the University



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


is now
fixation decade

of femoral

shaft the









as the fractures.

heavy was

skeletal performed


on the next






or so that


(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,



; Rascher


et al 1972; Clawson 1984).



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.



flexible nails subtrochanteric for


first reported


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.


of fractures.

A classification


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








From June 106 femoral




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

nal or lateral


no cortical
stability. Under

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

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


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




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.

© 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.


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



near its tip with a bone HH Classification The ‘wind-swept’ facilitate lateral direct lateral An AO awl and image the hole approach. JANUARY 1990 . 1. the trochanteric bursa is used to broach the trochanter enlarged to about 2 cm end is by bent 1 cm nibbler. down to just the Manual into dial reduction distal of the then fragment. 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. management. 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. 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. At wound Antibiotics completion out reserved operation.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. the medullary to its destination or lateral and passed fracture. medial allows femoral and the nail condyle. according femoral Fig. The postoperative by the fracture configuration. 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. and for a suction ‘high the knee drain cases is gently risk’ position fluoroscopy with the uninjured of the fracture. adequate fixation. Through an 8 to 10 cm is exposed. No. is then 2 shaft fractures. limb depressed to flexed through Postoperative ment as full a range as possible. 3 The inserted. the traction is released to the tendency to distraction at the fracture site. only. manage- is determined VOL. 72-B. After the of the first nail. 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.

is applied patient the for loss is to lend allowed of weight. thus months 88 postoperatively compound with fractures postoperatively. knee partial achieved. block pillow Fig. 1 30 ml (50 to (100 to 800 ml) Average blood loss was 150 ml. the traction the period patient is is Foam rubber postoperatively.S. z 13 12 ii 1-9 operation. stability B . THE JOURNAL OF BONE AND JOINT SURGERY . R. at limb and active is is elevated. started postoperative when free.I. infection. movement 6. on is raising a foam started immediately. =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. WALTERS. physiotherapy straight as possible.I. allowed up longitudinal but and stability. Type C.’ traction complete. At over patients final showed review some the range of knee in Figure angulation. 5). 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. T. excluding time for on the fracture or wide anaesthetic took an 5 positioning table. When is applied weight-bearing. solid range of knee There was complete bone union with the movement was 0 100’ 110’ 120’ RANGE 130’ 140’ 150’ 0#{176} to 135#{176}.6% union). and muscle interposition butterfly fragments. available ranged to patients had from within had fracture. - 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. The average ofconcomitant hospital stay injuries. 250 ml) for closed reduction and when additional open reduction Duration of hospital stay related Fig. SHEPHERD-WILSON. used 4 to elevate the fractured limb RESULTS Of the 100 patients 64 with an abbreviated weeks disrupted patients. for those with an AIS of 18 or less with an AIS over 18 (Fig. - The of tures by the intercondylar < au_ 0 LU - 25 4 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 z - 12 10 separation The induction of loose procedure. was the 27 days average but was for taking 21 days those as reflected by the abbreviated injury score (AIS). 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-. resonails in was Fig. Union occurred in all but and three 35 days fractures RANGE (96. W. is as for Types a cast with A and brace partial B. CLOSE Type rubber A . The pillow fractured (Fig.16 J. but presented some this responded three months to drainage. aiming 4). and the and antibiotics. physiotherapy is maintained 3 to 4 weeks. 17 were for fractures.>18 ______ 21 35 25 at from least the of fractures. Type achieved. fracture greater and closed nine notch. Twenty-six but only 100#{176} in all cases. of the 105 were sites trochanter Eight 1 06 femora with 106 injury ofsepticaemia pelvic fractures.S. 12 tip the frac- I- z 20 I-. 5 to the severity necessary. LYONS. as shown femoral four Range of knee movement at final follow-up. case of infection initial surgery.<19 A. leg leg and with is is is lateral partial fr. (I) A. 6 debridement lution of the situ.

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. the time of with subtroGreat care DISCUSSION Until 1982. 1. Fig. seven responded one settled after to the injection removal oflocal of protruding anaesthetic and nails and steroid. 7). JANUARY 1990 . Late in our series. B#{246}hlerand Collon 1976. Partridge oblique cerclage fracture. Corzatt and Bosch 1978 . 8) (H#{228}gglund. This did not significantly increase Trochanteric discomfort truding nails or disturbance was minimised by ensuring resulted from either proof the bursa. Hall and Ainscow 1981). This makes least 9 kg to shortening excessive operative therefore proximal varus. 72-B. the of movement was a devised flexible as possible. although a few papers reported their use for the fixation ofshaft and Hovelius pathological fractures (Pankovich 1979. This gives a rough idea as to the number of nails that the femoral canal can be expected to accommodate. At operation. the use of Ender nails was largely confined to intertrochanteric and subtrochanteric fractures (BOhler 1972. LindenFleming and Smith 1982). is advised. Ifthere is distraction at the should the site. Muckle and fractures (Katzner et al 1979 . and et al 1976). time of insertion fracture. Eriksson Siddiqi 1982). to locking nail final at position to the interposition ofa bony fragment and the remaining three were 25. 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. et al 1984). It is important to contour the nail to suit its After knee operation. in contrast to reported chanteric and intertrochanteric attained experience fractures. One femur in four patients. No. VOL. Leg length all due discrepancy with Type of over 10 mm occurred C fractures. a nail passing into the medial femoral condyle must be the shape of an elongated S (Fig. and 45 mm short respectively. Fig.FEMORAL SHAFT FRACTURES TREATED BY ENDER NAILS USING A TROCHANTERIC APPROACH 17 had angulation or rotation in excess of 10#{176}. was 15 mm long. Some at important is should of the to change to the trochanteric details emerged during our Before operation. nail has home’. Chapman et al 1981 . traction crossed be taken to assess the rotational position and the distal fragments and to correct anterior and posterior angulation at the ofeach nail. 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. valgus. The narrowest diame- ters ofthe ofstandard femoral canal in the AP and lateral projections radiographs are measured. this led us approach. There was trochanteric discomfort in 21 patients: 1 3 settled spontaneously. experience. morbidity and thus providing systems. should Once dressings through be flexed have been as full a range applied. Skeletal traction of necessary to overcome any tendency (Winquist traction injury baum. 30. empirically commonsense Postoperative to suit each approach management type of fracture. requiring no further treatment. destination . Kuderna. showed of the femur was the position fixation. fractures with butterfly fragments (Type B) and comminuted fractures (Type C) were sometimes treated by open reduction and the application of Partridge bands (Fig. Lidgren and Nordstrom 1982). Ender nails bent to conform 7 to their destination. Radiographic greatly reduced an attractive review the problem alternative that the of shortening.

