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Immediate intramedullary nailing of femoral shaft fractures due to gunshots
Injury Vol. 26, No. 4. pp.257-259, 1995 Copyright 0 19% Elsevier Science Ltd for ISBI Printed in Great Britain. All rights reserved 002&1383/95 $lO.OO+O.OO
0020-1383(95)00012-7
Immediate fractures R. M. Nicholas
intramedullary due to gunshots
With
increasing
violence
in
our
society, fhe number of gunshot
increase. Fourfeen femoral fractures caused by gunshot injuries were treated with statically locked intramedullay to
nailing within 8 h of injury. Three patients had concomitant femoral arterial injuries.Al follow-up (average 22 months) the results were assessedusinga sfandardired gradingsystem. Thirteen fractures had progressed to stable bony union and there were no deep infections. Nine fractures had an excellent oulcome and four a good outcome. One fracture was graded as a poor outcome because of a non-union which was treated with an exchange nailing procedure and progressed to bony union. Our experience of immediate intramedullay nailing ofgunshof femoral fractures has yielded results which approximate lo those observed in treating closed femoral fractures. We would therefore recommend this as the treatment of choice in fractures of the femoral shaff caused by gunshots.
Injury, Vol. 26, No. 4, 257-259, 1995
Introduction Fractures of the femoral shaft causedby gunshot wounds have been reported asbeing difficult to managebecauseof an unstable, comminuted fracture configuration and the failure to maintain an adequate reduction. The associated soft-tissue injuries include contaminated missiletracks and the possibility of neurological or vascular damage. The experience of surgeons in the United States with intramedullary nailing of gunshot-induced femoral shaft fractures has been reported by Wiss et al.‘, Hollmann and Horowitz’ and Renner and Zych3. All authors reported satisfactory outcomes, although the delay to intramedullary nailing was between 8.5 and 14 days after injury. Bergman et a1.4described the treatment of these injuries with reamed intramedullary nails at an average of z days after injury (range 0-14 days) with satisfactory results and no deep infections. This paper reports our experience with immediate (within 8 h of injury) reamed intramedullary nailing of femoral shaft fractures caused by gunshot wounds of various velocities.
Patients
of femoral
shaft
and G. F. McCoy
The Fracture Clinic, Royal Victoria Hospital, Belfast, Northern
fracturesis likely
nailing
and methods
A retrospective analysis of medical records at the Royal Victoria Hospital was performed to identify all patients
Ireland, UK
who had sustained femoral shaft fractures caused by gunshots (of any velocity) which had been treated by immediate intramedullary nailing. There were 12 male patients with 14 fractures and no femalesin the series.The mean age of patients was 26.6 years (range 18-46 years). Three of the patients had concomitant femoral arterial injuries which required reversed vein graft repairs at the time of primary surgery. One patient had a contralateral, cornminuted, intra-articular distal femoral fracture which required stabilization with a dynamic condylar screw and two patients had less significant gunshot fractures in the feet and wrists. Two patients sustained sciatic nerve injuries which manifested as foot drop. Clinical and radiographic follow-up data were obtained for all patients at outpatient review clinics where the patients were assessed by both authors. The mean time to follow-up was 21.6 months (range 9-39 months). All fractures were classified according to the method of Winquist and Hansen5.Using this classification, all fractures were grade III or grade IV comminution. On admissionto hospital, all patients were assessed and resuscitated in the Accident and Emergency department. Clinical evaluation of the injured limbs included assessment of entry and exit wounds along with careful neurological and vascular examination. Patients who had diminished or absent pulseshad angiography or exploration of the femoral artery performed. Tetanus prophylaxis and broad spectrum antibiotics were administered intravenously on admissionand were continued for 5 days. Following transfer to the operating theatre, closed statically locked intramedullax-y nailing was performed with the patient in the supine position on a standard fracture table. All patients had surgery within 8 h of injury. A technique similar to that describedby Groose6was used to insert the Grosse & Kempf femoral intramedullary nail (Howmedica International Inc, Kiel, Germany). Distal locking was performed using a freehand technique without the use of commercially available targetting devices. All procedures were performed by senior registrars or consultants. In comminuted fractures where little or no cortical contact was left between proximal and distal fragments, radiographic comparison with the length of the uninjured limb was made. In this ‘well-leg technique’ a nail of known length is laid against a radiograph of the uninjured femur and thus assessmentof the required femoral nail length may be calculated. In two patients with bilateral commin-
258
Injury:
International
Journal
of the Care of the Injured
Vol. 26, No. 4, 1995
Figure 1. Pre-operativeradiographof a typical gunshotfracture
of the femur.
