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Four patients with bilateral femoral shaft fractures sustained 4 peroneal nerve palsies and 2 compartment syndromes during supine intramedullary nailings of their fractures. In each case, the compartment syndrome or common peroneal nerve palsy or both developed in the leg that was placed initially in the calf-supported leg holder during intramedullary rodding of the contralateral femur. Three of 4 patients had near to full recovery of motor strength postoperatively. The authors recommend that a leg with a fractured femur not be positioned in a calf-supported leg holder.

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Salmonella typhi osteomyelitis is an uncommon disease, usually associated with sickle cell anemia and other hemoglobinopathies, as well as with other disease states. In this case, Salmonella osteomyelitis was apparently caused by hematogenous spread after typhoid or enteric fever. After bone debridement, a segmental defect of the midradius resulted. Normal function was restored after radical debridement, intravenous antibiotics, and delayed tricortical iliac crest bone grafting of the segmental defect.

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An experimental four-part unstable intertrochanteric (IT) femoral fracture was created with either a large or small posteromedial fragment (PMF). Sixty-eight adult embalmed femoral anatomic specimens were fractured and subjected to axial loading after fixation. The maximum load prior to failure for femora from the same anatomic specimen was compared to differentiate between different methods of fixation. In the presence of the large PMF variation, anatomic reduction and fixation allowed the femur to resist an average maximum load 57% greater than identical fractures with the fragment excluded. Fixation of the small PMF increased construct strength by an average of 17% over no fixation. The PMF is the keystone to mechanical stability for IT fractures of the femur. When anatomic reduction is possible, its fixation becomes progressively more critical as its size increases.

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Closed flexible intramedullary biopsy was performed in 24 patients requiring surgical stabilization of 17 pathologic and ten impending pathologic fractures from metastatic carcinoma. The biopsy was positive for carcinoma in 25 of 27 cases and either confirmed the diagnosis of metastatic disease or revealed a carcinoma cell type of unknown origin. The technique of closed biopsy using an intramedullary flexible, large bore, plastic catheter in patients with metastatic carcinoma produced information comparable to other biopsy techniques.

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Between June 1981 and August 1983, six patients were treated with flexible intramedullary nails for both femoral and tibial fractures in six floating knees. All six patients were males averaging 26 years of age and all six were involved in motor vehicle accidents. Concomitant associated injuries were common. Two femoral and five tibial fractures were open. All fractures were stabilized within 24 hours of injury by closed intramedullary nailing with Ender nails. At final followup, there was one femoral and one tibial nonunion in the same patient. For the remaining patients, femoral union averaged 10.3 weeks and tibial union averaged 18 weeks. Five patients regained full motion at the hip, and four regained full motion at the knee and ankle. Four patients returned to their preinjury level of function; two were less active, one ambulating without the use of external assistive devices, and one using a cane.

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In a retrospective, multicenter analysis, 79 subtrochanteric fractures of the femur were treated with flexible intramedullary nails. Seventy fractures were traumatic in origin, three were pathologic, and six occurred in spinal cord patients. All of the fractures healed, and there were no fixation failures. Thirteen patients (16%) required adjunctive internal fixation, bone grafts, or postoperative traction. Shortening greater than 1 cm occurred in four patients (5%). Reoperation with one week of surgery was necessary in eight patients (10%). The single greatest complication was knee complaints, which occurred in 17 patients (21.5%). However, only six of these patients required revision prior to fracture union. In one patient a deep wound infection developed, which eventually healed without evidence of osteomyelitis. All patients who were ambulatory before their fracture were able to bear weight.

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Forty-eight pathologic and impending pathologic fractures of the proximal femur were surgically treated in 38 patients averaging 70 years of age. The most common tumors were breast (45%), multiple myeloma (24%), and lung (11%). Tumor size, aggressiveness, and location influenced the type of fixation. Sixty-four percent of the lesions were treated by flexible intramedullary nails. This "stress sharing" device afforded sufficient stability to provide pain relief, restore function, and permit healing. Pain was relieved in 92% of the patients, and 84% became ambulatory. The rate of fracture union for patients surviving more than two months was 89%. The average postsurgical survival was nine months. Internal fixation of pathologic and impending pathologic fractures has been recommended in the literature and should not be precluded by advanced age.

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A case of a broken guide pin fragment retained in the femoral head and hip joint during compression screw fixation of a femoral neck fracture is presented. A new method for its retrieval is described.

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Thirty-nine patients with fifty impending pathological fractures of the femur were prophylactically stabilized with flexible intramedullary nails. Indications included lesions causing unremitting pain and either measuring greater than 2.5 cm in diameter or involving more than 50% cortical destruction. Painful lesions not meeting these radiographic criteria were also considered for prophylactic nailing if radiation therapy failed to relieve pain. Ninety-five percent of patients experienced marked pain relief after nailing, and 92% were ambulatory with or without assistive devices at discharge. Complications included one fracture at the nail insertion site and three cases with nondisabling knee pain. There were no infections.

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Twenty-seven patients with fractures of the shaft of the tibia, involving 15 closed and 12 open fractures, were treated by Ender intramedullary fixation from December 1978 through July 1981. All closed fractures required Ender nailing due to failure to obtain initial satisfactory closed reduction or failure to maintain adequate reduction after initial closed treatment. Following debridement, all grade I and grade II open fractures that did not meet criteria for satisfactory reduction by closed methods were treated with Ender nailing. Union occurred in 100% of grade I and grade II open fractures, and 93% of closed fractures. One failure of fixation, one delayed union, and one nonunion occurred.