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The orthopaedic surgeon has a multitude of internal fixation devices and techniques available for use in the treatment of subtrochanteric fractures of the proximal femur. The successful use of second-generation locking nails is technically demanding. Close attention to positioning of the patient, reduction of the fracture, placement of the guide-wire, and insertion of the nail and of the proximal and distal locking screws is mandatory. The newer, high-strength hip-screws allow good fixation of a fracture that extends into the piriformis fossa. If medial comminution is present, this technique is best performed in conjunction with indirect reduction and bone-grafting. With proper technique, these devices allow the surgeon to manage predictably a complex subtrochanteric fracture that previously had to be treated with traction or extensive dissection and with (frequently inadequate) internal fixation.

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Between 1962 and 1987, we treated fifty-six patients for sixty broken intramedullary nails, using a custom-made hook to extract the distal fragment of the nail. The charts and radiographs of all of the patients were reviewed. Thirty-nine of the nails had been inserted in a fresh fracture, which usually was comminuted; eight had been used for fixation of an osteotomy; nine, for fixation of a non-union; and four, for treatment of a pathological fracture. Several small-diameter intramedullary nails broke at the site of the fracture or non-union. In contrast, the sites of breakage in the interlocking nails were the interlocking holes and the welded junction of the top insertional portion and the proximal slot. Many of the breakages were in patients who had an unstable fracture pattern. The interval between insertion and breakage ranged from one to 120 months.

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We divided 131 patients who had a subtrochanteric fracture into four clinical groups: elderly patients who had a fracture secondary to minor trauma, patients who had a fracture due to high-energy trauma, those who had a pathological fracture, and patients who had a fracture that previously had been treated unsuccessfully with internal fixation. In each patient operative fixation was performed using the Zickel device, and overall satisfactory results were obtained in 90 per cent. Considering the challenging nature of subtrochanteric fractures, complications, which included a rate of non-union of approximately 5 per cent, were minimum. Technical details for each of the four groups are emphasized.

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One hundred five consecutive patients with a diagnosis of delayed union (61 patients) or nonunion (44 patients) of the femoral shaft from February 1968 to November 1983 were managed by intramedullary reaming and nailing. The procedure was accomplished by closed techniques in 82 of the cases. Adequate follow-up study was obtained in 101 patients; all but four showed clinical and radiologic union at an average of 20 weeks following the procedure, with an overall union rate of 96%. The four patients whose fractures failed to consolidate with this treatment had repeat procedures with placement of thicker nails, and all subsequently healed.

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Closed intramedullary osteotomies offer a safe way to correct many femoral deformities. It is the safest method for correcting leg length inequality in adults, having a low infection rate and low complication rate. Unfortunately, the procedure, is technically demanding, requiring great attention by two surgeons. The derotational osteotomy is not nearly as complex; it is a relatively simple procedure for a surgeon experienced in closed intramedullary nailing. Correction is adequate with goniometer measurement, but an interlocking nail is necessary to maintain position. Correction of angulatory deformities is more difficult and requires careful study of anteroposterior, lateral, and oblique radiographs to be certain that the procedure is technically possible. Intramedullary bone grafting is frequently necessary for an open wedge. Distal osteotomies are encumbered by nonunion problems.

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The results of ten acute, displaced proximal femoral fractures in patients 14 years and under are reported. These high-risk fractures were managed with urgent open reduction and pin or screw fixation with supplemental spica casting. The exception to this protocol was in two Delbet's type IV (intertrochanteric) fractures which were managed by closed reduction and spica casting. There was a case of partial avascular necrosis of the femoral head in a type I transepiphyseal fracture. At a minimum followup of 2 years the patients were asymptomatic with no significant limitation of hip motion.

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We treated fifty-seven consecutive ipsilateral fractures of the femur and tibia in fifty-four adults from 1968 through 1978. Twenty-one patients had concomitant life-threatening injuries, and in thirty-three extremities the fractures were open. All but one of the femoral fractures and about half of the tibial fractures were internally fixed. The length of hospitalization averaged five weeks. Local complications included one below-the-knee amputation, three deep infections, and four ununited fractures. A fat embolism syndrome was diagnosed in 13 per cent of the patients. At the last follow-up examination, at an average of 40.5 months after injury, the mean range of motion of the knee was 129 degrees. Over-all, a good or excellent functional result was achieved in about 80 per cent of the patients. The best results were achieved when both fractures were stabilized surgically.