uted fractures a ‘best guess’assessmentof femoral length had to be made on the basis of radiographs and clinical evaluation intra-operatively. Initial excision of the wound margin was performed along with thorough saline irrigation and excision of the missile tracks with delayed primary closure of the wounds between the fifth and seventh postoperative day. The postoperative care of patients who had had unilateral static intramedullary nailing included early mobilization on two crutches with avoidance of much weight-bearing on the injured limb until evidence of callusappearedat follow-up. At that fime, a progressive increasein weight-bearing was permitted as tolerated. The time to union was defined as the interval between injury and the time when the patient was able to bear weight without external support and the fracture appeared to be healed on radiographs taken in two planes. Assessmentof fracture outcome was graded asexcellent if there was stable bony union, less than 1 cm of bone shortening, lessthan 5” of rotational or angular deformity and knee flexion to 100". A good outcome grading was allocated to the following features: stablebony union, less than t cm of bone shortening, lessthan IO” of rotational or angular deformity and knee flexion to at least 90”. A poor outcome grading was allocated to the following features: fracture non-union, more than 2 cm of bone shortening, greater than 10” of rotational or angular deformity and knee flexion of lessthan 90”.
Figure 2. The samepatient’s radiograph following statically
locked intramedullary nailing of the fracture. This patient proceededto stablebony union.
Results Fracture union occurred in 13 ouf of the 14 femoral fractures at an average of 5.5 months (range 3-8 months) after injury. In one patient there was a non-union which required an exchange intramedullary nailing procedure. This patient then proceeded to bony union. In one of the other patients there was an area of cortical bone loss comprising approximately 40-50 per cent of the circumference of the femur. Albeit that the fracture united, the deficient area was bone grafted with an autologous bone graft to give structural integrity to the femur. There were three femoral fractures with associated vascular injuries. These required immediate vascular surgical repair using reverse vein grafts. In two patients there were no further problems with either bony or vascular healing, but in one patient graft patency could not be
Nicholas
and McCoy:
Nailing
for gunshot
fractures
259
of the femur
maintained despite several attempts at reconstruction of the distal femoral artery. Ultimately, this patient required an amputation below the knee. The average delay from injury to nailing was 6 h (range 5-8 h). There were no deep infections. There were two patients who had local wound erythema and clear discharge which settled on antibiotics. There were no casesof nail or screw breakage in our patients. Assessmentof fracture outcome using the parameters above yielded nine patients with an excellent result, four with a good result and one with a poor outcome. The femoral fracture in the patient who required below knee amputation healed satisfactorily.
We did experience one non-union in the serieswhich responsedto an exchange femoral nailing procedure and ultimately healed. It is interesting to note that this non-union occurred in one of the bilaterally nailed patients, with the other femoral fracture healing at a normal rate. There has been apprehension about the use of internal fixation in contaminated gunshot fractures. Our experience of immediate intramedullary nailing of gunshot fractures of the femur has yielded results which approximate to those observed in closed femoral fractures**. We would therefore recommend the use of statically locked intramedullary nails as the immediate treatment of choice in fractures of the femoral shaft due to gunshots.
