. Grade IV fractures have no predicted cortical contact between the fracture fragments and are often referred to as segmentally comminuted. This was originally used to determine whether a locking nail should be used and if so, whether it should be locked statically or dynamically. Grade 0 and I fractures are stable in length and can theoretically be treated without interlocking; grade II fractures are at risk for rotational abnormalities and interlocking is recommended; fractures that are grade III and IV require interlocking to prevent shortening and rotational malunion. However, because of the possibility of unrecognized comminution and the predictable performance of statically locked nails, it is unusual to consider using an unlocked implant with currently available nailing systems and techniques. 
See text and Table 52-1 for explanation.
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Figure 52-2
The Winquist–Hansen classification for diaphyseal femoral comminution.
See text and Table 52-1 for explanation.
See text and Table 52-1 for explanation.
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Table 52-1
Winquist and Hansen Classification of Fracture Comminution33,34
Grade Degree of Comminution
0 No comminution
I Small butterfly fragment (<25%) or minimally comminuted segment with at least 75% cortical contact remaining between the diaphyseal segments
II Butterfly fragment or comminuted segment with (approximately 25–50%) with at least 50% cortical contact between the diaphyseal segments
III Large butterfly fragment or comminuted segment (approximately 50–75%) with minimal cortical contact between the diaphyseal segments
IV Complete cortical comminution such that there is no predicted cortical contact between the diaphyseal segments. Segmentally comminuted
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The AO-Orthopedic Trauma Association classification is based largely on the fracture morphology and includes the fracture location as well as the degree and type of comminution (Fig. 52-3). Type A fractures are considered simple and include spiral, oblique, and transverse patterns. Type B fractures are wedge fractures and include spiral wedge, bending wedge, and segmental wedge patterns. Type C fractures are considered complex patterns that have no predicted cortical contact between the major proximal and distal fractures. These fractures are divided on the basis of the same characteristics described for B fractures. Each of these fractures is further divided on the basis of location as subtrochanteric, middle, or distal. Although the precise alphanumeric classification assigned to each femoral fracture is of limited utility, an understanding of the fracture pattern and its location assists with surgical planning and may be useful for documenting and categorizing large numbers of femoral fractures. Further, the severity of the femoral shaft fracture according to this classification system has been shown to be predictive of accompanying trauma and associated injuries212 This may be useful for avoiding missed injuries through a heightened awareness of the association of additional trauma based on the fracture pattern. 
Figure 52-3
Association for the Study of Internal Fixation classification of fractures of the shaft of the femur.
 
Simple fractures (type A) are distinguished by the degree of obliquity of the fracture line. Wedge fractures (type B) are subclassified according to the anatomy of the wedge fracture. Complex fractures (type C) can be spiral, segmental, or irregular.
Simple fractures (type A) are distinguished by the degree of obliquity of the fracture line. Wedge fractures (type B) are subclassified according to the anatomy of the wedge fracture. Complex fractures (type C) can be spiral, segmental, or irregular.
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Figure 52-3
Association for the Study of Internal Fixation classification of fractures of the shaft of the femur.
Simple fractures (type A) are distinguished by the degree of obliquity of the fracture line. Wedge fractures (type B) are subclassified according to the anatomy of the wedge fracture. Complex fractures (type C) can be spiral, segmental, or irregular.
Simple fractures (type A) are distinguished by the degree of obliquity of the fracture line. Wedge fractures (type B) are subclassified according to the anatomy of the wedge fracture. Complex fractures (type C) can be spiral, segmental, or irregular.
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Biomechanics and Nailing in Femoral Shaft Fractures

The femur is subjected to significant bending, axial, and torsional forces that can exceed three to four times the body weight during normal activities. The commonly observed fracture patterns are determined by the magnitude of the applied load, rate of load application, and strength of the femur. Like all long bones, the femur is strongest in compression and usually fails in tension as determined by the direction of the applied load. A purely torsional force results in the spiral fracture pattern typically seen in elderly patients. In younger patients, a combination of bending and axial loading produces the commonly observed transverse and bending wedge fractures. As the applied force increases, so does the diaphyseal comminution. The necessary bending force to produce a femoral shaft fracture in the normal adult has been estimated at 250 Nm.172 However, in purely axial compression, the loads necessary to produce a fracture may exceed 8,000 Nm.300 
The tubular anatomy of the femur makes intramedullary nailing an ideal treatment biomechanically and practically. An intramedullary nail is a strong device in axial loading and bending given its centrally located cross-sectional moment and the symmetry in its design. Thus, a nail can support loads equally in all directions. Early nail designs were open-sectioned implants that did not have the capability to accept interlocking screws. As a result, these implants resisted bending forces only and primarily maintained the angular alignment of the femur. 
However, the ability of these implants to resist torsion and to maintain length was limited. In response to these biomechanical limitations, nail designs have changed significantly over the past 40 years. Most nails are made of either stainless steel or titanium, each with its own unique biomechanical properties. The impact on healing of each material because of its associated modulus of elasticity has not been clearly elucidated. 
The torsional rigidity of a femur fracture treated with an intramedullary nail is determined by a combination of nail characteristics and fracture characteristics. Important nail characteristics include the presence or absence of an open section or slot, the wall thickness, the cross-sectional shape, and the presence or absence of interlocking screws.272 The presence of a slot, or an open section, significantly decreases the torsional rigidity of the nail. Similarly, increasing the wall thickness of the nail will result in an increase in the nail’s torsional stiffness. Therefore, with slotted and/or thin-walled nails, torsional loads may result in rotational changes in the fractured femur–nail construct, despite interlocking. In clinical practice, the torsional stability of the nail itself is of minor concern, provided the loads encountered do not exceed the nail’s elastic deformation limits. Bending stiffness is primarily determined by the outer diameter of the implant272 and the material (stainless steel vs. titanium). The modulus of elasticity of 316L stainless steel is approximately twice that of titanium. The ultimate strength of titanium is approximately 1.6 times that of stainless steel. Resistance to axial loading of the implant bone construct is primarily determined by the presence of interlocking screws and the bone contact at the fracture if applicable. It becomes obvious that multiple factors determine the final construct stiffness, all of which should be understood and considered when choosing a particular intramedullary nail. In the case of a purely transverse mid-diaphyseal femur fracture with predicted cortical interdigitation after nailing, the biomechanical characteristics of the implant are less important than in a segmentally comminuted fracture that will have no inherent stability after re-establishment of the length, alignment, and rotation. The effect on torsional and flexural rigidity of the cross-sectional shape and wall thickness of intramedullary nails has been studied.301 Implants of the same length and diameter were found to have greater than a twofold difference in flexural rigidity and greater than a threefold difference in torsional rigidity depending on these specific design parameters.301 
In many currently available nails manufactured, there is a large mismatch between the radius of curvature of the nail and the radius of curvature of the femur, which has been estimated to be between 109 and 120 cm.88,152 From a museum skeleton collection and a hospital biomechanics laboratory, the femoral bow was determined in 948 femurs from 474 matched pairs using a computer curve-fitting program.88 The average femoral radius of curvature was found to be 120 cm. Age and femoral length were not found to influence the radius of curvature. However, race did have an effect on anterior bow: African Americans donor femurs were noted to have less curvature. The radius of curvature of eight antegrade nails were measured and found to range from 186 to 300 cm, indicating that the implants were much straighter than the femurs that they are designed to stabilize. This mismatch could have an effect on nail entry, femoral bursting, and final femoral alignment in the sagittal plane. In response to this mismatch between the nail design and the average curvature of the femur, several implant manufacturers have designed implants with a smaller radius of curvature that more closely approximates the human femur. In addition, several new nail designs have a radius of curvature that varies along the length of the femur. The impact of several parameters and their effect on femoral bursting and fracture instability were determined by Tencer et al. and Johnson and Greenberg.153,300,301 The parameters that affect bursting of the femur during antegrade piriformis nail insertion include mismatch in curvature of the nail and femur, high bending stiffness, and poor location of the starting hole. An anterior offset of the starting hole of 6 mm from the centerline of the femoral canal was found to significantly increase the hoop stresses of the proximal femur. Factors identified that decrease in the force of femoral nail insertion includes overreaming and the use of a nail with a lower bending rigidity.152 
Location, angulation, number, and size of interlocking screws are variable, depending on the manufacturer. The number of distal interlocking screws necessary to maintain the proper length, alignment, and rotation of the implant bone construct depends on numerous factors including fracture comminution, fracture location, implant size, patient size, bone quality, and patient activity. Although the use of a single distal interlocking screw for femoral shaft fractures has been shown in a single study to provide equivalent torsional rigidity and axial load to failure when compared with two distal screws, these other factors must be considered when determining the number of screws.123 Distal fractures, extensive comminution, poor bone quality, and the expectation of early weight bearing are all variables that suggest the need for two distal interlocking screws. In addition, interlocking screws are highly loaded in axial compression during weight bearing. Although the static stability may be similar with one versus two screws, constructs with two screws can endure more cyclic loading. 
Bone healing after intramedullary nailing is usually predictable. Closed intramedullary nailing in closed fractures has the advantage of maintaining both the fracture hematoma and the attached periosteum. In addition, if standard reaming is performed, these elements provide a combination of osteoinductive and osteoconductive materials to the site of the fracture. Finally, reaming may produce a periosteal vascular response that increases the local blood flow. As a result, secondary bone healing with abundant fracture callus formation is expected in most femur fractures treated with intramedullary nailing. This leads to the ability to bear weight early after intramedullary nailing and a low refracture rate after nail removal in clinically indicated cases. 

Outcome Measures for Femoral Shaft Fractures

Historically, in the majority of publications, the outcomes after femoral nailing have been focused on rates of union, infection rates, and alignment in the coronal, sagittal, and axial planes.312,331,337 However, more recent publications have used hip kinematics, the Short Form Musculoskeletal Functional Assessment, and the Western Ontario and McMaster’s Universities Osteoarthritis Index hip function score12,243,284 (It is anticipated that these patient-oriented functional outcomes’ measure will continue to improve the treatment of femoral shaft fractures as techniques develop and are refined. 

Pathoanatomy and Applied Anatomy Relating to Femoral Shaft Fractures

The femur is the longest bone in the human body. It is tubular and has an anterior bow with a radius of curvature of approximately 120 cm. Proximally, the relevant osseous structures include the femoral head, femoral neck, calcar femorale, lesser trochanter, and greater trochanter. Distally, the femur widens into the metaphysis. The relevant distal osseous structures include the medial and lateral condyles, medial and lateral epicondyles, and distal femoral articulation. 
The shaft of the femur is cylindrical anteriorly, medially, and laterally. The thickened posterior cortex of the femur coalesces into the linea aspera in the central diaphysis of the femur. The linea aspera divides proximally to the lesser and greater trochanters, and distally to the medial and lateral femoral condyles. The linea aspera serves as a muscle attachment site as well as a buttress along the concavity of the femoral diaphysis. 
The femur is almost completely encased in muscles, most of which have attachments to the bone itself (Fig. 52-4). Knowledge of these muscle attachments is important for performing atraumatic surgical dissections and for understanding the commonly observed deformity patterns associated with fractures of the femur. The proximal muscular attachments include the hip abductor and short external rotator insertions at the greater trochanter, gluteus maximus osseous insertion at the posterolateral proximal femur, and iliacus and psoas insertions on the lesser trochanter. The adductors insert on the posterior and medial aspects of the femur along its length. The vastus lateralis origin is proximal, just distal to the gluteus medius insertion. The anterior and lateral femur serves as the origin for the vastus intermedius along the majority of the diaphysis. On the medial and posteromedial portions of the femur is the origin of the vastus medialis. Distally, the gastrocnemius originates from the posterior aspect of the femoral condyles. 
Figure 52-4
 
The primary muscular attachments on the anterior (A) and posterior aspects of the femur (B). Anterior view.
The primary muscular attachments on the anterior (A) and posterior aspects of the femur (B). Anterior view.
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Figure 52-4
The primary muscular attachments on the anterior (A) and posterior aspects of the femur (B). Anterior view.
The primary muscular attachments on the anterior (A) and posterior aspects of the femur (B). Anterior view.
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The resting tones of the primary muscles attaching to and spanning the femur largely determine the observed deformities (Fig. 52-5). Shortening is universally observed because of the pull of the hamstrings and quadriceps muscles. In proximal fractures (in the subtrochanteric region), the proximal segment is typically flexed, abducted, and externally rotated by the muscular pull of the hip abductors, external rotators, and iliopsoas. 
Figure 52-5
Muscular attachments and fracture location determine the observed deformities and displacements.
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The distal fragment is usually medialized because of the pull of the adductors. In distal fractures, the gastrocnemius muscle origins at the femoral condyles are largely responsible for the commonly observed fracture extension deformity. The shaft of the femur is frequently medialized because of the attachments of the adductor muscles. Because of these largely unopposed muscle forces, the exercise of attempting to reduce proximal and distal fractures with an increasing distraction force is typically futile. Limb position, strategic bumps, and externally applied forces are much more helpful than brute strength in improving the angulatory and translational deformities that occur. 
The thigh is divided into three main compartments that are separated by the medial, lateral, and posterior intermuscular septae (Fig. 52-6). The anterior compartment of the thigh contains the quadriceps femoris, iliacus, psoas, sartorius, and pectineal muscles. The neurovascular structures of the anterior compartment include the femoral artery and vein, femoral nerve, and lateral femoral cutaneous nerve. The posterior compartment contains the biceps femoris, semimembranosus, semitendinosus, and distal portion of the adductor magnus. The neurovascular structures of the posterior compartment include branches of the profunda femoris artery, sciatic nerve, and posterior femoral cutaneous nerve. The medial compartment contains the adductor brevis, the adductor longus, most of the adductor magnus, and the gracilis. The neurovascular structures of the medial compartment include the profunda femoris artery, obturator artery, and obturator nerve. 
Figure 52-6
Cross-sectional diagram of the thigh demonstrates the three major compartments.
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The relevant vascular anatomy includes both the vessels passing through the thigh as well as those perfusing the muscles and femur (Fig. 52-7). The external iliac artery becomes the femoral artery as it passes behind the inguinal ligament and enters the anterior compartment in the femoral triangle. The profunda femoral artery branches off the femoral artery and gives rise to the medial and lateral femoral circumflex arteries. The profunda femoral artery gives off numerous perforating branches along the length of the femur that pass posteriorly. Distally, the femoral artery passes through the hiatus of the adductor magus as it becomes the popliteal artery. Knowledge of the location of these vessels helps make surgical approaches uneventful. 
Figure 52-7
The vascular anatomy of the thigh as viewed from anterior (A) and posterior (B).
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The blood supply to the femur is from the primary nutrient vessel(s) and small periosteal vessels. The nutrient arterial supply to the femur was described in detail by Laing173 in a barium sulfate injection study of 10 adult femurs. The nutrient arteries were found to arise as branches of the profunda femoris perforating arteries. In four specimens, two nutrient arteries were present, similar to that found in pediatric long bones. However, in six specimens only one nutrient artery supplied the femoral shaft. In all cases the nutrient artery was found to enter the femur in the region of the linea aspera and branched proximally and distally to supply the medullary cavity. In most instances the nutrient artery enters in the proximal half of the femur; oftentimes it enters in the proximal third. The location of entry for this vessel has implications during surgical approaches. 
The linea aspera should not be stripped of its muscular attachments to preserve this nutrient vessel. The periosteal vascular supply to long bones has been described in detail by Rhinelander251 and was largely based on numerous animal studies and surgical dissections. He showed that the periosteal arteries are derived from the blood vessels that also supply the surrounding muscles of the bone. Anastomoses exist between the medullary and periosteal circulations, and the normal direction of flow through the entire cortical thickness is unidirectional from the medullary vessels to the periosteal vessels. With displaced fractures, the medullary arteries are disrupted, leaving the periosteal vessels with the principle role of providing circulation to the bone. The normal direction of blood flow is reversed with the loss of the medullary circulation, thus allowing cortical revascularization.251 
The entire femur can be approached laterally through a muscle-sparing interval from the greater trochanter to the knee. A lateral skin incision centered at the femoral shaft is used. The fascia lata can be incised along its length exposing the vastus lateralis beneath. The vastus lateralis can then be carefully dissected off the lateral intermuscular septum, allowing identification and ligation of the multiple perforating vessels. The vastus lateralis and underlying vastus intermedius can then be elevated, taking care to leave the underlying periosteum intact. 
Percutaneous or minimally invasive methods of plate application for the femur have been described.93 These techniques have the advantage of sparing significant portions of the perfusion to the femur. This has been confirmed in a dye injection cadaver study in which minimally invasive techniques were found to spare the nutrient and perforating arteries and were associated with a significant improvement in medullary and periosteal perfusion compared with open dissection techniques.93 

Femoral Shaft Fracture Treatment Options

Closed and Nonoperative Treatment of Femoral Shaft Fractures

Several methods of closed and nonoperative management exist for the treatment of femoral shaft fractures. These include spica casting, traction, cast bracing, or combinations thereof. Currently, closed management as definitive treatment for femoral shaft fractures is largely limited to instances in which devices for internal fixation are unavailable or in patients with significant medical comorbidities that make femoral stabilization impossible. However, the techniques of traction are applicable for the temporary stabilization of femur fractures until definitive fixation can be performed and in cases in which infection requires removal of all internal stabilizing implants. Although the use of cast braces is usually unnecessary with modern techniques for femoral stabilization, these techniques may be useful in limited circumstances such as in patients who cannot tolerate an anesthetic or as an augmentative device in patients with distal or shaft fractures in which adequate internal fixation was not obtained. 

Traction

Skeletal and skin traction can be used to regain length to the limb. Skin traction has limited utility because of the inability to apply sufficient and sustained forces without damaging the skin. This makes the use of skin traction a poor choice as a definitive treatment modality. However, in the initial stabilization of a patient in the field before evaluation at a hospital, some form of noninvasive traction using a temporarily applied splint may assist with aligning the limb, providing patient comfort, and limiting additional soft tissue injury caused by the mobile femoral shaft fracture segment. 
Skeletal traction for the femur can be applied after placement of an appropriate pin. This can be placed at the distal femur or the proximal tibia. Small-diameter pins (2 mm) can be optimized with the use of tensioned bows, obviating the need for large threaded Steinman pins. A traction pin should be placed with sterile technique if possible, and knowledge of the location of the relevant anatomical structures in the region of the pin entry and exit locations should minimize complications. The entry and exit tracts for the pin should be appropriately anesthetized with local anesthesia. Safe pin placement is usually from medial to lateral at the distal femur and from lateral to medial at the proximal tibia. Placement at the distal femur as opposed to the proximal tibia for fractures of the femoral shaft allows for direct traction of the fractured bone and avoids distraction across the potentially injured knee joint. Distal femoral pins should be placed in an extra-articular location to avoid septic arthritis. Proximal tibia pins are typically positioned at the level of the tibial tubercle and placed in a bicortical location. 
Temporary traction in anticipation of definitive operative femoral fracture treatment may consist of the application of weights attached to pulleys at the end of the bed, or some form of balanced suspension. Ideally, traction applied to the distal femur or proximal tibia is balanced against countertraction applied to the proximal femoral segment. Proximal countertraction can be accomplished with the weight of the patient or with Trendelenburg positioning. For definitive treatment of femoral shaft fractures with traction, the angle of limb, applied weight, and direction of the applied traction will all require adjustment based on the fracture location. 
Definitive treatment of femoral shaft fractures has been successfully accomplished with Neufeld roller traction and modifications thereof.42,102,151,186 The main advantages with Neufeld traction are early knee motion, enhanced patient mobility, and earlier discharge from the hospital. Fracture position can be well maintained despite the enhanced knee and patient mobility. In a study of 30 patients treated with Neufeld roller traction either temporarily or definitively, Browner et al.42 observed no nonunions and no infections. Similarly, Gates et al.102 reported on their experience with the use of hinged casts and roller traction in 121 patients in developing countries. In their series, hospital stay was short and all but one fracture healed. 

Cast Braces

Similar to traction techniques, cast braces are now used uncommonly for the treatment of femoral shaft fractures. However, cast braces can be used successfully, and the techniques of application for the appropriate indications are important to understand. In unusual circumstances, they can be used to augment intramedullary fixation if unlocked implants are used.277 For distal and femoral shaft fractures, cast braces allow early patient mobilization and may be used in combination with a period of traction.71,127,200 They are thought to work by converting the thigh into a semirigid hydraulic tube that maintains the alignment of the femur.200 Typically, traction is initially used until there is some stability to the fracture, usually for 6 to 8 weeks. Clinical resolution of fracture site discomfort, radiographic evidence of callus formation, and lack of fracture instability on clinical examination are all good indicators of early healing. Like any form of closed management, success depends on the technique of application and the proper implementation of weight bearing. Cast braces cannot be used to correct angulatory or rotational deformities. 
The indications, techniques, and success of cast brace application have been described in detail by Mooney et al.200 They described the application of a proximal thigh cast and a long leg cast incorporating the foot combined with a hinge at the knee joint. The authors reviewed the treatment of 150 patients with femoral shaft fractures treated with cast braces. The average time in traction was 7.3 weeks, and the average time of casting was 7.2 weeks. There were no nonunions or refractures. This compares to a group of patients treated by the same authors with traction followed by spica casting. In these patients the total treatment time was more than 24 weeks, and more than 10% of patients had either a nonunion or a refracture.200 In another study reviewing an experience with cast braces for femoral fractures, Hardy127 reported acceptable results in 106 patients. Union was predictable and comminuted mid-diaphyseal fractures were observed to shorten more than distal fractures.127 Similarly, Connolly et al.71 followed 143 patients with femoral shaft fractures treated with traction followed by cast bracing. Although shortening of up to 2 cm was observed frequently, nonunion and clinically significant malunion were uncommon. The conclusions of these studies demonstrate that cast braces can be successfully used for the treatment of femoral shaft fractures after a period of traction. 

Comparison Studies

The current preference for closed interlocked nailing over traction followed by cast bracing or spica casting of femoral shaft fractures is generally considered obvious. This was studied, and the improved outcomes with nailing were documented. Locked nailing was associated with a much shorter hospital stay, decreased time to union, and improved alignment when compared with traction plus casting.324 Similarly, Johnson et al.151 reported an average hospital stay of 31 days in patients treated with roller traction compared with 20 days for patients treated with intramedullary nails. The frequency of failure, defined as an unplanned reoperation or unacceptable alignment, was reported in 66% of fractures treated with roller traction compared with 4% of those treated with a locked intramedullary nail. Although these results come as no surprise, they do emphasize the significant improvements in treatment that have been observed with intramedullary nailing. 

External Fixation of Femoral Shaft Fractures

External fixation as a definitive treatment method for femoral shaft fractures has limited indications. However, temporary external fixation is used with increasing frequency in some valuable circumstances. External fixation is most easily accomplished with a unilateral frame (Fig. 52-8) but circular frames are designed specifically for the femur. Unfortunately, these devices are poorly tolerated by the patient over the extensive time necessary to ensure adequate healing of the femur. 
Figure 52-8
 
Association for the Study of Internal Fixation external half pin fixator used for temporary stabilization of a shaft fracture.
Association for the Study of Internal Fixation external half pin fixator used for temporary stabilization of a shaft fracture.
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Figure 52-8
Association for the Study of Internal Fixation external half pin fixator used for temporary stabilization of a shaft fracture.
Association for the Study of Internal Fixation external half pin fixator used for temporary stabilization of a shaft fracture.
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External fixation has several advantages, especially as a temporizing measure for the initial stabilization of a fractured femur. The procedure is rapid, and a temporary external fixator can be reliably applied in less than 30 minutes. This is particularly important in the critically ill patient.5,40,215,232,271 The vascular supply to the femur is not damaged to a significant degree during the application of an external fixator, and this may be important in high-energy and open injuries with significant damage to the extraosseous and intraosseous blood supply. No additional foreign material is introduced in the region of the fracture, which may be particularly advantageous in open fractures and injuries with infection. Further, external fixation allows access to the medullary canal and the surrounding tissues in open fractures with significant contamination. Dressing changes and local soft tissue care are maintained with external fixation, although other methods may allow improved access. 
Most of the disadvantages of femoral external fixation are related to this technique as a definitive treatment measure. Pin tract infections occur commonly and are related to the time the fixator is in place, the amount of soft tissues that the pins must traverse, and the sterility at the time of the initial application.128 Loss of knee motion occurs commonly. Angular malunion and femoral shortening occur more frequently than with other methods. There are still concerns about the potential increased infection risk associated with conversion of an external fixator to another definitive treatment method. Finally, unilateral external fixation has limited ability to adequately stabilize the femoral shaft. This is largely because of the large weight of the leg combined with the distance between the femoral shaft and the bar of the external fixator. 

Indications/Contraindications

The indications for external fixation (Table 52-2) are continuing to evolve.5,40,76,139,199,215,232234,261,271 Initially, extensive comminution and open fractures were considered to be relative indications for the use of femoral external fixation as a definitive treatment for femoral shaft fractures. However, as other treatment methods such as intramedullary nailing have continued to improve and low complication rates have been demonstrated with nails even in the most complex injuries, the indications for the use of external fixation have become more limited. Currently, the primary indications include use as a temporary bridge to intramedullary nailing (Fig. 52-9), in the severely injured patient who cannot tolerate reaming and/or placement of a medullary implant as a form of damage control orthopedics, in a patient with an ipsilateral arterial injury that require repair, and in patients with severe soft tissue contamination in whom a second debridement would be limited by other devices. Which patients are more suitable for initial placement of an external fixator followed by secondary conversion to a medullary implant continues to be better defined but includes patients with a severe head injury, elevated Injury Severity Score (ISS), associated thoracic trauma, or multiple extremity injuries. In patients with an accompanying ipsilateral arterial injury, an external fixator can be rapidly applied, produces temporary length appropriate stability of the limb, and can easily be converted to another form of stabilization.139 
Figure 52-9
 
A comminuted femoral diaphyseal fracture (A) in a patient with multiple other injuries including a pulmonary contusion, liver laceration, and head injury. Temporary external fixation (B) was rapidly applied initially to provide stability and alignment. Conversion to an antegrade nail 7 days later resulted in uneventful healing (C).
A comminuted femoral diaphyseal fracture (A) in a patient with multiple other injuries including a pulmonary contusion, liver laceration, and head injury. Temporary external fixation (B) was rapidly applied initially to provide stability and alignment. Conversion to an antegrade nail 7 days later resulted in uneventful healing (C).
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Figure 52-9
A comminuted femoral diaphyseal fracture (A) in a patient with multiple other injuries including a pulmonary contusion, liver laceration, and head injury. Temporary external fixation (B) was rapidly applied initially to provide stability and alignment. Conversion to an antegrade nail 7 days later resulted in uneventful healing (C).
A comminuted femoral diaphyseal fracture (A) in a patient with multiple other injuries including a pulmonary contusion, liver laceration, and head injury. Temporary external fixation (B) was rapidly applied initially to provide stability and alignment. Conversion to an antegrade nail 7 days later resulted in uneventful healing (C).
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Table 52-2
Indications and Contraindications for External Fixation
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Table 52-2
Indications and Contraindications for External Fixation
Indications
Severe soft tissue injuries with extensive contamination
Evolving muscular crush that requires an extensive secondary debridement
Medullary contamination
Associated vascular injury requiring stabilization prior to repair
Polytrauma or injuries that prevent other treatments; as a temporary bridge to femoral nailing (damage control orthopedics)
Contraindications
No absolute contraindications exist but external fixation is uncommonly used as a definitive treatment
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Technique

Application of a temporary unilateral frame is relatively straightforward and based on the biomechanical principles of external fixation. For patients requiring rapid application of a temporary spanning fixator, the goals should be limb realignment, patient comfort, and prevention of further soft tissue damage. Pins can be placed anteriorly, anterolaterally, or laterally. Anterior pins require placement through the extensor mechanism and should be avoided if possible. Laterally placed pins require placement through the iliotibial band and may similarly limit knee motion. To minimize this, the iliotibial band should be incised in line with the leg at the time of fixator placement. Pins can be placed from an anterolateral location, anterior to the iliotibial tract. This may minimize knee stiffness but is technically more difficult because the pins are out of plane with the typically obtained fluoroscopic images that are used for their placement. 
In adults, the pins should be at least 5 mm in diameter. A minimum of two pins per segment should be placed. A pin should be placed near the fracture but out of the predicted fracture hematoma. Another pin should be placed as far away from the fracture in each segment. If the external fixator is planned as a temporizing measure, a perfect reduction of the femur may be unnecessary. However, depending on the original indications for placement of the external fixator, the device may ultimately remain in position for longer than expected. As a result, every attempt should be made to realign the limb and re-establish the femoral length to facilitate the secondary intramedullary nailing procedure. 

Outcomes

Initially, external fixation was used definitively for femoral shaft fractures with extensive comminution, associated open wounds, or multiple life-threatening injuries. Several small series reported fracture union, early mobilization, rare infections, and limited impact on knee motion.5,76,116,261 Alonso et al.5 treated 24 patients with femoral shaft fractures with external fixation. This was a temporary treatment in 14 patients, although in 10 patients this was definitive. Healing was ultimately observed in 88%, but almost half of the patients had significant loss of knee motion. Shortening was noted in two patients treated definitively with external fixation. On the basis of their experience, the authors recommended the use of external fixation in several circumstances including the aggressive management of soft tissue injuries, for the severely head injured or traumatized patient, and for infected femoral nonunions. The limitations of external fixation as a definitive treatment method in open femoral shaft fractures were further elucidated by Mohr et al.,199 who reported a lengthy treatment period of more than 5 months, early deep infections in 11%, late deep infections in 11%, shortening in 7%, and restricted knee motion in 20%. Although all fractures healed, the high incidence of complications and secondary surgeries in this group of patients cannot be overlooked. 
The use of temporary spanning external fixation in a large series of patients was reported by Nowotarski et al.215 Of more than 1,500 femoral shaft fractures treated with intramedullary nailing during the same time period, 54 patients were treated with external fixation followed by planned conversion to an intramedullary nail. The primary indications for this protocol included critically ill patients (n = 46) or patients who required expedient femoral fixation for repair of an ipsilateral vascular injury (n = 8). The average ISS of these patients was 29, and open injuries were present in 19. The average period of external fixation was 7 days with a range of 1 to 49 days. The majority of patients underwent conversion from an external fixation to an intramedullary nail at a single operative procedure (n = 55), but this was done in a staged fashion in four patients who had significant pin site drainage. In these four patients, traction with intravenous antibiotics lasting an average of 10 days was instituted to allow resolution in the intervening time period. Overall, healing was observed in 97% of patients within 6 months. One patient developed an infected nonunion, and one patient had an aseptic nonunion. The average knee motion was 107 degrees. The authors concluded that immediate external fixation followed by early conversion to intramedullary nailing for femoral shaft fracture was safe in selected multiply injured patients.215 The safety of temporary external fixation with delayed conversion to an intramedullary implant was further corroborated in a retrospective study of 173 patients with 192 fractures. The infection rates with initial external fixation followed by conversion to an intramedullary device were similar to that in patients treated with primary intramedullary nailing in multiply injured patients. Pin site contamination was observed more commonly when the fixator was left in place for more than 2 weeks, suggesting a timely conversion to a medullary implant whenever possible.128 
More recently, the use of temporary femoral external fixation has been investigated to further define the indications in multiply injured patients. This has led to the concept of “damage control orthopedics” in selected patients who may be poor candidates for early definitive intramedullary nailing of the femur. Scalea et al.271 reported their results with early external fixation followed by definitive intramedullary nailing in 43 patients with contraindications to primary nailing. This included patients with associated head injury, hemodynamic instability, thoracoabdominal trauma, and multiple other injuries. Similarly, Pape et al.234 reported their conversion from early total care of patients to “damage control orthopedics” in the polytraumatized patient. This was characterized by more frequent use of spanning and temporary external fixation to treat lower-extremity and femoral fractures followed by delayed conversion to intramedullary nailing. The incidence of multiple organ system failure was noted to decrease with this change in treatment philosophy and was believed to be an adequate alternative in patients at high risk for development of acute respiratory distress syndrome (ARDS) or multiple organ system failure.233,234 In a prospective, randomized, multicenter study, a sustained inflammatory response was seen after primary (<24 hours) intramedullary femoral instrumentation, but not after initial external fixation or after secondary conversion to an intramedullary implant. These findings may become clinically relevant in patients at high risk of developing complications. In addition, it confirms previous studies that suggest damage control orthopedic surgery minimizes the additional surgical impact induced by acute stabilization of the femur.233 With time and further study, the indications for early external fixation followed by delayed conversion to intramedullary nailing will become better defined. 

Operative Treatment of Femoral Shaft Fractures

Plate Fixation for Femoral Shaft Fractures

Operative stabilization with any technique offers numerous advantages compared with nonoperative methods and includes early patient mobilization and early functional rehabilitation of the injured extremity. The use of plate fixation for the routine treatment of femoral shaft fractures has decreased with the increased use of intramedullary nails. Several distinct advantages to plating do exist, including the ability to obtain an anatomical reduction in appropriate fracture patterns and the lack of additional trauma to remote locations such as the femoral neck, acetabulum, and distal femur. The main disadvantages associated with plate fixation when compared with intramedullary nailing are the need for an extensive surgical approach with its associated blood loss, infectious complications, and soft tissue insult. This can result in associated quadriceps scarring and its effects on knee motion and quadriceps strength. Further, the impact of the plate on the femur after fixation cannot be minimized. This includes the decreased vascularization beneath the plate and the stress shielding of the bone spanned by the plate. Minimally invasive techniques of plate application, although not addressing all of the issues associated with plating, do minimize the additional vascular insult to the periosteal and medullary blood supply of the femur.93 However, minimally invasive techniques have been associated with an increased incidence of malreduction.349 Finally, because the plate is a load-bearing implant, implant failure is expected if union does not occur. Although implant failure will ultimately occur with any orthopedic device in the case of nonunion, a load-sharing implant of sufficient size such as a nail will likely have increased longevity compared with a plate. 

