FEMORAL ENDER NAILS

SHAFF USING

FRACTURES A TROCHANTERIC

TREATED

BY

APPROACH

JOHAN

WALTERS,

WILLIAM

SHEPHERD-WILSON,

TIMOTHY

LYONS,

ROGER

CLOSE

From

Groote

Schuur

Hospital

and

the University

ofCape

Town

We describe the use of Ender nails for the internal technique via the greater trochanter and report the treatment were reviewed 12 months or more after operation. There significant angulation, rotation or leg length discrepancy management which we have evolved. The use of intramedullary
ideal form It was of internal not until the

fixation of femoral shaft fractures by a closed of 100 patients with 106 fractures, of which 88 was primary union in 85 fractures (96.6%) and in eight (9%). We discuss the principles of

nails
last

is now
fixation decade

widely
of femoral

accepted
shaft the

fixation

with

Ender

nails

at

Groote

Schuur

Hospital,

as the fractures.

Cape
heavy was

Town.
skeletal performed

On

admission
on the next

the

patient
available

was
splint.

placed
Surgery

in
list

or so that

traction

(9 kg) in a Thomas

benefit of closed prograde intramedullary acknowledged, adding fresh impetus to the this technique (B#{246}hler1968 ; Clawson, Smith

nailing was popularity of and Hansen Winquist,

operating

1971
Hansen

; Rascher

and

et al 1972; Clawson 1984).

Rothwell

1982;

provided the patient The indications fracture alignment,

patients as soon shaft the tip femoral below fractures of the

was fit for anaesthesia. for operation were unacceptable and the desire to rehabilitate the
We recorded way details from to 45 mm of all 75 mm above treated greater in this trochanter

as possible.

Ender

and

Simon-Weidner
flexible nails subtrochanteric for

(1970)

first reported

the

use of multiple chanteric and

the fixation of intertrofractures by a medial

supracondylar approach. This was later extended to femoral shaft fractures by the same approach (Eriksson and Hovelius 1979; Pankovich, Goldflies and Pearson 1979; Muckle and Siddiqi 1982). We encountered a high incidence of postoperative knee problems, so we developed a trochanteric approach. Our method can be used for a wide range of fractures of the femoral shaft, including simple, comminuted or segmental injuries extending from the subtrochanteric to the supracondylar regions (Fig. 1). The method is comparatively easy and quick and requires little specialised instrumentation.

the intercondylar notch as measured from the most proximal or distal extent of the fracture. The surgery was performed by seven specialists and 13 registrars with
varying surgical expertise.

affication

of fractures.

A classification

based

on that

described by Pankovich et al (1979) and Tencer et al (1984) was adopted in order to rationalise the postoperative management Type A : Bicortical (Fig. 2). contact. Simple transverse or short

oblique

fractures

with

bicortical

contact
with

which

main-

PATIENTS,
From June 106 femoral

MATERIALS

AND

METHODS

tamed longitudinal and lateral stability. Type B : Unicortical contact. Fractures fragment and/or unicortical comminution longitudinal but not lateral stability. Type C: No cortical contact.

a butterfly maintaining

1984 to December shaft fractures

1986, 100 patients with were treated by internal

fractures,
nal or lateral

with

no cortical
stability. Under

Comminuted or long oblique contact and thus no longitudigeneral anaesthesia, traction trochanter the tble of the is

Operative
J. Walters,
Service 1. Lyons, FCS(O)(SA), Senior
FRCS,

technique.