Discussion
Acknowledgements
The use of firearms is increasing within civilian life in the United Kingdom. This will inevitably result in increasesin patients with gunshot injuries presenting at Accident and Emergency departments. This will necessitate the awareness of attending orthopaedic surgeons of the management strategies available for gunshot fractures. Previously, this was almost exclusively the domain of the military surgeon or the orthopaedic surgeon who practised in the ‘troubled province of Ulster. The degree of soft tissuedisruption varies with the level of energy transfer. This kinetic energy is proportional to the massof the missile and the square of the velocity of impact. In our series the missile velocities varied from approximately 350 m/s (low velocity) to 75Om/s (high velocity). Even though there was extensive bony comminution and soft-tissue disruption in the high-velocity injuries the immediate insertion of an intramedullary nail did not appear to disturb fracture or soft-tissue healing. The presence of arterial injuries in association with femoral shaft fractures creates the dual demand of stabilization of the fracture and re-establishment of arterial supply. In Belfast, the practice of vascular shunting is performed until fracture stabilization hasbeen achieved7-9. After intramedullary nailing the delicate vascular repair may proceed without the risk of disruption. In this series, three out of 14 fractures had associated femoral arterial injuries, in contrast to only one in 65 patients in the series of Bergman et al.4. Our practice of wound cleaning and irrigation in our gunshot-fracture patients resulted in satisfactory wound healing and no deep infections. It has been suggested that cleaning in low-velocity gunshot wounds is unnecessaryro, but in view of our uncertainty of the muzzle velocities in our seriesof fractures and our desire for a standardized protocol in the managementof theseinjuries, we elected to clean and thoroughly irrigate the wounds and perform delayed primary suture at between the fifth and seventh days after operation. Using this soft-tissue care we did not experience any deep wound infections. We recommend the administration of a broad-spectrum antibiotic initially and to continue this for five days. Limb length, frat ture rotation and angulation have all been describedasproblems in the managementof unstable femoral shaft fractures but our use of the ‘well-leg’ and ‘best guess’ techniques for leg length, along with careful foot positioning for rotational alignment with intramedullary nailing resulted in none of these difficult problems in this series.
The authors wish to thank their orthopaedic colleaguesfor allowing inclusion of their patients in this report and also wish to thank the Department of Illustration (Royal Victoria Hospital) for their help in preparing the photographs.
References I WissDA, BrienWW and BeckerV. Interlocking nailing for the treatmentof femoralfracturesdue to gunshotwounds.] Bone Joinf Surg [Am] 1991; 73A: 598.
2 HollmannMW and Horowitz M. Femoralfracturessecondary to low velocity missiles:treatment with delayed intramedullaryfixation. 1 Orthop Trutlma1990; 4: 64. 3 Renner NL and Zych GA. Treatment of civilian gunshot fracturesof the femoralshaft.He/v Chir Acta 1991; 58: 683. 4 BergmanM, Tornetta I’, Kerina M et al. Femurfractures caused by gunshots: treatment by immediate reamed intramedullarynailing.] Trauma1993;34: 783. 5 Winquist RA and HansenST. Comminutedfracturesof the femoralshafttreated by intramedullarynailing. Orthop C/in North Am 1980; 11: 633. 6 Grosse A. Manual for Osteosynfhesis for Femoral and Tibia1 Shaft Fractures. Kiel: HowmedicaInternational.1991.
7 Barros D’Sa AAB. The rationale for arterial and venous
8 9
10
11
shunting in the management of limb vascular injuries. Eur ] Vast Surg 1989; 3: 471. Barros D’Sa AAB. Hassard TH, Livingston RH et al. Missile-induced vascular trauma. Injury 1980; 12: 13. Elliott JRM, Templeton J and Barros D’Sa AAB. Combined bony and vascular limb trauma: a new approach to treatment. ] Bone ]oinf Surg [Brl 1984; 66B: 281. Hampton OP. The indications for debridement of gunshot (bullet) wounds of the extremities in civilian practice. ] Trauma 1961; 1: 368. Christie J, Court-Brown C, Kinninmonth AW et al. Intramedullary locking nails in the management of femoral shaft fractures. ] Bone joint Surg [Br] 1988; 7OB: 206.
Paper accepted 12 January 1995.