Indications/Contraindications

Almost any fracture of the femur can be successfully plated. However, with the predictable results of intramedullary nails for both the initial treatment of femoral fractures and the salvage of other failed fixations, the use of plates as a primary treatment method is limited (Table 52-3). That being stated, certain clinical situations and patient factors may make plates desirable. In most instances, the relative indications for plating are the same as the relative contraindications for intramedullary nailing. In patients with an extremely narrow medullary canal in whom intramedullary nailing is impossible or difficult, plates remain an excellent option. Plates are useful in fractures that occur adjacent to or through a previous malunion, or in cases in which there is obliteration of the canal because of infection or previous closed management. Plates may be advantageous in fractures that have associated proximal or distal extension into the pertrochanteric or condylar regions because fracture reduction and stabilization may be difficult with a medullary implant. 
 
Table 52-3
Indications and Contraindications for Plating
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Table 52-3
Indications and Contraindications for Plating
Indications
Patients with an extremely narrow medullary canal
Fractures around or adjacent to a previous malunion
Fractures extending proximally or distally into the pertrochanteric or metaphyseal region
Associated vascular injury requiring repair
Ipsilateral neck shaft fractures
Fractures at or near previously place implants (e.g., periprosthetic or peri-implant fractures)
Skeletal immaturity
May be possible or considered for any femoral shaft fracture
Contraindications
There are few if any absolute contraindications to plating but this method is not frequently used in adults given the success and early weight bearing associated with intramedullary nailing
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In patients with an associated vascular injury, the exposure for the vascular repair frequently involves a wide exposure of the medial femur. If rapid femoral stabilization is desired, a plate can be applied quickly through the medial open exposure. However, in this circumstance the rate of nonunion is likely increased by the combination of the injury and surgical exposure. One should consider that any salvage procedures in this scenario will require a repeat surgical exposure through a scarred medial approach around a vascular repair. 

Surgical Procedure: Plating of the Femoral Shaft

Preoperative Planning.
A radiolucent table will be necessary for adequate imaging. Depending on the fracture configuration, an open or a submuscular technique may be applicable. For simple fracture patterns that allow an accurate cortical reduction of the majority of the femoral shaft, an open technique with compression plating using AO principles is advisable. However, in fracture patterns that have near circumferential or segmental comminution, bridge plating techniques are applicable. This can be accomplished with submuscular plate placement or an open technique that leaves all the intercalary comminuted segments undisturbed. No matter what technique is chosen, the vascularity to the femoral shaft and the associated fracture segments should be preserved. The size of the patient and the fracture configuration will determine the necessary plate size and length needed for fixation. In general, a longer implant is preferable. Contouring of the plate to the normal femoral anatomy is important for both submuscular plating and open plating, especially if nonlocked fixation is planned (Table 52-4). 
 
Table 52-4
Preoperative Planning Checklist
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Table 52-4
Preoperative Planning Checklist
OR table: A radiolucent flat top table that allows unimpeded radiographic imaging
Position/positioning aids: Can be accomplished either supine or lateral. If supine, a rolled blanket, bolster or positioning pillow placed beneath the injured buttock produces internal rotation of the hip to neutral, allowing predictable AP and lateral imaging. A foam ramp or soft support beneath the leg assists with lateral imaging
Fluoroscopy location: The C-arm is usually placed opposite the injured side if the patient is supine; this allows for AP and lateral imaging without moving the leg. If lateral position is used, the C-arm is placed opposite the surgeon and perpendicular to the OR table; the surgeon is positioned posterior to the laterally positioned patient
Equipment: Large fragment plates accommodating 4.5 mm nonlocked or 5 mm locked screws. Narrow and broad plates should be available depending on the patient’s size. If the fracture is located distally or proximally, precontoured or anatomically designed plates may be advantageous. Large fragment set, large reduction forceps, femoral distractor, 5 mm Schanz pins, large plate bender, drill
Special considerations: This technique may be used on any femoral shaft fractures but is usually reserved for those with a complicating issue such as a narrow canal, previous deformity, open physes, an associated vascular injury, proximal or distal fracture extension, or fractures of ipsilateral femoral neck or acetabulum
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Positioning

The patient can be positioned supine or lateral on a completely radiolucent table to allow unimpeded fluoroscopic imaging of the femur from the hip to the knee. Lateral positioning eases the retraction of the vastus lateralis in open techniques but may not be applicable in the polytraumatized patient. In addition, proximal imaging can be more difficult with the patient positioned laterally. For supine positioning, the entire limb should be prepped in the surgical field, including the groin to allow access to femoral vessels if necessary. A small bump beneath the ipsilateral hip helps to internally rotate the limb to neutral, simplifying the surgical approach and making the intraoperative assessment of rotation easier. A radiolucent ramp or several folded blankets placed beneath the thigh and leg improves the lateral fluoroscopic imaging by elevating the leg relative to the contralateral extremity. 
Surgical Approach.
For open compression plating of simple fracture patterns, a lateral incision is used. The length of the incision should be of adequate size to allow placement of a long plate directly on the lateral femur without traumatic retraction of the muscular envelope. The iliotibial band is sharply incised along the length of the incision. The vastus lateralis is then atraumatically elevated from the posterior limb of its fascia, from distal to proximal. The perforating vessels should be sequentially identified, isolated, and ligated. The muscle can then be elevated off the periosteum at the lateral femur. No periosteal stripping is necessary, and no deep retractors placed over the anterior femur should be used. If a minimally invasive plating technique is used, small incisions placed laterally at the proximal and distal aspects of the femur will allow for implant placement along the lateral aspect of the distal femur. 
Technique (Table 52-5).
 
Table 52-5
Plating Femoral Shaft Fracture Surgical Steps
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Table 52-5
Plating Femoral Shaft Fracture Surgical Steps
Determine whether a minimally invasive submuscular approach or an open approach will be used
Expose the lateral femur using a lateral approach preserving the vastus lateralis if an open approach is used
Re-establish length either with manual traction or a femoral distractor
Determine if bridge plating, lag screw fixation and neutralization plating, or compression plating is desired
If bridge plating, contour the lateral plate of appropriate length and apply to the lateral femur
If compression plating of a transverse, fix the overcontoured plate to one side and compress the fracture
Ensure adequate plate length and screws on either side of the fracture
Confirm length, alignment, and rotation of the femur
X
Reduction of the femur can be difficult, and several useful adjuncts are available. The patient should be pharmacologically paralyzed to allow for re-establishment of femoral length. Several useful intraoperative measures are available to assist with the indirect reduction of the femoral shaft. A femoral distractor can be applied to facilitate restoration of length, alignment, and rotation. Alternatively, a distal femoral traction pin can be applied, allowing for manual distraction and rotational control. The plate can be applied and fixed to one end of the femur followed by the use of a push screw or the articulated tensioner distractor. Finally, joysticks consisting of 5-mm Schanz pins can be placed into each femoral segment to assist with control of the alignment and rotation. 
The size and length of the implant remain controversial. Even in simple patterns, a 10-hole, 4.5-mm plate should be considered a minimum length. The choice of a broad or a narrow plate depends on the femoral diameter and the size of the patient. As the fracture comminution increases, so should the plate length such that at least five screw holes of plate length are present on each side of the fracture (Fig. 52-10). For transverse fractures, appropriate overcontouring of the plate should be performed, and the fracture should be appropriately compressed. This can be accomplished with a pull screw, the articulated tensioning device, eccentric screw placement(s) within the holes, or combinations thereof. For oblique fractures, overcontouring of the plate is inadvisable and compression should be obtained with standard techniques using the obliquity of the fracture relative to plate. A lag screw through the plate increases the construct rigidity and should be used if appropriate. The number of screws necessary for adequate stabilization remains unknown, although eight cortices on each side of the fracture have been recommended in the past.180 The number of screws and the number of cortices are less important than the plate length.290,291 There are very few disadvantages to the use of a longer plate with fewer screws other than the need for a longer incision (Fig. 52-11). However, screws can be placed percutaneously if a longer implant with a smaller surgical approach is desired. Three screws in each segment should maximize the biomechanical fixation. This should include a screw at the end of the plate (preferably directed obliquely) and a screw as close as possible to the fracture. A third screw in each segment further increases the torsional stability of the bone implant construct.291 
Figure 52-10
Femoral plating for a simple fracture pattern.
 
Plate length and screw position are more important than screw number.
Plate length and screw position are more important than screw number.
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Figure 52-10
Femoral plating for a simple fracture pattern.
Plate length and screw position are more important than screw number.
Plate length and screw position are more important than screw number.
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Figure 52-11
This 74-year-old male sustained a periprosthetic femoral shaft fracture after a motor vehicle crash (A, B).
 
He had no previous problems with his hip prosthesis. The femur was plated using an extensile lateral approach (C–F). Given the spiral fracture configuration, a direct fracture reduction with lag screw fixation was performed. A long neutralization plate that spanned the entire femur was used.
He had no previous problems with his hip prosthesis. The femur was plated using an extensile lateral approach (C–F). Given the spiral fracture configuration, a direct fracture reduction with lag screw fixation was performed. A long neutralization plate that spanned the entire femur was used.
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Figure 52-11
This 74-year-old male sustained a periprosthetic femoral shaft fracture after a motor vehicle crash (A, B).
He had no previous problems with his hip prosthesis. The femur was plated using an extensile lateral approach (C–F). Given the spiral fracture configuration, a direct fracture reduction with lag screw fixation was performed. A long neutralization plate that spanned the entire femur was used.
He had no previous problems with his hip prosthesis. The femur was plated using an extensile lateral approach (C–F). Given the spiral fracture configuration, a direct fracture reduction with lag screw fixation was performed. A long neutralization plate that spanned the entire femur was used.
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The technique of submuscular plating for the femur is similar to that in other long bones.319,326,349 The goal is to minimize any associated trauma to the muscular envelope and the periosteum surrounding the femur. This can be accomplished by using small incisions at the palpable proximal and distal aspects of the lateral femur. A plate of appropriate length can be contoured and slid beneath the vastus lateralis along the length of the femur. A plate that spans most of the femur exploits the palpable portions of the femur proximally and distally and is actually easier to apply than a shorter plate. The lack of an appropriate anterior bow in long plates can make plate application difficult in simple patterns. However, in comminuted fractures in which bridging fixation is planned and submuscular techniques are most applicable, the use of a straight plate is usually not problematic. After the plate is placed on the midlateral aspect of the femur, the length, alignment, and rotation of the femur should be restored either manually or with a femoral distractor. Screws can then be fixed proximally and distally without difficulty. Additional screws are placed through percutaneous stab incisions along the lateral femur according to the aforementioned biomechanical principles. 
Postoperative Care.
External supports such as casts or cast braces are unnecessary after a properly performed plate application for a femoral fracture. Early active range-of-motion exercises should be encouraged as soon as wound healing allows. Weight bearing should be limited to the weight of the leg until there is radiographic evidence of healing and resolution of fracture site discomfort. Radiographic evaluations at 6-week intervals are usually adequate for following the progression of healing. If direct reduction and compression plating are used, primary bone healing is predicted. As a result, radiographic evidence of healing and, thus, weight bearing are frequently delayed for 4 to 5 months.104,255 If bridge plating and indirect reduction techniques are used, healing should progress similar to intramedullary nailing with callus formation evident on radiographs. As a result, weight bearing can usually begin earlier. Plate removal should be limited to symptomatic patients and should be delayed for a minimum of 18 to 24 months because of the risk of refracture. 
Potential Pitfalls and Preventative Measures.
There are a number of potential problems that can be encountered with femoral plating. Fracture malreduction can be anticipated and minimized by obtaining contralateral radiographs. These can be used to judge the proper femoral length as well as the coronal and sagittal plane alignments of the femur. This may be especially applicable if a bridge plating technique is planned. Careful contouring of the plate is especially important if nonlocking screws are anticipated. In order to decrease the incidence of nonunion and infection, the biologic impact of the surgical approach on the femoral blood supply should be minimized. Minimally invasive techniques, avoidance of fragment devitalization with clamps or retractors, and bridging techniques can all contribute to decreasing the biologic insult of the plating procedure (Table 52-6). 
 
Table 52-6
Potential Pitfalls and Preventative Measures
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Table 52-6
Potential Pitfalls and Preventative Measures
Pitfall Prevention
Fracture malreduction in length
  1.  
    Obtain contralateral femur radiographs if bridge plating is planned
  2.  
    Use of a femoral distractor to re-establish length
  3.  
    Careful contouring of the plate
Fracture malreduction in the coronal or sagittal planes
  1.  
    Obtain contralateral radiographs if bridge plating is planned
  2.  
    Careful plate contouring
Devitalization of the fracture fragments
  1.  
    Avoidance of an aggressive surgical approach
  2.  
    Avoidance of large medial retractor placements
  3.  
    Use of minimally invasive techniques
  4.  
    Avoiding the desire to anatomically reduce comminuted intercalary fragments, especially if bridge plating is applicable
X
Outcomes.
The early experience with compression plating of femoral shaft fractures using AO techniques were relatively consistent. Implant loosening occurred in 6% to 11% of cases, nonunion in 2% to 8%, and infection in 0% to 7%. Bone grafting was recommended for defects or in cases with questionable fixation.62,181,264,302 For the most part, direct reduction and stable fixation of the fracture were recommended. Ruedi and Luscher264 reported on the results of plating 126 comminuted fractures using Association for the Study of Internal Fixation techniques. Plate failures and nonunion were observed in less than 10% of cases, yet the authors still recommended bone grafting in all fractures of the femoral shaft fixed with a plate. Surprisingly, as early as 1979, bridge plating of comminuted fractures was recommended in an effort to maximize the vascularity and healing of these fragments.183 
Riemer et al.255 reported on 141 comminuted diaphyseal femur fractures treated with immediate plate fixation. More than one-third of these fractures were open. Autogenous bone grafting, typically from the ipsilateral proximal tibial metaphysis, was performed in 95% of patients. Ten plate failures were observed (7%), and most healed after subsequent treatment with an intramedullary nail. There was one infection in a patient with an open fracture. The average time to union was 17 weeks. Similarly, Geissler et al.104 reported a 93% union rate at 16 weeks in 71 plated femoral shaft fractures. Cancellous bone grafting was used in 69% of patients and was recommended as a standard supplement in this technique. 
Currently, the routine use of cancellous bone grafting in plated femoral shaft fractures may be unnecessary if indirect reduction techniques and a biologically friendly surgical approach are used.263,319,326,349 Although simple fracture patterns continue to be amenable to direct reduction and stable fixation, comminuted fractures can be treated by completely avoiding the fracture fragments. By bridging the fracture using incisions well away from the fracture, a plate can be slid beneath the vastus lateralis and applied to the lateral femur with a combination of percutaneously applied and openly applied screws. The main goals of this technique are restoration of femoral length, alignment, and rotation with preservation of blood supply to the fracture and comminuted fragments. Early reports suggest that this technique can be safely performed with results similar to other indirect methods for femoral stabilization.263,319,326,349 
The use of traditional open reduction and submuscular plating was retrospectively compared by Zlowodski et al. No bone grafts were used in either group and a low infection rate was observed and was unrelated to the surgical approach. However, the submuscular technique was associated with a higher rate of suboptimal reductions (29%) compared to a biologically respectful open approach.349 

Antegrade Intramedullary Nailing for Femoral Shaft Fractures

Indications/Contraindications

The vast majority of femoral shaft fractures can be treated with intramedullary nailing (Table 52-7). Fracture comminution is not a contraindication to nailing. Other techniques of femoral fixation may be considered in certain circumstances including significant femoral deformity, a narrow femoral canal, a history of a medullary infection, open growth plates, or some severely polytraumatized patients. Antegrade femoral nailing can be one of the most predictable procedures in orthopedic traumatology (Table 52-8). It is the most common treatment for femoral shaft fractures in adults, and virtually all orthopedic surgeons have had some exposure and experience with the techniques necessary to successfully perform a femoral nailing. However, there are numerous aspects to the procedure that require emphasis to ensure a good result with minimal complications. Many of the technical aspects of planning, positioning, reduction, nailing, and interlocking are appreciated with increasing experience. 
Table 52-7
Antegrade Nailing of Femoral Shaft Fractures (Piriformis Entry) Indications and Contraindications
Indications
The vast majority of femoral shaft fractures
Isolated femoral shaft fractures
Comminuted femoral shaft fractures
Open fractures
Contraindications
A narrow canal that will not accommodate a nail
Open growth plates
Previous malunion that prevents nail placement
History of intramedullary infection
Associated ipsilateral femoral neck or acetabular fracture (relative)
Polytraumatized patients with associated thoracic injury (relative)
X
Table 52-8
Selected Reports of Femoral Fracture Treatments and Results
N Treatment Nonunion (%) Infection (%) Special
Alonso et al.5 24 External fixation 12 4
Mohr et al.199 17 External fixation 0 11 Only open femur fractures
Nowotarski et al.215 54 External fixation then nailing 3 2 Planned early conversions
Ruedi and Luscher264 131 Plate 7 6
Riemer et al.255 141 Plate 7 1
Geissler et al.104 71 Plate 7 0
Loomer et al.181 46 Plate 2 7
Tornetta and Tiburzi312 83 Reamed antegrade nail 0 0
Wolinsky et al.337 551 Reamed antegrade nail 6 1
Wiss et al.334 112 Reamed antegrade nail 2 0
Brumback et al.48 87 Reamed antegrade nail 2 1
Canadian Orthopaedic Trauma Society53 121 Reamed antegrade nail 2 ?
Hammacher et al.125 129 Unreamed antegrade nail 5 3
Canadian Orthopaedic Trauma Society53 107 Unreamed antegrade nail 8 ?
Tornetta and Tiburzi312 89 Unreamed antegrade nail 0 0 Time to union higher for unreamed
Ostrum et al.220 54 Retrograde nail 2 ?
Ricci et al.252 134 Retrograde nail 6 ?
Tornetta and Tiburzi311 31 Retrograde nail 0 0
X
Preoperative Planning (Table 52-9).
 
Table 52-9
Preoperative Planning Checklist
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Table 52-9
Preoperative Planning Checklist
OR table: Either a fracture table or a radiolucent flat top table that allows unimpeded radiographic imaging, depending on the preference of the surgeon and the available assistance for the procedure
Position/positioning aids: Can be accomplished either supine or lateral. If supine on a radiolucent flat top table, a rolled blanket or positioning pillow placed beneath the injured buttock produces internal rotation to neutral, allowing predictable AP and lateral imaging. A foam ramp or soft support beneath the leg assists with lateral imaging with the patient positioned supine on a flat top table. For supine positioning on a fracture table, a support beneath the buttock will assist with maintaining the proper rotation of the proximal femoral segment
Fluoroscopy location: The C-arm is usually placed opposite the injured side if the patient is supine; this allows for AP and lateral imaging without moving the leg. If lateral position is used, the C-arm is placed opposite the surgeon and perpendicular to the OR table; the surgeon is positioned posterior to the laterally positioned patient
Equipment: Nails of proper length and diameter with the appropriate interlocking bolts. Reduction tools including 5 mm Schanz pins, large reduction forceps, a femoral distractor, intramedullary reduction tools, etc. Distal femoral traction pin with a traction bow. Reamers, drills, guidewires
Special considerations: Intraoperative length and rotation must be carefully assessed. The femoral neck should be evaluated for a possible fracture prior to and following all nailing procedures
X
Preoperative planning begins with an understanding of the fracture pattern, which is dependent on an understanding of the mechanism of injury and the applied force. Good-quality biplaner radiographic images are necessary and should be reviewed to determine the canal dimensions, femoral length, presence of comminution, femoral morphology, and presence of nondisplaced fracture extensions that may complicate treatment. Contralateral femoral radiographs can be obtained if there is concern regarding the femoral morphology or in cases with significant comminution, which makes estimates of femoral length unreliable. The lateral radiograph should be scrutinized to determine the femoral bow. Because virtually all femoral nails have a radius of curvature that is greater (i.e., less curved) than the normal femoral, increasing femoral bow can make nailing difficult using unmodified implants. The radiographs should be viewed to determine whether there is any associated preinjury osseous pathology such as metastatic disease, primary bone tumor, osteomyelitis, or malunion. 
As a part of the preoperative plan, the proper length and diameter of a femoral nail should be anticipated before considering operating on a patient. The femoral length can be determined by several methods. Radiographs of the contralateral femur can be measured with a ruler that is corrected for magnification. In fractures without significant comminution, traction radiographs of the injured femur can be used to estimate the length. Alternatively, a long ruler can be used to measure the uninjured femur from the palpable greater trochanter to the lateral epicondyle. The diameter of the intramedullary canal should be estimated at the narrowest portion of the femoral canal at the femoral isthmus. This is usually based on the lateral radiograph. Although these measures are estimates only and a more accurate assessment can be obtained intraoperatively, this allows the surgeon to ensure that an adequate supply of femoral nails with the predicted lengths and diameters are available. Patients with small femoral canals (<10 mm) may require special implants specifically designed for these situations. 
Some type of femoral traction should be maintained during the time period extending from identification of the injury to surgical stabilization. Because delay is unpredictable and frequently unanticipated, skeletal traction should be placed as early as possible. Traction maintains femoral length, prevents further soft tissue injury, provides patient comfort, and may limit the amount of ongoing blood loss into the thigh. A distal femoral traction pin is preferred to a proximal tibial pin because of the more direct line of pull and the high incidence of associated knee ligamentous injuries. A large traction pin is painful, traumatic to place, and unnecessary. A small pin (5/64 in or 2 mm) can be placed from medial to lateral at the distal femur and tensioned with a traction bow. The ideal location is anterior in the distal metaphyseal region of the femur, allowing future passage of the antegrade nail. Approximately 15 to 20 pounds of weight (or up to 15% of body weight in larger patients) is usually adequate to maintain femoral length in most patients if traction is applied acutely. A pulley system at the end of the bed or, ideally, balanced suspension should be used. 
In closed fractures, preoperative prophylactic antibiotics consisting of a first-generation cephalosporin in patients without an allergy should be used. Additional antibiotic coverage is necessary in open fractures and is dependent of the level of contamination, and the estimated associated soft tissue injury. 
Patient Positioning.
Patient positioning for treatment of a femoral shaft fracture depends on numerous factors including the method of stabilization, associated injuries, and surgeon comfort (Table 52-10). In a patient with a known spine injury or in a patient who cannot be adequately evaluated before femoral stabilization, protection of the spine from further injury is vital. Lateral bending of the spine can be minimized with supine positioning on a radiolucent table and femoral stabilization with a retrograde nail, an external fixator, or a plate. Supine positioning on a radiolucent table with antegrade nailing requires some degree of lateral bending to allow access to the starting point. This can be minimized with placement of a trochanteric entry nail, which allows a more lateral starting point than with piriformis entry nails. 
 
Table 52-10
Lateral versus Supine Positioning for Antegrade Nailing
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Table 52-10
Lateral versus Supine Positioning for Antegrade Nailing
Supine: Radiolucent Table Supine: Fracture Table Lateral: Fracture Table
Multiple injuries or polytrauma + + + + ++ +/–
Associated spine injurya + +
Acetabular fracture (associated pattern) + + ++
Obesity +++
Positioning time Decreased Increased Increased
Need for assistance Increased Decreased Decreased
X
Antegrade femoral nailing can be successfully performed with the patient lying supine or lateral, each position having specific advantages and disadvantages. In addition, nailing can be done on a fracture table or a radiolucent table with or without traction. With either position on either type of table, the accurate placement of a distal femoral traction pin assists with the intraoperative assessment of femoral rotation and attainment of the proper length. Even if a pin has been placed in the emergency department for temporary application of traction, the pin position should be confirmed fluoroscopically in the operating room and changed if not in the proper location. An ideal pin should be perfectly parallel to a condylar overlap lateral of the distal femoral condyles, ensuring that the rotation of the distal femur is known. This is best accomplished by placing the pin under fluoroscopic guidance on the lateral view with the femur properly rotated. In addition, the pin should be positioned anteriorly to allow passage of the nail posterior to the pin. This eliminates the time-consuming and frustrating exercise of trying to remove the traction pin as the femoral nail is passed later in the procedure. Because of the natural tendency for a valgus deformity when performing antegrade nailing in the lateral position, consideration can be given to placing the pin somewhat angulated in the coronal plane (proximal lateral to distal medial). 
Supine positioning allows unencumbered access to the entire patient by the anesthesiologists, general surgeons, neurosurgeons, and other physicians involved with ongoing resuscitation and treatment. This is especially important in patients with multiple thoracic or abdominal injuries, spine fractures, pelvic ring injuries, or multiple extremity fractures. Patients with multiple extremity injuries can undergo simultaneous treatment if positioned supine. Rotational and angular deformities maybe minimized with supine positioning compared with lateral positioning. The rotation of the leg is more easily judged with the entire limb accessible. The main disadvantage with supine positioning is difficulty with identifying the proper starting point if a first-generation antegrade nail is anticipated. The gluteal muscles and the associated fat on the lateral thigh make palpation of the greater trochanter difficult. Hip adduction improves access to the proximal femur. With lateral positioning, patient access is limited and pulmonary function is suboptimal. However, identification of the starting point is improved because the hip is flexed, angulating the torso away from the line of the femoral shaft. As well, because of the natural adduction of the hip, the soft tissues of the lateral hip tend to fall away from the anticipated incision. 
Supine positioning on the fracture table is time consuming but allows consistent and untiring intraoperative traction (Fig. 52-12). Although not necessarily supported in the literature, use of the fracture table may minimize the number of surgical assistants necessary. A distal femoral traction pin is preferable to traction applied to the foot with the fracture table. This allows direct control of the distal femoral segment, ensuring an accurate assessment of rotation without distracting across the knee joint. In addition, distal femoral traction allows the knee to be flexed, minimizing the intraoperative stretch and tension on the sciatic nerve. Alternatively, a traction pin can be placed at the proximal tibial metaphysis. This pin location prevents interference with the medullary implant, however, traction is applied across the potentially injured knee joint and is not in direct line with femoral axis. A combination of limb adduction and tilting of the trunk away from the ipsilateral hip improves access to the nail entry site. However, this requires that the patient’s lumbar and thoracic spines are stable to positioning alterations. Fluoroscopic imaging in the AP and lateral planes is usually without difficulty. The uninjured leg can be positioned with the hip and knee flexed to 90 degrees. However, numerous reports of unrecognized compartmental syndrome in the uninjured leg during lengthy femoral nailing procedures with the use of a well-leg holder that supports the calf emphasize the need to either check the leg intraoperatively every hour or abandon this position completely.6,86,193 The relationship between compartmental pressures and time in a well-leg holder was evaluated by Tan et al.297 in a study of 10 patients undergoing femoral nailing procedures. The authors demonstrated an immediate increase in pressure with positioning in the well-leg holder that trended upward with time. The pressure immediately returned to normal when the leg was taken out of the holder. They further identified a correlation between leg pressure and body mass index.297 The combination of decreased perfusion caused by leg elevation and external pressure from a calf support has been confirmed to cause a decrease in the difference between diastolic blood pressure and the intramuscular pressure when the uninjured leg is placed into a well-leg holder on a fracture table.193 On the basis of their study in healthy volunteers, Meyer et al.193 demonstrated that positioning that leaves the calf free increases the difference between the diastolic and intramuscular pressure, potentially decreasing the risk of compartmental syndrome. This can be accomplished by supporting the leg at the knee and the heel, leaving the calf free to hang.193 Alternatively, the uninjured leg can be placed into a foot holder on the traction table. The uninjured leg can be “scissored” with the hip and knee extended. In this position, lateral fluoroscopic imaging of the proximal femur is compromised but the safety of the uninjured leg is increased. 
Figure 52-12
Supine position for closed intramedullary nailing using a fracture table.
 
The image intensifier is positioned on the side opposite the injured extremity. In order to obtain intraoperative lateral imaging, the uninjured leg can be extended (as shown).
The image intensifier is positioned on the side opposite the injured extremity. In order to obtain intraoperative lateral imaging, the uninjured leg can be extended (as shown).
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Figure 52-12
Supine position for closed intramedullary nailing using a fracture table.
The image intensifier is positioned on the side opposite the injured extremity. In order to obtain intraoperative lateral imaging, the uninjured leg can be extended (as shown).
The image intensifier is positioned on the side opposite the injured extremity. In order to obtain intraoperative lateral imaging, the uninjured leg can be extended (as shown).
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X
Intramedullary nailing may be easier for the surgeon when the patient is positioned laterally (Fig. 52-13). The initial positioning is more time consuming and there is limited access to the patient if the patient is positioned laterally on a fracture table. This may be important in the patient with associated thoracic trauma or pulmonary injury. However, a large study of 988 patients treated with antegrade nails in either the supine or lateral position demonstrated no increased risk of mortality or ICU admission from lateral positioning.10 During nailing procedure with the patient positioned laterally, there is a natural tendency for excessive internal rotation of the femur, and the initial patient positioning should combat this. Internal rotation of the distal segment should be limited to 10 or 15 degrees during positioning. The uninjured leg is positioned with the knee and hip extended, allowing unimpeded fluoroscopic imaging in both planes. The knee height should be appropriately adjusted to resist the commonly observed valgus deformity. As an alternative, lateral positioning with the leg draped free and without the use of a fracture table can be performed. Intraoperative imaging can be accomplished, and the procedure can be performed safely and effectively.28 
Figure 52-13
Lateral patient position for closed intramedullary nailing.
 
Image intensifier is positioned anterior to patient. A: View from behind patient. B: View from in front of the patient.
Image intensifier is positioned anterior to patient. A: View from behind patient. B: View from in front of the patient.
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Figure 52-13
Lateral patient position for closed intramedullary nailing.
Image intensifier is positioned anterior to patient. A: View from behind patient. B: View from in front of the patient.
Image intensifier is positioned anterior to patient. A: View from behind patient. B: View from in front of the patient.
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X
An alternative to positioning on the fracture table is supine positioning on a radiolucent table with manual traction or intraoperative distraction155,188,281,289 (Fig. 52-14). This technique has been used successfully and is the standard in most trauma centers. The main disadvantage to the manual technique is the need for a trained assistant. However, the strategic use of an intraoperative femoral distractor or modification of the operating room table to allow weights to be placed at the end of the bed minimizes the need for assistance. For supine nailing on a radiolucent table, a bump is placed medially beneath the hip and the patient is moved as laterally as possible to maximize access to the lateral hip and flank. The bump is placed beneath the pelvis and not the greater trochanter, therefore maximizing access to the hip. The entire leg and ipsilateral hip are prepped proximally past the level of the iliac crest. A distal femoral traction pin can be placed as previously described to allow for application of manual traction and to control rotation. Alternatively, a femoral distractor can be applied, eliminating the need for a distal femoral traction pin as well as an assistant.188 Distally, a half pin can be placed anteriorly in the metaphysis from lateral to medial. Proximally, a half pin can be placed from anterior to posterior at the level of the lesser trochanter, medial to the predicted path of the nail. This pin position is at least 2.5 cm from the femoral nerve and 3 cm from the femoral artery based on cadaveric dissections.188 Alternatively, the proximal pin can be placed from lateral to medial at the lesser trochanter, posterior to the predicted path of the nail. The half pin locations and technique have been described in detail by Baumgaertel et al.19 The success of femoral nailing without a fracture table has been confirmed in several recent studies. Karpos et al.155 prospectively followed 32 consecutive femoral fractures that were reduced and stabilized with manual traction. They reported good overall alignment and decreased operative time compared with comparable femoral nailing using a fracture table. In addition, more than one-third of the patients were able to undergo multiple extremity procedures with the same operative draping.155 Similarly, Sirkin et al.281 reported similar results with femoral nailing on a radiolucent table using manual traction only. Compared with the use of a fracture table, they found the procedure to be more rapid, required fewer table transfers, allowed accurate reduction, and produced no increased morbidity.281 In a prospective study comparing the use of a fracture table with manual traction, Stephen et al.289 reported an increased incidence of malrotation and increased operative time with the use of a fracture table. 
Figure 52-14
Supine positioning on a radiolucent table.
 