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Femoral neck fractures in young adults have a poor prognosis because the incidence of non-union and aseptic necrosis is high. We reviewed the results in twenty-seven consecutive patients with a femoral neck fracture who were younger than fifty years and who were treated with a standard protocol at Harborview Medical Center from 1975 to 1981. There were twenty-two male and five female patients, and they ranged in age from twelve to forty-nine years (mean, 32.4 years). Twenty patients were involved in high-velocity trauma and twelve of them had significant injuries to other organ systems. One of the remaining seven patients had sustained the fracture while running, and in the other six the fracture was associated with a metabolic disorder. Eight patients had a Garden Stage-II fracture; twelve, Stage-III; and seven, Stage-IV. The fractures were fixed with multiple 6.5-millimeter cancellous screws after adequate closed reduction, which was usually performed within eight hours after injury. All of the fractures united and there were no wound infections. Aseptic necrosis of the femoral head developed in five patients (20 per cent), three of whom had symptoms at the time of writing and will require surgical revision of the hip.

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Intramedullary nailing was performed on 520 femoral fractures in 500 patients. The series included eighty-six open fractures and 261 comminuted fractures. Closed intramedullary nailing was used in 497 femora and open intramedullary nailing with cerclage wiring, in twenty-three. The union rate was 99.1 per cent. The range of motion of the knee at follow-up averaged 130 degrees. Complications included four infections (0.9 per cent). Shortening of more than two centimeters occurred in ten patients (2.0 per cent) and malrotation of more than 20 degrees was observed in twelve patients (2.3 per cent). After prompt emergency measures had been taken, routine treatment included strong preoperative traction followed by accurate positioning of the patient on the operating table; selection of the correct insertion point for a properly sized, prebent, flexible, bullet-tipped nail; and accurate reduction of the fracture. Careful rehabilitation of the patient also contributed to the excellence of the results.

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Thirty-one postoperative pelvic computed tomographic (CT) scans in 29 patients studied between 1 day and 7 years after open reduction and internal fixation of acetabular fractures were reviewed. CT was most useful in the immediate postoperative period for detecting residual intraarticular fragments, localizing metallic fixation devices, and assessing the adequacy of reduction. CT scans obtained in the late postoperative period were useful primarily for determining the position and extent of ectopic bone before surgical removal.

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Nonunion of the tibia was treated by Küntscher intramedullary nailing un 48 patients. Thirty patients were treated with a completely closed intramedullary nailing and 18 required an open tibial osteotomy to realign the fracture. Bone grafting was not performed. The average time elapsed from injury to surgery was 15 months and the average healing time, as determined roentgenographically, was nine months following surgery. Three postoperative infections cleared with debridement and antibiotic therapy and subsequently united. There were two failures with persistent nonunion. Closed intramedullary nailing is an effective method of managing nonunion of the tibia in properly selected cases.

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Thirty-one consecutive patients who sustained acetabular fracture or posterior femoral head dislocations were examined by computed tomography (CT). By analysis of closely spaced, thin CT images, it was possible to characterize the three-dimensional nature of these injuries. Traditional classification into anterior column, posterior column, and complex two-column fractures was facilitated. CT was especially useful in evaluation of the two-column fractures in which unique information concerning the configuration of the fracture, integrity of the acetabular dome and quadrilateral surface, and identification of the stable fragment was obtained. Surprisingly constant fracture patterns were identified. CT was also useful in determination of presence or absence of loose bodies in the joint and in evaluation of the femoral head and sacroiliac joint in all types of fracture.

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Computed tomography (CT) and plain radiography of the pelvis were compared in 26 adult patients in whom acetabular fractures or posterior femoral head dislocations were demonstrated or suspected on initial radiographs. The detection of abnormalities of the sacrum, sacroiliac joint, iliac wing, acetabular roof, joint space, anterior pelvic column, posterior pelvic column, posterior acetabular lip, pubic rami, and quadrilateral surface of the ilium by the two methods was compared. The ability of the two techniques to establish the stable fragment was also examined. Three independent readings of each examination for each pelvic region were tabulated, and sensitivity and specificity values were calculated. There was no significant difference between plain radiography and computed tomography in detection of fractures of the iliac wing, anterior pelvic column, posterior pelvic column, and the pubic rami, with high sensitivity and specificity for both examinations. CT was more sensitive than plain radiography in detecting fractures involving the sacrum, quadrilateral surface, acetabular roof, and posterior acetabular lip. In addition, abnormalities of the hip joint space, principally loose bone fragments, were detected more often by CT. Sensitivity of both examinations for abnormalities of the sacroiliac joint was relatively poor, but examinations were highly specific. Determination of the stable fracture fragment(s) was readily accomplished by CT scanning in all 26 patients; in five patients incorrect determinations were made with conventional radiographs alone.