CLOSE We have applied this method of fixation to a wide HiggIund range are of fracture highly suitable types since and levels. Nahigian SH. LYONS. Council for financial support. WALTERS.240 Rascber JJ.66-A :529-39. der trochanteren Acta chir Austriaca Bruche mit 1970 .63-A:l4-28. Simon-Weidner runden elastischen (Eng. Schvingt E. SHEPHERD-WILSON. Ender nailing the femur. Treatment of intertrochanteric and of the hip by the Ender :604-11. Babin S. method. et al. abstr. Hansen ST.64-B :12-6. and twenty THE JOURNAL OF BONE AND JOINT SURGERY .58-A DJ. cases associated two Fleming with closed LL. have been difficult to fix internally Hofmann A. Closed intramedullary Winquist in fractures 1979. Schoenvogel R. femoral-shaft fractures. l981-82. Siddiqi S.53-A :681-92. Intramedullary Ender nailing with Parnham’s modified band in the treatment of subtrochanteric fractures : report offour cases. Segmental loose fractures fragment is of the to many torsion of the G. RevChirOrthop 1976.6l-A: of Chapman pins aawson Corzatt MW. Nordstrom B.64-A :934-8.75 :480-4. Closed nailing J Bone Joint Surg [Am] l972.) Kuderna H.2 :297-305.54-A: for comminuted femoral Rothwell K#{252}ntscher nailing shaft AV. Closed fractures. J Bone Joint Closed Ender nailing of Surg [Am] 1979 . J Bone Joint Surg [Am] 1971 . intramedullary nailing of the femur. Pudendal-nerve a result of traction on a fracture table : a report Bone Joint Surg [Am] l982. of nail-plate fixation and Ender’s J Bone Joint Surg [Br] neuropraxia as would method. assistance for secretarial and the Medical Research No benefits from a commercial this article. Smith intramedullary B#{246}hler J. Calmes E. hip. Katmer of four cases. J authors would van like Eyssen to thank and Vera Michael Barrow Wyeth for the artwork. B#{246}hler J. DK. Pearson RL fractures. Johnston of various ofthe femur. J Bone Joint Surg [Am]l984. J Bone Joint Surg [Br] Johnson KD. AF. methods l982.ren L. Brown JE. 1972. Jones RE. RD. Jacquemarie B. in any form have been received or will be received party related directly or indirectly to the subject of M. C/in Orthop Surg [Am] and a study of the 1982. Closed l968.13:287-91. Die Fixierung Condylennageln. A biomechanical of stabilization of subtrochanteric Ender J. combined eliminated. Gill K. Bosch l978. Comparison nailing for intertrochanteric 1981 . fractures by any The Mesdames We were surprised by the versatility finding that it provided a solution that other Jean Hall G. Tencer R. Closed intramedullary the femur. of nailing of femoral fractures : a report of five hundred cases.6l :613-20.) comparison fractures J Orthop Res l984. L’enclouage selon Ender dans les fractures mCtastatiques deu femur : s#{233}rie de l3cas. aa Eriksson E. femoral-shaft 222-32. Percutane trochanterosteotomie chanterer oberschenkelbrUche. Injury Muckle bei der Nagelung intertroMonatsschr Unfa//heilkd DS. DK. DW. The use of Ender’s J Bone Joint Surg [Am] nailing JAMA of in extracapsular fractures 1981 . J Bone Lindenbaum REFERENCES SD. Smith RF. Lid. :1366-7. Hoveius L. Pankovich AM. Pudendal-nerve palsies femoral fixation : a report of mechanism of injury. fractures. J Bone Joint Surg [Am] of the diaphysis :1175-81. Csongradi of the JJ. Acta Orthop Trauma Surg l982. abstr. B#{246}hlerN.(Eng. technique. Internal fixation by the Ender method. 534-44.lOO:13l-3. Bowman WE. AG. Macys JR.63-B:24-8.60:51-67.18 J. Ender’s nailing DW. J Bone Joint in femoral shaft fractures. Ainscow DAP.l :40. R. W. T.6l-A RA. Colon subtrochanteric fractures Joint Surg [Am] l976. Hansen ST Jr. Goldifies ML.64-A :136-8.