A small bump placed centrally combined with lateral placement of the patient allow access to the proximal femur. Intraoperative traction can be used.
A small bump placed centrally combined with lateral placement of the patient allow access to the proximal femur. Intraoperative traction can be used.
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Figure 52-14
Supine positioning on a radiolucent table.
A small bump placed centrally combined with lateral placement of the patient allow access to the proximal femur. Intraoperative traction can be used.
A small bump placed centrally combined with lateral placement of the patient allow access to the proximal femur. Intraoperative traction can be used.
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X
Surgical Technique—Reduction.
Obtaining and maintaining a reduction of the femoral shaft can be difficult and is required during several key stages of femoral nailing. The fracture must be reduced during guidewire passage, during reaming, and when the nail is passed. There are a number of techniques that can facilitate reduction, many or all of which may be required. Many of these reduction maneuvers are dependent on the patient’s position and the type of operative table. 
Femoral length can be obtained as previously described by using a femoral distractor, manual traction, or a fracture table. The use of a femoral distractor has been described in detail as a useful adjuvant for obtaining length in both acute fractures as well as delayed nailings19,188 (Fig. 52-15). Although only one half pin is placed into each of the proximal and distal segments of the femur, surprisingly good control of alignment can be obtained. In fractures without segmental comminution, an accurate assessment of the length after application of a femoral distractor is easily obtained from fluoroscopic clues. If segmental comminution exists, the distractor is useful for indirectly reassembling the intercalary fragments by tensioning the soft tissue attachments, frequently providing indications regarding length. If the length cannot be determined fluoroscopically, comparison with the uninjured femoral length or postoperative CT scanning may be necessary. 
Figure 52-15
 
A: A femoral distractor can be placed to allow for restoration of femoral length and rotation. This requires strategic placement of the half pins to ensure that the path of the intramedullary nail is not violated. The distal pin can be placed transversely from lateral to medial in the metaphysis. The proximal pin can be placed from lateral to medial or from anterior to posterior as depicted. B: The location of the relevant soft tissue structures in the vicinity of a pin placed from anterior to posterior at the level of the lesser trochanter. (Redrawn after McFerran MA, Johnson KD. Intramedullary nailing of acute femoral shaft fractures without a fracture table: technique of using a femoral distractor. J Orthop Trauma. 1992;6:271–278.)
A: A femoral distractor can be placed to allow for restoration of femoral length and rotation. This requires strategic placement of the half pins to ensure that the path of the intramedullary nail is not violated. The distal pin can be placed transversely from lateral to medial in the metaphysis. The proximal pin can be placed from lateral to medial or from anterior to posterior as depicted. B: The location of the relevant soft tissue structures in the vicinity of a pin placed from anterior to posterior at the level of the lesser trochanter. (Redrawn after McFerran MA, Johnson KD. Intramedullary nailing of acute femoral shaft fractures without a fracture table: technique of using a femoral distractor. J Orthop Trauma. 1992;6:271–278.)
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Figure 52-15
A: A femoral distractor can be placed to allow for restoration of femoral length and rotation. This requires strategic placement of the half pins to ensure that the path of the intramedullary nail is not violated. The distal pin can be placed transversely from lateral to medial in the metaphysis. The proximal pin can be placed from lateral to medial or from anterior to posterior as depicted. B: The location of the relevant soft tissue structures in the vicinity of a pin placed from anterior to posterior at the level of the lesser trochanter. (Redrawn after McFerran MA, Johnson KD. Intramedullary nailing of acute femoral shaft fractures without a fracture table: technique of using a femoral distractor. J Orthop Trauma. 1992;6:271–278.)
A: A femoral distractor can be placed to allow for restoration of femoral length and rotation. This requires strategic placement of the half pins to ensure that the path of the intramedullary nail is not violated. The distal pin can be placed transversely from lateral to medial in the metaphysis. The proximal pin can be placed from lateral to medial or from anterior to posterior as depicted. B: The location of the relevant soft tissue structures in the vicinity of a pin placed from anterior to posterior at the level of the lesser trochanter. (Redrawn after McFerran MA, Johnson KD. Intramedullary nailing of acute femoral shaft fractures without a fracture table: technique of using a femoral distractor. J Orthop Trauma. 1992;6:271–278.)
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X
A variety of devices can be applied externally to assist with reduction of the femur. Crutches, cooled mallets, large retractors, and large reduction levers can all be used depending on the patient position and the primary deformities. If supine nailing on a radiolucent table is used, soft bumps of varying heights placed under the leg near the fracture can be used to correct the angular and translational deformities seen on the lateral fluoroscopic projection. In addition, a cannulated nail can be placed into the proximal segment after it has been prepared with an awl or reamers, thus allowing control of the proximal segment and passage of the guidewire. A short small-diameter nail or a specifically designed cannulated device is available from many nail manufacturers specifically for this purpose. 
The use of percutaneously placed half pins to facilitate reduction has been described as well.106 This technique allows correction of both angular and rotational deformities simultaneously. Through small lateral (or anterior) stab incisions, half pins can be placed either unicortically in the midlateral aspect of the femur or posteriorly in the thick portion of the linea aspera. These pins can be used to manipulate the fracture in the coronal sagittal planes by attaching T-handle chucks to each. If the sagittal plane translational deformity is largely corrected by strategically placed bumps, lateral unicortical pins can be used to correct the coronal translation and angulation with simple manipulations. The reduction can be maintained while the guidewire is passed as well as during reaming (Fig. 52-16). To avoid damage to the reamers, the tips of the pins should not be within the intramedullary canal. 
Figure 52-16
 
The presence of a segmental fracture of the diaphysis of the femur can make reduction and intramedullary nailing more difficult (A). Temporary Schanz pins can be placed percutaneously to allow manipulation, control, and reduction of the fracture (B, C). Initially, the pins can be placed into the medullary canal to optimize control of the fracture segments. During reaming, the pins should be backed out until they are unicortical. The reduction can be maintained with the pins until after the nail is placed across the fractures (D).
The presence of a segmental fracture of the diaphysis of the femur can make reduction and intramedullary nailing more difficult (A). Temporary Schanz pins can be placed percutaneously to allow manipulation, control, and reduction of the fracture (B, C). Initially, the pins can be placed into the medullary canal to optimize control of the fracture segments. During reaming, the pins should be backed out until they are unicortical. The reduction can be maintained with the pins until after the nail is placed across the fractures (D).
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Figure 52-16
The presence of a segmental fracture of the diaphysis of the femur can make reduction and intramedullary nailing more difficult (A). Temporary Schanz pins can be placed percutaneously to allow manipulation, control, and reduction of the fracture (B, C). Initially, the pins can be placed into the medullary canal to optimize control of the fracture segments. During reaming, the pins should be backed out until they are unicortical. The reduction can be maintained with the pins until after the nail is placed across the fractures (D).
The presence of a segmental fracture of the diaphysis of the femur can make reduction and intramedullary nailing more difficult (A). Temporary Schanz pins can be placed percutaneously to allow manipulation, control, and reduction of the fracture (B, C). Initially, the pins can be placed into the medullary canal to optimize control of the fracture segments. During reaming, the pins should be backed out until they are unicortical. The reduction can be maintained with the pins until after the nail is placed across the fractures (D).
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X
The intraoperative assessment of rotation (Fig. 52-17) is difficult and is described in detail in the “Complications” section under the heading of “Rotational Malalignment.” 
Figure 52-17
The shape of the lesser trochanter can be used to assist with the intraoperative determination of femoral rotation during intramedullary nailing.
 
Before starting the procedure, an anteroposterior (AP) fluoroscopic image of the uninjured proximal femur with the femur in neutral rotation is stored (A). Before interlocking of the injured extremity, the rotation of the proximal segment is adjusted such that the contour and shape of the lesser trochanter are identical to the other side (B). If the proximal segment is internally rotated (external rotation of the entire femur), the lesser trochanter will appear smaller (C). If the proximal segment is externally rotated (internal rotation, of the entire femur), the lesser trochanter will appear larger (D). (Redrawn after Krettek C, Miclau T, Grun O, et al. Intraoperative control of axes, rotation, and length in femoral and tibial fractures. Technical note. Injury. 1998;29:C29–C39.)
Before starting the procedure, an anteroposterior (AP) fluoroscopic image of the uninjured proximal femur with the femur in neutral rotation is stored (A). Before interlocking of the injured extremity, the rotation of the proximal segment is adjusted such that the contour and shape of the lesser trochanter are identical to the other side (B). If the proximal segment is internally rotated (external rotation of the entire femur), the lesser trochanter will appear smaller (C). If the proximal segment is externally rotated (internal rotation, of the entire femur), the lesser trochanter will appear larger (D). (Redrawn after Krettek C, Miclau T, Grun O, et al. Intraoperative control of axes, rotation, and length in femoral and tibial fractures. Technical note. Injury. 1998;29:C29–C39.)
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Figure 52-17
The shape of the lesser trochanter can be used to assist with the intraoperative determination of femoral rotation during intramedullary nailing.
Before starting the procedure, an anteroposterior (AP) fluoroscopic image of the uninjured proximal femur with the femur in neutral rotation is stored (A). Before interlocking of the injured extremity, the rotation of the proximal segment is adjusted such that the contour and shape of the lesser trochanter are identical to the other side (B). If the proximal segment is internally rotated (external rotation of the entire femur), the lesser trochanter will appear smaller (C). If the proximal segment is externally rotated (internal rotation, of the entire femur), the lesser trochanter will appear larger (D). (Redrawn after Krettek C, Miclau T, Grun O, et al. Intraoperative control of axes, rotation, and length in femoral and tibial fractures. Technical note. Injury. 1998;29:C29–C39.)
Before starting the procedure, an anteroposterior (AP) fluoroscopic image of the uninjured proximal femur with the femur in neutral rotation is stored (A). Before interlocking of the injured extremity, the rotation of the proximal segment is adjusted such that the contour and shape of the lesser trochanter are identical to the other side (B). If the proximal segment is internally rotated (external rotation of the entire femur), the lesser trochanter will appear smaller (C). If the proximal segment is externally rotated (internal rotation, of the entire femur), the lesser trochanter will appear larger (D). (Redrawn after Krettek C, Miclau T, Grun O, et al. Intraoperative control of axes, rotation, and length in femoral and tibial fractures. Technical note. Injury. 1998;29:C29–C39.)
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Entry Point Nails: Entry Site Choice and Soft Tissue Impact.
Current nail designs allow for placement of antegrade intramedullary implants at the piriformis fossa and in the region of the greater trochanter. Nails designed to enter at the trochanteric tip are specifically designed with an additional proximal lateral bend to facilitate nail placement through this eccentric starting portal relative to the femoral canal. The piriformis nail entry location has the advantage of predictably aligning with the femoral canal in both planes. A trochanteric entry may be easier to identify given the improved access to the greater trochanter. This may be especially important in obese patients.254 However, proper placement of the implant requires the surgeon to accurately match the intraoperative fluoroscopic entry angle with the lateral bend of the specific nail. A mismatch can be associated with iatrogentic proximal femoral fracture in shaft fractures, and malreduction in subtrochanteric fractures.103,153,223 
The use of the term “piriformis fossa” for nail entry is actually a misnomer. The actual location of the ideal entry point for a medullary implant that is aligned with femoral canal is more accurately termed the “trochanteric fossa.”227 However, given the general acceptance of the term “piriformis fossa” when referring to the depression on the inner surface of the greater trochanter (the “trochanteric fossa”), “piriformis fossa” will be used in this chapter. 
The insertion of any antegrade intramedullary nail is associated with injury to the local soft tissues at the hip.9,84,101,107,187,198,225,242 The functional consequences are largely unknown, but the local damage may contribute to the frequently observed incidence of hip pain (10% to 40%) following antegrade intramedullary nailing. As a result, alternative entry sites at the proximal femur have been investigated.101,198,242 Patient and limb positioning may have an impact on the local soft tissue injury during percutaneous antegrade piriformis entry femoral nailing. In a cadaver study based on retrograde placement of a reamer proximally to simulate the correct entry site for antegrade nailing, Ozsoy et al.225 measured the distance to and identified the potential risk of injury to the superior gluteal nerve. The authors concluded that limited hip flexion and adduction during nail insertion increases the risk of injury to the superior gluteal nerve and the gluteus medius muscle. Therefore, lateral patient positioning or free-legged positioning may allow increased hip flexion and adduction, thereby limiting these risks.225 
The impact of the nail entry location on the local soft tissues has been investigated in detail by Dora et al.84 Using a cadaver model and three different nail entry portals (piriformis fossa, in the usual location of a first-generation nail; anterior to piriformis fossa, in the usual location of a reconstruction nail; and at the tip of the greater trochanter, in the location of some trochanteric nails), the authors identified injury to multiple structures. Specifically, the trochanteric entry portal was associated with frequent injury to the piriformis tendon (80%) and the obturator internus (25%), the reconstruction nail entry portal was associated with less frequent injury to the piriformis tendon (50%) and the gluteus minimus (25%), and the piriformis fossa entry portal was associated with frequent injury to the obturator internus (86%), the piriformis tendon (71%), the obturator externus (29%) and branches from the medial femoral circumflex artery.84 With a trochanteric tip entry location, the medial femoral circumflex vessel and the hip joint capsule are not injured based on cadaver studies (in contrast to the piriformis entry which has been shown to damage the medial femoral circumflex, the obturator internus, and the obturator externus muscles). In another cadaver study supporting a lateral nail entry point, Moein et al. confirmed an increased incidence of injury to branches of the medial femoral circumflex with a piriformis nail entry.198 The impact of injury to branches of the medial femoral circumflex during antegrade intramedullary nailing is unknown although the remote possibility of avascular necrosis of the femoral head exists. However, since the introduction of antegrade intramedullary nailing, this complication has been limited to a few recent isolated case reports,117,245 indicating that avascular necrosis is extraordinarily uncommon and the relationship to nail entry is unspecified. 
Trochanteric entry nails have been introduced largely because of the improved ease of starting point identification and nail insertion (Fig. 52-18). The local soft tissue impact of these trochanteric entry femoral implants has been investigated with conflicting conclusions.101,187,198,242 Trochanteric entry nails with large screws or helical blades into the femoral head require a large (usually 17 mm) entry site reamer. In a study using a cadaver model to investigate the impact of a large entry portal at the tip of the greater trochanter, McConnell et al.187 reported disruption of an average of 27% of the gluteus medius tendon. However, a modified medial trochanteric portal placed just medial to the trochanteric tip (using a 14-mm reamer) was associated with no visible damage to the tendinous insertion of the gluteus medius in a different cadaver model (Fig. 52-19).242 Further, the presence of an alternative entry site lateral and distal to the tip of the greater trochanter has been demonstrated. This greater trochanteric bald spot is covered by the subgluteus bursa, is without tendinous insertion, and may represent an alternative entry site for specific nail designs.101 
Figure 52-18
On the AP radiographic view, the entry location and direction for a piriformis nail is depicted with the black arrow and is parallel with the femoral shaft on both radiographic views.
 
The entry angle and location for a trochanteric nail depends on the specific design parameters of the implant. Typically, a 4- to 6-degree entry angle is required (blue and gray arrows) although some implants use a lateral entry on the proximal femur with a larger entry angle.
The entry angle and location for a trochanteric nail depends on the specific design parameters of the implant. Typically, a 4- to 6-degree entry angle is required (blue and gray arrows) although some implants use a lateral entry on the proximal femur with a larger entry angle.
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Figure 52-18
On the AP radiographic view, the entry location and direction for a piriformis nail is depicted with the black arrow and is parallel with the femoral shaft on both radiographic views.
The entry angle and location for a trochanteric nail depends on the specific design parameters of the implant. Typically, a 4- to 6-degree entry angle is required (blue and gray arrows) although some implants use a lateral entry on the proximal femur with a larger entry angle.
The entry angle and location for a trochanteric nail depends on the specific design parameters of the implant. Typically, a 4- to 6-degree entry angle is required (blue and gray arrows) although some implants use a lateral entry on the proximal femur with a larger entry angle.
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Figure 52-19
 
This 37-year-old patient sustained multiple injuries including a comminuted right femoral shaft fracture (A, B). A trochanteric nail was chosen. The angle of the entry portal is determined by the specific design of the proximal nail bend and is demonstrated by the wire placement (C, D) and the entry reamer (E). The postoperative radiographs (F, G) demonstrate the alignment which was maintained to healing at 5 months (H, I). (Case courtesy of Brad Henley, MD, Harborview Medical Center)
This 37-year-old patient sustained multiple injuries including a comminuted right femoral shaft fracture (A, B). A trochanteric nail was chosen. The angle of the entry portal is determined by the specific design of the proximal nail bend and is demonstrated by the wire placement (C, D) and the entry reamer (E). The postoperative radiographs (F, G) demonstrate the alignment which was maintained to healing at 5 months (H, I). (Case courtesy of Brad Henley, MD, Harborview Medical Center)
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This 37-year-old patient sustained multiple injuries including a comminuted right femoral shaft fracture (A, B). A trochanteric nail was chosen. The angle of the entry portal is determined by the specific design of the proximal nail bend and is demonstrated by the wire placement (C, D) and the entry reamer (E). The postoperative radiographs (F, G) demonstrate the alignment which was maintained to healing at 5 months (H, I). (Case courtesy of Brad Henley, MD, Harborview Medical Center)
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Figure 52-19
This 37-year-old patient sustained multiple injuries including a comminuted right femoral shaft fracture (A, B). A trochanteric nail was chosen. The angle of the entry portal is determined by the specific design of the proximal nail bend and is demonstrated by the wire placement (C, D) and the entry reamer (E). The postoperative radiographs (F, G) demonstrate the alignment which was maintained to healing at 5 months (H, I). (Case courtesy of Brad Henley, MD, Harborview Medical Center)
This 37-year-old patient sustained multiple injuries including a comminuted right femoral shaft fracture (A, B). A trochanteric nail was chosen. The angle of the entry portal is determined by the specific design of the proximal nail bend and is demonstrated by the wire placement (C, D) and the entry reamer (E). The postoperative radiographs (F, G) demonstrate the alignment which was maintained to healing at 5 months (H, I). (Case courtesy of Brad Henley, MD, Harborview Medical Center)
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This 37-year-old patient sustained multiple injuries including a comminuted right femoral shaft fracture (A, B). A trochanteric nail was chosen. The angle of the entry portal is determined by the specific design of the proximal nail bend and is demonstrated by the wire placement (C, D) and the entry reamer (E). The postoperative radiographs (F, G) demonstrate the alignment which was maintained to healing at 5 months (H, I). (Case courtesy of Brad Henley, MD, Harborview Medical Center)
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Piriformis Technique: Piriformis Entry Nails (Table 52-11).
Table 52-11
Antegrade Nailing of the Femoral Shaft (Piriformis Entry) Surgical Steps
Obtain length using a fracture table, manual traction, distal femoral traction, or a femoral distractor
Identify the proper starting point based on AP and lateral radiographic imaging of the hip
Make an incision proximal to the greater trochanter that is in line with the femoral canal, allowing placement of all instrumentation for the nailing procedure
Establish the entry portal using either a large cannulated drill over a terminally threaded pin or an entry awl
Place a ball-tipped guidewire through the entry portal and down the canal of the femur
Reduction of the fracture with strategic bumps, Schanz pins such as joysticks, traction, etc.
Placement of the guidewire across the fracture and central into the distal femur
Determine the anticipated proper nail length using the guidewire
Ream the canal while the reduction is maintained
Place the nail with the proper rotation of the implant and the proper length and rotation of the femur
Confirm the nail depth, implant rotation, and femoral rotation
Interlock proximally and distally
Confirm (again) the implant placement and the femoral length, alignment, and rotation; check for an associated femoral neck fracture; check for any associated knee ligamentous injury
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Both open and percutaneous approaches for insertion of an antegrade nail are possible. The traditional open approach is accomplished through a longitudinal incision that begins at the proximal tip of the greater trochanter and extends proximally over a variable distance depending on the size of the patient. Curving the incision posteriorly in line with the natural bow of the femur maximizes access to the proper starting point. The gluteus maximus fascia is incised in line with the incision, and the muscle fibers can be separated bluntly. The greater trochanter can be palpated directly, as can the enveloping fascia of the gluteus medius. The piriformis fossa (or more accurately named, the trochanteric fossa227) can then be palpated directly, allowing placement of a curved awl or terminally threaded pin. Alternatively, a relatively percutaneous approach can be used (Fig. 52-20). This technique requires placement of a pin into the piriformis fossa followed by the use of an appropriately sized cannulated drill with a diameter of 8 to 10 mm. Frequently, this incision (10 to 20 mm in length) is located 10 to 20 cm proximal and slightly posterior to the palpable greater trochanter. 
Figure 52-20
The starting point for a femoral nail is shown in the AP (A) and lateral (B) fluoroscopic images.
 
The lateral image demonstrates the pin position relative to the femoral neck, greater trochanter, and calcar femorale. The outline of the piriformis (trochanteric) fossa should be apparent intraoperatively and is highlighted in red on the AP and lateral views.
The lateral image demonstrates the pin position relative to the femoral neck, greater trochanter, and calcar femorale. The outline of the piriformis (trochanteric) fossa should be apparent intraoperatively and is highlighted in red on the AP and lateral views.
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Figure 52-20
The starting point for a femoral nail is shown in the AP (A) and lateral (B) fluoroscopic images.
The lateral image demonstrates the pin position relative to the femoral neck, greater trochanter, and calcar femorale. The outline of the piriformis (trochanteric) fossa should be apparent intraoperatively and is highlighted in red on the AP and lateral views.
The lateral image demonstrates the pin position relative to the femoral neck, greater trochanter, and calcar femorale. The outline of the piriformis (trochanteric) fossa should be apparent intraoperatively and is highlighted in red on the AP and lateral views.
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If a starting awl is used in an open approach, its position should be confirmed fluoroscopically on the AP and lateral planes (Fig. 52-21). If the awl appears to be on top of the lateral aspect of the femoral neck on the AP fluoroscopic projection, the starting point is too anterior relative to the piriformis fossa. The piriformis fossa is somewhat posterior to the femoral neck on the lateral fluoroscopic image and inferior to the cephalad neck of the femur on the AP image. The awl can then be advanced in line with the intramedullary canal on both views. If a cannulated drill is chosen to initiate the starting portal, the guide pin can be advanced with a drill or a mallet down the canal of the femur using fluoroscopic imaging to confirm accurate placement. The starting point is critical to ensure safe passage of a medullary implant, and a suboptimal position should not be accepted. A starting point that is too anterior increases the proximal femoral hoop stresses and increases the likelihood of femoral bursting. With the patient positioned supine on a radiolucent table, access to the proper starting point is improved with maximal adduction of the leg. In more proximal fractures in which manual adduction of the leg fails to adduct the proximal femoral segment, a percutaneously placed spike pusher or Schanz pin at the lateral aspect of the proximal femur can assist with presenting the starting point. 
Figure 52-21
Placement of the entrance hole is critical for a successful closed nailing.
 
The tip of the awl should be in line with the longitudinal axis of the medullary canal in both the AP and mediolateral planes. A more anterior placement of the entrance hole can result in inadvertent perforation of the anterior cortex of the proximal femur x.
The tip of the awl should be in line with the longitudinal axis of the medullary canal in both the AP and mediolateral planes. A more anterior placement of the entrance hole can result in inadvertent perforation of the anterior cortex of the proximal femur x.
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Figure 52-21
Placement of the entrance hole is critical for a successful closed nailing.
The tip of the awl should be in line with the longitudinal axis of the medullary canal in both the AP and mediolateral planes. A more anterior placement of the entrance hole can result in inadvertent perforation of the anterior cortex of the proximal femur x.
The tip of the awl should be in line with the longitudinal axis of the medullary canal in both the AP and mediolateral planes. A more anterior placement of the entrance hole can result in inadvertent perforation of the anterior cortex of the proximal femur x.
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The ideal radiographic starting point for placement of an antegrade piriformis entry nail has been reviewed in some detail.103,107 The medullary cavity proximal exit point was defined in one study using 16 cadaver femora. The location was determined by obtaining radiographs in 12 sequential planes separated by 15 degrees axially in femurs that were filled with a radiopaque substance. In 88% of specimens, the entry point for a straight nail was identified at the medial border of the greater trochanter, at the tendinous insertion of the piriformis, and 2.1 cm anterior to the posterior border of the greater trochanter. For nails with a radius of curvature of 100 cm the nail entry point is only 0.7 mm anterior to the dorsal edge of the trochanter.103 Because most available antegrade nails have a femoral bow that is greater than 100 cm, logic suggests that the ideal starting point is located somewhere between these reported locations. 
After the starting hole has been made, a bulb-tipped guidewire can be passed down the canal of the femur and confirmed with biplanar fluoroscopic imaging. In young patients with dense bone, T-handled hand reamers may be necessary to define the intramedullary canal in the pertrochanteric region. This step can be avoided if a cannulated drill technique is used for initiation of the starting point, assuming that the drill is passed distally enough in line with the medullary canal. The guidewire should be bent distally to allow some directional control. A guidewire without a ball tip should not be used if reaming is planned. The guidewire is then advanced down the canal of the femur to the level of the fracture. With pharmacologic relaxation, the fracture is then reduced to allow passage of the guidewire across the fracture and into the distal segment. Numerous reduction maneuvers as previously outlined are useful for this easily described yet practically difficult portion of the procedure. The bend at the end of the guidewire can be exploited to assist with passage of the guidewire (Fig. 52-22). The guidewire is then advanced distally and should terminate centrally in the distal femur. Any residual angulation should be corrected before advancement of the guidewire distally. This is especially true in fractures that are distal to the femoral isthmus, especially if the fracture is in the distal third. A mallet is used to seat the guidewire into the dense bone of the distal femur to ensure that it remains in position during reaming. For distal fractures, a true AP and lateral image of the distal femur should be obtained to ensure central placement of the guidewire. Femoral length should then be confirmed before determining the desired nail length. A second guidewire of equal length can be used to determine the proper length of the nail necessary. Knowledge of the specific nail characteristics and the normal level of insertion at the piriformis fossa is necessary to determine the proper length. 
Figure 52-22
 
A small bend at the end of the bulb-tip guide pin allows for manipulative correction of any residual translation at the fracture site the tip is advanced across the fracture site, then rotated to correct the translation.
A small bend at the end of the bulb-tip guide pin allows for manipulative correction of any residual translation at the fracture site the tip is advanced across the fracture site, then rotated to correct the translation.
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Figure 52-22
A small bend at the end of the bulb-tip guide pin allows for manipulative correction of any residual translation at the fracture site the tip is advanced across the fracture site, then rotated to correct the translation.
A small bend at the end of the bulb-tip guide pin allows for manipulative correction of any residual translation at the fracture site the tip is advanced across the fracture site, then rotated to correct the translation.
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Flexible reamers can then be passed over the guidewire and down the canal of the femur. The fracture should be maintained in a reduced position during the passage of each reamer to minimize eccentric bone removal. The process of reaming produces elevated intramedullary canal pressures and embolism of fat into the venous system. This is related both to the technique and the design of the reamers. Reamers should be advanced slowly and incrementally increased in diameter to minimize the pressure and fat embolism. Reamers should be sharp, have deep flutes, and have a narrow flexible shaft.30,209,230,240 With the currently available locked intramedullary implants, the placement of large-diameter nails with an intimate fit along a long length of the medullary canal is no longer necessary. Depending on the biomechanical characteristics of the nail, the patient’s size, the presence of comminution, and the desire for immediate weight bearing, a minimum nail diameter can be chose by the surgeon. A nail diameter that is coincident with isthmic cortical chatter felt during reaming is probably adequate in most cases. The canal is overreamed by 1 to 1.5 mm to allow passage of the nail. Failure to enlarge the medullary canal can result in nail incarceration or iatrogenic femoral comminution, both of which are avoidable complications. 
The ball-tipped guidewire can then be exchanged for a straight guidewire using a flexible exchange tube. However, many currently available nailing systems allow removal of the ball-tipped guidewire through the nail, eliminating this step in the procedure. The selected nail dimensions are then confirmed, and the nail is attached to the proximal locking jig and placed over the guidewire. The anterior bow of the nail can be used to ease the initial insertion into the starting hole at the piriformis fossa. By internally rotating the nail by 90 degrees, the tip of the nail can be placed around the medial greater trochanter. The rotation of the nail is then corrected to match the rotation of the femur. The nail is advanced to the level of the fracture. At this point, the length, alignment, and rotation of the femur should be corrected accurately. The nail is advanced across the fracture, and the reduction parameters should be confirmed. The nail is then driven distally to the appropriate depth (Fig. 52-23). 
Figure 52-23
 