Consultant/Lecturer
Associate Professor and Head of Trauma

W. Shepherd-Wilson,

patient is placed in a wind-swept fractured limb raised maximally

supine on an orthopaedic position, making the prominent. and the The foot contralateral

FRCS, Registrar R. Close, MB, ChB, Senior Registrar UniversityofCapeTown, DepartmentofOrthopaedicSurgery, School, Observatory 7925, Cape Town, Republic Correspondence should be sent to Dr J. Walters.

of the same side leg is depressed

Medical

ofSouth

Africa.

maximally view ofthe

(Fig. 3) to facilitate the lateral fluoroscopic proximal femur. The traction is applied either
traction pin and stirrup table. under image intensification.
OF BONE AND JOINT SURGERY

1989 British

Editorial Society of Bone and Joint 0301-620X/90/l 196 $2.00 J Bone Joint Surg [Br] 1990; 72-B : 14-8.

Surgery

through the existing skeletal via the boot of the orthopaedic The fracture is reduced
THE JOURNAL

or

14

FEMORAL

SHAFT

FRACTURES

TREATED

BY ENDER

NAILS

USING

A TROCHANTERIC

APPROACH

15

A simple transverse fracture (a) and a segmental and internal fixation by prograde Ender nails.

fracture

(b) ofthe

femoral

shaft

treated

by closed

reduction

TYPE Bicortical

A Contact

TYPE Unicortical

B Contact

TYPE NoCortical

C Contact

If closed
open

reduction

reduction

is not possible an additional limited is performed. Through an 8 to 10 cm is exposed. near its tip
with a bone

HH
Classification The wind-swept
facilitate lateral

direct lateral An AO awl

and image the hole

approach, the trochanteric bursa is used to broach the trochanter

enlarged to about

2 cm
end is

by bent

1 cm

nibbler. according
femoral
Fig.

The

correct

length
and The first canal its

ofnail in either
nail

is selected the medial

inserted short of

by using
appropriately

the

intensifier condyle. the medullary

to its destination

or lateral
and passed fracture.

is then

2
shaft fractures.

down

to just

the

Manual into
dial

reduction distal
of the

then fragment, medial

allows femoral
and

the

nail condyle.

to be insinuated in the The

into the

of femoral

the
aspect

its tip ending

is directed

posteromenext nail
lateral

is similarly

introduced

femoral alternately introduction

minimise

condyle and subsequent nails are inserted into medial and lateral condyles. After the of the first nail, the traction is released to
the tendency to distraction at the fracture site.

The
capacity

number
of the

of

nails for

introduced
canal but

depends
more than

upon
four

the
are

medullary

rarely image cortex

easily

necessary intensifier perforation

be missed.

adequate

fixation.

The

use

of

the as can

during introduction is imperative or penetration at the fracture site is washed are

of the

K:Ic:EE2a
Fig. 3

The inserted.
only. At

wound Antibiotics
completion

out reserved
operation,

and for

a suction high
the knee

drain cases
is gently

risk

position
fluoroscopy

with the uninjured

of the fracture.

limb depressed

to

flexed through Postoperative ment

as full a range as possible. management. The postoperative by the fracture configuration.

manage-

is determined

VOL. 72-B, No.

1, JANUARY

1990

16

J. WALTERS,

W. SHEPHERD-WILSON,

T. LYONS,

R. CLOSE

Type
rubber

The
pillow

fractured (Fig. aiming 4), at

limb and active is

is elevated, physiotherapy straight as possible. started postoperative when

free,

on is raising

a foam started

immediately, knee partial achieved. Type achieved, stability B

.

leg
leg

and
with is is is lateral partial
fr.
-

flexion

to 90#{176} as quickly

Walking control

weight-bearing

The
as for a cast before In

immediate Type brace the view of

management but when to leg take control additional

the same

A fractures, is applied patient the for loss is

to lend allowed of

weight. Type C.
traction complete, allowed up

longitudinal but and

stability, physiotherapy

is maintained

3 to 4 weeks,

is as for Types
a cast with

A and
brace partial

B. When
is applied weight-bearing.

the

traction
the

period
patient

is
is
Foam rubber postoperatively. block pillow Fig. used 4 to elevate the fractured limb

RESULTS
Of the 100 patients 64 with an abbreviated
weeks disrupted patients, thus months 88 postoperatively compound with fractures postoperatively. fracture greater and closed nine notch. of the 105 were sites trochanter Eight 1 06 femora with 106 injury ofsepticaemia pelvic fractures, available ranged to patients had from within had fracture. 17 were for fractures, score one (AIS) related Ofthe lost review 75 mm to patient of 41 died aged six
30
6

to a severely 99 remaining follow-up;

(I)

A.I.S.<19
A.I.S.>18

______

21 35

25

at from

least the of fractures.