Requests for reprints should be addressed to: Mr R. Nicholas, The
Fracture Clinic, Royal Victoria Hospital, Belfast BT12 6BA, Northern
Ireland, UK.
0020-1383(95)00012-7
Immediate fractures R. M. Nicholas
intramedullary due to gunshots
With
increasing
violence
in
our
society, fhe number of gunshot
increase. Fourfeen femoral fractures caused by gunshot injuries were treated with statically locked intramedullay to
nailing within 8 h of injury. Three patients had concomitant femoral arterial injuries.Al follow-up (average 22 months) the results were assessedusinga sfandardired gradingsystem. Thirteen fractures had progressed to stable bony union and there were no deep infections. Nine fractures had an excellent oulcome and four a good outcome. One fracture was graded as a poor outcome because of a non-union which was treated with an exchange nailing procedure and progressed to bony union. Our experience of immediate intramedullay nailing ofgunshof femoral fractures has yielded results which approximate lo those observed in treating closed femoral fractures. We would therefore recommend this as the treatment of choice in fractures of the femoral shaff caused by gunshots.
Injury, Vol. 26, No. 4, 257-259, 1995
Introduction Fractures of the femoral shaft causedby gunshot wounds have been reported asbeing difficult to managebecauseof an unstable, comminuted fracture configuration and the failure to maintain an adequate reduction. The associated soft-tissue injuries include contaminated missiletracks and the possibility of neurological or vascular damage. The experience of surgeons in the United States with intramedullary nailing of gunshot-induced femoral shaft fractures has been reported by Wiss et al.‘, Hollmann and Horowitz’ and Renner and Zych3. All authors reported satisfactory outcomes, although the delay to intramedullary nailing was between 8.5 and 14 days after injury. Bergman et a1.4described the treatment of these injuries with reamed intramedullary nails at an average of z days after injury (range 0-14 days) with satisfactory results and no deep infections. This paper reports our experience with immediate (within 8 h of injury) reamed intramedullary nailing of femoral shaft fractures caused by gunshot wounds of various velocities.
Patients
of femoral
shaft
and G. F. McCoy
The Fracture Clinic, Royal Victoria Hospital, Belfast, Northern
fracturesis likely
nailing
and methods
A retrospective analysis of medical records at the Royal Victoria Hospital was performed to identify all patients
Ireland, UK
who had sustained femoral shaft fractures caused by gunshots (of any velocity) which had been treated by immediate intramedullary nailing. There were 12 male patients with 14 fractures and no femalesin the series.The mean age of patients was 26.6 years (range 18-46 years). Three of the patients had concomitant femoral arterial injuries which required reversed vein graft repairs at the time of primary surgery. One patient had a contralateral, cornminuted, intra-articular distal femoral fracture which required stabilization with a dynamic condylar screw and two patients had less significant gunshot fractures in the feet and wrists. Two patients sustained sciatic nerve injuries which manifested as foot drop. Clinical and radiographic follow-up data were obtained for all patients at outpatient review clinics where the patients were assessed by both authors. The mean time to follow-up was 21.6 months (range 9-39 months). All fractures were classified according to the method of Winquist and Hansen5.Using this classification, all fractures were grade III or grade IV comminution. On admissionto hospital, all patients were assessed and resuscitated in the Accident and Emergency department. Clinical evaluation of the injured limbs included assessment of entry and exit wounds along with careful neurological and vascular examination. Patients who had diminished or absent pulseshad angiography or exploration of the femoral artery performed. Tetanus prophylaxis and broad spectrum antibiotics were administered intravenously on admissionand were continued for 5 days. Following transfer to the operating theatre, closed statically locked intramedullax-y nailing was performed with the patient in the supine position on a standard fracture table. All patients had surgery within 8 h of injury. A technique similar to that describedby Groose6was used to insert the Grosse & Kempf femoral intramedullary nail (Howmedica International Inc, Kiel, Germany). Distal locking was performed using a freehand technique without the use of commercially available targetting devices. All procedures were performed by senior registrars or consultants. In comminuted fractures where little or no cortical contact was left between proximal and distal fragments, radiographic comparison with the length of the uninjured limb was made. In this ‘well-leg technique’ a nail of known length is laid against a radiograph of the uninjured femur and thus assessmentof the required femoral nail length may be calculated. In two patients with bilateral commin-
258
Injury:
International
Journal
of the Care of the Injured
Vol. 26, No. 4, 1995
Figure 1. Pre-operativeradiographof a typical gunshotfracture
of the femur.