An antegrade nail can effectively stabilize a segmental femoral fracture with a proximal isthmic component combined with a distal metaphyseal fracture (A–D).
An antegrade nail can effectively stabilize a segmental femoral fracture with a proximal isthmic component combined with a distal metaphyseal fracture (A–D).
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An antegrade nail can effectively stabilize a segmental femoral fracture with a proximal isthmic component combined with a distal metaphyseal fracture (A–D).
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Figure 52-23
An antegrade nail can effectively stabilize a segmental femoral fracture with a proximal isthmic component combined with a distal metaphyseal fracture (A–D).
An antegrade nail can effectively stabilize a segmental femoral fracture with a proximal isthmic component combined with a distal metaphyseal fracture (A–D).
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An antegrade nail can effectively stabilize a segmental femoral fracture with a proximal isthmic component combined with a distal metaphyseal fracture (A–D).
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Proximal Interlocking.
Proximal interlocking is simplified with the use of an external jig that allows placement of screws using multiple sleeves. The configuration and location of these screws are unique to each nailing system and may be transverse or oblique in direction. Static and dynamic screws may be available proximally or distally. The choice to use one or two proximal interlocking screws depends on the fracture stability after nailing, fracture location, patient’s size, nail and screw diameters, and predicted postoperative activity. 
Distal Interlocking.
Distal interlocking is usually accomplished using a free-hand technique that is highly dependent on fluoroscopic imaging. External targeting jigs remain under investigation but have limited applicability because of targeting inaccuracies. This is because of the long length of the implant and the deformation that occurs with nail passage. Computer-assisted navigation systems continue to be explored and will likely increase in popularity in the near future. 
Regardless of how distal interlocking is accomplished, the alignment, especially in rotation, must be maintained until at least one screw is placed. With supine nailing on a radiolucent table, the usual error in a rotationally unstable pattern is to externally rotate the distal segment in an attempt to align the nail with the image intensifier. To avoid this, the bump should be removed from beneath the ipsilateral hip and the entire leg should be rotated as a single unit. There are numerous choices for a free-hand technique. Radiolucent drills, tapered pins, and radiolucent handles are all available to assist with distal interlocking. Regardless of the technique, the goal is to expeditiously place one or two interlocking screws through the nail with the minimum amount of radiation. 
The image intensifier is first used to localize a perfectly round circle of the interlocking screw hole. A small longitudinal skin incision is made followed by an incision through the iliotibial band in line with the fibers. A sharp drill bit, preferably with a trochar tip, is angulated obliquely to allow imaging, and the tip is placed in the exact center of the projected hole as confirmed by the lateral fluoroscopic image. The drill is then positioned parallel to the path of the beam and advanced. The drill is then removed, leaving the drill bit in position to confirm the direction and placement. Small adjustments can be made on the basis of the interpretation of the fluoroscopic image. The drill is then advanced through the nail, a depth gauge is used to determine the screws length, and an interlocking screw can be placed. The same procedure is repeated for a second interlocking screw if necessary. In order to decrease the radiation exposure, the operative time, and the incidence of missed interlocking bolts, new technologies using electromagnetic fields have been introduced for distal interlocking175,287 Results from these studies suggest that electromagnetic fields require no radiation exposure, are faster, and result in fewer missed interlocking bolts compared to free-hand techniques.175,287 These technologies and techniques may prove useful in the future, and further studies will likely elucidate the cost effectiveness. 
Outcomes.
Reamed Intramedullary Nailing Using a Piriformis Entry Technique.
The early experience with intramedullary nailing was universally positive.65,68,92,126,159,168,262,329331 Most of these reports used the techniques described by Kuntscher167 and reamed nails were placed in a closed fashion without interlocking. These implants relied on the endosteal contact between the nail and the femur for control of rotation, angulation, and length. The perceived advantages compared with other techniques included early joint mobility, early weight bearing, shortened hospital stay, decreased pain, and predictable union. Fracture comminution and segmental fractures could be treated with antegrade reamed nails with reports of 100% union and no infections.329,330 In the classic series of 520 femoral fractures in 500 patients treated with reamed intramedullary nailing, Winquist et al.331 reported a union rate of 99.1%. However, shortening of greater than 2 cm occurred in 10 patients and rotation of greater than 20 degrees was identified in 12 patients.331 
As interlocking became available, the indications for antegrade intramedullary nailing continued to expand and the results have continued to improve. Brumback et al. described the technical decision making, the need for static locking, and the expected healing in a series of three articles reviewing locked intramedullary nailing of femoral shaft fractures.43,45,46,48 The previously reported problems with shortening and postoperative loss or rotational alignment were largely eliminated.23,38,45,52,66,150,156,160,283,333,334,337 Comminuted and rotationally unstable fractures healed in 98% of 112 reamed and interlocked nailings reported by Wiss et al.334 Similar results were reported by Sojbjerg et al.283 and Kempf et al.156 The use of interlocked nails in segmental femoral fractures was similarly reviewed with healing observed in 97% of patients at an average of 32 weeks without any additional interventions other than nail dynamization.333 Brumback et al.48 investigated the need for planned conversion from static to dynamic fixation in a prospective study of 100 femoral shaft fractures treated with intramedullary nailings. They reported healing in 98% with static interlocking fixation and concluded that the routine conversion to dynamic fixation was not necessary.48 Complications related to closed interlocked nailing was reported by Benirschke et al.23 in a review of 267 patients evaluated retrospectively and prospectively. Intraoperative technical complications were observed uncommonly, but functional outcomes were not as good as previously appreciated; 37% of patients had pain and 39% had some limitations with ambulation or standing. More recently, Wolinsky et al.337 reported their results with 551 femoral shaft fractures treated with closed, locked antegrade intramedullary nailing. The authors reported union in 98.9%, infection in 1%, and no malunions with greater than 10 degrees of angulation. 
The positive effects of reaming on fracture healing is thought to be from a combination of altered blood flow to the bone and the local muscles, and the deposition of marrow and cortical elements at the site of the fracture.27,120,121,136,137,157,249,274,275 The impact of these factors has been studied in animal models in both the tibia and the femur. More recent studies suggest that reaming increases a number of growth factors (platelet-derived growth factor, vascular endothelial growth factor, insulin-like growth factor I, transforming growth factor beta-1, and bone morphogenic protein-2) and this is hypothesized to contribute to the positive healing effects of reaming.112 A potential negative effect of reaming includes injury to the inner two-thirds of the bone.157 Animal studies in the tibia suggest that this process is reversed by 12 weeks after reamed nailing and by 6 weeks after unreamed nailing.274 However, reaming has been shown to have a positive influence on the surrounding muscle perfusion, which may have implications for the extraosseous blood supply to the bone and the healing fracture.137 In one study, periosteal blood flow was found to increase by a factor of six within 30 minutes of reaming.249 Total blood flow and callus blood flow increases have been similarly demonstrated in animal models.120 
Unreamed Femoral Nailing.
The role of unreamed intramedullary nailing for the treatment of femoral shaft fractures remains unclear. Although the decreased damage to the endosteal blood flow has been demonstrated in animal studies, the clinical relevance with respect to infection and union remains elusive. In addition, the ill effects of reaming on pulmonary function, especially in the multiply injured patient, have not been definitively demonstrated.3033,51,57,59,87,114,149,229,230,235,241,335,339,340 The early clinical results of unreamed nailing for femoral shaft fractures reported by Krettek et al.163 were favorable, with only minor implant-related complications reported. Nonunion was reported in 5.1% of patients in a multicenter review of unreamed nails reported by Hammacher et al.125 The authors conceded that the use of a small nail inserted without reaming did not produce a decrease in the number of patients with adult respiratory distress.125 Herscovici et al.131 reported similar results in 125 fractures treated with unreamed nails. Although this represented a mixture of antegrade and retrograde nailings, only 93% healed after the index procedure. 
Reamed versus Unreamed Antegrade Intramedullary Nailing.
The potentially negative effects of reaming for insertion of intramedullary nails include elevated intramedullary pressures, elevated pulmonary artery pressures, increased fat embolism, and increased pulmonary dysfunction. The potential advantages of reaming include the ability to place a larger implant, increased union, and decreased hardware failure. The increased union is believed to be attributable to both the enhanced biomechanical environment of a larger implant and the enhanced biologic environment produced during reaming. Reaming increases the periosteal blood flow and deposits osteoinductive elements at the fracture, both of which may contribute to improved healing.120,249 
Several studies evaluate specifically the clinical results of treating femoral shaft fractures with intramedullary interlocked nails with and without intramedullary reaming.26,54,67,108,250,306,310 Of interest are the different results observed with the retrospective and prospective studies comparing the two techniques. 
In a retrospective study of 147 consecutive patients treated with reamed (n = 50) and unreamed femoral nails (n = 97), Giannoudis et al.108 reported union at an average of 26.9 weeks in the unreamed group compared with 20.5 weeks in the reamed group. The operative time was shorter with the unreamed technique, and there was no increased risk of infection, angular deformity, or limb length discrepancy. This led the authors to conclude that the unreamed technique was more rapid and had no associated clinical problems of significance. Similarly, Reynders and Broos250 retrospectively reviewed 107 closed femoral fractures treated with reamed (n = 54) and unreamed (n = 53) intramedullary nailings. The authors reported no difference in union time but significantly less operative time with the unreamed technique. This led to the recommendation that unreamed femoral nailing should be used to treat acute closed femoral shaft fractures. 
However, several prospective and randomized trials have presented differing results with contrasting conclusions. In a prospective and randomized study of 81 patients treated with a stainless steel statically locked intramedullary nail inserted with and without reaming, Tornetta and Tiburzi310 reported statistically similar operative times, transfusion requirements, and time to union when the entire groups were compared. Reaming was associated with more rapid callus formation yet higher blood loss. Further analysis of the data revealed faster union in the subpopulation of patients with distal fractures when reaming was used. Intraoperative technical complications occurred more commonly with the unreamed technique.310 In a subsequent study by the same authors,312 172 patients were prospectively randomized and their results were compared. With the larger data set available, the authors were able to show a significant improvement in the time to union with reaming (80 days) compared with those nails placed without reaming (109 days). This led to the conclusion that there is no advantage to the routine use of nailing without reaming.312 Clatworthy et al.67 reported their results of a prospective and randomized trial comparing reamed and unreamed nails in 45 patients with femoral shaft fractures. Of note, the study was stopped early because of the high rate of implant failure in the unreamed group. They reported more significantly more rapid union (28.5 vs. 39.4 weeks) and a much lower proportion of nonunions at 9 months (18% vs. 57% nonunion) in patients treated with reamed nails compared with those treated with unreamed nails. Secondary procedures to achieve union were more common in the unreamed group. Finally, in a multicenter, prospective, randomized clinical trial from seven level-I trauma centers sponsored by the Canadian Orthopaedic Trauma Society, 224 patients were enrolled to compare the rate of nonunion after intramedullary nailing with and without reaming. The authors reported nonunions in 7.5% of patients treated without reaming compared with 1.7% of patients treated with reaming. They determined that the relative risk of nonunion was 4.5 times greater without reaming and with the use of a relatively small-diameter nail.54 
Reaming certainly adds time to the surgical procedure, but the impact of this additional surgical time is unknown. However, to understand the relative contribution of reaming to the overall time of the operative procedure, Crist and Wolinsky prospectively evaluated 54 reamed femoral nailing procedures. The average time for reaming the femur was less than 7 minutes, which represented less than 5% of the surgical time and approximately 3% of the total operative time. While firm conclusions cannot be drawn from this, it is obvious that the relative time for reaming is quite small. The potential advantages as previously outlined should be weighed against this time contribution. 
In a systematic review and meta-analysis of lower-extremity long bone fractures, Bhandari et al.26 attempted to determine the effects of reaming on the rates of nonunion, implant failure, malunion, compartmental syndrome, pulmonary embolus, and infection. Only prospective and randomized trials were used as part of the analysis. Although the data represented both tibias and femurs treated with intramedullary nails, the evidence suggests that reamed nailing significantly reduces the rates of nonunion and implant failure compared with unreamed nailing.26 These results were corroborated by a systematic review evaluating the available randomized literature on treatment of femoral shaft fractures with either reamed or unreamed nails. Reaming was associated with lower reoperation and nonunion rates, but with no increase in mortality or ARDS.85 
Postoperative Care.
Operative stabilization of femoral shaft fractures allows early patient mobilization, decreases pain, facilitates nursing care, minimizes joint stiffness, and allows early functional rehabilitation. Early mobilization avoids many of the complications associated with prolonged recumbency such as pulmonary compromise, pressure sores, and muscle deconditioning. 
Patients usually experience significantly diminished pain after femoral stabilization. As a result, they should be encouraged to sit up and get out of bed immediately after fixation. Because of the strength of a femur treated with a statically locked intramedullary nail, there should be virtually no concern by the patient or the physician regarding the stability of the mechanical construct. This applies to femurs stabilized with both antegrade and retrograde nailing techniques. Quadriceps and hamstrings exercises can proceed according to the patient’s comfort. Unrestricted active and passive range-of-motion exercises of the knee and hip can similarly be instituted immediately after surgery. Restoration of motor strength is dependent on the traumatic injury to the muscles, any associated injuries, and the patient’s motivation. In patients with isolated femoral shaft fractures, supervised outpatient physical therapy may not be absolutely necessary. However, a specific rehabilitation protocol that focuses on the known impairments associated with femoral intramedullary nailing has been shown to be effective and can predictably restore function. These targeted impairments include abduction weakness, knee extensor weakness, anterior knee pain, and gait abnormalities.238 
Weight bearing on the extremity is guided by a number of factors including the patient’s associated injuries, the soft tissue injury, and the location of the fracture. For fractures treated with the currently manufactured intramedullary nails, immediate weight bearing is safe from a mechanical standpoint. Brumback et al.47 reported the biomechanical and clinical results of simulated and actual early weight bearing using commonly available implants. They found that immediate weight bearing of segmentally comminuted midisthmal fractures treated with a statically locked intramedullary nail using two distal interlocking screws was safe and allowed healing without shortening or nail fatigue failure. Similarly, Arazi et al.11 followed 24 patients with comminuted diaphyseal femur fractures for a minimum of 1 year. Unrestricted weight bearing was allowed, and most patients were able to bear weight between 2 and 4 weeks after surgery. No nail-related mechanical failures occurred, and all fractures healed without complications. An interlocking screw in each of the two patients demonstrated some bending, but this was without consequence. The experience reported in these two studies supports the contention that early weight bearing after reamed statically locked antegrade intramedullary nailing is safe. Early weight bearing may encourage callus formation and should be encouraged in applicable patterns. Fractures with proximal or distal extension and associated ipsilateral femoral fractures require individual modification to the weight-bearing progression. If weight bearing is limited during the first 6 to 12 weeks, an ankle dorsiflexion splint or orthosis should be used to avoid an equinus contracture. 
Radiographic evaluations are usually obtained at 6 weeks, 12 weeks, and 6 months and should include two views of the entire femur to include the proximal and distal interlocking screws as well as the hip and knee joints. Groin pain in a patient who has sustained a femoral shaft fracture should be evaluated at any point in the postoperative course given the possibility of an associated clandestine or iatrogenic femoral neck fracture. However, clandestine femoral neck fracture has been observed in asymptomatic patients as well.256 A femoral neck fracture was ultimately identified in 10 patients without radiographic evidence before plating of an ipsilateral diaphyseal femoral fracture. This review emphasizes the need for dedicated hip radiographs postoperatively and at any time a patient becomes symptomatic.256 
Potential Pitfalls and Preventative Measures.
Although femoral nailing has predictable results when properly performed, there are a number of potential intraoperative complications that can be avoided with anticipation and planning (Table 52-12). The proper length, rotation, and alignment should be restored following antegrade intramedullary nailing. A combination of adequate traction, muscle paralysis, and comparison with the contralateral extremity radiographs allow the surgeon to re-establish the proper femoral length. The alignment in the coronal plane can be properly restored with proper guidewire placement, reduction during reaming and nail placement, and with comparison to the other side if alignment cannot be confidently assessed during surgery. Femoral rotational assessment will be described in detail in later sections of this chapter, as will the assessment of angular deformities. Iatrogenic femoral shaft fracture during nail placement can be avoided with the use of a proper nail entry that is colinear with the femoral canal. A careful evaluation of the femoral neck prior to and following intramedullary nailing will minimize the occurrence of a missed femoral neck fracture. 
 
Table 52-12
Potential Pitfalls and Preventative Measures
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Table 52-12
Potential Pitfalls and Preventative Measures
Pitfall Prevention
Failure to obtain the proper length
  1.  
    Adequate muscular paralysis intraoperatively
  2.  
    Obtain contralateral radiographs, especially in comminuted patterns
  3.  
    Adequate intraoperative traction
Fracture malreduction in the coronal or sagittal planes
  1.  
    Obtain contralateral femoral radiographs prior to nailing
  2.  
    Center the guidewire, reamers, and nail on both radiographic views in both segments
  3.  
    Obtain a proper starting point in the trochanteric (piriformis fossa) that is parallel with the shaft of the femur
Iatrogenic femoral shaft fracture during nail placement
  1.  
    Preoperative assessment of any femoral deformity and anticipation of the proper starting point
  2.  
    Obtain a proper starting point in the trochanteric (piriformis fossa) that is parallel with the shaft of the femur
  3.  
    Overream the canal by 1–2 mm larger than the anticipated nail size
  4.  
    Establish that there are no intramedullary cortical fragments that would block the nail passage
Femoral malrotation
  1.  
    Obtain contralateral AP imaging of the contralateral side in known rotation in order to judge the lesser trochanteric profile
  2.  
    Image the contralateral side to determine the femoral neck anteversion
Missed diagnosis of a femoral neck fracture
  1.  
    Obtain preoperative imaging of the femoral neck to investigate the presence of a fracture prior to surgery; may include dedicated hip radiographs and/or a CT scan
  2.  
    Avoid deep impaction of the nail, especially if the aiming arm proximally has a larger diameter than the nail
  3.  
    Use caution in patients with a valgus femoral neck during nail placement
  4.  
    Confirm the lack of a femoral neck fracture after all femoral nailing procedures
Placement of interlocking bolts that miss the nail
  1.  
    Avoidance of significant forces on the aiming arm for proximal interlocking
  2.  
    Careful intraoperative imaging during drilling and interlocking bolt placement
  3.  
    Confirmation radiograph following interlocking
X

Trochanteric Entry Antegrade Nails in Femoral Shaft Fractures

Indications and Contraindications

Trochanteric entry nails have been used with success for the treatment of intertrochanteric, subtrochanteric, pertrochanteric, combination fractures of the proximal femur, and femoral shaft fractures (Table 52-13). Some of the potential advantages of the trochanteric starting portal for placement of a medullary implant include less operative time and less intraoperative fluoroscopy, largely because of ease of identification of the trochanter as a starting point. However, if a nail designed for placement into the piriformis fossa is placed through the more readily accessible trochanteric tip, the complications of iatrogenic fracture comminution and varus malreduction are increased.103,153,223 Newer nail designs with appropriate proximal bends have allowed for placement of a medullary implant through or slightly medial to the trochanteric tip. However, the initial nail designs used for stabilization of these proximal injuries were characterized by a large proximal segment, typically requiring a 17-mm reamer at the entry site. In a cadaver model designed to investigate the impact of this large entry portal in the tip of the greater trochanter, a significant portion (average of 27%) of the gluteus medius tendon insertion was found to be disrupted.187 The clinical significance of this is currently unknown. Newer nail designs require a smaller entry reamer and hence, less damage to the tendinous insertion of the hip abductors at the nail entry site. 
 
Table 52-13
Trochanteric Entry Nailing of the Femoral Shaft
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Table 52-13
Trochanteric Entry Nailing of the Femoral Shaft
Indications/Contraindications
Indications
The vast majority of femoral shaft fractures
Isolated femoral shaft fractures
Comminuted femoral shaft fractures
Open fractures
Open growth plates (specifically designed implants with a smaller diameter)
(The vast majority of femoral shaft fractures)
Contraindications
A narrow canal that will not accommodate a nail
Previous malunion that prevents nail placement
History of intramedullary infection
Associated ipsilateral femoral neck or acetabular fracture (relative)
Polytraumatized patients with associated thoracic injury (relative)
X
The indications for trochanteric entry nails include all femoral shaft fractures similar to piriformis entry femoral nails. In addition, trochanteric nails can be used in obese patients where identification and localization of the piriformis entry may be difficult. There are specific nails with a smaller diameter designed to enter through the greater trochanter for patients with open growth plates. 

Surgical Procedure: Trochanteric Nailing

Preoperative Planning.
The surgical planning for trochanteric nailing is similar to that of piriformis entry nailing (Table 52-14). The choice of the OR table, patient position, and reduction tools are virtually identical. For trochanteric nails, an AP radiograph of the contralateral hip may greatly facilitate the localization of the proper starting point for the trochanteric nail.292 Unlike piriformis entry nails, trochanteric nails are designed with a proximal lateral bend that varies between 5 and 10 degrees. As a result, the location and angulation of the entry reamer is based on a radiographic estimation that matches the lateral bend of the nail. The trochanteric tip has actually been shown to be the proper starting point in the minority of cases where a 6 degree lateral bend trochanteric nail was used.292 The ideal staring point was found to be medial to the trochanteric tip in 70% of patients and lateral in only 23% of patients. As a result, it is recommended that contralateral templating should be considered and the proper entry site determined based on this.292 
 
Table 52-14
Preoperative Planning Checklist
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Table 52-14
Preoperative Planning Checklist
OR table: Either a fracture table or a radiolucent flat top table that allows unimpeded radiographic imaging, depending on the preference of the surgeon and the available assistance for the procedure
Position/positioning aids: Can be accomplished either supine or lateral. If supine on a radiolucent flat top table, a rolled blanket or positioning pillow placed beneath the injured buttock produces internal rotation to neutral, allowing predictable AP and lateral imaging. A foam ramp or soft support beneath the leg assists with lateral imaging with the patient positioned supine on a flat top table. For supine positioning on a fracture table, a support beneath the buttock will assist with maintaining the proper rotation of the proximal femoral segment
Fluoroscopy location: The C-arm is usually placed opposite the injured side if the patient is supine; this allows for AP and lateral imaging without moving the leg. If lateral position is used, the C-arm is placed opposite the surgeon and perpendicular to the OR table; the surgeon is positioned posterior to the laterally positioned patient
Equipment: Nails of proper length and diameter with the appropriate interlocking bolts. Reduction tools including 5 mm Schanz pins, large reduction forceps, a femoral distractor, intramedullary reduction tools, etc. Distal femoral traction pin with a traction bow. Reamers, drills, guidewires
Special considerations: Intraoperative length and rotation must be carefully assessed. The femoral neck should be evaluated for a possible fracture prior to and following all nailing procedures
X
Positioning.
Similar to other antegrade nailing techniques, trochanteric nailing can be accomplished with the patient positioned either supine or lateral. Intraoperative traction can accomplished similar to the techniques described for piriformis entry antegrade nailing. 
Technique.
The technical aspects of trochanteric nailing are virtually identical to those used in piriformis entry nails with the exception of identification and creation of the nail entry location (Table 52-15). For trochanteric nailing, the nail entry location and orientation can be based on templating from the contralateral uninjured hip AP radiograph, or estimated intraoperatively based on the lateral bend of the nail. Typically, the trochanteric entry location is easier to identify, resulting in decreased fluoroscopy and operative time.12,254,284 After the nail staring point is identified and the entry reamer is used, the remainder of the nailing procedure is the same as other antegrade nailing techniques previously described. 
Table 52-15
Trochanteric Entry Nailing of the Femoral Shaft Surgical Steps
Obtain a contralateral hip AP radiograph to be used to template the proper starting location and entry angle based on the lateral bend of the chosen implant
Obtain length using a fracture table, manual traction, distal femoral traction, or a femoral distractor
Identify the proper starting point based on AP and lateral radiographic imaging of the hip
Make an incision proximal to the greater trochanter that allows placement of guide pin at the greater trochanter
Establish the entry portal using a large cannulated drill over a terminally threaded pin
Place a ball-tipped guidewire through the entry portal and down the canal of the femur
Reduction of the fracture with strategic bumps, Schanz pins such as joysticks, traction, etc.
Placement of the guidewire across the fracture and central into the distal femur
Determine the anticipated proper nail length using the guidewire
Ream the canal while the reduction is maintained
Place the nail with the proper rotation of the implant and the proper length and rotation of the femur
Confirm the nail depth, implant rotation, and femoral rotation
Interlock proximally and distally
Confirm (again) the implant placement and the femoral length, alignment, and rotation; check for an associated femoral neck fracture; check for any associated knee ligamentous injury
X
Postoperative Care.
Similar to piriformis entry nails, trochanteric nails allows early patient mobilization, decreases pain, facilitates nursing care, minimizes joint stiffness, and allows early functional rehabilitation. Because of the strength of a femur treated with a statically locked intramedullary nail, there should be virtually no concern by the patient or the physician regarding the stability of the mechanical construct. Weight bearing on the extremity is guided by a number of factors including the patient’s associated injuries, the soft tissue injury, and the location of the fracture. For fractures treated with the currently manufactured intramedullary nails, immediate weight bearing is safe from a mechanical standpoint. Radiographic evaluations are usually obtained at 6 weeks, 12 weeks, and 6 months and should include two views of the entire femur to include the proximal and distal interlocking screws as well as the hip and knee joints. Groin pain in a patient who has sustained a femoral shaft fracture should be evaluated at any point in the postoperative course given the possibility of an associated clandestine or iatrogenic femoral neck fracture. 
Potential Pitfalls and Preventative Measures.
In addition to the pitfalls associated with piriformis entry antegrade femoral nailing, starting point errors occur with trochanteric nails (Table 52-16). It is critical that the lateral bend of the nail is known, and the entry site is exactly identified. A starting point that is not well aligned can result in an iatrogenic fracture of the femur, or coronal plane angular deformities. In one study reviewing the use of a nail with a 10 degree lateral bend used in patients with femoral shaft fractures, an anterior starting point in the greater trochanter was associated with greater than a twofold increase in the incidence of valgus malalignment of the femoral shaft, and iatrogenic fractures in 13%.248 
 
Table 52-16
Potential Pitfalls and Preventative Measures
View Large
Table 52-16
Potential Pitfalls and Preventative Measures
Pitfall Prevention
Failure to obtain the proper length
  1.  
    Adequate muscular paralysis intraoperatively
  2.  
    Obtain contralateral radiographs, especially in comminuted patterns
  3.  
    Adequate intraoperative traction
Fracture malreduction in the coronal or sagittal planes
  1.  
    Obtain contralateral femoral radiographs prior to nailing
  2.  
    Center the guidewire, reamers, and nail on both radiographic views in both segments
  3.  
    Obtain a proper starting point at the greater trochanteric that is angulated the same number of degrees as the lateral bend of the nail
Iatrogenic femoral shaft fracture during nail placement
  1.  
    Preoperative assessment of any femoral deformity and anticipation of the proper starting point
  2.  
    Obtain a proper starting point at the greater trochanter with the proper angulation based on the lateral bend of the chosen nail
  3.  
    Avoid placement of the nail anterior in the greater trochanter
  4.  
    Overream the canal by 1–2 mm larger than the anticipated nail size
  5.  
    Establish that there are no intramedullary cortical fragments that would block the nail passage
Femoral malrotation
  1.  
    Obtain contralateral AP imaging of the contralateral side in known rotation in order to judge the lesser trochanteric profile
  2.  
    Image the contralateral side to determine the femoral neck anteversion
Missed diagnosis of a femoral neck fracture
  1.  
    Obtain preoperative imaging of the femoral neck to investigate the presence of a fracture prior to surgery; may include dedicated hip radiographs and/or a CT scan
  2.  
    Avoid deep impaction of the nail, especially if the aiming arm proximally has a larger diameter than the nail
  3.  
    Use caution in patients with a valgus femoral neck during nail placement
  4.  
    Confirm the lack of a femoral neck fracture after all femoral nailing procedures
Placement of interlocking bolts that miss the nail
  1.  
    Avoidance of significant forces on the aiming arm for proximal interlocking
  2.  
    Careful intraoperative imaging during drilling and interlocking bolt placement
  3.  
    Confirmation radiograph following interlocking
X
Treatment Specific Outcomes.
Trochanteric entry nails for the treatment of routine diaphyseal femur fractures is a relatively contemporary approach that is used increasingly with outcomes similar to piriformis entry nails. Newer nail design characteristics including a smaller proximal diameter of the implant and an appropriate lateral bend proximally have allowed placement through or medial to the trochanteric tip. The smaller entry portal has the theoretic advantage of minimizing any additional soft tissue damage at the gluteus medius tendon. In addition, the trochanteric entry portal minimizes injury to several other associated anatomical structures that may be harmed as a result of a piriformis entry portal including the obturator internus and externus tendons, the medial femoral circumflex vessels, the superior gluteal nerve, and the hip joint capsule.8,9,84 This trochanteric entry portal may positively influence the incidence postoperative hip pain as well as hip function and gait. However, an understanding of the exact nail design characteristics and the proper entry portal are critical to the success of trochanteric nailing. In one study reviewing a more lateral entry portal than the trochanteric tip, high rates of intraoperative fracture and malalignment were reported.248 
The clinical success and impact of antegrade nailing using a trochanteric entry portal have been investigated in several recent studies8,12,254,284 Ricci et al.,254 in a prospective nonrandomized study, compared the results after treatment with antegrade nails placed either through the piriformis fossa or the greater trochanter. In both techniques, alignment was maintained and no iatrogenic fracture comminution occurred. The average fluoroscopy time was significantly greater in the piriformis insertion group, and a longer average operative time was required in these patients. These differences were amplified in obese patients in whom identification of the piriformis starting portal is difficult. Patient outcomes were similar between the two groups. The authors suggested that a specifically designed trochanteric entry nail represents a viable alternative for the management of femoral shaft fractures.254 In a prospective and randomized comparison of piriformis and trochanteric nails of 110 patients, Stannard et al.284 demonstrated decreased operative time and decreased fluoroscopy time with trochanteric entry nails. Functional outcomes and muscle strength testing were the same at 1 year, but the trochanteric nails demonstrated improved functional scores at several earlier time points. These results were corroborated by a retrospective comparison of functional outcomes in patients treated with piriformis or trochanteric nailing in a small group of patients. Extensive evaluations were performed including gait testing, muscle strength testing, magnetic resonance imaging of the musculature of the hip, and electromyographic evaluation of the superior gluteal nerve. The piriformis entry nails were associated with damage to the superior gluteal nerve and muscular apparatus of the hip and resulted in decreased hip function and gait abnormalities.8 The combination of these studies and clinical experience with trochanteric nailing using a smaller-diameter implant suggest that these implants, if used properly, have a high success rate and can be performed more expeditiously than piriformis nails. 

Retrograde Intrameduallry Nailing for Femoral Shaft Fractures

Retrograde femoral nailing was first introduced by Kuntscher168 for the treatment of pertrochanteric femoral fractures. A variety of techniques and implants were subsequently described including flexible implants introduced through extra-articular distal femoral portals with and without distal femoral locking capabilities. These implants were used to treat both distal and proximal femoral fractures, as well as to prophylactically stabilize proximal femoral metastases.91,269,348 An extra-articular medial condylar starting portal was suggested by Swiontkowski et al.294 for the treatment of ipsilateral femoral neck and shaft fractures, using antegrade femoral implants. Sanders et al.268 expanded the indications to include the multiply injured patient, other ipsilateral fractures, and pregnancy. Insertion of both femoral nails and tibial nails was possible using a medial condylar distal femoral entry site, enabling fracture healing in difficult situations. 
The use of short supracondylar nails placed through an intercondylar distal femoral starting portal was introduced in 1991 with the genucephalic nail.130 This implant was initially used to treat distal femoral fractures and as an alternative for revision of failed fixations in the distal femur. The use of this implant expanded to include treatment of intercondylar fractures and periprosthetic fractures of the distal femur. Because of the short length of the implant, the initial application to diaphyseal injuries was limited.130,182,273 Experience and difficulties with the shorter nails, combined with the success of longer retrograde femoral implants placed through various starting portals, ultimately led to the development of retrograde femoral nails specifically designed to span the entire femur.119,132,196,221,239 The major implant design changes that have facilitated the expansion of indications include a more appropriate anterior bow, multiple distal interlocking options, anterior to posterior proximal interlocking options, and variable nail dimensions. These implants can now be used to treat many femoral diaphyseal fractures. 

Indications and Contraindications

The early experience with the use of retrograde nails has produced a number of clinical circumstances in which the implants may offer an advantage over other techniques of femoral shaft stabilization.132,268 However, these remain relative indications (Table 52-17; Fig. 52-24). The major advantage with a retrograde entry portal is the ease in properly identifying the starting point. In addition, distraction of the fracture site is decreased with retrograde nailing compared with the antegrade technique. In situations in which surgical time and repositioning cannot be tolerated by the patient, retrograde nailing may be more suitable than the antegrade technique. Ipsilateral injuries such as femoral neck, pertrochanteric, acetabular, patellar, or tibial shaft fractures may make retrograde nailing a desirable option. In the case of an ipsilateral intracapsular femoral neck fracture, proper fixation of the femoral neck should remain a priority and is best accomplished with multiple cannulated screws, a sliding hip screw, or combinations thereof. The femoral shaft fracture can be treated with a retrograde nail or plate fixation, both of which have been shown to predictably produce fracture union (Fig. 52-25). Depending on the surgical technique and the planned operative approach in a patient with an ipsilateral acetabular fracture, retrograde nailing remains a consideration. This is most relevant if a planned extensile or posterior approach to the acetabulum is planned because the antegrade nail insertion site may be within the subsequent surgical exposure. This is probably not a large clinical concern for most surgeons experienced in the treatment of acetabular fractures. If a retrograde technique is used in this situation, consideration should be given to overreaming the femoral canal significantly to allow for atraumatic retrograde nail placement, avoiding further surgical impact on the already injured acetabulum. In patients with ipsilateral tibial shaft fractures (i.e., a “floating knee”), a single percutaneous incision for the placement of a retrograde femoral nail and an antegrade tibial nail has been advocated and accomplished with good results. However, the length of the incision for the percutaneous placement of an antegrade femoral nail is limited, and the advantage of avoiding this remains unknown. The presence of an ipsilateral patellar fracture requiring surgical fixation certainly allows for easy identification of the starting point for a retrograde femoral nail. However, similar to the situation in patients with an ipsilateral tibial fracture, the morbidity associated with the introduction of an additional surgical incision at the hip is probably minimal. 
Figure 52-24
 
An antegrade nail can be placed quite distally (A). This closely approximates the normal location of an appropriately placed retrograde nail (B).
An antegrade nail can be placed quite distally (A). This closely approximates the normal location of an appropriately placed retrograde nail (B).
View Original | Slide (.ppt)
Figure 52-24
An antegrade nail can be placed quite distally (A). This closely approximates the normal location of an appropriately placed retrograde nail (B).
An antegrade nail can be placed quite distally (A). This closely approximates the normal location of an appropriately placed retrograde nail (B).
View Original | Slide (.ppt)
X
Figure 52-25
A retrograde nail was used to stabilize the femoral shaft fracture in a patient with an ipsilateral intertrochanteric fracture.
 
The nail can be placed proximally to the level of the sliding hip screw barrel (A, B).
The nail can be placed proximally to the level of the sliding hip screw barrel (A, B).
View Original | Slide (.ppt)
Figure 52-25
A retrograde nail was used to stabilize the femoral shaft fracture in a patient with an ipsilateral intertrochanteric fracture.
The nail can be placed proximally to the level of the sliding hip screw barrel (A, B).
The nail can be placed proximally to the level of the sliding hip screw barrel (A, B).
View Original | Slide (.ppt)
X
 
Table 52-17
Retrograde Nails Indications and Contraindications
View Large
Table 52-17
Retrograde Nails Indications and Contraindications
Relative Indications
Multiply injured patients or polytrauma
Bilateral femur fractures
Morbid obesity
Distal metaphyseal fractures
Pregnancy
Associated vascular injury
Associated spine fracture
Ipsilateral femoral neck fracture
Ipsilateral acetabular fracture
Ipsilateral patella fracture
Ipsilateral tibia fracture
Ipsilateral through knee amputation
Relative Contraindications
Subtrochanteric fracture
Limited knee motion (if starting point inaccessible)
Patellar baja
X
Several other relative indications for retrograde nails have been suggested. The presence of multiple other fractures and multiple other organ system injuries suggest that rapid stabilization of a patient in the supine position maybe optimal. Although femoral nailing certainly can be quickly accomplished with an antegrade technique, the retrograde entry site may be performed more rapidly in some circumstances. The rapid placement of a small-diameter unreamed retrograde nail in the multiply injured patient as an alternative to temporary external fixation has been described as “Damage Control Nailing” and can be considered.133 Bilateral femoral fractures can be treated with retrograde nails without repositioning the patient, potentially decreasing the total operative time in a critically injured patient. In patients with an associated vascular injury, rapid treatment with an initially unlocked retrograde implant can be performed, allowing fracture stabilization to facilitate the subsequent vascular repair. In the morbidly obese patient in whom the entry site for antegrade nailing is particularly difficult, a retrograde nail may be a reasonable alternative and has been associated with decreased operative time and radiation exposure.314 Similarly in pregnant patients, retrograde nails may be easier to place and have the advantage of potentially decreased radiation exposure around the hip. In patients with distal femoral periprosthetic fractures above a total knee arthroplasty, a retrograde femoral nail may offer a reasonable fixation option. The design of the femoral component and the available space for placement of the retrograde implant are necessary before consideration of retrograde medullary fixation. The fixation of the medullary implant in the stress-shielded distal femoral metaphysis may be poor, making consideration of other strategies necessary. Finally, an ipsilateral through knee amputation in a patient with an associated femoral shaft fracture is a good indication for a retrograde nail. 
Several contraindications for the use of retrograde nails exist. Because of the need for knee flexion that allows nail placement,305 patients with restricted knee motion may be poor candidates for retrograde femoral nailing. Similarly, patients with patellar baja may not have adequate room for placement of a retrograde nail between the patella and anterior tibial plateau with the knee flexed. Subtrochanteric fractures, although successfully treated with retrograde nails in some instances, may be difficult to control unless the nail is placed in an extremely cephalad location. The presence of an associated open traumatic wound may make retrograde nailing less desirable because these open injuries have an increased nonunion rate and may be associated with an increased risk of infection with the potential for subsequent septic arthritis of the knee. However, recent studies have shown that the incidence of an acute or subsequent septic knee is quite low.20,219 

Surgical Procedure: Retrograde Femoral Nailing

Preoperative Planning.
The surgical planning for retrograde femoral nailing is similar to that of antegrade nailing (Table 52-18). However, because a flat radiolucent table (as opposed to a fracture table) is typically used for retrograde nailing, assistance with regaining length must be anticipated. The patient is positioned supine on a radiolucent table that allows unimpeded fluoroscopy from the knee to the hip. A small bump beneath the ipsilateral flank may help avoid external rotation of the leg. The entire leg and hip are prepped to the iliac crest and medially to allow access to the femoral artery if needed. Pharmacologic relaxation is necessary in all cases, especially if manual traction is the primary reductive force. The C-arm is positioned perpendicular to the long axis of the table on the contralateral side to allow for ease with imaging and placement of interlocking screws. Knee flexion of 34 to 52 degrees305 is necessary to allow identification of the proper entry portal and placement of the nail. This can easily be accomplished with several bolsters or a large radiolucent triangle. Femoral length and fracture reduction can be accomplished manually, with a femoral distractor197 or with percutaneous and unicortical Schanz pins used as joysticks.106 A femoral distractor can be used to maintain length, alignment, and rotation during the entire procedure. The proximal pin can be placed from anterior to posterior, medial to the predicted nail path. Distally the pin is placed from lateral to medial, anterior to the predicted nail path. Percutaneous Schanz pins for manipulative reduction can be placed from lateral to medial, unicortically, and close to the fracture. As with any nailing procedure, the fracture should be reduced during reaming and nail placement, and until interlocking is complete. 
 
Table 52-18
Preoperative Planning Checklist
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Table 52-18
Preoperative Planning Checklist
OR table: A radiolucent flat top table that allows unimpeded radiographic imaging
Position/positioning aids: Supine positioning with a rolled blanket or positioning pillow placed beneath the injured buttock to produce internal rotation to neutral, allowing predictable AP and lateral imaging. A foam ramp or soft support beneath the leg assists with lateral imaging with the patient positioned supine on a flat top table. A radiolucent triangle or similar is helpful for optimizing knee flexion for starting point identification and nail placement
Fluoroscopy location: The C-arm is usually placed opposite the injured side allowing for AP and lateral imaging without moving the leg
Equipment: Nails of the proper length and diameter with the appropriate interlocking bolts. Reduction tools including 5 mm Schanz pins, large reduction forceps, a femoral distractor, intramedullary reduction tools, etc. Reamers, drills, guidewires
Special considerations: Intraoperative length and rotation must be carefully assessed. The femoral neck should be evaluated for a possible fracture prior to and following all nailing procedures
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Positioning.
Supine positioning is used for retrograde nailing procedures. 
Surgical Technique (Table 52-19).
 