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We evaluated 245 cases of comminuted femoral fractures treated by intramedullary nailing and graded them by fracture pattern and degree of stability as segmental fractures, and grade I, grade II, grade III, and grade IV comminuted fractures. The infection rate was 0.4 per cent, and the nonunion rate was 0.8 per cent. Shortening of more than 2 cm. was seen in seven cases (3 per cent), and malrotation of more than 20 degrees was noted in four cases (1.7 per cent). These more common problems of shortening and rotation were almost eliminated by the increased use of cerclage wire and postoperative traction and spica casts. Knee range of motion averaged 128 degrees. These fractures provide interesting and difficult challenges. Intramedullary nailing of the segmental fractures is technically demanding but offers excellent results in these otherwise difficult fractures. Patients with grade I and grade II comminuted fractures do well with intramedullary nailing and the bones remain stable. Grade III and grade IV comminuted fractures are unstable and pose the risk of shortening and rotation. Therefore, to gain anatomic restoration in a young person we believe that it is reasonable to perform an open reduction and cerclage wiring of these fractures. The postoperative treatment of the comminuted femoral fracture is determined by both fracture stability and patient reliability, and frequent roentgenograms are indicated. Most importantly, the surgeon should be prepared to apply whatever form of treatment he believes to be necessary to gain optimal results in each individual.

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Patients at risk for compartmental syndromes challenge both the diagnostic and the therapeutic abilities of the physician. Suboptimum results may be due to delays in diagnosis and treatment, to incomplete surgical decompression, and to difficulties in the management of the limb after decompression. Although careful clinical assessment permits the diagnosis of a compartmental syndrome in most patients, we have found measurement of tissue pressure and direct nerve stimulation to be helpful for resolving ambiguous or equivocal cases. In our experience, the four-compartment parafibular approach to the leg and the ulnar approach to the volar compartments of the forearm provide efficient and complete decompression of potentially involved compartments. The skeletal stabilization of fractures associated with compartmental syndromes may facilitate management of the limb after surgical decompression.

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Closed intramedullary reaming and nailing with a prebent cloverleaf nail provides a biomechanically ideal method of internal fixation for femoral fractures. With a properly trained surgical team and careful technical control, all the theoretical advantages of this technique can be realized. These include a very high union rate, minimal risk of infection, early mobilization, and shortened hospitalization. Reaming and insertion of the nail is performed through a starting point at the junction of the base of the femoral neck and trochanter. When reaming is done, the nail can be sufficiently large to withstand the forces of early ambulation, thereby allowing an early return to normal function for most patients. In comminuted fractures an intramedullary nail can be used as an internal splint. In conjunction with traction and/or guarded weight-bearing and/or cast-brace, this procedure can assure earlier and more anatomic union and earlier return to function. In 300 fresh femoral fractures treated with closed intramedullary nailing, most patients had early and nearly anatomic union with excellent knee function and maintenance of muscle strength. Significant complications included one non-union, which required renailing, and 19 malunions, most of which were relatively minor. Because the procedure is technically demanding and requires extensive special equipment, it is best suited for use in trauma centers.

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Closed intramedullary shortening of the femur in the adult provides a method for leg length equalization that poses minimal operative risks, maximizes healing, and produces an excellent functional and cosmetic result. The etiology of anisomelia and any associated abnormalities must be carefully analyzed preoperatively. A series of 40 closed intramedullary shortenings of the femur were performed; shortening averaged 3.3 cm (range 2.0 to 5.0 cm). Three patients had significant complications: delayed union in one patient required renailing; two cases of symptomatic external rotation deformity required correction. The technique for the procedure is demanding in terms of experience and equipment. Otherwise, intramedullary femoral shortening is an excellent method for managing adult anisomelia.

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Twenty acute segmental fractures of the femoral shaft were treated with closed intramedullary nailing. The severity of the soft-tissue damage and associated injuries necessitated careful preoperative care. The surgical technique and means of reduction are outlined. Follow-up of at least one year on all patients showed a 100 per cent rate of union with no infections. Major complications included splitting of the greater trochanter during nailing (one case) and an 11-degree valgus deformity (one case). Maximum shortening was 1.5 centimeters. Knee flexion averaged 135 degrees in these acute fractures. The results in this series indicate that closed intramedullary nailing is an excellent method of treatment for this difficult fracture.

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