uted fractures a ‘best guess’assessmentof femoral length had to be made on the basis of radiographs and clinical evaluation intra-operatively. Initial excision of the wound margin was performed along with thorough saline irrigation and excision of the missile tracks with delayed primary closure of the wounds between the fifth and seventh postoperative day. The postoperative care of patients who had had unilateral static intramedullary nailing included early mobilization on two crutches with avoidance of much weight-bearing on the injured limb until evidence of callusappearedat follow-up. At that fime, a progressive increasein weight-bearing was permitted as tolerated. The time to union was defined as the interval between injury and the time when the patient was able to bear weight without external support and the fracture appeared to be healed on radiographs taken in two planes. Assessmentof fracture outcome was graded asexcellent if there was stable bony union, less than 1 cm of bone shortening, lessthan 5” of rotational or angular deformity and knee flexion to 100". A good outcome grading was allocated to the following features: stablebony union, less than t cm of bone shortening, lessthan IO” of rotational or angular deformity and knee flexion to at least 90”. A poor outcome grading was allocated to the following features: fracture non-union, more than 2 cm of bone shortening, greater than 10” of rotational or angular deformity and knee flexion of lessthan 90”.
Figure 2. The samepatient’s radiograph following statically
locked intramedullary nailing of the fracture. This patient proceededto stablebony union.
Results Fracture union occurred in 13 ouf of the 14 femoral fractures at an average of 5.5 months (range 3-8 months) after injury. In one patient there was a non-union which required an exchange intramedullary nailing procedure. This patient then proceeded to bony union. In one of the other patients there was an area of cortical bone loss comprising approximately 40-50 per cent of the circumference of the femur. Albeit that the fracture united, the deficient area was bone grafted with an autologous bone graft to give structural integrity to the femur. There were three femoral fractures with associated vascular injuries. These required immediate vascular surgical repair using reverse vein grafts. In two patients there were no further problems with either bony or vascular healing, but in one patient graft patency could not be
Nicholas
and McCoy:
Nailing
for gunshot
fractures
259
of the femur
maintained despite several attempts at reconstruction of the distal femoral artery. Ultimately, this patient required an amputation below the knee. The average delay from injury to nailing was 6 h (range 5-8 h). There were no deep infections. There were two patients who had local wound erythema and clear discharge which settled on antibiotics. There were no casesof nail or screw breakage in our patients. Assessmentof fracture outcome using the parameters above yielded nine patients with an excellent result, four with a good result and one with a poor outcome. The femoral fracture in the patient who required below knee amputation healed satisfactorily.
We did experience one non-union in the serieswhich responsedto an exchange femoral nailing procedure and ultimately healed. It is interesting to note that this non-union occurred in one of the bilaterally nailed patients, with the other femoral fracture healing at a normal rate. There has been apprehension about the use of internal fixation in contaminated gunshot fractures. Our experience of immediate intramedullary nailing of gunshot fractures of the femur has yielded results which approximate to those observed in closed femoral fractures**. We would therefore recommend the use of statically locked intramedullary nails as the immediate treatment of choice in fractures of the femoral shaft due to gunshots.