Table 52-19
Retrograde Nailing of Femoral Shaft Fracture Surgical Steps
Position the knee over a radiolucent triangle or bolsters that allow for knee flexion of between 35 and 50 degrees
Identify the proper starting point based on AP and lateral radiographic imaging of the knee
Make an incision centered between the patella and tibial tubercle based on the radiographic estimation of the starting point
Establish the entry portal using a large cannulated drill over a terminally threaded pin
Place a ball-tipped guidewire through the entry portal and up the canal of the femur
Reduction of the fracture with strategic bumps, Schanz pins such as joysticks, traction, etc.
Placement of the guidewire across the fracture and central into the proximal femur, past the level of the lesser trochanter
Determine the anticipated proper nail length using the guidewire
Ream the canal while the reduction is maintained
Place the nail with the proper rotation of the implant and the proper length and rotation of the femur
Confirm the nail depth, implant rotation, and femoral rotation
Interlock proximally and distally
Confirm (again) the implant placement and the femoral length, alignment, and rotation; check for an associated femoral neck fracture; check for any associated knee ligamentous injury
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A longitudinal incision centered between the inferior pole of the patella and the tibial tubercle is optimal. A smaller incision of 2 to 3 cm at the location of the perfect starting portal is certainly possible and preferred by many surgeons. The approach can be accomplished medial to or through the central portion of the infrapatellar tendon. The starting point can be palpated or identified radiographically. The location for the proper starting point is anterior to the posterior cruciate ligament origin and at or slightly medial to the intercondylar sulcus in line with the canal of the femur. This has been identified as 6.2 to 12 mm anterior to the posterior cruciate ligament femoral attachment and through the articular cartilage of the posterior intercondylar sulcus.58,164 Alternatively, the entry site can be identified radiographically on the basis of the lateral fluoroscopic image. With the femur rotated into a perfect condylar overlap lateral view, the proper entry site is at the apex of Blumensaat line (Fig. 52-26). However, the optimal entry side based on the lateral radiographic projection is dependent on the implant design and may be more anterior than previously suggested.205 Given the anatomical valgus of the distal femur the entry angle should not be perpendicular to the femoral articulation because this can produce a varus reduction if the fracture is located distal to the femoral isthmus. Instead, the entry angle should be in 5 to 9 degrees of the valgus as confirmed on the intraoperative AP fluoroscopic image, coincident with the axis of the femoral canal. The starting point can be initiated with either a sharp awl or a cannulated drill. Use of a cannulated drill has the advantage of allowing for minor corrections in the entry angle before committing with a large opening in the distal femoral articular surface. Both reamed and unreamed techniques have been described, and the relative advantages of each are probably similar to those of antegrade techniques. For placement of a reamed nail, a ball-tipped guidewire is placed across the fracture and into the medullary canal of the opposite segment. The guidewire should be advanced proximal to the lesser trochanter to ensure placement of a long implant. Reaming is performed with the fracture reduced and the knee flexed to the proper degree that minimizes damage to the inferior pole of the patella, the proximal tibia, and the distal femoral articulation. The canal should be overreamed by at least 1 mm greater than the desired nail diameter. If a proximal femoral or ipsilateral acetabular fracture is present, consideration should be given to overreaming by 1.5 to 2 mm to allow for atraumatic nail passage. 
Figure 52-26
The proper starting point for a retrograde nail can be confirmed intraoperatively with image intensification.
 
On the AP view, the starting point should be in line with the femoral shaft, at an angle of 5 to 9 degrees relative to the distal femoral articular surface (A). On the lateral view, the starting point should be at the apex of the Blumensaat line, slightly posterior to the location in (B).
On the AP view, the starting point should be in line with the femoral shaft, at an angle of 5 to 9 degrees relative to the distal femoral articular surface (A). On the lateral view, the starting point should be at the apex of the Blumensaat line, slightly posterior to the location in (B).
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Figure 52-26
The proper starting point for a retrograde nail can be confirmed intraoperatively with image intensification.
On the AP view, the starting point should be in line with the femoral shaft, at an angle of 5 to 9 degrees relative to the distal femoral articular surface (A). On the lateral view, the starting point should be at the apex of the Blumensaat line, slightly posterior to the location in (B).
On the AP view, the starting point should be in line with the femoral shaft, at an angle of 5 to 9 degrees relative to the distal femoral articular surface (A). On the lateral view, the starting point should be at the apex of the Blumensaat line, slightly posterior to the location in (B).
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Most current nail designs have an anterior bow with a radius of curvature that is greater than that of the normal human femur. As a result, extension of the fracture may occur despite a proper entry portal for the implant. A more posterior entry site, in addition to potentially damaging the femoral posterior cruciate ligament origin, can result in accentuation of fracture site extension. In contrast, a more anterior starting point will produce fracture site flexion and will be located in the patellofemoral articulation. The nail should be recessed beneath the cartilage surface distally and above the lesser trochanter proximally (Fig. 52-27). In a study using a cadaveric femoral model tested with pressure sensitive film, Morgan et al.204 demonstrated that placement of the nail 1 mm prominent at the knee joint resulted in significant increases in patellofemoral joint contact pressures at 90 and 120 degrees of knee flexion when compared with nails placed flush or recessed. Distal interlocking is typically facilitated with a targeting jig that allows placement of a variable number of screws from lateral to medial. For some nail designs, endcaps are available that contact the ultimate distal interlocking screw, preventing toggle of the screw–nail junction. Locking of the distal interlocking bolts to the nail may be beneficial for decreasing fracture site motion.299 In addition, bolts are available that can be placed on the medial ends of the screws as they exit the medial metaphyseal femoral cortex, potentially increasing the fixation in osteoporotic bone. The knee joint should be vigorously irrigated after nail placement to remove any debris that has accumulated from reaming. Proximal interlocking can be performed from anterior to posterior or from lateral to medial depending on the design of the nail. Given the need to maintain the proper femoral rotation throughout the procedure, anterior to posterior proximal interlocking is usually easier. Because of the potential for injury to the neurovascular structures located medially, internal rotation of the nail relative to the femur should be avoided. The major structures at risk during placement of anterior to posterior interlocking screws include the femoral artery and branches of the profunda artery medially, and the sciatic nerve posteriorly. The relative safe zone for placement of anterior to posterior interlocking screws has been described at the level of the lesser trochanter. In this location, the safe corridor was identified from 7 degrees medial to 20 degrees lateral relative to the sagittal axis. This safe zone decreased by 52% in patients with an ipsilateral acetabular fracture, according to examination of CT scans.41 
Figure 52-27
A retrograde nail is ideally placed proximal to the level of the lesser trochanter.
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Postoperative Care.
The postoperative care following retrograde intramedullary nailing is similar to antegrade nailing techniques for femoral shaft fractures. The presence of a reamed statically locked implant placed in a retrograde direction should allow for mobilization, weight bearing, and activities similar to other nailing techniques. 
Potential Pitfalls and Preventative Measures.
In general, many of the potential pitfalls associated with retrograde nailing are similar to those in antegrade nailing techniques (Table 52-20). However, there are several complications that are unique to retrograde nailing. Injury to the local neurovascular structures with proximal interlocking is possible and has been reported, including injury to a branch of the profunda femoris artery.73 An incision that allows direct palpation of the anterior femur combined with avoidance of internal rotation of the nail minimizes this risk. In addition, locking performed above the level of the lesser trochanter further minimizes the risk of injury to the local neurovascular structures.257 Although injury to the popliteal artery has been reported with retrograde nailing, this complication appears to be more related to the injury than to the implant or the retrograde technique.16 Heterotopic ossification in intra-articular and periarticular locations has been reported after retrograde nailing, and this should remain a concern in patients with associated risk factors.134 Synovial metallosis has been observed after retrograde medullary nailing, but the impact of this is unknown.148 The negative impact of the retrograde femoral reaming on the blood flow to the distal femur and the cruciate ligaments has been demonstrated in an animal model, but the clinical impact is unclear.89 The use of retrograde nails for the treatment of proximal fractures remains controversial. In a review of 17 subtrochanteric femur fractures treated with retrograde nails, DiCicco et al.82 reported healing with greater than 5 degrees of varus malalignment in 35% of patients. Similarly, Ricci et al.252 reported more problems with angular malalignment of proximal third femoral fractures treated with intramedullary nailing when compared with middle third fractures. The exact distance between the proximal extension of the fracture and the interlocking screws is unknown, but 5 cm is probably advisable as a minimum length of intact femoral diaphysis. 
 
Table 52-20
Potential pitfalls and Preventative Measures
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Table 52-20
Potential pitfalls and Preventative Measures
Pitfall Prevention
Failure to obtain the proper length
  1.  
    Adequate muscular paralysis intraoperatively
  2.  
    Obtain contralateral radiographs, especially in comminuted patterns
  3.  
    Adequate intraoperative traction
Fracture malreduction in the coronal or sagittal planes
  1.  
    Obtain contralateral femoral radiographs prior to nailing
  2.  
    Center the guidewire, reamers, and nail on both radiographic views in both segments
  3.  
    Obtain a proper starting point at the knee at the apex of Blumensaat line and consistent with the normal valgus of the distal femur articulation
Iatrogenic femoral shaft fracture during nail placement
  1.  
    Preoperative assessment of any femoral deformity and anticipation of the proper starting point
  2.  
    Overream the canal by 1–2 mm larger than the anticipated nail size
  3.  
    Establish that there are no intramedullary cortical fragments that would block the nail passage
Femoral malrotation
  1.  
    Obtain contralateral AP imaging of the contralateral side in known rotation in order to judge the lesser trochanteric profile
  2.  
    Image the contralateral side to determine the femoral neck anteversion
Missed diagnosis of a femoral neck fracture
  1.  
    Obtain preoperative imaging of the femoral neck to investigate the presence of a fracture prior to surgery; may include dedicated hip radiographs and/or a CT scan
  2.  
    Confirm the lack of a femoral neck fracture after all femoral nailing procedures
Placement of interlocking bolts that miss the nail
  1.  
    Careful intraoperative imaging during drilling and interlocking bolt placement
  2.  
    Confirmation radiograph following interlocking
Iatrogenic injury to the structures at the knee
  1.  
    Ensure proper starting point for the nail at the knee
  2.  
    Irrigate the knee joint following reaming and nail placement
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Outcomes.
The early clinical experience with the use of long retrograde nails placed through an intercondylar starting point for the treatment of femoral shaft fractures was largely limited to the multiply injured patient and those patients with severe ipsilateral lower-extremity injuries.119,132,196,239 Patterson et al.239 reported on 17 femur fractures in 16 patients treated with retrograde nails and followed for an average of almost 2 years. Medullary nails normally designed for antegrade implantation were used in these patients. The indications for the use of a retrograde nail was an ipsilateral femoral neck fracture in eight patients, an ipsilateral through or above knee amputation in five patients, and other associated injuries including a traumatic arthrotomy and an ipsilateral acetabular fracture. Fourteen of these 17 injuries were open fractures. Complications were observed commonly and were likely related to the severity of the initial injuries. The poor results were due to nonunions, loss of knee motion, and infection; hardware removal was required commonly. Despite this, the authors believed that knee function was not adversely affected and that the intercondylar starting point could be used successfully in difficult injuries.239 Moed and Watson196 described their experience with 22 femoral shaft fractures treated with unreamed retrograde nails placed through the intercondylar starting point. Union occurred in less than 4 months in 19 cases, and the major complications were 3 nonunions and a rotational malunion. Restriction of knee motion was not observed. Herscovici and Whiteman132 further described the indications for the use of retrograde nails based on their experience with 45 fractures. They observed a rotational abnormality in one patient and two nonunions that both healed after a revision procedure. Knee motion averaged 129 degrees; however, decreased flexion and an extensor lag were observed in a minority of patients. The authors suggested that the relative indications for this procedure may include ipsilateral femoral fractures, ipsilateral acetabular fractures, ipsilateral tibial fractures, morbid obesity, and bilateral femoral shaft fractures. These initial studies, although promising, suggest that knee-related morbidity does exist with these implants and that union rates may be lower than in patients treated with antegrade, statically locked, reamed medullary nailing. However, the complexity of these injuries and the use of antegrade nails placed in a retrograde fashion in the most severe injuries likely have contributed to these observations. 
As full-length nails specifically designed for retrograde applications became more readily available, prospective studies evaluating their use in all femoral fractures as well as in comparison with antegrade techniques became possible. Early reports demonstrated an increased number of nonunions and delayed unions compared with historical reports of antegrade, reamed medullary nailing techniques.197,221 Moed et al.197 prospectively reported on a consecutive series of patients with femoral shaft fractures treated with unreamed retrograde nails placed through a patellar tendon splitting approach. Early nail dynamizations were performed at 6 to 12 weeks. The authors observed a decrease rate of nonunion (6%) and time to union (12.6 weeks) when compared with their earlier study. There were minimal complaints of knee pain, and knee function was rated as excellent using a clinical rating system. Ostrum et al.221 similarly reported on a prospective and consecutive series of 61 fractures treated with a reamed 10-mm retrograde nail placed through a medial parapatellar incision. More than half of these fractures had significant (Winquist type 3 or 4) comminution, and 26% were open injuries. The authors observed a union rate of 95% when they included one planned bone grafting for traumatic bone loss and five nail dynamizations. One case of knee sepsis was observed, leading the authors to recommend caution in patients with open fractures. Associated knee problems were not encountered. 
Antegrade and retrograde nailing techniques have been directly compared and reported in one retrospective study, one prospective, and two prospective and randomized studies.220,252,312,314 In a retrospective study comparing 134 femoral fractures treated with a retrograde technique and 147 fractures treated with an antegrade technique, Ricci et al.252 compared the rates of delayed union, nonunion, malunion, and complications at an average of 23 months. Union occurred after the initial procedure in 89% of the fractures treated with antegrade nails and 88% of those treated with retrograde nails. The final rate of union after additional interventions and the rate of malunions were the same between the two groups. After excluding patients with ipsilateral hip or knee injuries, the authors reported a significantly higher rate of pain at the associated entry site for each group. In patients treated with retrograde nails, 36% had knee pain compared with 9% of those treated with antegrade nails. Ipsilateral hip pain was reported in 10% of patients treated with antegrade nails compared with 4% of patients treated with retrograde nails. This led the authors to conclude that although union rates between the two treatment approaches are comparable, complications related to the knee and hip are related to the nail insertion site. Ostrum et al.220 compared femoral fractures treated with antegrade and retrograde nails in a prospective and randomized study of 100 patients. Small-diameter (10-mm) nails were inserted after reaming in both groups. The authors reported fewer nail dynamizations and more rapid healing with the antegrade technique by almost 4 weeks. Knee pain was found to be equal in both groups, but thigh pain was observed to be associated with antegrade nails. Final healing after secondary procedures was similar between the two groups. In another prospective and randomized study comparing antegrade and retrograde femoral nailing for femoral shaft fractures, Tornetta and Tiburzi312 found no difference in operating time, blood loss, technical complications, nail size, or the need for blood transfusions in 69 fractures. Reamed nails were used with both insertional techniques. The authors reported an increased rate of rotational and length discrepancies with the retrograde technique. In their study, the antegrade procedures were performed using a fracture table, whereas the retrograde procedures were accomplished with manual traction on a radiolucent table. The time to union and the rate of union (100%) were the same for both surgical approaches. Because of the limited length of follow-up, no conclusions could be drawn regarding long-term knee function or complications. In a more recent follow-up presentation, Tornetta et al.306 reported similar results in knee range of motion, stair-climbing ability, pain medication requirements, and Short Form-36 outcomes in patients prospectively randomized to treatment with either an antegrade or retrograde nail. In a prospective and nonrandomized multicenter study, Tucker et al.314 demonstrated similar outcomes in patients treated with an antegrade or a retrograde technique. The emphasis of their study was primarily on the difference in patients who were obese (defined as body mass index greater than or equal to 30 kg/m2). In obese patients, the retrograde technique was associated with significantly decreased operative and radiation exposure times, supporting the use of this technique in some obese patients.314 

Special Fracture Patterns and Associated Injuries in Femoral Shaft Fractures

Intramedullary Nailing in the Multiply Injured Patient

The treatment of the femur fracture in the multiply injured patient, especially those patients with associated chest trauma, remains a topic of some contention. Early retrospective studies suggested that immediate internal fixation of long bone fractures was beneficial in patients with multiple injuries, and this included the use of reamed intramedullary nails.114,149,259,260,296 Although the risk of fat embolism was recognized, most series suggested that early femoral stabilization actually decreased the incidence of severe fat embolism and pulmonary complications. Talucci et al.296 reported five cases of fat embolism syndrome in patients treated with delayed intramedullary nailing and no cases in patients treated with immediate nailing. Johnson et al.149 retrospectively evaluated 132 patients with multiple musculoskeletal injuries with an ISS of 18 or higher. They found that early operative stabilization of the majority of fractures was associated with a decreased incidence of ARDS. Because of the retrospective nature of the study, however, firm conclusions could not be determined. In a landmark article, Bone et al.31 addressed the impact of early stabilization of long bone fractures on pulmonary complications, hospital stay, and the number of days in the intensive care unit. In a prospective and randomized study, 178 patients were treated with either early (<24 hours) or delayed femoral stabilization. The patients were divided on the basis of the number of associated injuries as either isolated or multiply injured. The incidence of pulmonary complications including ARDS, fat embolism, and pneumonia was lower in both groups of patients treated with immediate femoral stabilization. 
Although early stabilization of long bone injuries appears to be clearly important in the multiply injured patient, the impact of femoral nailing and especially reaming is less clear. This has been especially contentious in the patient with a concomitant pulmonary injury. Several investigators have therefore looked specifically at the effects of reaming and intramedullary nailing on pulmonary function in animal models.87,231,335,339,340 In a hemorrhagic shock and lung contusion model, Pape et al.231 found increased pulmonary artery pressure and increased lung capillary permeability in animals treated with reamed nails compared with unreamed nails. In contrast, Wolinsky et al.335 found that femoral reaming did not affect pulmonary shunt or pulmonary compliance in an ARDS sheep model if appropriately resuscitated. Similarly, Duwelius et al.87 found that pulmonary dysfunction did not increase in a pulmonary contusion model. 
Given the contrasting findings in these laboratory investigations, several clinical studies sought to address the issue of reaming and intramedullary nailing on pulmonary function and mortality in patients with an associated thoracic injury.33,35,57,59,229,318 Pape et al.229 investigated whether early intramedullary stabilization of femoral shaft fractures in multiply injured patients may be detrimental in the subpopulation of patients with an associated thoracic injury. In a retrospective review of 766 patients, 106 met the inclusion criteria and all were multiply injured (ISS >18). The authors reported an increased incidence of ARDS and mortality in the patients who had associated severe chest trauma and were treated with immediate nailing. However, this is in contradistinction to the study by Charash et al.59, who arrived at a different conclusion. That is, pulmonary complications were decreased in all patients who underwent early femoral stabilization with reamed nailing, including those with thoracic trauma. 
In an effort to look specifically at the impact of reamed femoral nailing on the multiply injured patient and the patient with thoracic trauma, Bosse et al.33 designed a study considering patients treated at two different centers. Although the patient populations and the protocols for trauma care were similar at the two centers, reamed intramedullary nailing was used in 95% of patients at one institution, whereas plating was used in 92% of patients at the other institution. This allowed for comparison of the effects of reamed nailing and not necessarily the impact of a femoral fracture on outcomes. The overall incidence of ARDS was only 2% in patients with a femoral fracture compared with 6% to 8% in patients without a femur fracture but with a thoracic injury. The occurrence of ARDS, pneumonia, pulmonary embolism, multiple organ system failure, and death were similar regardless of the type of treatment or the presence of a thoracic injury. This led to the conclusion that nailing with reaming for the acute stabilization of femoral fractures in the multiply injured patient with a thoracic injury did not increase the occurrence of the aforementioned complications. 
Currently, ongoing investigations continue evaluating the impact of intramedullary instrumentation on the pulmonary complications and mortality in the multiply injured patient.54,109,110,206,232,233,234,236 In a prospective and randomized evaluation of patients treated with early intramedullary nailing for their femoral fractures, no difference was found in the incidence of ARDS in patients treated with reamed or unreamed nails. The authors observed a low overall incidence of ARDS and could not detect a difference given the small sample size of multiply injured patients.54 However, there continues to be a significant body of evidence that suggests that in a specific subpopulation of patients, early intramedullary nailing may be deleterious and is associated with elevation of certain proinflammatory markers, especially interleukin (IL)-6.109,110,206,232,233,234,236 Both the femoral fracture and the process of reaming has been shown to increase IL-6 levels, which may indicate an increase in the inflammatory response and the presence of an additional insult due to the surgical treatment.206 This IL-6 increase has been shown to be closely correlated with injury severity and the development of a systemic inflammatory response state.109,236 This has led to the recommendation that early external fixation of long bone fractures followed by delayed intramedullary nailing may minimize the additional surgical impact in patients at high risk for developing complications. However, the exact and optimal timing of femoral shaft fracture repair remains unclear in the multiply injured patient, especially in the setting of an associated thoracic or lung injury.207,218 In a large multicenter study of over 3,000 patients with multisystem trauma, Morshed et al.207 demonstrated a reduction in mortality by approximately 50% in patients who underwent femoral shaft fracture repair beyond 12 hours; this timing was hypothesized to allow for adequate resuscitation. The need for an adequate resuscitation prior to femoral stabilization was further demonstrated by O’Toole et al.218 in a review of 227 polytraumatized patients with femoral shaft fractures who underwent reamed nailing. Despite using a damage control approach in only 12% of patients, most of whom had an associated lung injury, the rate of ARDS and mortality were quite low.218 It appears that adequate resuscitation, limited use of a damage control approach, and femoral stabilization based on multiple parameters is a rational overall treatment strategy. (See Chapter 9 for an in-depth review of this topic). 

Open Fractures

Open femoral shaft fractures are typically the result of high-energy trauma. These patients frequently have multiple other orthopedic injuries and involvement of several organ systems. Vascular injuries are commonly observed in association with open femoral shaft fractures. 
Because of the thick muscular envelope surrounding the femoral shaft, an associated open traumatic wound suggests significant initial displacement and associated soft tissue disruption. Unlike the tibia, which is entirely subcutaneous over its anteromedial face, the femur is completely covered in muscle except at the palpable proximal and distal aspects. For that reason, a small skin disruption is usually indicative of a much larger soft tissue injury. As a result, the usual classification system of Gustilo and Anderson for open fractures cannot necessarily be accurately applied.122 Although previous articles have used this system for open femoral shaft fractures,43,118,122,178,215,216,265,328 no studies exist that compare its reliability and reproducibility. 
The initial management of an open femoral fracture is similar to that of other open long bone fractures and includes antibiotics, debridement, and stabilization. Repeated examinations of the open wound outside of the operating room should be avoided. Antibiotics and tetanus prophylaxis should be administered immediately. Early operative debridement, preferably within 6 to 8 hours, should be performed depending on the patient’s other associated injuries. In the operating room, any planned incisions for surgical stabilization of the femur should be drawn on the skin to allow for intelligent surgical extensions of the open wound for definitive debridement. If appropriate, the traumatic wounds should be extended to allow a complete examination of the bone ends and medullary canal. A separate surgical incision for the purposes of debridement can be used if the traumatic wound is located in a poorly extensile location. All devitalized cortical fragments should be removed with the intention of not routinely reimplanting these segments. The bone ends should be debrided and cleaned of any foreign material while avoiding further soft tissue devitalization. Multiple liters of saline should be used to clean the contaminated fragments. A thorough debridement should be performed to decrease the overall risk of early and late infection. In circumstances in which gross contamination has occurred and the initial debridement is questionable, a second debridement at 48 hours should be planned. 
If the initial debridement is believed to be adequate and was performed in a timely fashion, definitive stabilization of the femoral shaft can proceed, usually with reamed intramedullary nailing. Historically, traction and external fixation have been used to definitively treat open femoral shaft fractures. However, these methods have numerous disadvantages that have precluded their routine use. Specifically, traction requires a period of immobilization and supine positioning that is undesirable in the polytraumatized patient. The delay in stabilization of the femoral shaft has been shown to be associated with increased mortality, and every effort should be made to stabilize the limb within 24 hours.31 In addition, length and alignment are poorly controlled and fracture instability contributes to early patient discomfort. Nursing care is difficult, because patients must remain in a relatively fixed position. Management of other associated injuries is further jeopardized by the need for constant traction on the extremity. External fixation is a reasonable temporizing measure in specific circumstances but is associated with multiple difficulties as a definitive treatment method. In patients with multiple injuries that preclude early operative stabilization of their open femur fractures and in patients with severe soft tissue injuries that require a second debridement, temporary external fixation is a reasonable and rapid initial management approach that allows delayed conversion to a medullary implant at 5 to 10 days. External fixation as a definitive treatment is associated with pin tract infections, shortening, and loss of knee motion. 
Immediate or delayed intramedullary nailing of open femoral shaft fractures (Fig. 52-28), including type III open wounds, has been found to have an acceptable complication rate in several studies and remains the treatment of choice in most instances.43,178,216,265,328 Lhowe and Hansen178 reported on 42 patients after immediate reamed intramedullary nailing of open femoral diaphyseal fractures who were followed for a minimum of 12 months. Union occurred in all patients, and infection, angular malunion, and limb length inequality were observed infrequently. Brumback et al.43 retrospectively identified 89 open femoral fractures, the majority of which were type III open fractures. Immediate reamed nailing was performed in 56 patients, whereas 33 patients underwent delayed stabilization at 5 to 7 days. Fractures that had a delay in the initial debridement of more than 8 hours were typically treated with staged nailing. All fractures healed and no infections were observed in type I, II, and IIIA open fractures. In the type IIIB injuries, infections were observed in 11% and occurred in injuries treated immediately and those treated delayed. Whether early nailing resulted in a higher infection rate was further investigated by Williams et al., who prospectively assigned 42 patients with open femoral fractures to immediate versus delayed intramedullary nailing. They observed a low rate of infection and nonunion, and found no relationship with timing or the associated soft tissue injury.328 The initial treatment of open femoral shaft fractures with immediate, reamed intramedullary nailing has been confirmed by multiple other studies.216,265 
Figure 52-28
 
This patient sustained a contaminated open femur fracture with bone loss after a motorcycle crash (A). An antegrade nail was used to stabilize the femur, and antibiotic beads were used to fill the dead space (B, C). Iliac crest bone grafting was performed at 6 weeks. Healing proceeded uneventfully (D, E).
This patient sustained a contaminated open femur fracture with bone loss after a motorcycle crash (A). An antegrade nail was used to stabilize the femur, and antibiotic beads were used to fill the dead space (B, C). Iliac crest bone grafting was performed at 6 weeks. Healing proceeded uneventfully (D, E).
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Figure 52-28
This patient sustained a contaminated open femur fracture with bone loss after a motorcycle crash (A). An antegrade nail was used to stabilize the femur, and antibiotic beads were used to fill the dead space (B, C). Iliac crest bone grafting was performed at 6 weeks. Healing proceeded uneventfully (D, E).
This patient sustained a contaminated open femur fracture with bone loss after a motorcycle crash (A). An antegrade nail was used to stabilize the femur, and antibiotic beads were used to fill the dead space (B, C). Iliac crest bone grafting was performed at 6 weeks. Healing proceeded uneventfully (D, E).
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While most open femoral shaft fractures are treated with antegrade nailing using a piriformis or trochanteric entry nail, retrograde nailing is a possibility. The risk of a future knee joint sepsis is quite low in these patients despite the presence of an open femoral shaft fracture, and has been reported to be approximately 1%.20,219 However, the surgeon should additionally consider the need for secondary procedures in these patients and the associated risks when considering the nail entry location. 

Gunshot Fractures

Fractures of the femoral diaphysis caused by low-velocity missiles are observed relatively commonly in most urban trauma centers. They are typically the result of handgun injuries, and four classic types of fractures have been described in the femur. These include the “drill-hole,” incomplete, butterfly, and spiral fractures. The former is result of a metaphyseal injury in which the bullet passes through the bone, producing minimal comminution and maintaining the integrity of the remaining femur. Incomplete fractures occur when the bullet grazes the cortex of the femur with a subcritical force. Fracture comminution occurs when the missile impacts the diaphyseal bone, resulting in the commonly observed butterfly fragmentations. Spiral fractures typically occur in a slightly remote location relative to the path of the bullet and likely represent an associated torsional force caused by weight bearing at the time of impact.282 
The results of immediate reamed intramedullary nailing of femoral shaft fractures caused by gunshots have been uniformly good.25,177,214,309,341 This has led to significant cost savings and early patient mobilization compared with the traditional approach of traction, antibiotics, and delayed intramedullary fixation.177,332,341 For fractures caused by low- and midvelocity gunshots, treatment with immediate nailing without a formal debridement of the comminuted diaphyseal fragments and bullet particles has resulted in predictable union with acceptable complications25 (Fig. 52-29). Nowotarski and Brumback214 retrospectively reviewed 39 femoral fractures caused by handgun missiles, which were treated with early (<24 hours) intramedullary nailing at an average follow-up of more than 1 year. Complications included one delayed union, one nonunion, and one infection, all of which healed with a single additional operative procedure. Similarly, Tornetta and Tiburzi309 reported on the results of antegrade intramedullary nailing of distal femur fractures caused by gunshots. Despite close proximity to the distal interlocking screws in all cases, fractures healed predictably and no secondary bone grafting procedures were required. Because of the good results in these and other studies combined with the cost savings by decreasing the length of hospitalization, immediate intramedullary nailing of gunshot femoral fractures is recommended.25,177,214,309,332,341 
Figure 52-29
 
This patient sustained a gunshot wound to the leg with an associated femoral shaft fracture (A, B). An antegrade, statically locked, reamed nail allowed early weight bearing and healing (C, D).
This patient sustained a gunshot wound to the leg with an associated femoral shaft fracture (A, B). An antegrade, statically locked, reamed nail allowed early weight bearing and healing (C, D).
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Figure 52-29
This patient sustained a gunshot wound to the leg with an associated femoral shaft fracture (A, B). An antegrade, statically locked, reamed nail allowed early weight bearing and healing (C, D).
This patient sustained a gunshot wound to the leg with an associated femoral shaft fracture (A, B). An antegrade, statically locked, reamed nail allowed early weight bearing and healing (C, D).
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Femoral shaft fractures caused by high-velocity missiles and shotgun blasts are an entirely different injury than those caused by handguns. Shotgun injuries are characterized by significant contamination, devitalization, and soft tissue injury. Occasionally, if the injury occurred at close range, the wadding may be present within the wound and represents a foreign body. These injuries frequently require multiple debridements to decrease the rate of infection. Similarly, high-velocity missile injuries caused by hunting and assault rifles produce massive tissue injuries that require an aggressive and radical debridement of all devitalized fragments, and serial debridements are frequently necessary. 