12 tip the frac-

I-

20
I-.

The
of tures by the intercondylar

< au_
0
LU
-

25

45 mm segmental

15
-

S
2 16

compound

Of all the
reduction

fractures
prograde because

93 were
means of either

reduced
but

and

internally
limited

fixed
open

:D10

1 3 required

12

10

separation The
induction

of loose procedure,
and

muscle interposition butterfly fragments. excluding time for

on the fracture

or wide anaesthetic
took an

positioning

table,

=L
7 14

--

21

28

35

#{241}F1E
42 49 >50 DAYS and number of injuries

average
being 350 was account ml

of 50 minutes. 1 30 ml (50 to
(100 to 800 ml)

Average blood loss was 150 ml, 250 ml) for closed reduction and
when additional open reduction
Duration of hospital stay related

Fig. 5
to the severity

necessary.

The

average
ofconcomitant

hospital

stay
injuries,

was
the

27 days
average

but
was for

taking
21 days those

as reflected

by the abbreviated

injury

score (AIS).

for those with an AIS of 18 or less with an AIS over 18 (Fig. 5).
Union occurred in all but

and
three

35 days
fractures

RANGE

(96.6%

union). bone further after One the

pseudarthrosis

Two grafting

of the and
with

three the
no loss

failures third had

of function

had a

successful painless
: he declined

onlay fibrous
any
U)

18 17 16 15 14

atfinal

OF

MOTION

review

I-.

13 12 ii

1-9

operation. case of infection initial surgery,

but

presented some this responded

three months to drainage, resonails in was

Fig. 6

debridement lution of the

situ, and the

and antibiotics. infection, solid

range of knee

There was complete bone union with the

movement was

100

110

120 RANGE

130

140

150

0#{176} to 135#{176}.

At over
patients

final
showed

review
some

the

range

of knee in Figure
angulation,

movement 6. Twenty-six
but only

100#{176} in all cases,

as shown
femoral

four

Range

of knee movement

at final follow-up.

THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

FEMORAL

SHAFT

FRACTURES

TREATED

BY ENDER

NAILS

USING

A TROCHANTERIC

APPROACH

17

had

angulation

or rotation

in excess

of

10#{176}. Leg

length all due

discrepancy with Type

of over 10 mm occurred C fractures. One femur

in four patients, was 15 mm long,

morbidity and thus providing systems. Radiographic

greatly reduced an attractive review

the problem alternative that the

of shortening, to locking nail final at position

to the interposition ofa bony fragment and the remaining three were 25, 30, and 45 mm short respectively. There was trochanteric discomfort in 21 patients: 1 3 settled spontaneously, requiring no further treatment, seven responded one settled after to the injection removal oflocal of protruding anaesthetic and nails and steroid.

showed

of the femur was the position fixation, in contrast to reported chanteric and intertrochanteric

attained experience fractures.

the time of with subtroGreat care

DISCUSSION
Until 1982, the use of Ender nails was largely confined to intertrochanteric and subtrochanteric fractures (BOhler 1972; Kuderna, B#{246}hlerand Collon 1976; Corzatt and Bosch 1978 ; Chapman et al 1981 ; Hall and Ainscow 1981), although a few papers reported their use for the fixation ofshaft and Hovelius pathological fractures (Pankovich 1979; Muckle and fractures (Katzner et al 1979 ; Eriksson Siddiqi 1982), and

et al 1976).

