The use of two implants to manage concomitant ipsilateral femoral
shaft and proximal femoral fractures has been indicated, but no
studies address the relationship of dynamic hip screw (DHS) side
plate screws and the intramedullary nail where failure might occur
after union. This study compares different implant configurations
in order to investigate bridging the gap between the distal DHS
and tip of the intramedullary nail. A total of 29 left synthetic femora were tested in three groups:
1) gapped short nail (GSN); 2) unicortical short nail (USN), differing
from GSN by the use of two unicortical bridging screws; and 3) bicortical
long nail (BLN), with two angled bicortical and one unicortical bridging
screws. With these findings, five matched-pairs of cadaveric femora
were tested in two groups: 1) unicortical long nail (ULN), with
a longer nail than USN and three bridging unicortical screws; and
2) BLN. Specimens were axially loaded to 22.7 kg (50 lb), and internally
rotated 90°/sec until failure.Objectives
Methods
We report a 30-year-old patient who was involved in a high-velocity road traffic accident and developed a left-sided hemiparesis, which was noted in the post-operative period following bilateral femoral intramedullary nailing. CT scanning of the brain revealed infarcts in the right frontal and parietal lobes in the distribution of the right middle cerebral artery. CT angiography showed occlusion of the right internal carotid artery consistent with internal carotid artery dissection. He was anticoagulated and nine months later was able to walk independently. An awareness of this injury is needed to diagnose blunt trauma to the internal carotid artery. Even in the absence of obvious neck trauma, carotid artery dissection should be suspected in patients with a neurological deficit in the peri-operative period.
The results of the treatment of 31 open femoral fractures (29 patients) with significant bone loss in a single trauma unit were reviewed. A protocol of early soft-tissue and bony debridement was followed by skeletal stabilisation using a locked intramedullary nail or a dynamic condylar plate for diaphyseal and metaphyseal fractures respectively. Soft-tissue closure was obtained within 48 hours then followed, if required, by elective bone grafting with or without exchange nailing. The mean time to union was 51 weeks (20 to 156). The time to union and functional outcome were largely dependent upon the location and extent of the bone loss. It was achieved more rapidly in fractures with wedge defects than in those with segmental bone loss. Fractures with metaphyseal defects healed more rapidly than those of comparable size in the diaphysis. Complications were more common in fractures with greater bone loss, and included stiffness of the knee, malunion and limb-length discrepancy. Based on our findings, we have produced an algorithm for the treatment of these injuries. We conclude that satisfactory results can be achieved in most femoral fractures with bone loss using initial debridement and skeletal stabilisation to maintain length, with further procedures as required.