Associated Vascular Injury

The approach to the patient with an associated femoral shaft fracture and an ipsilateral vascular injury requires communication and coordination between the vascular surgeon and the orthopedic surgeon. The goal of treatment should be skeletal stabilization combined with expeditious lower-extremity revascularization. In many cases, management should include fasciotomies of the leg to avoid time-dependent reperfusion compartmental syndrome. Prophylactic compartment releases distal to the site of vascular injury should be considered if there is greater than 3 hours of ischemia. Vascular flow to the extremity should be re-established within 6 hours if possible to maximize limb salvage rates. Therefore, the orthopedic management is largely based on the time from injury to surgery. If stabilization can proceed expeditiously and allows enough time for vascular repair, definitive treatment with a nail or a plate can be performed primarily. If the time from injury to presentation is unknown or lengthy, then limb perfusion should be re-established first. This can be accomplished with either temporary shunting or definitive vascular repair. A temporary shunt provides restoration of blood flow, which can then be followed with definitive skeletal stabilization. This allows a stable skeleton to simplify the definitive vascular repair. In addition, if a definitive vascular repair precedes orthopedic stabilization, there is always the risk of injuring the vascular repair as the limb length is re-established. If vascular repair with a saphenous interposition graft is performed before skeletal stabilization, some redundancy of length is recommended to prevent disruption during re-establishment of femoral length. 
The femur can be temporarily stabilized with an external fixator.139 This can be useful in cases in which definitive stabilization with a plate or nail cannot be performed because of time constraints or other injuries of the patient. Early exchange to an intramedullary nail can then be performed as the patient’s overall clinical condition allows.139 In most instances, definitive internal femoral stabilization can be performed during the same surgical procedure as the vascular repair. The choice of a plate or a nail depends on the surgical exposure, the fracture location, and the associated injuries. In open femoral fractures with an associated vascular injury, the surgical approach for medial plating is usually accomplished by a combination of the traumatic injury and vascular approach. A plate can usually be applied quickly. Because of the potentially increased risk of nonunion and infection in these patients, the surgeon must consider the possibility that a repeat procedure in this location may be necessary. Intramedullary nailing can be performed with the same indications and concerns as any closed or open femoral fractures as applicable. 
Starr et al.286 retrospectively evaluated 19 patients with femoral fractures requiring stabilization and an associated vascular injury that required repair. Internal fixation preceded vascular repair in 10 patients, whereas in 9 patients femoral stabilization followed vascular repair. Their favorable results led them to conclude that internal fixation could safely precede vascular repair, and vascular shunts should be used in cases of prolonged ischemic time. Despite skeletal stabilization and limb revascularization, open femur fractures with associated vascular injuries have significant complications. The long-term results of 13 blunt femoral fractures with associated arterial injuries were reviewed by DiChristina et al.81 In two patients, double level arterial injuries were identified. In the eight open fractures, two patients had above knee amputation, three patients had persistent drainage, and no patients regained more than 90 degrees of knee motion. In contrast, in five patients with closed fractures, all regained full function and full knee motion. The authors again stressed that femoral stabilization can be performed before arterial repair if sufficient time is available for the vascular procedure. As with most injuries, the outcomes were dependent on the associated soft tissue injury, specifically the presence of an open fracture.81 

Associated Head Injury

The timing for treatment of femoral shaft fractures in patients with associated craniocerebral trauma remains controversial. Patients with significant head trauma are at risk for secondary brain injury as a result of surgical management of any injury including their femoral shaft fracture. Transient hypotension is frequently implicated as a potential cause of further cerebral insult. This may be because of the inability of these patients with a head injury to adequately autoregulate their cerebral perfusion pressure. However, these patients are frequently multiply injured and at risk for pulmonary complications related to a delay in fixation of their femoral shaft fracture. As a result, the management of patients with complicated injuries requires coordination between the relevant surgical services including the general, neurologic, and orthopedic surgeons. 
Previous reports regarding the timing of femoral shaft stabilization in patients with an associated head injury are difficult to interpret. The retrospective nature of all of these studies introduces significant selection biases and limits definitive conclusions.7,145,189,285,313 However, some useful information can be obtained from these studies. Sixty-one patients with severe or moderate closed head injuries (Glasgow Coma Scale score <9) with femur fractures were retrospectively reviewed by Townsend et al.313. They found that patients treated for their femur fractures within 2 hours were eight times more likely to experience a hypotensive event than those patients treated after 24 hours. The majority (74%) of patients with intracranial monitoring experienced cerebral perfusion of less than 70 mm Hg. Similarly, Jaicks et al.145 found a trend toward increasing intraoperative hypotension and hypoxia in patients treated with early femoral stabilization. Although the neurologic complication rate was similar between patients undergoing early versus delayed femoral stabilization, the average discharge Glasgow Coma Scale score was significantly lower in the early fixation group. In a study of 17 patients with an average ISS of 35, Anglen et al.7 monitored intracranial pressure during reamed intramedullary nailing. The average cerebral perfusion pressure decreased by 17 mm Hg, and 70% of patients had an average intraoperative cerebral perfusion pressure of less than 75 mm Hg. However, the impact of transient hypotension on neurologic outcome is not known. 
In contrast, Starr et al.285 were unable to identify a statistically significant predictor or central nervous system complications in 32 patients with combined head injuries and femoral fractures. They did find that a delay in femur stabilization was a strong predictor of pulmonary complications, concluding that a delay made pulmonary complications 45 times more likely. McKee et al.189 used a retrospective, case control study to determine the effect of a femoral shaft fracture treated with intramedullary nailing on the neurologic disability and mortality in patients with associated head injuries. They identified 46 patients with closed head injuries with femur fractures and matched these with 99 patients with a similar ISS and Glasgow Coma Scale score yet no femur fracture. The authors found no significant difference in early mortality, length of hospital stay, level of neurologic disability, or the results of cognitive testing. However, the small number of patients may limit the conclusions of this study. In a detailed cohort study evaluating the effect of timing of nonneurologic operative interventions, Wang et al.321 compared early (≤24 hours) and late (>24 hours) surgical treatment on functional outcomes, morbidity, and mortality. At 6 months following injury, patients treated early had significantly improved neuropsychological scores. In addition, a higher incidence of pneumonia and a longer hospital stay was associated with a delay in surgical treatment. This led the authors to conclude that in patients with combined multisystem trauma and nonoperative traumatic brain injury, early treatment of orthopedic injuries under general anesthesia was not associated with worse neuropsychological or functional outcomes.321 

Ipsilateral Neck and Shaft Fractures

The imaging, identification, and treatment of combined femoral neck and shaft fractures have been a source of controversy since the first descriptions of the injury pattern. Concomitant femoral neck fractures occur in 3% to 10% of patients with femoral shaft fractures.3,323,336,346 Many of the associated femoral neck fractures are nondisplaced, and missed injuries have been reported in 30% to 57% of cases (Table 52-21). 
Table 52-21
Percentage of Missed, Delayed, or Occult Femoral Neck Fractures in Patients with Combined Injuries
Author Year Percentage Missed or Delayed
Alho2 1997 30%
Bennet et al.24 1993 31%
Riemer et al.256 1993 31%
Yang et al.346 1998 57%
X
In a systematic review of 65 publications reporting on 722 cases of ipsilateral hip and femoral shaft fractures, Alho3 identified the commonly observed fracture patterns and results of treatment. The median age of the patients in the review was 34 years, and men were injured in 78% of cases. The hip fracture diagnosis was delayed in 30% of cases. Hip fracture treatment was uniformly successful with 99% healing and only 5.1% complicated by aseptic necrosis. Locked intramedullary nailing for treatment of the femoral shaft yielded the most predictable result when compared with unlocked nailing and plate fixations. There were no reported cases of infection or nonunion with locked nailing of the femoral shaft in this systematic review. 
Several predictable and commonly observed proximal femoral fracture patterns appear to be associated with ipsilateral femoral shaft fractures. In his systematic review, Alho reported the locations of the associated hip fracture as subcapital in 2%, midcervical in 21%, basicervical in 39%, pertrochanteric in 14%, and intertrochanteric in 24%.3 In a review of 52 patients with ipsilateral proximal femoral and shaft fractures, the fracture line inferior exit point was observed to be at the inferomedial femoral neck and proximal to the lesser trochanter. Only three fracture configurations were seen. The most common pattern was a basicervical neck fracture (AO 31-B2.1) in 55% followed by a vertical midcervical intracapsular shear pattern (AO 31-B2.3) in 35% and an intertrochanteric fracture through the greater trochanter (AO 31-A1.2) in 10%. This indicates that the majority of these proximal femoral fractures are extracapsular in location. All of the observed intracapsular femoral neck fractures were vertically oriented, making fixation particularly difficult in displaced patterns. Of the fractures that were initially missed, none were intertochanteric in location.279 
Most articles suggest that the rates of femoral neck nonunion and aseptic necrosis are lower in patients with combined femoral neck and shaft fractures than in young patients with high-energy femoral neck fractures in isolation.2,3,24 This may be because of the commonly observed extracapsular location of the neck fracture, the tendency for these fractures to be minimally or nondisplaced, or a combination of the two. The delay in diagnosis of the femoral neck fracture and treatment of the femoral neck after stabilization of the femoral shaft fracture (i.e., in cases of iatrogenic or occult femoral neck fractures) have not necessarily produced complications.3,24 
The delay in diagnosis of the femoral neck or intertrochanteric fracture is the result of several concurrent factors. Because of the presence of an ipsilateral fracture of the femoral shaft, AP imaging of the injured extremity before stabilization of the femoral shaft fracture is typically hampered by external rotation of the proximal femoral segment.77 Because these patients are frequently in severe discomfort as a result of their shaft fracture, suboptimal imaging of the hip may unfortunately be accepted. Even with careful positioning of the lower extremity for quality images of the hip as a part of the routine radiographic evaluation of a femoral shaft fracture, proximal segment control is inadequate because of the shaft fracture. It has been noted serendipitously that in patients with known or suspected ipsilateral acetabular fractures, the obturator oblique radiograph frequently demonstrates the femoral neck along its longest axis, assisting with the radiologic evaluation. 
Because of the high incidence of missed femoral neck fractures in patients with femoral shaft fractures, review of all available imaging studies at multiple time points in the patient’s evaluation and treatment is recommended (Table 52-7). First, dedicated hip radiographs should be obtained as a part of the initial radiologic evaluation of any patient with a femoral neck fracture. Second, if pelvic oblique radiographs are obtained because of a suspected or known ipsilateral acetabular fracture, these should be scrutinized for the presence of a femoral neck fracture. Third, if a CT scan is obtained for evaluation of abdominal or pelvic trauma, this should be reviewed because occult fractures are frequently demonstrated on the relevant axial images (Fig. 52-30). Fourth, intraoperative fluoroscopic images before initiating antegrade nailing of a femoral shaft fracture should be obtained. Fifth, hip fluoroscopic images and/or radiographs should be obtained after femoral shaft stabilization with the hip in 10 to 15 degrees of internal rotation. Finally, dedicated postoperative hip radiographs should be obtained before leaving the operating room to confirm the integrity of the femoral neck. By using a best-practice protocol consisting of a dedicated internal rotation plain radiograph of the hip, a 2-mm CT scan through the femoral neck, a fluoroscopic lateral of the femoral neck before fixation, and postoperative orthogonal hip radiographs in the operative room, Tornetta et al. demonstrated a substantial improvement in the rate of missed femoral neck fractures in patients with femoral shaft fractures. The delay in femoral neck fracture diagnosis was reduced by 91% by using these consistent radiographic evaluations.307 
Figure 52-30
Computed tomography (CT) scan of the pelvis and abdomen was obtained in this patient with multiple injuries, including a femoral shaft fracture.
 
The femoral neck fracture was demonstrated on the axial images, despite normal radiographs of the pelvis and hip.
The femoral neck fracture was demonstrated on the axial images, despite normal radiographs of the pelvis and hip.
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Figure 52-30
Computed tomography (CT) scan of the pelvis and abdomen was obtained in this patient with multiple injuries, including a femoral shaft fracture.
The femoral neck fracture was demonstrated on the axial images, despite normal radiographs of the pelvis and hip.
The femoral neck fracture was demonstrated on the axial images, despite normal radiographs of the pelvis and hip.
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Yang et al.346 reviewed the impact of abdominal CT scan evaluations on the ability to demonstrate nondisplaced fractures of the femoral neck. In a series of 152 femoral shaft nailings, 14 femoral neck fractures were ultimately identified. Of these, eight were not visible on the initial screening pelvic radiographs. On retrospective review of the abdominal CT scans, six of these eight femoral neck fractures were shown to be present but nondisplaced. The remaining two femoral neck fractures were not visible on preoperative CT scans and were thus believed to be iatrogenic according to the authors. However, CT scans do no guarantee that an associated femoral neck fracture will be identified as demonstrated by a blind comparison of plain pelvis radiographs and CT scans obtained during the preoperative assessment of the femoral neck.217 In this study, plain radiographs of the pelvis had a sensitivity of 56% for identification of an associated femoral neck fracture; however, axial CT scans had a poor sensitivity rating as well at 64%.217 These findings suggest that all imaging modalities possible should be used to identify an associated femoral neck fracture, including postoperative dedicated ipsilateral hip imaging. 
The delay in identification of the femoral neck fracture may be accentuated if the fracture is truly nondisplaced. However, there is always the possibility that the fracture is iatrogenically produced during the manipulation, reduction, and placement of an antegrade intramedullary nail. It has been suggested that iatrogenic fractures do occur as evidenced by normal preoperative CT scans in patients later found to have a nondisplaced fracture of the femoral neck after intramedullary nailing.346 This was investigated by Simonian et al.,280 who compared the proximal femoral anatomy and nail insertion depths in 4 patients with iatrogenic femoral neck fractures with 311 patients without this complication. They found a higher neck shaft angle of 139 degrees in the patients with femoral neck fractures than in those without (125 degrees). Further, in the four patients with femoral neck fractures, the nails were inserted below the tip of the greater trochanter. This was not observed in patients with similarly elevated neck shaft angles but without femoral neck fractures. This led the authors to recommend avoiding deep insertion of the femoral nail beyond the tip of the greater trochanter in patients with a valgus femoral neck. Although these findings may be specific to the nail insertional jig used, an awareness of this potential complication is necessary. However, the majority of femoral neck fractures that are diagnosed after femoral nailing are likely missed injuries. This is emphasized in a report of “clandestine” femoral neck fractures in a group of patients treated with plate fixations for their femoral shaft fractures. Riemer et al.256 reported delayed identification of a femoral neck fracture in 31% of patients treated with plating of their femoral shaft fracture, a procedure unlikely to produce significant associated proximal femoral injury. 
The treatment of this combination of injuries continues to be controversial. Experience has led many authors to suggest that these two noncontiguous fractures should each be treated with an implant that optimizes fracture healing while simultaneously prioritizing the femoral neck fracture fixation (Fig. 52-31). This is in large part because of the increased difficulty observed with managing complications associated with inadequate or suboptimal femoral neck fixation such as aseptic necrosis, nonunion, malunion, and failure of fixation. The major complications associated with failure of the available methods for treating the femoral shaft component of this injury combination are generally familiar and more straightforward. This has led to the recommendation that the femoral neck or intertrochanteric fracture should be treated with multiple lag screws or a sliding hip screw, with or without capsulotomy, as appropriate. The femoral shaft component can be treated with whichever method is most familiar and reliable, typically a retrograde femoral nail or lateral plate fixation.293,294,323 Femoral plating combined with multiple screws or a sliding hip screw for the femoral neck fracture has yielded good results in several series.61,105 
Figure 52-31
 
This patient sustained displaced ipsilateral femoral shaft and femoral neck fractures after a motor vehicle crash (A, B). Treatment consisted of open reduction and internal fixation of the femoral neck fracture followed by retrograde intramedullary nailing of the femoral shaft fracture. Healing of both injuries proceeded without complications (C, D).
This patient sustained displaced ipsilateral femoral shaft and femoral neck fractures after a motor vehicle crash (A, B). Treatment consisted of open reduction and internal fixation of the femoral neck fracture followed by retrograde intramedullary nailing of the femoral shaft fracture. Healing of both injuries proceeded without complications (C, D).
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Figure 52-31
This patient sustained displaced ipsilateral femoral shaft and femoral neck fractures after a motor vehicle crash (A, B). Treatment consisted of open reduction and internal fixation of the femoral neck fracture followed by retrograde intramedullary nailing of the femoral shaft fracture. Healing of both injuries proceeded without complications (C, D).
This patient sustained displaced ipsilateral femoral shaft and femoral neck fractures after a motor vehicle crash (A, B). Treatment consisted of open reduction and internal fixation of the femoral neck fracture followed by retrograde intramedullary nailing of the femoral shaft fracture. Healing of both injuries proceeded without complications (C, D).
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A number of technical aspects and decisions require emphasis. The type of fixation for the femoral neck fracture should not differ from isolated injuries in this location. Typically, multiple lag screws are used to stabilize subcapital and transcervical fractures, whereas a sliding hip screw is used for basicervical and intertrochanteric fractures. The order of fixation is influenced by the two treatment methods chosen combined with the urgency of early reduction and stabilization of an intracapsular femoral neck fracture. If the proximal femoral fracture is intracapsular in location and displaced, consideration should be given to completing this portion of the procedure first if the patient’s overall medical condition allows. This is largely to allow for urgent preservation of the femoral head blood supply. In cases in which a retrograde nail is desired for stabilization of the femoral shaft fracture, the canal should be overreamed to allow for atraumatic passage of the nail to avoid any additional stress on the femoral neck. If a basicervical femoral neck fracture is stabilized with a sliding hip screw, unicortical screws can be initially placed in the side plate and exchanged for longer screws that avoid the retrograde nail. This will allow for placement of a retrograde nail as proximally as possible. 
In the event that an ipsilateral nondisplaced femoral neck fracture is identified after antegrade femoral nailing, strategic lag screw fixations anterior to the nail can be successfully performed. An additional hip joint capsulotomy can be performed to relieve any intracapsular tamponade if the fracture location warrants. In cases in which a displaced femoral neck fracture is identified after placement of an antegrade nail, the ultimate treatment depends largely on the fracture location. If the fracture communicates with the nail entry site, it is unlikely that an anatomical reduction of the femoral neck can be obtained with the nail still in position. Nail removal, anatomical fixation of the femoral neck, and alternative fixation of the femoral shaft should be performed. 
Alternatively, a single implant such as a cephalomedullary (reconstruction) nail has been used to treat combined femoral neck and shaft fractures. This has been associated with good results in several small series and has been recommended as an option. However, in a retrospective review of ipsilateral neck and shaft fractures treated with multiple different methods, Watson and Moed323 found that 75% of the femoral neck nonunions that occurred at their institution developed after the use of a reconstruction nail. Jain et al.146 reported on 23 cases of ipsilateral hip and shaft fractures treated with a single implant over a 4-year period. Complications of the femoral neck fixation included one nonunion, one varus malunion, and one aseptic necrosis, for an overall rate of 13%. There are a number of technical and conceptual difficulties with the use of a reconstruction nail for the treatment of combined neck and shaft fractures. First, a medullary implant is unlikely to be the treatment of choice for fractures of the femoral neck. Second, the entry site for the reconstruction nail is frequently in the same location as the femoral neck fracture. Even with an open reduction of the femoral neck, there is potential for further displacement during nail placement. Third, it can be technically challenging to seat the nail properly with the correct anteversion to allow placement of two screws accurately into the femoral head and parallel to the femoral neck. By avoiding a nail entry site that is through or near the femoral neck fracture, a trochanteric entry cephalomedullary implant to treat this combination of fractures may alleviate some of these technical challenges. 
An interesting concept has been recently introduced regarding the routine management of femoral shaft fractures. Because of the relatively high incidence of an associated femoral neck fracture that is often not identified prior to intramedullary nailing of the shaft fracture, Collinge et al.70 have investigated the option of using a cephalomedullary nail with fixation across the femoral neck as the routine implant and method for all femoral shaft fractures. In this way, if a nondisplaced femoral neck fracture existed, the implant would stabilize this injury as well as the femoral shaft fracture. Good results were obtained in a series of 61 patients, and there were no complications related to the insertion of proximal interlocking screws into the femoral head. The authors additionally suggest that placement of a cephalomedullary nail is protective for future trauma about the hip that would normally produce a femoral neck fracture after routine femoral nailing. A subsequent cost-effective analysis does not support this as a routine method based on current implant costs, but may prove to be effective in the future.94 

Comminution and Associated Fracture Patterns

In addition to fractures of the femoral neck, other associated ipsilateral fracture patterns can further complicate the management of femoral shaft fractures (Fig. 52-32). Segmental comminution, characterized by circumferential loss of cortical contact even after reduction, can be successfully managed with closed intramedullary nailing.333 In a series of 33 segmental femur fractures treated with reamed antegrade nailing, Wiss et al.333 identified infrequent complications that included one nonunion and two malunions. This led the authors to conclude that virtually all fractures between the lesser trochanter and the femoral condyles can be successfully managed with intramedullary nailing. Technical difficulties with nailing segmentally comminuted fractures include the intraoperative determination of the proper length and rotation of the femur, as the visual clues at the fracture itself are less helpful. Preoperative assessment of the contralateral femoral length can be used as a guide to judge the length of the injured extremity. However, an accurate length determination is still difficult to obtain, even in experienced hands. If there is uncertainty regarding the femoral length following femoral nailing, a CT scanogram for length determination postoperatively can be considered. In a prospective study investigating the efficacy of routine postoperative CT scanograms in 28 patients with comminuted femur fractures, limb length discrepancies were common and 36% of patients were found to have a limb length discrepancy of over 10 mm.317 Segmental femoral injuries characterized by multiple noncontiguous fractures should be differentiated from fractures with segmental comminution and deserve special mention. These fractures are particularly difficult to treat with intramedullary nailing because of the need to simultaneously maintain two reductions. Percutaneous Schanz pins placed as joysticks into each segment can greatly assist with maintenance of reduction during reaming and nail placement. For fractures with a “napkin ring” segment of diaphyseal bone, the free segment should be stabilized with either a percutaneous pin or a percutaneous clamp during reaming to avoid spinning the fragment on its soft tissue attachments. 
Figure 52-32
This patient sustained combined fractures of the femoral neck, femoral shaft, and distal femoral lateral condyle.
 
The femoral neck was first stabilized. The lateral condyle was then treated with open reduction and internal fixation. Finally, the femoral shaft was stabilized with a retrograde nail (A, B).
The femoral neck was first stabilized. The lateral condyle was then treated with open reduction and internal fixation. Finally, the femoral shaft was stabilized with a retrograde nail (A, B).
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Figure 52-32
This patient sustained combined fractures of the femoral neck, femoral shaft, and distal femoral lateral condyle.
The femoral neck was first stabilized. The lateral condyle was then treated with open reduction and internal fixation. Finally, the femoral shaft was stabilized with a retrograde nail (A, B).
The femoral neck was first stabilized. The lateral condyle was then treated with open reduction and internal fixation. Finally, the femoral shaft was stabilized with a retrograde nail (A, B).
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Distal femoral articular fractures can occur in combination with femoral shaft fractures, posing additional challenges. The articular fracture should be prioritized from an implant standpoint, but not necessarily from a timing standpoint. The stabilization of femoral shaft fractures in a critically ill patient still takes priority over the operative fixation of periarticular fractures. However, a thoughtful preoperative plan can ensure that an accurate articular reduction of the distal femur can be accomplished as well. If the patient can tolerate a longer procedure, the articular injury should be reduced and stabilized first with whatever implants are necessary, because there is more flexibility with stabilization of the femoral shaft fracture. Screw fixations alone are frequently adequate for coronal plane articular fractures of the distal femur and will not interfere with passage of an antegrade nail. For medial and lateral femoral condyle fractures, a combination of strategically placed lag screws and plates will usually not interfere with nail placement. For a supracondylar intercondylar distal femoral fracture combined with a noncontiguous femoral shaft fracture, the articular surface of the intercondylar component must first be reduced and stabilized followed by stabilization of the remaining supracondylar and shaft fractures. Depending on the locations of the distal and shaft fractures, single (plate or nail) or multiple (plate and plate or plate and nail) implants may be necessary. In general, combined plate and screw fixations of the distal articular fracture should be performed. Reasonable results have also been obtained by using a combination of lag screws to reduce the distal articular injury with a nail to stabilize both the femoral shaft and the distal supracondylar components. However, in their review of 10 patients with intercondylar distal femoral fractures combined with a femoral shaft fracture, Butler et al.50 reported some articular displacement in 40% of cases in which screws alone were used to stabilize the intercondylar component. 
Combined noncontiguous fractures of the ipsilateral femoral neck, femoral shaft, and distal femur have been reported. This combination of injuries occurs in less than 0.5% of femoral fractures. All femoral neck fractures in one series were vertical in orientation and all distal femoral articular injuries were unicondylar. A recommended treatment algorithm was presented by Barei et al.15 and was based on their experience with seven patients. Open reduction and internal fixation of the displaced femoral neck fracture should be prioritized followed by fixation of the displaced distal articular fracture. Finally, the diaphyseal fracture can be treated with a technique that does not jeopardize either of the other two fixations. Specifically, this can be with either a plate or an intramedullary nail (antegrade or retrograde). 
Combined injuries to the ipsilateral extensor mechanism, hip joint, and femoral shaft, although rare, do occur. These are frequently caused by a dashboard injury with direct impact on the knee with the hip joint flexed. The extensor mechanism disruption may be a patellar fracture, an infrapatellar tendon injury or a quadriceps tendon rupture. A treatment protocol based on their experience with managing 10 patients with this combination of injuries was reported by Mosheiff et al.208 They recommended intramedullary nailing of the femur, followed by open reduction and internal fixation of the acetabular fracture, followed by extensor mechanism repair. Frequently, multiple stages were required, but this protocol simplified each surgical episode and maximized patient recovery. 

Bilateral Fractures

Patients with bilateral femoral shaft fractures are known to have a worse overall prognosis and a higher mortality than patients with unilateral femur fractures.72,213 Several factors may contribute to this including increased associated injuries, increased blood loss, a higher risk of adult respiratory distress syndrome, or the increased systemic effects of multiple long bone fractures. In addition, the presence of bilateral femur fractures is associated with other complications including compartmental syndrome, peroneal nerve palsy, and delayed union. The incidence of bilateral femoral shaft fractures in patients treated at tertiary referral trauma centers ranges from 7.3% to 9.6%. These patients tend to have a higher ISS and a lower Glasgow Coma Scale score than patients with unilateral femoral shaft fractures.72,213 
In a review of 885 consecutive patients with blunt trauma who were admitted with femoral fractures, Copeland et al.72 reported increased ISS, mortality, and ARDS in 85 patients with bilateral injuries. The mortality rate in patients with bilateral femur fractures was 25.9% compared with 11.7% in patients with unilateral injuries. Similarly, ARDS was diagnosed in 15.7% of patients with bilateral fractures compared with 7.3% of patients with unilateral fractures. The increase in mortality was found to be related to the associated injuries and various physiologic parameters as opposed to the presence of bilateral fractures.72 The increased mortality in patients with bilateral fractures was confirmed in another study reviewing 689 patients with unilateral injuries and 54 patients with bilateral injuries treated with reamed intramedullary nailing for their femoral shaft fractures.213 Patients with bilateral femur fractures were found to have a higher average ISS and a longer length of stay than patients with unilateral fractures. Mortality in patients with bilateral femur fractures was 5.6% compared with 1.5% in patients with unilateral femur fractures. The relative risk of death in patients with bilateral fractures was 3.8 times higher than in patients with unilateral fractures. Multiple linear regression and logistic regression with age and ISS as covariants were used to compare patients with a similar degree of trauma. This revealed an odds ratio of 3.3 for mortality in patients with bilateral femur fractures compared with patients with unilateral femur fractures. Because the ISS does not increase with the presence of a second femoral shaft fracture, the ISS may not accurately reflect mortality in patients with bilateral femur fractures.213 
Definitive treatment of bilateral femoral shaft fractures is the same as that for unilateral femoral shaft fractures. Reamed intramedullary nailing, whether antegrade or retrograde, can be expected to produce similar rates of union compared with treatment in unilateral injuries. Retrograde nails have been used successfully and mortality appears to be similar to other studies using predominantly antegrade nails.55 The use of temporary external fixation consistent with damage control orthopedics may be considered in these patients depending on their associated injuries. 

Intramedullary Nailing in the Obese

Obesity is a rapidly expanding health concern and is not likely to decrease in the near future. There are several technical aspects of antegrade intramedullary nailing that make the procedure more difficult in obese patients. Osseous landmarks are difficult to palpate, and femoral adduction is usually somewhat limited. In addition, the common locations of excess adipose tissue usually limit the surgeon’s ability to align a guide pin or an awl with the femoral canal when attempting to localize the correct starting point. This frequently leads to the need for a large surgical approach to simply identify the osseous anatomy proximally. Although lateral positioning greatly assists with identifying the starting point, this may not be a practical position depending on the size of the patient. Reduction of the femoral shaft is increasingly difficult with increasing patient size, and the usual techniques may be impractical. As well, the external jig that is used for proximal interlocking may not clear the lateral thigh tissues. Because of the difficulties associated with identifying the piriformis antegrade starting point, alternative nail entry sites have been recommended in obese patients.254,314 Ricci et al.254 demonstrated decreased surgical time and radiation exposure yet similar functional outcomes in obese patients treated with a trochanteric entry nail compared to a piriformis entry nail. Similar results have been demonstrated using retrograde nailing as an alternative in obese patients.314 The authors found similar decreases in operative and fluoroscopy time when a retrograde nail was used compared to an antegrade nail placement. Although the retrograde starting point may be easier to identify in obese patients, proximal interlocking can be a lengthy experience given the distance between the anterior skin of the thigh and the anterior femoral cortex. Long drill bits, long screwdrivers, and a suture tied to the interlocking screw may assist with proximal interlocking of a retrograde nail. 
The complications and surgical difficulties in seven morbidly obese patients treated with reamed antegrade nailings were reported by McKee and Waddell.190 The patients had an average weight of more than 300 pounds with an average body mass index of 49.2. The surgical procedures averaged 3.8 hours in duration with an average blood loss of 1,100 mL. Numerous complications were noted including two iatrogenic trochanteric fractures, two wound infections, four deep venous thromboses, and one fatal pulmonary embolism. 

Fractures in the Elderly

Femoral fractures in the elderly occur from both low- and high-energy mechanisms. More frequently, they are the result of falls from standing. However, motor vehicle accidents and pedestrians hit by cars occur in this patient demographic as well. Particular challenges in this group of patients include fixation in relatively osteopenic bone and management of the multiple associated medical problems frequently observed. 
In elderly patients, cortical thinning and decreased bone mineral density occur and are more commonly observed in females. As a result, fixation becomes particularly difficult. In addition, pre-existing arthritic conditions frequently limit the excursion of the knee and hip joints, potentially prohibiting specific fixation options. Of particular importance is the identification and treatment of pre-existing medical diseases that occur frequently in this patient population. In a cohort of 102 elderly (average age of 81 years) patients who sustained a femur fracture, Sartoretti et al.270 identified commonly observed comorbid conditions that included cardiovascular disease in 80%, musculoskeletal disease in 75%, gastrointestinal disease in 67%, psychiatric disease in 61%, urologic disease in 55%, and pulmonary disease in 41%. The postoperative mortality was 11%, and the mean hospitalization was 30 days. 
Intramedullary nailing of femoral shaft fractures in elderly patients is uniformly associated with high union rates yet a high incidence of complications including mortality. In a series of 138 patients aged more than 65 years with femoral shaft fractures, complications were observed in 46% and mortality in 20%.34 Other authors have reported mortality rates that are similar to those in elderly patients with hip fractures.4,36,203 The mental status of the patient has been found to be a significant predictor of survival,34 and the development of a new medical problem after injury has been associated with a poor result.36 In surviving patients, fracture union can be expected after intramedullary nailing for fractures of the femoral shaft. In a review of 12 femoral fractures treated with statically locked intramedullary nails, union was observed in all patients. 
Several technical aspects of intramedullary nailing specific to elderly patients must be observed. Because of the relatively thin cortices, care must be taken to accurately identify the starting portal. Iatrogenic comminution can occur with manipulation of the femoral shaft despite relatively low applied forces. Interlocking screws frequently have poor purchase. If there is a mismatch between the sagittal bow of the femur and the nail, an iatrogenic distal femoral fracture may occur if a long antegrade nail is chosen.222 A careful preoperative evaluation of the shape of the femur on both the AP and lateral views is necessary before deciding on a medullary implant in elderly patients. Because of the capacious canal, a large-diameter implant may be necessary. 
In response to these issues with obtaining stability in osteopenic bone, many manufacturers have made specific design changes in medullary implants. Some interlocking screws are designed with a large washer on the lateral side and a large nut with washer that can be threaded on the leading (medial) side of the screw. Some retrograde nails allow placement of a locking bolt that prevents coronal plane toggling of the most distal interlocking screw. Multiplanar distal metaphyseal locking screws and spiral blades are available with some nails and may assist with purchase in the capacious metaphysis. Knowledge of the specific implant characteristics is important when deciding the treatment plan in these challenging fractures. 

Pathologic and Atypical Insufficiency Fractures

The treatment of pathologic fractures and impending fractures caused by skeletal metastases is discussed in Chapter 20. Because the proximal femur is the most commonly affected site of metastases in the appendicular skeleton, the relevant management will be discussed. The diagnosis of metastases should not be assumed despite clinical suggestions and a history of carcinoma in another location. Discussion with an orthopedic oncologist will help to avoid the complications associated with treatment of an unknown femoral lesion.144 
The goal of treatment of metastatic femoral lesions is to provide femoral stability, thereby decreasing pain, allowing mobilization, and facilitating nursing care. Fracture healing depends on the type of tumor. Osseous healing may not occur in many of these injuries despite stabilization. In 129 pathologic fractures of long bones, Gainor and Buchert100 observed healing in 67% of fractures from multiple myeloma, 44% from renal carcinoma, 37% from breast carcinoma, and in no fractures secondary to lung carcinoma. Overall, the fracture healing rate was 35%, but this increased to 74% in patients who survived longer than 6 months. Although a significant percentage of these fractures were treated without internal fixation, this emphasizes the difficulty with obtaining union in these patients. 
Prophylactic treatment, usually with an intramedullary nail, for metastatic lesions of the femoral shaft is based loosely on clinical symptoms, expected length of survival, and lesion size. Guidelines for the size of a metastatic lesion that requires prophylactic internal fixation has been suggested by Menck et al.192 in a radiographic study of 69 patients. They recommended stabilization if the ratio between the width of the metastasis and the bone diameter was greater than 0.6, if the axial cortical destruction in the femoral shaft was greater than 30 mm, or if the cortical destruction of the femoral circumference was greater than or equal to 50%. 
Stabilization can be best accomplished with plates or intramedullary implants.144 If plate fixation is chosen, cement should be used to augment the fixation in most instances. Locked implants can be considered given the frequently present poor bone quality. Intramedullary nailing is optimal in most femoral fractures resulting from metastatic disease because of the biomechanical properties of the load-sharing implant. To span the entire femur including the femoral neck, a cephalomedullary nail should be used in pathologic fractures. Patients can safely bear weight after stabilization. However, intramedullary nailing for metastatic disease is associated with increased perioperative complications including fat embolism and mortality. Barwood et al.18 observed intraoperative oxygen desaturation in 24% of patients with death in 7% of patients treated with intramedullary nail fixation for their overt or impending femoral fractures. Cole et al.69 reported their experience with reamed and unreamed intramedullary nailing in 73 femurs with metastatic disease. Both techniques were found to sufficiently stabilize the femur, and implant failures were uncommon. Death associated with the nailing procedure occurred in one patient treated with a reamed nail and in one patient treated with an unreamed nail. In general, second-generation reconstruction nails or other cephalomedullary implants should be used for the treatment of metastatic femoral fractures. Although a standard femoral nail is adequate for lesions confined to the femoral diaphysis, minimization of the need for future stabilization procedure can be accomplished with the use of an implant that effectively protects the entire femur. 
Recently, a new form of insufficiency fracture in the proximal femoral shaft or subtrochanteric region has been described. This fracture has been associated with the use of alendronate and is thought to be associated with the prolonged suppression of bone remodeling with this medication.113,171,176,211 Alendronate is a bisphosphonate that inhibits bone resorption by osteoclastic suppression. Decreased bone turnover and impaired repair of microscopic damage has been implicated in the propagation of these subtrochanteric or proximal femoral shaft fractures. Several characteristics were common to these fractures based on a review of 17 patients with low-energy subtrochanteric and proximal femoral fractures by Kwek et al.170 and included cortical thickening on the lateral side of the subtrochanteric region, a transverse fracture, and a medial cortical spike (Fig. 52-33). The majority of patients (76%) had prodromal pain and bilateral involvement (53%).170 Given the potential for bilateral involvement, it is generally recommended that contralateral femur radiographs be obtained to look for early signs prior to fracture. Neviaser et al.211 additionally demonstrated this relationship between chronic alendronate use, the presence of a simple transverse fracture, and unicortical beaking in the area of cortical hypertrophy. Although the exact causal relationship between alendronate therapy and these atypical fractures has yet to be confirmed, recognition of this pattern is important especially given the prodromal symptoms and consistency of bilateral involvement.113,171,176,211 
Figure 52-33
This elderly woman sustained a low-energy femoral shaft fracture after a fall from standing.
 