Fig. Ender nails bent to conform

7 to their destination. Fig. Partridge oblique cerclage fracture. bands 8 adding stability to a long

was and

Our experience unsatisfactory nail protrusion

with the medial condylar approach because postoperative knee stiffness were very real problems; this led us approach. experience. Some at important is should of the

to change to the trochanteric details emerged during our

Before operation. Skeletal traction of necessary to overcome any tendency

(Winquist traction injury baum, et al 1984). This makes

least 9 kg to shortening excessive operative

therefore proximal varus, valgus, time of insertion fracture, nail has home. traction crossed

be taken to assess the rotational position and the distal fragments and to correct anterior and posterior angulation at the ofeach nail. Ifthere is distraction at the should the site, be released and before as soon as the first it is finally driven

unnecessary and decreases the risk of perineal (Hofmann, Jones and Schoenvogel 1982; LindenFleming and Smith 1982). The narrowest diame-

ters ofthe ofstandard

femoral canal in the AP and lateral projections radiographs are measured. This gives a rough idea as to the number of nails that the femoral canal can be expected to accommodate. It is important to contour the nail to suit its

After
knee

operation.
should

Once

dressings
through

be flexed

have been as full a range

applied, the of movement was a devised flexible

as possible. empirically commonsense

Postoperative to suit each approach

management type of fracture; is advised.

At operation.

destination ; a nail passing into the medial femoral condyle must be the shape of an elongated S (Fig. 7). Late in our series, fractures with butterfly fragments (Type B) and comminuted fractures (Type C) were sometimes treated by open reduction and the application of Partridge bands (Fig. 8) (H#{228}gglund, Lidgren and Nordstrom 1982). This did not significantly increase

Trochanteric discomfort truding nails or disturbance was minimised by ensuring

resulted from either proof the bursa. The incidence that nails were buried within the approach to a more of incision in the gluteus the bone near the tip of the

the trochanter and by modifying proximal mini-Hardinge type medius tendon and entering

trochanter.

VOL.

72-B. No. 1, JANUARY

1990

18

J. WALTERS,

W. SHEPHERD-WILSON,

T. LYONS,

R. CLOSE

We

have

applied

this

method

of fixation

to a wide

HiggIund

range
are

of fracture
highly suitable

types
since

and

levels.

Segmental
loose

fractures
fragment is of the to many

torsion

of the

G, Lid;ren L, Nordstrom B. Intramedullary Ender nailing with Parnhams modified band in the treatment of subtrochanteric fractures : report offour cases. Acta Orthop Trauma Surg l982;lOO:13l-3.
combined

eliminated. technique, fractures by any

The
Mesdames

We were surprised by the versatility finding that it provided a solution that other
Jean

Hall G, Ainscow DAP. Comparison nailing for intertrochanteric

1981 ;63-B:24-8.

fractures.

of nail-plate fixation and Enders J Bone Joint Surg [Br] neuropraxia as

would method.

have

been

difficult

to fix internally

Hofmann A, Jones RE, Schoenvogel R. Pudendal-nerve a result of traction on a fracture table : a report Bone Joint Surg [Am] l982;64-A :136-8. Katmer

of four cases. J

authors

would
van

like
Eyssen

to thank
and Vera

Michael
Barrow

Wyeth

for the

artwork,
assistance

for secretarial

and the Medical

Research

No benefits
from a commercial this article.

Council for financial support. in any form have been received or will be received
party related directly or indirectly to the subject of

M, Babin S, Calmes E, Jacquemarie B, Schvingt E. Lenclouage selon Ender dans les fractures mCtastatiques deu femur : s#{233}rie de l3cas. RevChirOrthop 1976;6l :613-20.(Eng. abstr.)

Kuderna

H, B#{246}hlerN, Colon subtrochanteric fractures Joint Surg [Am] l976;58-A

DJ.

Treatment

of intertrochanteric

and

of the hip by the Ender :604-11.

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THE

JOURNAL

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AND

JOINT

SURGERY