Internal fixation of a segmental fracture of the femur with a Küntscher-Herzog tibial nail

340

Injury 12, 340-342

Printedin

GreatBritain

Internal fixation of a segmental fracture of the femur with a Kiintscher-Herzog tibia1 nail M. A. Qureshi Consultant Orthopaedic Surgeon, Croydon Area Health Authority

M. A. Pena Medico Girujuno Orthopaedic Department, Mayday Hospital, Cro ydon

Summary

This article presents the technique and the results of internal fixation of a severely unstable and displaced segmental fracture with a Kiintscher-Herzog tibia1 nai in a young patient with associated multiple fractures. CASE REPORT A MAN aged 38 years was admitted to Mayday Hospital after having been involved in a road traffic accident in which he was thrown off his motorcycle, having lost control at 40 mph. His injuries comprised: a right brachial plexus lesion; a closed fracture of the shaft of the right humerus; a comminuted fracture of the right radius and ulna; an open fracture of the midshaft of the right femur; a comminuted fracture of the left tibia and a segmental fracture ofthe left femur with a l4-cm segment-displaced medially (Figs. I and 2). ARer initial resuscitation and blood transfusion, bilateral skeletal traction was applied and a belowknee plaster-of-Paris cast was applied incorporating a Steinmann pin in the upper end ofthe left tibia. All the fractures in the right upper limb were stabilized by internal fixation without any complication. The position of the segmental fracture did not improve with traction. The l4-cm segment between the supracondylar and mid-shah of the femur was still grossly displaced medially, although without any vascular complications. After careful consideration of the extent of the fractures of the femurs, it was decided to carry out simultaneous Kiintscher nailing of the right femur and internal fixation of the left segmental femoral fracture with a Kiintscher-Herzog tibia1 nail. The patient was placed in a supine position with a perineal post and traction applied through the foot stirrup with the foot in neutral position. A 20-cm

incision was made on the lateral side of the left thigh, starting from the lateral condyle, to just above the middle fragment of the segmental fracture. The fascia lata was divided in the line of the incision and the lateral condyle was exposed without opening the joint. The supracondylar fracture was reduced with bone hooks with little damage to the periosteum and muscles. A 25 x 3.6 cm tibia1 nail was introduced to secure the alignment of the fracture. The proximal fracture near the middle of the shaft was then reduced with bone hooks and held with bone holding forceps whilst the tibia1 nail was driven up the medullary cavity past the fracture. Both the fractures were secured in anatomical position by driving the nail home. The previous slight instability at the site of the fractures was controlled by impacting the divergent part of the nail. The wound was sutured and Hamilton Russell traction was used for two weeks, during which time static quadriceps exercises were encouraged. After removing the traction, more active flexion and extension exercises were started. In view of the other injuries, including the right brachial plexus lesion, weight-bearing activities were not possible, but hydrotherapy was carried out. Ten weeks after operation clinical and radiological examination revealed firm union of the fracture (Frgs. 3-5). There was no varus or valgus deformity of the knee and the patient had a full range of knee movements, DISCUSSION Insertion of a Kiintscher-Herzog tibia1 nail (Kiintscher, 1967) through the lateral femoral condyle is a simple procedure and no radiological control or extensive equipment

Qureshi and Pena Medico Girujuno:Kijntscher-Herzog Tibia1Nail

341

Fig. 1 Fig. 2 Fig. I. Anteroposterior view of left femur. Fig. 2. Lateral view of left femur.

Fig. 5. Upper left femur showing length ofnail.

non-articular part of the femoral condyle to reduce damage to the periosteum and muscles during reduction of the fractures, as opposed to the extensive disruption caused by internal fixation with a long plate. No reaming of the medullary cavity of the middle fragment (Cloke, 1970) or of the rest of the femur was carried out, so as to avoid damage to the cortical bone. The angular part of the Kiintscher-Herzognail (centre of angle ISO) stays in the supracondylar region after impaction of the diverging part of Fig. 3 Fig. 4 the nail. The fractures are kept in alignment by F/g. 3. Anteroposterior view IO weeks after fixation 1 creating a certain degree of tension as the nail with Kiintscher-Herzog tibia1 nail. provides three strong contact points, which is not possible with the normal Kiintscher nail. Frg. 4. Lateral view IO weeks after fixation with The stabilization of the fracture with a tibia1 Kiintscher-Herzog nail. nail is not rigid as the advantage of rigid fixation is offset (BShler, 1968) by the higher risk of causing a fracture, particularly of the distal This procedure has given rapid (Rothwell and Fitzpatrick, 1978) is required as segment. recovery of the knee function without any in closed nailing ofa femoral shaft fracture. The quadriceps muscles were not divided and shortening or rotational deformity and therefore no periosteum was stripped from the segment. has a place in dealing with multiple injuries .^ The nail was introduced through the lateral requlrlng internal tlxatlon.

342

Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 4

REFERENCES Bohler J. (1968) Closed intramedullary nailing. Clin. Orthop. 60,5 1. Cloke, J. H. (1970) Closed nailing of femoral shaft fractures. J. Bone Joint Surg. 52B, 174.

Kiintscher G. (1967) l’he Practice of’Intramedullary Nailing. Springfield, Ill., Charles C. Thomas. Rothwell A. G. and Fitzpatrick C. B. (1978) Closed Kiintscher nailing of femoral shaft fixtures. J. Bone Joint Surg. 60B, 504.

Requestsfor reprintsshouldbe addressedto: Mr M. A. Qureshi, 1 Baltimore House, Griff~ths Road, Wimbledon, London SW19 ISR.