She had been treated with alendronate for a number of years and had a several month history of proximal thigh pain prior to her fracture. The fracture has a short oblique configuration with associated lateral cortical hypertrophy (A, B). Treatment consisted of placement of a trochanteric entry cephalomedullary nail with the starting point demonstrated (C, D). Fixation into the femoral head was used to protect the femoral neck (E, F). Healing progressed uneventfully as demonstrated at 1 year (G, H). (Case courtesy of James Krieg, MD, Harborview Medical Center).
She had been treated with alendronate for a number of years and had a several month history of proximal thigh pain prior to her fracture. The fracture has a short oblique configuration with associated lateral cortical hypertrophy (A, B). Treatment consisted of placement of a trochanteric entry cephalomedullary nail with the starting point demonstrated (C, D). Fixation into the femoral head was used to protect the femoral neck (E, F). Healing progressed uneventfully as demonstrated at 1 year (G, H). (Case courtesy of James Krieg, MD, Harborview Medical Center).
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She had been treated with alendronate for a number of years and had a several month history of proximal thigh pain prior to her fracture. The fracture has a short oblique configuration with associated lateral cortical hypertrophy (A, B). Treatment consisted of placement of a trochanteric entry cephalomedullary nail with the starting point demonstrated (C, D). Fixation into the femoral head was used to protect the femoral neck (E, F). Healing progressed uneventfully as demonstrated at 1 year (G, H). (Case courtesy of James Krieg, MD, Harborview Medical Center).
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Figure 52-33
This elderly woman sustained a low-energy femoral shaft fracture after a fall from standing.
She had been treated with alendronate for a number of years and had a several month history of proximal thigh pain prior to her fracture. The fracture has a short oblique configuration with associated lateral cortical hypertrophy (A, B). Treatment consisted of placement of a trochanteric entry cephalomedullary nail with the starting point demonstrated (C, D). Fixation into the femoral head was used to protect the femoral neck (E, F). Healing progressed uneventfully as demonstrated at 1 year (G, H). (Case courtesy of James Krieg, MD, Harborview Medical Center).
She had been treated with alendronate for a number of years and had a several month history of proximal thigh pain prior to her fracture. The fracture has a short oblique configuration with associated lateral cortical hypertrophy (A, B). Treatment consisted of placement of a trochanteric entry cephalomedullary nail with the starting point demonstrated (C, D). Fixation into the femoral head was used to protect the femoral neck (E, F). Healing progressed uneventfully as demonstrated at 1 year (G, H). (Case courtesy of James Krieg, MD, Harborview Medical Center).
View Original | Slide (.ppt)
She had been treated with alendronate for a number of years and had a several month history of proximal thigh pain prior to her fracture. The fracture has a short oblique configuration with associated lateral cortical hypertrophy (A, B). Treatment consisted of placement of a trochanteric entry cephalomedullary nail with the starting point demonstrated (C, D). Fixation into the femoral head was used to protect the femoral neck (E, F). Healing progressed uneventfully as demonstrated at 1 year (G, H). (Case courtesy of James Krieg, MD, Harborview Medical Center).
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X
Understanding the exact incidence of these atypical fractures and proving their association with bisphosphonates has proven to be an undertaking.1,80,303 For instance, in two large academic referral hospitals in the United Kingdom, 7% of the 156 subtrochanteric femur fractures (of 3,515 patients with a fracture of the proximal femur) were atypical fractures; the vast majority of these patients were receiving bisphosphonates for a mean of 4.6 years.303 To better understand the incidence of these injuries, Dell et al.80 used an extensive database of 188,814 patients taking bisphosphonates. The incidence of atypical fractures was 1.79 per 100,000 per year in patients with shorter-term bisphosphonate treatment (0.1 to 1.9 years) and this incidence increased to 113.1 per 100,000 per year with exposure of 8 to 9.9 years.80 This certainly suggests the time relationship between bisphosphonate use and the occurrence of these atypical fractures, especially in patients on treatment beyond 5 years. The existence of the relationship between bisphosphonate use and atypical femoral fractures was further confirmed in a review by Abrahamsen and Einhorn.1 
Treatment of these atypical fractures has been particularly problematic.247,303 The combination of the quality of the bone itself and the capacity to heal are both potentially contributory. To better understand the difficulties associated with the treatment of these atypical fractures related to bisphosphonate use, Prasarn et al.247 reviewed the surgical complications in 25 patients with an atypical fracture and compared these to 20 similar fractures in patients not treated with bisphosphonates. There were complications related to both intramedullary nailing and plate procedures for the atypical femoral fractures. Intraoperative fractures during nail insertion were seen in 29%, and postoperative plate failures in 30% of the patients with atypical fractures; these complications were not seen in the control patients.247 For these atypical fractures in the subtrochanteric region, the use of cephalomedullary nails, an exact and proper entry location, and a good fracture reduction are probably all important to decrease the complications associated with the treatment of these difficult injuries. 

Management of Expected Adverse Outcomes and Unexpected Complications in Femoral Shaft Fractures (Table 52-22)

Table 52-22
Management of Expected Adverse Outcomes and Unexpected Complications
Nonunion
Prevention: Avoidance of opening the fracture site during nailing if possible; allowing early weight bearing in nailed fractures; biologically respectful plating techniques
Treatment: Revision fixation dependent on the type, location, and cause of the nonunion; often treated with increased fixation, typically without bone grafting; options include plating around a nail, exchange nailing, conversion from a plate to a nail, or conversion from a nail to a plate (all with or without bone grafting)
Angular Malalignment
Prevention: Identification of difficult patterns with proximal or distal involvement or extension; good intraoperative imaging; careful technique; use of multiple distal interlocking screws in infraisthmal fractures
Treatment: If identified early, revision fixation can be performed. If late, an osteotomy may be required
Rotational Malalignment
Prevention: Identification of difficult patterns; good intraoperative imaging; attention to details during surgery; use of the lesser trochanteric profile, cortical widths, and femoral anteversion during surgery.
Treatment: Revision fixation after CT scan evaluation to determine exact correction necessary
Infection
Prevention: Careful technique, prophylactic antibiotics
Treatment: Irrigation, debridement, local and intravenous antibiotics, maintain fixation if stable, replace if loose (with or without interval external fixation)
Nerve Injury
Prevention: Careful patient positioning, avoidance of excessive traction on the traction table, avoidance of circumferential dressings, avoidance of placement of the opposite extremity in a calf-supported leg holder, especially if fractured
Treatment: Treatment is difficult and is usually expectant with observation
Knee Stiffness
Prevention: Careful technique when plating, avoidance of the retrograde entry portal
Treatment: If secondary to anterior cortical fragments, may consider excision; quadricepsplasty may be necessary after healing
Broken Nails or Interlocking Screws
Prevention: Usually secondary to nonunion, so anticipation and treatment of that complication prior to nail fracture important; broken screws may be indicative of instability and are more common with smaller-diameter nails, therefore using a nail with bolts of adequate size is recommended
Treatment: Broken screws may not require removal if the fracture is healed; broken nail removal consistent with nonunion and removal frequently necessary, followed by treatment of the nonunion
X

Nerve Injury

Iatrogenic nerve injury occurs infrequently with closed intramedullary nailing. The primary nerves at risk are the femoral, sciatic, peroneal, and pudendal. Patient positioning and intraoperative traction are usually implicated as causal. A careful preoperative neurologic examination should be performed and documented to avoid unnecessary confusion if a patient is discovered to have nerve dysfunction after femur stabilization. 
Associated pudendal nerve injury and erectile dysfunction are complications of femoral nailing and are likely related to the use of traction table with a perineal post.44,96,184 
Brumback et al.44 prospectively studied 106 patients treated with static antegrade nailing to determine the duration and magnitude of intraoperative traction that was associated with the development of pudendal nerve palsy. Pudendal nerve palsies occurred in 10 patients, 6 of whom were male. Sensory changes were present in nine instances, and one patient had erectile dysfunction. Symptoms resolved in all but one patient. The magnitude of the traction was noted to be significantly higher in those patients who developed pudendal nerve injury. Patients who developed a postoperative pudendal nerve palsy had slightly longer procedure times, although this is not statistically significant. The association of a pudendal nerve palsy and the use of a fracture table were further emphasized in a combined retrospective and prospective study by France and Aurori.96 Retrospectively, pudendal palsies were identified in 1.9% of patients, and only 1 patient of the 36 developed this complication during the prospective portion of their study. Erectile dysfunction has been shown to be highly prevalent after intramedullary nailing of femoral shaft fractures. In one study, more than 40% of patients had some erectile dysfunction and was postulated to be related to direct pressure on the pudendal nerves by the perineal post.184 
Sciatic and peroneal nerve injuries may occur during the process of femoral nailing. This complication is likely caused by stretching of the nerve during various reduction maneuvers. It is important to avoid any prolonged overdistraction of the limb during the procedure. Although this is unlikely if manual traction is used, it is possible if a femoral distractor or the fracture table is used to maintain femoral length during nailing. Knee flexion during surgery can relax the sciatic nerve and its terminal branches; knee extension should be avoided. In addition, circumferential dressings, especially at the knee, should be avoided postoperatively. Although a case report exists,39 suggesting that a postoperative sciatic nerve injury was caused by bow stringing of the nerve between the fracture surfaces in a displaced proximal femoral fracture, this is unlikely given the large numbers of reported femoral nailings without this complication.330,337 Assuming that all other causes of sciatic nerve injury are excluded, a stretch injury can usually be observed with expected return. 
Patients with bilateral femur fractures treated with antegrade intramedullary nailing are of particular concern. In four patients with bilateral femur fractures, Carlson et al.56 reported four peroneal nerve palsies and two compartmental syndromes in the leg that was stabilized second. In each case, the injured leg was initially placed into a calf-supported leg holder. On the basis of their experience the authors cautioned against this type of positioning in patients with bilateral lower-extremity injuries. The incidence of contralateral leg compartmental syndrome is a well-documented complication even in patients without bilateral injuries. 

Muscle Weakness and Entry Site Injury

Femoral fractures are associated with traumatic injury to the surrounding muscles in addition to the obvious and treatable osseous injury. In addition, surgical treatment is associated with a further insult to the lower-extremity musculature. In the case of open plating, this usually involves a lateral approach to the femur with associated dissection of the vastus lateralis. In antegrade femoral nailing, injury to the hip abductors and external rotators may occur as a result of the surgical approach, nail insertion, or both.9,14,84,187,198,225 The approach for antegrade femoral nailing, whether percutaneous or open, may have an effect on subsequent muscle function. 
In an early study of thigh muscle function in adults with femoral shaft fractures, Mira et al.195 reviewed 29 patients at a minimum of 16 months from injury. The patients were treated with both open and closed methods including spica casting, cast bracing, open plating, and intramedullary nailing. Quadriceps impairment was identified in 83% of patients. Prompt healing, young age, and fracture location at the midshaft level were found to predict better function. Patients treated with a plate or an intramedullary nail were found to have a better overall functional result but did not have a measurable increase in quadriceps strength.195 In a study of hip abductor function after femoral nailing, Bain et al.14 reviewed 32 patients clinically and radiographically. In addition to trochanteric pain, thigh pain, and a limp, the authors found a significant difference in abductor strength and the abduction ratio compared with asymptomatic controls. A correlation between abductor weakness and patient complaints was also noted. In contrast, other authors found no difference in hip abduction strength at greater than 2 years from injury in 23 patients with femoral fractures treated with intramedullary nailing. However, a significant decrease in knee extension strength when compared with the contralateral extremity was found.78 This was subsequently confirmed in a study of 17 patients with healed femoral fractures evaluated at least 18 months after surgery. The authors evaluated the bone mineral density of the medial and lateral femoral cortices and the isometric strength of six separate muscle groups, which included the quadriceps, hamstrings, hip extensors, hip flexors, hip abductors, and hip adductors. They found a significant reduction in quadriceps strength but no difference in the remaining five muscle groups when compared with the contralateral extremity as a control. A decrease in the bone mineral density of the femoral cortices was found, but this could not be attributed to the implant or the change in muscle strength observed.154 Finsen et al.95 compared the quadriceps strength in 14 patients treated with intramedullary nails and 12 patients treated with open plating. Isokinetic thigh muscle function was fully restored in nailed patients, but there was a decrease in strength in plated patients. The authors noted a moderate flexion strength deficit in both groups. 
More recently, several studies have further elucidated the effects of antegrade femoral nailing on patient function and outcomes.12,129 Eight patients were evaluated for hip abductor weakness following antegrade femoral nailing of isolated femoral shaft fractures. The authors identified significant time-dependent gait abnormalities and dynamic hip abductor weakness in the 2-and 6-month evaluations. Patients did improve with time and their functional outcomes were found to correlate with ipsilateral trunk leaning.12,129 However, in a cohort of 21 patients evaluated at a minimum of 1 year after piriformis entry antegrade femoral nailing, normal gait patterns were observed. Although the authors observed lower peak torque by the hip abductors and extensors compared to the contralateral side, functional questionnaires demonstrated no significant disability.129 

Angular Malalignment

An angular deformity of the femur is usually defined as greater than 5 degrees of angulation in either the coronal (varus–valgus) or sagittal (flexion–extension) planes. Although the effects of an angular deformity and its impact on ipsilateral joint mechanics and contact pressures have been defined for the tibia, the same is not true for the femur. Periarticular angular deformities are more likely to have an increased effect on the proximate joint than malunions in the mid-diaphyseal portion of the femur. However, the impact of malunion of the femur on the knee joint is unknown. Surprisingly, despite sagittal and coronal plane angular malunions at over 20 year from injury, an association with knee arthritis was not shown.243 Fortunately, with the use of operative fixation for most femoral diaphyseal fractures, malunion is less common. 
Angular malalignment of fractures in the middle third of the femur occurs infrequently after intramedullary nailing, largely because of the intimate fit between the medullary implant and the cortical bone of the femoral isthmus. However, in the proximal and distal thirds of the femur, the more voluminous medullary canal ensures that cortical contact with the nail will not occur, allowing for angular deformities to occur. As well, fractures located proximally or distally have angular reductions that are more dependent on the starting points than those fractures located in the middle third. Overall, the rate of angular malalignment after medullary nailing is between 7% and 11%.155,253,337 In an investigation looking at the factors associated with angular deformities after femoral nailing, Ricci et al.253 found the highest rate of malalignment in proximal third fractures (30%) compared with fractures in the distal third (10%) or middle third (2%). Increased malalignment was seen in unstable fracture patterns (12%) as compared with stable fracture patterns (7%). They found no relationship between angular deformity and either the nail diameter or the direction of the nail insertion (i.e., retrograde or antegrade). Wolinsky et al.337 reported an increased rate of angular deformity in distal femoral fractures treated with reamed, locked, antegrade nailing. The use of manual traction as opposed to the fracture table has not been found to affect angular alignment.155,337 
Prevention of angular deformities during placement of a medullary implant in the proximal or distal thirds of the femur requires attention to detail during reduction, reaming, nail passage, and interlocking. In all femoral fractures, the sagittal plane alignment can be maintained with strategically placed bumps if manual traction is used. This assumes, however, that the proper femoral length is restored to prevent overlapping of the fractured bone ends. In proximal fractures, a properly aligned starting point will greatly assist with minimizing angular deformities. Percutaneous clamps, pushers, and joysticks can be used to control the proximal segment during the remaining portions of the nailing procedure. For distal fractures, it is important to ensure that reaming is accomplished over a well-centered guidewire to avoid eccentric bone removal. Similar to proximal fractures, percutaneously placed reduction tools can greatly assist with obtaining and maintaining the reduction and alignment in distal fractures. 
Although a single interlocking screw has been shown to provide adequate biomechanical stability in femoral shaft fractures,123 two distal interlocking screws should be strongly considered in fractures located distal to the isthmus. Because the diameter of the transverse hole in the nail is larger than the interlocking bolt that it accommodates, a certain amount of coronal plane deformation of the femur can occur. This is related to the specific nail design and tolerances, as well as the bone quality. Similarly, rotation around the interlocking bolt in the sagittal plane is possible with a single locking screw. Although a large distance between the proximal interlocking bolt and the fracture is desirable, Tornetta and Tiburzi309 demonstrated good maintenance of reduction in extremely distal femoral fractures treated with antegrade intramedullary nailing, despite having all proximal interlocking screws within 5 cm of the fracture. 
Correction of femoral malunions requires an osteotomy with fixation. Unlike in the tibia, femoral diaphyseal osteotomies may not require placement or removal of a wedged-shaped intercalary graft to allow the correction to occur. Depending on the deformity and the preoperative plan, a single- or double-level osteotomy may be required. Standing films from the hips to the ankles are necessary to plan for a correction that accurately restores the mechanical axis. Stabilization with an intramedullary nail offers a number of advantages including early weight bearing and predictable healing. If a medullary implant is chosen for stabilization, the osteotomy can be performed with an intramedullary saw or through a limited incision. Plate fixation requires a more extensive exposure, and weight bearing must be restricted until healing occurs. However, plate fixation allows for a more accurate correction of angular and rotational deformities (Fig. 52-34). 
Figure 52-34
 
Nonoperative treatment of this patient’s femoral shaft fracture resulted in a significant malunion with varus and extension (A, B). An osteotomy with plate stabilization was required to restore the mechanical axis of the limb (C, D).
Nonoperative treatment of this patient’s femoral shaft fracture resulted in a significant malunion with varus and extension (A, B). An osteotomy with plate stabilization was required to restore the mechanical axis of the limb (C, D).
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Figure 52-34
Nonoperative treatment of this patient’s femoral shaft fracture resulted in a significant malunion with varus and extension (A, B). An osteotomy with plate stabilization was required to restore the mechanical axis of the limb (C, D).
Nonoperative treatment of this patient’s femoral shaft fracture resulted in a significant malunion with varus and extension (A, B). An osteotomy with plate stabilization was required to restore the mechanical axis of the limb (C, D).
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Rotational Malalignment

Rotational malalignment of the femur may occur after any method of femoral stabilization. It is unlikely in compression plating of the femur, but does occur with antegrade nailing, retrograde nailing, external fixation, traction, and bridge plating. The amount of femoral rotation that can be well tolerated by the patient is largely unknown, but there appears to be increased symptoms and the need for operative correction in patients with more than 15 degrees of rotational malalignment.37,143,158,345 This has been confirmed by a review of 21 patients with 15-degree rotational deformities demonstrated on CT scans. These patients were found to have functional limitations and difficulties with demanding activities such as sports, running, and climbing stairs. Surprisingly, an external torsional deformity was associated with increasing symptoms compared with an internal torsional deformity.142,143 This may be due to the observation of decreased compensation and more physical complaints in patients with an external rotation malalignment.142 
In a review of 110 femurs treated with intramedullary nailing, 19% of patients were found to have a rotational deformity of 15 degrees or more. This was symptomatic in 38% of patients, compared with 12% of patients with deformities between 10 and 15 degrees. In contrast, no patient with less than 10 degrees of a rotational malalignment had relevant symptoms.37 In another review of 220 patients with CT scans obtained after femoral nailing, 23% were found to have a rotational difference of 15 degrees or more, and another 21% of patients had a rotational difference of between 10 and 15 degrees. Given these results, a rotational malalignment exceeding 15 degrees after antegrade intramedullary nailing using a statically locked implant ranges from 9% to 28%.37,143,345 Attempting to find identifiable risk factors for rotational malalignment has been difficult. Certainly fracture comminution, especially segmental comminution, is contributory as evidenced by one study identifying that almost half of the patients with unstable fractures and Winquist type 3 and 4 comminution had rotational malalignment that was independent of fracture location and patient position at the time of nailing.308 
Femoral rotation can be determined intraoperatively and postoperatively using several methods including clinical examination and radiologic evaluations. Clinically, rotation of the contralateral extremity can be confirmed by flexing the hip and knee to 90 degrees and recording the internal and external rotation of the leg. This can then be compared with the injured side after intramedullary nailing. There are several limitations to this method.162 First, there is some toggle between the interlocking bolts and the nail that allows some rotation of the femur around the implant. Second, if a slotted and relatively thin walled nail is used, the implant itself can rotate around its long axis, making the clinical measurement inaccurate. Third, these measurements rely on measuring rotation relative to the pelvis. The pelvis is usually tilted to allow for nail placement, making this measurement inaccurate. Finally, clinical examination is only useful after the nail and interlocking bolts have been placed. If a perceived difference is confirmed, revision is required. Although clinical measurement is the easiest and most readily available method for determining rotation, its accuracy is questionable at best. In a study using CT scans to confirm the final rotational alignment in 76 femurs treated with medullary nails, clinical examination failed to identify almost half of the patients with 20-degree deformities.143 
There are several readily available radiographic methods for determining femoral rotation, most of which can be accomplished easily during intramedullary nailing. Normally, the cortical thickness of the femur in the AP and lateral planes can be assessed fluoroscopically, helping to judge the proper rotation. Because the femoral canal is not perfectly cylindrical and the cortical thickness is not uniform around the diameter of the bone, small rotational differences will be reflected by a change in the apparent cortical thickness.174 In a study reviewing and describing the “cortical step sign” for assessing rotation of the femur during nailing, the lateral fluoroscopic image was found to be particularly helpful in determining rotation, but whether the rotational abnormality was internal or external proved to be difficult.174 In segmentally comminuted femur fractures, the lack of osseous apposition at the fracture makes this radiologic clue relatively useless. Another method is the determination of the femoral anteversion based on a lateral fluoroscopic image of the femoral neck. After confirming a true neutral rotation of the distal femur, a lateral hip fluoroscopic image can be obtained with the image intensifier in the same rotation, allowing for an accurate measurement of the femoral neck anteversion. This can be used to compare with the known femoral anteversion of the uninjured femur, which is obtained preoperatively.169,308 An alternative method for determining intraoperative femoral rotation is accomplished by comparing the shape and appearance of the lesser trochanter, a surprisingly sensitive sign.158,162 Before prepping the affected limb, the image intensifier is positioned laterally and a true condylar overlap lateral of the unaffected distal femur is obtained, thereby ensuring the rotation of the leg. The image intensifier is then rotated 90 degrees, and an AP view of the lesser trochanter is obtained and stored for comparison. Then, at the time of surgery, the distal femoral segment can similarly be rotated into a perfect lateral position. The proximal segment can then be rotated with a percutaneous Schanz pin or external jig to match the lesser trochanteric profile to the stored image of the unaffected leg. This method has been demonstrated to reproduce the proper rotation to within 4 degrees in 87% of cases, and to within 15 degrees in all cases158 (see Fig. 52-17). 
Rotational alignment of the femur should be carefully assessed at the time of nail passage, after interlocking, and before leaving the operating room. If there is any doubt or clinical suggestion of abnormality, a CT scan should be obtained to document the difference. CT can be used to assess the femoral anteversion (and thus, the femoral rotation) by comparing similar axial cuts of the injured and uninjured femurs at the levels of the femoral neck and distal femur (Fig. 52-35). By comparing the relative angles of the posterior femoral condyles and the long axis of the femoral neck, the femoral torsion can be assessed.37,38 However, poor intraobserved reliability due to inaccuracy of identification of the femoral neck axis has been previously demonstrated. Consideration should be given to taking multiple measurements as the intra- and interobserver variance has been shown to be approximately 4 degrees.141 It is important to strictly maintain the position and rotation of the legs between the tomographic cuts to ensure an accurate assessment. This can usually be accomplished by simply taping the legs down during the evaluation. Although this method has limited utility in the intraoperative assessment of femoral rotation, it can be used to judge rotation in suspected cases after surgery. If the deformity exceeds 15 degrees, consideration should be given to correcting the malalignment acutely. Acute correction of a rotational deformity can usually be accomplished by removing the distal interlocking screws and rotating the distal segment of the femur around the nail. Pins placed into the femur can be used to judge the rotation before and after correction. 
Figure 52-35
 
CT scan with axial cuts of the femoral neck (A) and distal femur (B) can be used to determine the relative rotation of the femur. Comparison with the opposite femur indicates a 25-degree external rotational deformity of the right femur.
CT scan with axial cuts of the femoral neck (A) and distal femur (B) can be used to determine the relative rotation of the femur. Comparison with the opposite femur indicates a 25-degree external rotational deformity of the right femur.
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Figure 52-35
CT scan with axial cuts of the femoral neck (A) and distal femur (B) can be used to determine the relative rotation of the femur. Comparison with the opposite femur indicates a 25-degree external rotational deformity of the right femur.
CT scan with axial cuts of the femoral neck (A) and distal femur (B) can be used to determine the relative rotation of the femur. Comparison with the opposite femur indicates a 25-degree external rotational deformity of the right femur.
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Knee Stiffness, Knee Pain, and Hip Pain

Some degree of temporary knee stiffness is commonly observed after a fractured femoral shaft. Stiffness is thought to be related to the type of treatment, fracture location, and associated injuries. An associated head injury and the formation of ectopic bone can both contribute to limited knee motion. High-energy mechanisms such as a motor vehicle crash, multiple procedures, and a delay in union were also associated with persistent knee stiffness after treatment in one study.140 Although treatment with a plate has been suggested to contribute to some knee stiffness,64 larger studies have failed to identify this relationship.62,104,255 Further, a trend toward improved knee motion was shown after treatment with an antegrade femoral nail compared with a retrograde femoral nail in a prospective and randomized evaluation comparing the two techniques.306 However, most studies have failed to report an association between retrograde nailing and knee stiffness. Both knee flexion and extension may be limited after a femoral fracture. Most typical is a combination of limited passive knee flexion and limited active knee extension (knee extension lag). Limited knee flexion is typically caused by scarring of the quadriceps muscles, especially the vastus intermedius, anteriorly in the region of the fracture. In these cases, treatment consists of an aggressive rehabilitation program including active knee flexion. If left untreated, scarring at the knee joint may occur, further complicating management. Knee stiffness usually improves in the first 6 to 12 weeks after surgical stabilization of a femoral shaft. If there is a lack of continued improvement clinically at 3 to 6 months, a knee manipulation and/or a surgical release can be considered. However, this is necessary in the minority of cases. The results of a Judet quadricepsplasty for the management of the posttraumatic stiff knee have been demonstrated in several studies and reports.140,202,322 In certain circumstances, the presence of an anteriorly displaced cortical fragment, anterior ectopic bone, and reduction in extension may further be associated with or contribute to a loss of knee flexion. Treatment of the underlying cause may be necessary in some circumstances. Knee and hip pain are reported commonly after the treatment of femoral shaft fractures. The relative incidence of each is associated with the method of treatment. Ricci et al.,252 in a comparison study of antegrade and retrograde femoral nails, reported an increased rate of knee pain with retrograde nails (36% vs. 9%) and an increased rate of hip pain with antegrade nails (10% vs. 4%). The incidence of hip pain after antegrade nailing ranges from 10% to 40%.83,252 This may be related to the formation of heterotopic bone in the region of the greater trochanter, although hip pain without radiographic evidence of nail prominence or ectopic bone does occur. Femoral nail removal29,115,138,194,304 should be restricted to symptomatic patients with hip pain. Partial resolution of symptoms can be expected in the majority of these patients. 
These complications are discussed in further detail in this chapter in the sections on antegrade nailing, retrograde nailing, femoral nail removal, and heterotopic ossification. 

Heterotopic Ossification

Proximal thigh pain and ipsilateral hip pain after intramedullary nailing may be related to the surgical procedure, the fracture, muscle weakness, or the presence of heterotopic ossification. Formation of ectopic bone at the entry site and overlying the starting point for an intramedullary nail is observed commonly, especially after reamed nailing (Fig. 52-36). Fortunately, the majority of heterotopic ossification is not associated with pain or limitations in motion.49,99,185,288 Further, surgical excision is rarely required. Overall, the incidence of heterotopic ossification ranges from 9% to 60%. Clinically significant heterotopic ossification occurs in only 5% to 10% of patients. The origin of proximal thigh pain and its relationship to heterotopic bone formation was investigated by Dodenhoff et al.83 in their review of 80 patients treated with antegrade intramedullary nailing. More than 40% of patients were found to have residual proximal thigh pain almost 2 years after surgery. The usual location was in the region of the greater trochanter. No correlation was found between the nail prominence and the incidence of pain. However, a strong relationship was found between the formation of heterotopic ossification and the presence of pain. 
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Figure 52-36
Heterotopic ossification at nail entry site.
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The association between heterotopic ossification and patient factors, injury patterns, or technical factors has been inconsistent. Several studies have confirmed the lack of association between nail prominence and ectopic bone formation.83,185 Heterotopic ossification formation has been found to be increased in association with male gender, a delay to surgery, and prolonged intubation.185,288 The most commonly identified risk factor is an associated head injury,185,288 although the Glasgow Coma Scale has not been consistent in predicting excessive bone formation.49 Reamed antegrade nails have been correlated to increased ectopic bone formation compared with unreamed nails, suggesting that the osteogenic reaming debris is primarily responsible. In this study, heterotopic bone was identified in 36% of patients treated with reamed nails compared with 9% of patients treated with undreamed nails. As well, the volume extent of bone formation was uniformly increased after reamed nailing.99 
The most complete evaluation of the incidence, description, and causes of heterotopic bone formation associated with antegrade nailing was that by Brumback et al.49 They reviewed the results of 80 intramedullary nails placed in an equal number of patients who were either treated with small volume bulb syringe irrigation or large volume pulsatile irrigation after nailing. The size of the ectopic bone was determined for comparison. Overall, no heterotopic bone was observed in 40% of patients, whereas 34% had mild, 15% had moderate, and 11% had severe bone formation. They observed a lack of correlation between bone formation and age, gender, delay to surgery, or ISS. The use of pulsatile irrigation did not decrease the incidence and volume of heterotopic bone formation.49 
In summary, heterotopic bone formation occurs commonly after antegrade reamed intramedullary nailing of femoral shaft fractures. However, clinically significant bone formation that requires operative excision or nail removal is infrequent. Although a correlation has been identified between bone formation and proximal thigh pain, a significant number of patients have completely normal radiographs and discomfort at the thigh and lateral hip. Further, it is unclear whether heterotopic bone formation is indicative of surgical trauma to the abductors, reaming with osteogenic elements, or patient factors that are not well defined. It is likely that heterotopic bone formation is a combination of these numerous patient, injury, and surgical factors. 

Refracture

Femoral refracture after operative fixation with plates or intramedullary nail is rarely encountered. If the fracture is truly healed, refracture of the femur through the implant would suggest additional trauma capable of injuring both the femur and the implant. However, fractures at the ends of plates can occur. Although this is uncommon and should not be a strong indication for the routine removal of plates in adults, patients with plates should be counseled regarding this possibility. 
The technique used for application of a plate has an impact on the time-related strength of the bone. If bridge plating is used to span a comminuted diaphyseal femur fracture, this indirect method of reduction should ensure that secondary bone healing occurs with abundant callus formation. Guidelines for timing of hardware removal are similar to that with intramedullary nails. If the plate is subsequently removed, the screw holes are a potential source of stress concentration that could lead to a refracture if a critical torsional force is applied. Although this is unlikely, patients should avoid high impact and torsional activities after plate removal. If an open plating procedure is used with direct compression of the fracture, the femur would be expected to heal with primary bone healing. As a result, callus formation would not be expected and plate removal should be delayed for at least 12 to 24 months to allow for maximal remodeling and maturation of fracture healing. Refracture is still unlikely; however, potential sites include the screw holes as well as the previous fracture. 
Refracture after nail removal in a healed femoral diaphyseal fracture is similarly uncommon. In 214 patients treated with static interlocking nailing, only 1 refracture was identified. This occurred through the site of the original fracture 6 weeks after nail removal. There were no secondary fractures at the site of the proximal or distal interlocking screw holes.45 In a number of subsequent studies reviewing nail removal, no cases of refracture or secondary fracture have been reported.29,115,304 

Implant Complications: Broken Nails, Broken Interlocking Screws, and Bent Nails

The main implant-related complications of antegrade and retrograde intramedullary nailing procedures are broken implants. With advances in nail design and an appreciation for the biomechanics of these implants, fatigue failure of the implant occurs much less frequently. Broken nails are indicative of femoral nonunion. If a fracture fails to heal, the nail will eventually fatigue and break. The timing of nail failure is dependent on numerous factors including the size of the implant, type of metal, location of the nonunion, fracture pattern, patient’s weight, and patient’s activity level. In a review of 60 broken nails in 56 patients, Franklin et al.97 identified the commonly observed sites of nail failure. The usual location for fatigue failure of the nail is at the site of the nonunion, where the implant deformation is maximal with motion. Other locations include transitional sites in the implant and locations where metal has been removed such as at the interlocking screw holes. Transitional sites of the nail are the proximal portion of the slot and the proximal nail waist in implants with an enlarged insertional diameter. 
Removal of a broken cannulated nail is predicted to be straightforward; however, difficulties are frequently encountered. If the femur and the broken implant are well aligned, implant extraction can proceed in a closed fashion from the antegrade entry site. The proximal portion of the nail can be removed using an extraction attachment or conical bolt. If necessary, the proximal segment can be overreamed slightly to facilitate removal of the distal segment of the nail. A long hook can then be placed down the cannulated portion of the nail as previously described.97 This frequently requires the use of a straight awl placed down the length of the cannulated nail to remove any bone that is present distal to the nail tip. If a hook fails to engage the distal nail segment, multiple guidewires can be stacked in the distal nail segment to produce an interference fit at the nail tip. In cases in which significant displacement of the nonunion has occurred since the time of nail breakage, an open procedure may be necessary to extract the distal portion of the nail. 
Broken interlocking screws occur commonly and are seen more frequently if small-diameter bolts and nails are used. The screws typically break at either the medial or lateral aspects of the nail. This location is important to determine before attempting removal. If the screw has broken at the medial aspect of the nail, removal of the broken portion of the screw before nail removal may not be necessary. However, if the screw breaks at the lateral aspect of the nail, the entire screw must be removed before attempting to back the nail out. Broken distal interlocking screws can usually be removed by first extracting the lateral screw section with an appropriate screwdriver. A large Steinmann pin with a diameter that approximates the minor diameter of the locking screw can then be used to push the medial segment of the locking screw into the soft tissues on the medial thigh. This can then be extracted through a separate incision. If the nail has migrated distally and the medial portion of the broken screw does not align well with the proximal portion, the nail can be extracted slightly to realign the screw before attempted removal. 
Bent nails, fortunately, do not occur commonly with current nail designs. However, even in a healed fracture, if enough force is applied the nail can bend. If the bend in the nail and the nail diameter are both small, the nail can be extracted without difficulty. However, significant bends usually require an open procedure for removal. The nail may need to be cut at the site of the new fracture or nonunion, and the proximal segment can then be removed in the usual fashion. The distal segment can be removed as described or directly from the site of the fracture or nonunion. 