Discussion
Acknowledgements
The use of firearms is increasing within civilian life in the United Kingdom. This will inevitably result in increasesin patients with gunshot injuries presenting at Accident and Emergency departments. This will necessitate the awareness of attending orthopaedic surgeons of the management strategies available for gunshot fractures. Previously, this was almost exclusively the domain of the military surgeon or the orthopaedic surgeon who practised in the ‘troubled province of Ulster. The degree of soft tissuedisruption varies with the level of energy transfer. This kinetic energy is proportional to the massof the missile and the square of the velocity of impact. In our series the missile velocities varied from approximately 350 m/s (low velocity) to 75Om/s (high velocity). Even though there was extensive bony comminution and soft-tissue disruption in the high-velocity injuries the immediate insertion of an intramedullary nail did not appear to disturb fracture or soft-tissue healing. The presence of arterial injuries in association with femoral shaft fractures creates the dual demand of stabilization of the fracture and re-establishment of arterial supply. In Belfast, the practice of vascular shunting is performed until fracture stabilization hasbeen achieved7-9. After intramedullary nailing the delicate vascular repair may proceed without the risk of disruption. In this series, three out of 14 fractures had associated femoral arterial injuries, in contrast to only one in 65 patients in the series of Bergman et al.4. Our practice of wound cleaning and irrigation in our gunshot-fracture patients resulted in satisfactory wound healing and no deep infections. It has been suggested that cleaning in low-velocity gunshot wounds is unnecessaryro, but in view of our uncertainty of the muzzle velocities in our seriesof fractures and our desire for a standardized protocol in the managementof theseinjuries, we elected to clean and thoroughly irrigate the wounds and perform delayed primary suture at between the fifth and seventh days after operation. Using this soft-tissue care we did not experience any deep wound infections. We recommend the administration of a broad-spectrum antibiotic initially and to continue this for five days. Limb length, frat ture rotation and angulation have all been describedasproblems in the managementof unstable femoral shaft fractures but our use of the ‘well-leg’ and ‘best guess’ techniques for leg length, along with careful foot positioning for rotational alignment with intramedullary nailing resulted in none of these difficult problems in this series.
The authors wish to thank their orthopaedic colleaguesfor allowing inclusion of their patients in this report and also wish to thank the Department of Illustration (Royal Victoria Hospital) for their help in preparing the photographs.
References I WissDA, BrienWW and BeckerV. Interlocking nailing for the treatmentof femoralfracturesdue to gunshotwounds.] Bone Joinf Surg [Am] 1991; 73A: 598.
2 HollmannMW and Horowitz M. Femoralfracturessecondary to low velocity missiles:treatment with delayed intramedullaryfixation. 1 Orthop Trutlma1990; 4: 64. 3 Renner NL and Zych GA. Treatment of civilian gunshot fracturesof the femoralshaft.He/v Chir Acta 1991; 58: 683. 4 BergmanM, Tornetta I’, Kerina M et al. Femurfractures caused by gunshots: treatment by immediate reamed intramedullarynailing.] Trauma1993;34: 783. 5 Winquist RA and HansenST. Comminutedfracturesof the femoralshafttreated by intramedullarynailing. Orthop C/in North Am 1980; 11: 633. 6 Grosse A. Manual for Osteosynfhesis for Femoral and Tibia1 Shaft Fractures. Kiel: HowmedicaInternational.1991.
7 Barros D’Sa AAB. The rationale for arterial and venous
8 9
10
11
shunting in the management of limb vascular injuries. Eur ] Vast Surg 1989; 3: 471. Barros D’Sa AAB. Hassard TH, Livingston RH et al. Missile-induced vascular trauma. Injury 1980; 12: 13. Elliott JRM, Templeton J and Barros D’Sa AAB. Combined bony and vascular limb trauma: a new approach to treatment. ] Bone ]oinf Surg [Brl 1984; 66B: 281. Hampton OP. The indications for debridement of gunshot (bullet) wounds of the extremities in civilian practice. ] Trauma 1961; 1: 368. Christie J, Court-Brown C, Kinninmonth AW et al. Intramedullary locking nails in the management of femoral shaft fractures. ] Bone joint Surg [Br] 1988; 7OB: 206.
Paper accepted 12 January 1995.
Requests for reprints should be addressed to: Mr R. Nicholas, The
Fracture Clinic, Royal Victoria Hospital, Belfast BT12 6BA, Northern
Ireland, UK.