Femoral Nail Removal

The need for and timing of femoral nail removal after fracture healing remains unknown. The initial recommendations of waiting at least 24 months before nail removal have been shown to be unnecessary in several studies. Nails removed in less than 1 year have not been associated with refracture in properly selected patients.115,138,194 Complete radiographic fracture consolidation and a lack of associated clinical symptoms are likely adequate to ensure that fracture healing is adequate in closed fractures. 
Removal of an antegrade femoral nail is not without complications. For that reason, nail removal in skeletally mature individuals should be restricted to symptomatic patients only.29,115,138,194,304 In a retrospective review of 164 femoral nails removed after fracture consolidation, the time interval between nail implantation and nail removal had no effect on operative time or the incidence of complications. In the 109 patients available for follow-up at a minimum of 2 years after nail removal, many were found to have persistent local symptoms. In the 53% of patients who underwent nail removal for symptoms, 78% were improved, 16% were no different, and 7% were worse. In the 47% of patients who were asymptomatic before nail removal, 20% had increased local symptoms after nail removal. Overall, 41% of patients were better, 40% were unchanged, and 13% were worse.115 
Further supporting the restriction of nail removal to symptomatic patients is the potential for wound complications, which have been reported in 4% to 10% of patients.29,138,194 This has been shown to be independent of the operative time, nail depth, heterotopic ossification, and experience of the surgeon.115 No difference has been observed in complications or operative time when removing titanium and steel implants.138 
From a technical standpoint, femoral nails can be removed in either the supine or lateral position depending on the surgeon comfort and size of the patient. The radiographs should be carefully scrutinized for implant identification and fatigue fracture in anticipation of all necessary removal equipment. Obviously, all interlocking bolts must be removed before backing out the nail. However, the extraction jig should be attached to the proximal aspect of the nail before removing all interlocking bolts to avoid advancing the nail down the canal and spinning the nail with tightening of the device. The presence or absence of an endcap should be anticipated. Of note, on the basis of experience in 164 nail removals in one study, endcap removal was found to be equally time consuming and as difficult as removal of ingrown bone at the top of the nail, leading to the authors’ recommendation that an endcap should be avoided at nail insertion.115 

Compartmental Syndrome

The incidence of a thigh compartmental syndrome complicating a femur fracture has been estimated at 1% to 2%.191,276 The diagnosis requires suspicion and frequent examination, especially given the amount of swelling that is commonly observed after a femoral shaft fracture. Intense thigh pain and tense swelling should alert the physician to the possibility of a thigh compartmental syndrome in the awake and cooperative patient. Pain with passive stretching of the involved muscles corresponding to the anterior, posterior, and medial compartments is consistent with the diagnosis. Loss of sensation in the distribution of the sensory nerves passing through the thigh provides further evidence. Thigh muscle weakness further supports the diagnosis. Although it is appreciated that most of these clinical signs are present in all patients with a femoral shaft fracture, the alerted physician is obliged to consider the diagnosis of a thigh compartmental syndrome in any patient with a femur fracture. The use of compartmental pressure monitoring in the awake patient is usually reserved for confirmation only because the diagnosis is usually made clinically. In the unconscious patient, the diagnosis may be more difficult and a high index of suspicion is similarly required. A tensely swollen thigh can be evaluated early in the unconscious patient with compartment pressure monitoring. The threshold for diagnosis in the thigh has not been firmly established but probably parallels the leg. Exact pressures of 30 or 40 mm Hg or a pressure threshold based on the patient’s diastolic blood pressure has been suggested.191,276,298 Morbidity was reported in 47% of patients with thigh compartmental syndrome in one study. Therefore, if the diagnosis is in question or if pressure monitoring equipment is unavailable to confirm the diagnosis, one should err on the side of early intervention. 
The predisposing risk factors for development of a thigh compartmental syndrome were identified in a review by Schwartz et al.276 as follows: systemic hypotension, coagulopathy, vascular injury, a history of external thigh compression, and trauma to the thigh with or without a fracture of the femur. In their review of 21 thigh compartmental syndromes, 10 had an associated femur fracture, half of which were open injuries. This suggests that an open fracture does not adequately decompress the thigh compartments, similar to the situation in the tibia. The relationship between intramedullary nailing and the development of a thigh compartmental syndrome has not been firmly established. It has been speculated, based on Schwartz et al.’s experience with five thigh compartmental syndromes after closed nailings, that the combination of the decreased thigh volume after fracture reduction and the normally associated bleeding associated with the injury is largely responsible.276 The impact of reaming with the associated deposition of additional volume in the thigh is unknown. However, according to knowledge of intramedullary nailing of tibia fractures, fracture reduction is thought to be largely responsible for the increase in pressure. 
The use of a tourniquet to assist with the treatment of other ipsilateral extremity fractures after intramedullary nailing of a femoral shaft fracture has been suggested as a potential cause of a thigh compartmental syndrome. In the event that multiple procedures are planned followed intramedullary nailing, a thigh tourniquet should be avoided to minimize this mitigating circumstance.201 
Treatment of a thigh compartmental syndrome consists of emergency decompressive fasciotomy. As described by several authors, this can be accomplished through an extensile lateral incision that gives access to the anterior and posterior compartments. The medial compartment pressures can then be reassessed to determine whether an additional medial approach is required. Because of the universally present significant associated swelling, delayed primary closure or skin grafting of the fasciotomy is usually delayed for at least 5 days.276,298 

Delayed Union and Nonunion

Nonunion occurs uncommonly after reamed nailing of femoral shaft fractures. The largest series of antegrade reamed interlocked nailings report final nonunion rates of 0.9%330 and 1.1%.337 These high rates of union with statically interlocked nails have been confirmed in multiple other studies of femoral diaphyseal fractures including those with segmental comminution.47,48,283,333,334 However, the incidence of nonunion is probably more frequent than what these reports indicate. In the series of 551 fractures reported by Wolinsky et al.,337 healing after the index intramedullary nailing procedure was 94%. In a study of 280 femoral fractures treated with intramedullary nailing, Pihlajamaki et al.244 identified delayed and nonunions that required further surgical intervention in 12.5%. Although their definition included patients with no radiographic progression of healing as early as 4 months, the incidence of further surgery in 35 fractures suggests that delayed and nonunion may be more common than predicted by some reports. Injury-related risk factors that would be expected to be associated with an increased incidence of nonunion include the presence of associated open wounds. However, several studies confirm that open fractures treated with immediate nailing unite predictably.43,118,265,328 The major identifiable treatment-related risk factor for delayed or nonunion appears to be treatment with an unreamed intramedullary nail based on several randomized studies.53,67,312 
Femoral nonunions may be caused by infection, impaired vascularity, lack of mechanical stability, fracture site distraction, bone loss, and/or soft tissue interposition. Open fractures are associated with delayed and nonunion due to a combination of impaired vascularity locally, as well as the frequent presence of multiple injuries in patients with open femoral shaft fractures. Several more recent reports confirm that a delay in weight bearing may be associated with nonunion of the femur after reamed intramedullary nailing.278,295 In patients with ipsilateral lower-extremity injuries that delayed weight bearing for 12 weeks, a higher incidence of femoral nonunions was reported by Taitsman et al. in 46 femoral nonunions which were compared to 92 control patients with a normal postinjury weight bearing protocol. Although the exact impact and frequency is unknown, the use of anti-inflammatory medications after injury has also been shown to be a significant risk factor for delayed and nonunion.111 Impaired vascularity may be related to the initial injury or to the treatment. Open fractures and excessive soft tissue stripping may contribute to nonunion by affecting the local bone blood supply. Mechanical stability may be inadequate if a small nail is used. Fracture distraction should be avoided to maximize healing. If a nonunion occurs in a closed fracture treated with an appropriately sized implant, a metabolic evaluation should be considered to help identify the underlying cause. 
The diagnosis and treatment of femoral nonunions remain controversial. Most femoral fractures treated with reamed nails heal in 3 to 6 months. In the prospective and randomized study by Tornetta and Tiburzi,312 union was observed in 80 days in patients treated with reamed nails. In contrast, almost 200 days were reported for union in the series by Clatworthy et al.67 Given the disparity in reported rates of healing, nonunion is probably best defined by a lack of progression of healing combined with clinical symptoms of discomfort at a minimum of 6 months from the time of treatment. Further, nonunion implies that healing is considered unlikely without further intervention. A broken nail in association with pain indicates a nonunion. 
There are several methods of treatment for femoral diaphyseal nonunions that were initially treated with an intramedullary nail. This includes nail dynamization, exchange nailing, plate fixations, bone grafting, and combinations thereof. Nail dynamization is an attractive option for treatment of a femoral nonunion because it involves the simple removal of one or two interlocking bolts depending on the nail design and the location of the nonunion. Most current nail designs have a dynamic slot that limits the potential shortening that can occur after removal of a single static interlocking screw. Alternatively, both of the proximal or distal interlocking screws can be removed in selected cases that are believed to be rotationally stable and in which significant shortening is not expected. However, the results of nail dynamization and the impact of this procedure on the actual conversion of a femoral nonunion to a union are questionable at best. Several large series by experienced surgeons have demonstrated little effect by routinely dynamizing statically locked intramedullary nails.48,283,333,334 In a series of 24 patients with statically locked nails, dynamizations at 4 to 12 months because of delayed healing failed to produce union in 42% of cases. Further, in the 10 cases of persistent nonunion after dynamization, shortening of greater than 2 cm was present in half of these patients.342 Nail dynamization in segmental fractures has been reported with similar results.343 In 12 patients who underwent nail dynamization at 5 to 10 months, 7 failed to unite and required a bone grafting procedure.343 In some instances, nail dynamization is associated with high complication rates directly related to the dynamization procedure. This is especially true in atrophic and unstable patterns of femoral shaft fractures and nonunions. In a review of 30 patients, significant shortening was observed.228 Perhaps the best indication for nail dynamization is the anticipated nonunion due to a technical error which occurred at the time of the original femoral nailing procedure. In cases of fracture distraction at the time of surgery, early dynamization may be a helpful treatment.135 Another potential indication is dynamization within 6 months in patients who have early fracture site resorption. However, it should be emphasized that a screw should be retained in a dynamic hole of the nail to ensure some rotational stability. Nonunion rates (and shortening) are higher in cases where all of the screws are removed from one end of the nail in an attempt to allow some shortening to occur135 Although dynamization may be effective in some cases, there is only retrospective literature suggesting some success in patients who may have otherwise healed if no intervention had been performed. 
The effectiveness of exchange nailing has been reviewed by several authors, and mixed results have been reported. Because all studies reviewing the success of exchange nailing are retrospective, the types of nonunions, length of time from the initial treatment to the exchange nailing procedure, and use of bone graft in addition to nail replacement are all confounding variables.98,124,244,278,325,327 An early study reported 96% success in treating delayed unions and nonunions of the femur with reaming and implantation of a larger nail.325 Furlong et al.98 reviewed their success with exchange nailing in 25 patients, almost half of whom had autologous bone grafting at the same time. Healing was observed in all but one patient at an average of 30 weeks. Union occurred more rapidly in patients undergoing a simultaneous bone grafting procedure. Hak et al.124 identified 23 patients treated with reamed intramedullary nails who had a lack of progression to healing for at least 4 months. The patients were treated with exchange nailing using an implant with a diameter 1 to 3 mm larger. All eight of the nonsmokers healed after exchange reamed nailing, whereas only 10 of the 15 patients who smoked healed. Their overall success rate was 78%. Positive intraoperative cultures did not preclude healing after exchange nailing in five patients. Weresh et al.327 retrospectively reviewed their experience with 19 patients with femoral nonunions defined as a lack of progressive healing for at least 3 months, clinical signs, and at least 6 months since the initial treatment. Exchange reamed nailing using an implant at least 2 mm larger in diameter was used as the primary treatment. Supplemental bone grafting was performed in four patients. Healing was observed in only 53% of patients. If exchange nailing is performed, the type of nonunion and the location are important considerations. There is evidence that atrophic nonunions are converted to unions less frequently after exchange nailing.278 Further, nonisthmic nonunions have been shown to have a lower healing rate after exchange nailing.347 This is likely due to the lack of rotational control that is obtained in the nonisthmic portions of the femur (despite placement of a larger nail during the exchange nailing procedure). In one review of 41 femoral shaft nonunions treated with exchange nailing, isthmic nonunions healed in 87% compared to only 50% in nonisthmic nonunions.347 
The use of plate fixations with or without bone graft has also been shown to be successful in the management of aseptic femoral nonunions that have been initially treated with intramedullary nailing21,315 (Fig. 52-37). Bellabarba et al.21 reported their results in treating a consecutive series of 23 patients with established femoral nonunions. The nonunions were classified as atrophic in 22%, oligotrophic in 48%, and hypertrophic in 30%. After nail removal, indirect reduction and plating techniques were used to correct the deformities and compress the nonunions. Supplemental autologous bone grafting was used in all of the atrophic nonunions and in 73% of the oligotrophic nonunions. Healing was observed in 91% of cases after the initial plating procedure. The two patients with persistent nonunions healed after a revision plating procedure. The main disadvantage to this method is the need for a period of protected weight bearing after the plating procedure. Augmentative plating for nonunions following intramedullary nailing has been associated with high success rates and could be considered as another alternative.63,237,315 Ueng et al.315 reported 100% union in 17 patients treated with augmentative plating for nonunions after femoral nailing.63 The patients in their series all had persistent rotational instability after intramedullary nailing, and the plates were applied in an attempt to control this. Early weight bearing was allowed, and bony union was observed at an average of 7 months after treatment.315 Similarly, in a series of 15 patients with femoral nonunions following intramedullary nailing, treatment with plate augmentation and bone grafting resulted in fracture union in all cases63 (Fig. 52-38). A nonisthmic nonunion location may be the best indication for plate augmentation for the treatment of a femoral nonunion.237 In this location, the ability of the nail to control rotation is limited, even after exchange nailing with a larger implant. This was confirmed in a study comparing 11 patients treated with augmentation plating for nonisthmic femoral nonunions after nailing to 7 patients treated with exchange nailing. The success of plating was 100% compared to only 28% in the patients treated with exchange nailing.237 
Figure 52-37
 
This 21-year-old man sustained injuries after a motorcycle crash including a distal femoral fracture with an associated sciatic nerve palsy (A, B). The fracture displacement produced vascular embarrassment that was relieved after open reduction of the femur. Retrograde nailing resulted in nonunion at 12 months (C, D), which was treated with compression plating (E, F).
This 21-year-old man sustained injuries after a motorcycle crash including a distal femoral fracture with an associated sciatic nerve palsy (A, B). The fracture displacement produced vascular embarrassment that was relieved after open reduction of the femur. Retrograde nailing resulted in nonunion at 12 months (C, D), which was treated with compression plating (E, F).
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This 21-year-old man sustained injuries after a motorcycle crash including a distal femoral fracture with an associated sciatic nerve palsy (A, B). The fracture displacement produced vascular embarrassment that was relieved after open reduction of the femur. Retrograde nailing resulted in nonunion at 12 months (C, D), which was treated with compression plating (E, F).
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Figure 52-37
This 21-year-old man sustained injuries after a motorcycle crash including a distal femoral fracture with an associated sciatic nerve palsy (A, B). The fracture displacement produced vascular embarrassment that was relieved after open reduction of the femur. Retrograde nailing resulted in nonunion at 12 months (C, D), which was treated with compression plating (E, F).
This 21-year-old man sustained injuries after a motorcycle crash including a distal femoral fracture with an associated sciatic nerve palsy (A, B). The fracture displacement produced vascular embarrassment that was relieved after open reduction of the femur. Retrograde nailing resulted in nonunion at 12 months (C, D), which was treated with compression plating (E, F).
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This 21-year-old man sustained injuries after a motorcycle crash including a distal femoral fracture with an associated sciatic nerve palsy (A, B). The fracture displacement produced vascular embarrassment that was relieved after open reduction of the femur. Retrograde nailing resulted in nonunion at 12 months (C, D), which was treated with compression plating (E, F).
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Figure 52-38
 
This 29-year-old female sustained multiple injuries in a motor vehicle crash including a femoral neck fracture, a comminuted midshaft femoral fracture, and a patella fracture. A retrograde nail was used to treat the femoral shaft, which subsequently resulted in a painful nonunion at 2 years despite a statically interlocked nail (A, B). This was treated through an open approach with lateral plating around the nail, without bone grafting (C, D). Note: The proximal interlocking screw was removed from the nail at the time of plating to allow intraoperative compression of the nonunion. Healing proceeds uneventfully (E, F, G, H). (Case courtesy of David Barei, MD, Harborview Medical Center)
This 29-year-old female sustained multiple injuries in a motor vehicle crash including a femoral neck fracture, a comminuted midshaft femoral fracture, and a patella fracture. A retrograde nail was used to treat the femoral shaft, which subsequently resulted in a painful nonunion at 2 years despite a statically interlocked nail (A, B). This was treated through an open approach with lateral plating around the nail, without bone grafting (C, D). Note: The proximal interlocking screw was removed from the nail at the time of plating to allow intraoperative compression of the nonunion. Healing proceeds uneventfully (E, F, G, H). (Case courtesy of David Barei, MD, Harborview Medical Center)
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This 29-year-old female sustained multiple injuries in a motor vehicle crash including a femoral neck fracture, a comminuted midshaft femoral fracture, and a patella fracture. A retrograde nail was used to treat the femoral shaft, which subsequently resulted in a painful nonunion at 2 years despite a statically interlocked nail (A, B). This was treated through an open approach with lateral plating around the nail, without bone grafting (C, D). Note: The proximal interlocking screw was removed from the nail at the time of plating to allow intraoperative compression of the nonunion. Healing proceeds uneventfully (E, F, G, H). (Case courtesy of David Barei, MD, Harborview Medical Center)
View Original | Slide (.ppt)
This 29-year-old female sustained multiple injuries in a motor vehicle crash including a femoral neck fracture, a comminuted midshaft femoral fracture, and a patella fracture. A retrograde nail was used to treat the femoral shaft, which subsequently resulted in a painful nonunion at 2 years despite a statically interlocked nail (A, B). This was treated through an open approach with lateral plating around the nail, without bone grafting (C, D). Note: The proximal interlocking screw was removed from the nail at the time of plating to allow intraoperative compression of the nonunion. Healing proceeds uneventfully (E, F, G, H). (Case courtesy of David Barei, MD, Harborview Medical Center)
View Original | Slide (.ppt)
Figure 52-38
This 29-year-old female sustained multiple injuries in a motor vehicle crash including a femoral neck fracture, a comminuted midshaft femoral fracture, and a patella fracture. A retrograde nail was used to treat the femoral shaft, which subsequently resulted in a painful nonunion at 2 years despite a statically interlocked nail (A, B). This was treated through an open approach with lateral plating around the nail, without bone grafting (C, D). Note: The proximal interlocking screw was removed from the nail at the time of plating to allow intraoperative compression of the nonunion. Healing proceeds uneventfully (E, F, G, H). (Case courtesy of David Barei, MD, Harborview Medical Center)
This 29-year-old female sustained multiple injuries in a motor vehicle crash including a femoral neck fracture, a comminuted midshaft femoral fracture, and a patella fracture. A retrograde nail was used to treat the femoral shaft, which subsequently resulted in a painful nonunion at 2 years despite a statically interlocked nail (A, B). This was treated through an open approach with lateral plating around the nail, without bone grafting (C, D). Note: The proximal interlocking screw was removed from the nail at the time of plating to allow intraoperative compression of the nonunion. Healing proceeds uneventfully (E, F, G, H). (Case courtesy of David Barei, MD, Harborview Medical Center)
View Original | Slide (.ppt)
This 29-year-old female sustained multiple injuries in a motor vehicle crash including a femoral neck fracture, a comminuted midshaft femoral fracture, and a patella fracture. A retrograde nail was used to treat the femoral shaft, which subsequently resulted in a painful nonunion at 2 years despite a statically interlocked nail (A, B). This was treated through an open approach with lateral plating around the nail, without bone grafting (C, D). Note: The proximal interlocking screw was removed from the nail at the time of plating to allow intraoperative compression of the nonunion. Healing proceeds uneventfully (E, F, G, H). (Case courtesy of David Barei, MD, Harborview Medical Center)
View Original | Slide (.ppt)
This 29-year-old female sustained multiple injuries in a motor vehicle crash including a femoral neck fracture, a comminuted midshaft femoral fracture, and a patella fracture. A retrograde nail was used to treat the femoral shaft, which subsequently resulted in a painful nonunion at 2 years despite a statically interlocked nail (A, B). This was treated through an open approach with lateral plating around the nail, without bone grafting (C, D). Note: The proximal interlocking screw was removed from the nail at the time of plating to allow intraoperative compression of the nonunion. Healing proceeds uneventfully (E, F, G, H). (Case courtesy of David Barei, MD, Harborview Medical Center)
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X
Aseptic nonunions in femoral shaft fractures previously treated with plate fixations are less commonly observed, largely due to the relative infrequency with which plates are used as a primary treatment for femoral shaft fractures given the success of intramedullary devices. The principles for treatment in a previously plated femoral shaft fracture are similar to that for other diaphyseal nonunions. Treatment is largely dictated by the combined goals of achieving mechanical stability in a biologically attractive environment that maximizes healing. In most cases, removal of the plate and placement of a reamed intramedullary nail achieves these goals and is the most reliable method of treatment.90 In a prospective and randomized study of 40 patients with nonunions following plate fixation, treatment consisted of interlocked reamed nailing with or without autogenous bone grafting. Treatment with a reamed nail without bone grafting resulted in similar results with less operating time and blood loss.90 

Infection and Infected Nonunions

Infection occurs uncommonly after treatment of closed femoral shaft fractures. The reported incidence of infection complicating reamed intramedullary nailing is less than 1% in most large series.67,283,311,312,333,334,337 The reported infection rates in patients treated with intramedullary nailing for open femoral fractures ranges from 2.4% to 4.8%.43,178,216,328 The increased infection risk is likely related to the extent of soft tissue stripping, amount of contamination, and adequacy of debridement. The diagnosis should be suspected in any patient with a femoral nonunion, regardless of whether the original injury was open or closed. 
The clinical signs and symptoms of most infections after intramedullary nailing make the diagnosis fairly obvious. Pain, swelling, and erythema may be present. More commonly, purulent drainage is present. This may be located at the site of a previous open wound, from a sinus tract that has formed in a remote location, at the nail entry site, or from one of the interlocking screw insertion sites. Purulent drainage from one of these locations is usually consistent with a deep infection and not a localized abscess in a coincidental location. Increasing pain, fevers, or constitutional symptoms may be present. Further laboratory studies should include a white blood cell count, a sedimentation rate and C-reactive protein. These studies may be less important for the diagnosis than for their value with following treatment in the future. Plain radiographs should be obtained in an attempt to determine fracture healing, the stability of the implant, and the presence of any obvious nonviable bone. Increased density is often consistent with a sequestrum, whereas periosteal new bone formation may indicate repair or attempts to heal around a segment of dead bone. 
In general, the treatment for an infection of the femur is surgical. All infected and necrotic tissues should be removed, and the bone should be assessed for viability. This requires an open surgical approach. Bone viability can be assessed visually or with a laser Doppler. Any dead or infected tissue should be removed. Intraoperatively, the stability of the implant should be assessed. If the implant is maintaining osseous stability, then it can potentially be left in position (assuming there is no associated deformity of the femur). Antibiotic selection should be based on the intraoperative cultures. If adequate stability is present, an infected femur can heal. After healing, the implant can be removed. In the case of an intramedullary nail, the canal is typically reamed to remove any residual infection. 
If the nail is found to be loose at the time of debridement, the nail should be removed and the canal should be reamed to remove the contaminated membrane and any residual medullary purulence. Replacement of the nail is desirable whenever possible. Fracture (or nonunion) stability must be obtained and maintained during treatment, because the implant itself is not the source of infection.338 Instead, the infection is likely perpetuated by mechanical and/or biologic inadequacies. There are several choices for maintaining stability at this juncture including external fixation, plate fixation, locked intramedullary nailing, and temporary placement of an antibiotic nail.17,60,160,226,258,316 External fixation has been used with success after an adequate intramedullary debridement. In a series of 15 infected femoral nonunions, Ueng et al.316 presented a two-stage protocol. Initial management consisted of a radical debridement, local antibiotic bead placement, and external fixation. The second stage consisted of bead removal, bone grafting, and continued external fixation. Despite a long period of external fixation, healing occurred. Barquet et al.17 successfully treated 11 of the 13 infected femoral nonunions with a similar protocol. A single stage protocol has also been used successfully in the treatment of infected femoral nonunions. In a series of 13 patients with an infected femoral nonunion previously treated with either a plate or a nail, eradication of infection was accomplished using an aggressive surgical debridement, correction of any associated deformity, and stable internal fixation with either a plate or a nail.246 In their series, bone grafting (if needed) was performed at a second operative procedure, but this was required in the minority of cases. Wave plating with bone grafting has also been used successfully to obtain union patients with infected nonunions in a series reported by Ring et al.258 The wave plate was specifically contoured to decrease the contact in the region of the nonunion and to allow placement of large quantities of bone graft at the site of the nonunion, and this was performed with success in 12 of the 13 patients. 
Replacement of the medullary implant with another nail after a thorough debridement of the canal and any associated devitalized bone has been used successfully to manage infected femoral nonunions as well.160 In a series of 38 infected femoral pseudarthroses, Klemm160 obtained fracture union in 34 patients after placement of an interlocking nail. He used a combination of debridement, antibiotic beads, insertion of an intramedullary nail, and an irrigation system to successfully treat these infected nonunions. Unlike plating and external fixation, exchange nailing after reaming allows early weight bearing. Finally, the use of a temporary antibiotic cement rod was demonstrated by Paley and Herzenberg.226 They were able to eradicate intramedullary infections in six femurs. Although four of the infections were caused by transports over nails and only two were infected pseudarthroses, the local delivery of high concentrations of antibiotics while maintaining some stability may be useful and merits further investigation. 

Author’s Preferred Method of Treatment for Femoral Shaft Fractures (Fig. 52-39)

Figure 52-39
Algorithm of author’s preferred method of treatment of femoral shaft fractures.
Rockwood-ch052-image039.png
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For closed femoral shaft fractures, the preferred treatment in the majority of cases is immediate closed, statically locked, reamed, antegrade intramedullary nailing using a piriformis starting portal. A trochanteric entry nail with a smaller proximal diameter is used in some instances, typically in obese patients or some other compelling reason to avoid the piriformis entry portal. We tend to use a percutaneous approach with the patient positioned supine on a radiolucent table with the leg draped free. A guide pin with a cannulated drill allows for a precise determination of the starting point. An intraoperative distal femoral traction accurately placed allows for distraction and reduction of the fracture as well as assessment of rotation.

 

Although femoral shaft fractures can be potentially life-threatening injuries, early treatment with nailing leads to union and allows early patient mobilization. Appropriate patient selection and careful attention to the numerous technical aspects of the procedure can minimize the potential complications. Early treatment of femur fractures with reamed nailing in polytraumatized patients decreases patient mortality.31 Static locking prevents shortening, maintains femoral rotation, and does not have a deleterious effect on union.48,337 Reaming allows for placement of an appropriately sized implant, increases the rate of union, and decreases the incidence of hardware failure.26,53,312 The potential negative impacts of reaming on the patient with multiple or thoracic injuries have not been confirmed clinically.33 Overall, union can be expected in 97% to 99% of cases.53,330,333,337

 

The choice of an antegrade versus a retrograde entry portal for nail placement is largely based on the preference of the surgeon. At our institution, an antegrade nail is chosen if at all possible mainly because of the ease and predictability of future or secondary procedures. If the patient develops a complication that requires either an exchange nail or implant removal, our preference is to do that procedure at an extra-articular location (the trochanteric fossa) as opposed to an intra-articular location (the knee). As well, the same “relative indications” for retrograde nails can be interpreted as “relative contraindications.” For instance, an ipsilateral patellar or articular injury at the knee suggests local trauma; the iatrogenic trauma of then going through the knee with reamers and a medullary implant seems unjustified. The situations that make a retrograde nail more attractive include ipsilateral femoral neck fractures, morbid obesity, and bilateral injuries in a critically ill patient. With an ipsilateral femoral neck fracture, I prefer to prioritize the femoral neck because of the lack of good salvage procedures for complications related to that injury. A retrograde nail can be placed after the femoral neck is stabilized; however, a plate can be used as well. In morbidly obese patients (BMI >35), in whom the extensive surgical approach for an antegrade nail is associated with an increased risk of infection, a retrograde nail may be desirable. For bilateral injuries in the critically ill patient, the ability to rapidly stabilize both femurs without the need to reposition the patient can make retrograde nailing a good option in rare circumstances. These nails can be placed and locked distally using the attached external jig, saving the proximal interlocking for a time when the patient can undergo a more extensive procedure. However, external fixation with conversion to antegrade intramedullary nails after the patient has stabilized is a reasonable option as well.232,233

 

The use of plate fixations for femoral shaft fractures is generally reserved for unusual circumstances given the excellent results with intramedullary nailing. Primarily, this procedure is used only in patients with an extremely narrow medullary canal, previously placed hardware, an associated vascular injury, proximal or distal fracture extensions, lack of fluoroscopy, or an associated femoral neck fracture. Submuscular and/or open techniques that maintain maximal femoral vascularity are used.

 

External fixation of the adult femur is virtually never used as a definitive treatment for a femoral shaft fracture in an adult. However, this technique may be used as a temporary form of stabilization until femoral nailing is deemed safe. This includes patients with an associated vascular injury, patients with multiple injuries, and patients with massive medullary canal contamination. Even in these circumstances, primary treatment reamed nailing is still usually preferred in the majority of circumstances.

Summary, Controversies, and Future Directions Related to Femoral Shaft Fractures

The management of femoral shaft fractures continues to evolve. Although statically locked, reamed femoral nailing is generally accepted as the optimal treatment for the adult with a femoral shaft fracture, investigations continue to elucidate the appropriateness in several circumstances. The choice of entry portal for placement of a femoral nail remains an area of continued study. In fractures of the femoral shaft, it is unlikely that the actual entry portal has a significant effect on the rate of fracture healing. More important are the techniques (reamed vs. unreamed) and the biomechanical properties of the medullary implant. If these are equal, it is unlikely that the rates of union, malalignment, infection, fat embolism, or compartmental syndrome will change solely on the basis of the choice of entry portal. The main advantages of alternative starting points appear to be the technical ease of identifying the starting point, the potential reduced time of the procedure, and the reduced radiation exposure. These factors may be amplified in obese patients. The trochanteric entry may offer the additional benefit of decreased local soft tissue damage and improved function. Therefore, the choice to use a starting point at the greater trochanter, the trochanteric fossa, or the intercondylar distal femur should be mainly based on the entry-site–related complications, the anticipated need for secondary surgical procedures at those locations, and any relevant patient-related concerns. Continued investigations will hopefully better define the indications for the use of different starting points for intramedullary femoral nailing. 
The use of a trochanteric entry point for femoral nailing has evolved into a viable option for antegrade nailing of femoral shaft fractures. Although the use of trochanteric entry nails has been advocated with success for pertrochanteric and subtrochanteric fractures for more than a decade, their use for femoral shaft fractures has only recently been advocated. Improvements in implant design and instrumentation have minimized the size of the entry portal, minimizing the damage to the abductor insertion. In addition, implant design changes have reduced the implant-related complication of fracture propagation previously observed with these devices. As the impact of this entry site for nail placement continues to be better defined, so will the relative indications. 
Intraoperative reduction techniques to facilitate the nailing procedure and the postoperative evaluation of the fracture reduction continue to improve but still prove to be problematic. This is particularly true with regards to the assessment of length and rotation. Improved techniques have been proposed and these will likely continue to be investigated in the future to decrease the need for secondary procedures to correct shortening and rotation. Computer-assisted reduction and assessment tools are likely to contribute to improvements in these areas. 
Distal interlocking of femoral nails continues to be investigated in an attempt to minimize the radiation exposure and surgical time associated with this portion of the procedure. Computer-assisted techniques and external jigs that allow rapid and predictable placement of interlocking bolts continue to evolve. 
Finally and most important, the impact of any orthopedic procedure, particularly reamed femoral nailing, on the overall morbidity and mortality of the multiply injured patients continues to be investigated. Especially critical is the treatment of patients with an associated head injury, a thoracic injury, or multiple extremity fractures. Timing of surgical treatment in patients with head injuries remains poorly understood. The impact of early operative stabilization to decrease mortality is balanced with the potentially yet unknown impact of decreased cerebral perfusion in patients who do not adequately autoregulate or have sustained hypotension. The balance of early operative intervention of all long bone fractures and “damage control orthopedics” in the multiply injured patient, especially those with associated thoracic trauma, continues to be studied with vigor. It is expected that the roles of these treatment approaches will be better defined in the near future. 

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