284554 TWERAMEDULLARY NATLING TREATMENT oF FEMORAL SHAFT FRICTURES IN ADULTS DR, NOSLEHUDDIN ARMED HACETTEPE UNIVERSIEY MEDICAL PACLIY ANTARA 3970ACKROWEDCRNENTS Tt ds giving ce fanense and unbound pleosure thot T hove got an opportunity to extend uy infinite eretitute to Professor De, @LICE Beyandar, M.D, vhose didsctiel direction vas 9 veluetle, provocative stinslus for ne to be absorbed in my thesis work, His persuasive personslity and untiring working capseity have inspired mo © lot, My sincere ‘thanks elso to Dog, Dr. M, Nesat Toketeogia, I for hig valusble instructions, No words can express my gratitude to Prof. Dr, thean Degranset, M.D., the President of Hacettepe University, for nis sympathetic attitude ond help in oll respeots, otherwise I would have faced many aigtioulties, ‘Tho photographers of Photographie Depar tent or Mscettepe Untversity heve anatehed away sone credit fron me by extending their vhole hearted cooperstions, Over a2, Tam thankful end grateful to ‘those who have helped ne divectiy or indirectly in bringing out ay thesis, HOSLERUDDIN AEDunre 08 Tee sees 2 11, Tntroduction « peer III, History of Intropedullory Tos2ing ws 7 TV, Austonioel Poouliertties of Femur ... 12 Yo dettsng! oat elateal sbeie Brae i Assessnent of the Patient ana Seasetteetscenstaue 1) Ansossnont of tho Patient . 8 B) Prescperative nanagonent B ©) operative Technique « 1» ‘D) Post-operative measures . ~ 27 WIE. Cooplicstion and Danger of Hesling .. 29 Wa, Materials... a TX, Results 3h X Diaousston and conctuston seeveesssse 60 (4) Discussion ns (it) Summary 1% (244) conetuston ” ‘XI, Bibliography se+e++ 7" CONTENTSI TITLE The history of husan progress is 8 series of teles, attempts, failures, persistence and ultinate success of the great discoverers, and inventors, who Lived, laboured, end died for the sake of humanity, Tt ds for their ceaseless toils ond tireless struggles thet man hes warched fron cave to the eatin, The achievenents of those pioneers have {1luuinated the progressive conditions of scientific set up, including nedical science advancenent, The world pays highest tritutes to those sofentists, physictans and surgeons for their stnegetions, for the tenefit of mankind, Fros the beginning of civilisation, to treat ‘the fractures of the shaft of the femur vas 0 burning protien, how to nenipulate and reduce the fracture properly, and, hov to obviste prolonged inaobilization and functional disability of the inb, Many endeavours hhad been strived for the better, concrete results, tut none of it could hold fectsteps, At last, it hes been sccepted that the internal fixation ts the better sethod for the treatuent of cenorel shoft fracture in edult, But it is also unaniscusly decided thet "THE INTRAMEDULLARY NAILING" ts the socredited best interna] fixetion method for adults in 911 respects, “The intrepedullery nating is the treateent method for the shaft fracture of long ‘bones, where a nei, nade of highly tenpered, electrolytically inert nets] { inserted into the medullary cans] of the bones, for stable and perfect osteosynthesis and union!wae IL, INTRODUCTION The vain idea to trest the fracture of the shaft of ‘the femur is that, the union of the tone should te perfect with the restoration of normal plane of functioss of the 1imb, ond Joints above end telow the frecture, reteining the snatontes? contour, Tt is applicable to other fractures too, Feilure to do 0 means, @ favourable chance is being made for the developrent of ostecerthnitie changes in the joint. Ja other uethods of treatment, the anatomical ond functioned results are not so perfect as in intramedullary hailing, Besides thet, pationt is to atey in the hospitel for ® prolonged period cousing mentel depression to the patient, also jeopardising the sociel end econonic Life. At the sane tine, due to prolonged and imperfect innobilizetion, there will be personent dissbility of the Linb - muscular atrophy, non anion, deleyed union, melunion, ond stiffaess of the Imee Joint. Even with pleting, external reinforeonent 4s necessary, Keeping the potient in a state of recumbency for 9 long period, depriving the patient trom his normal Life Teuth wil] olveys prevell, The authenticity of the en good result of intreneduliery natling hes been blooed in aitterent parts of the orld, Even the roaring critic votee of the simptic type of surgeons has cone dovn to the point of silence e2 their critioian ves nulled ond voided by the megniftcent Perforsanee of the netling, Intrenedullery ne{ling hee got Brependerant serits, snd efficacy, than other internal ‘ftxstions. It has also been proved that the intrenedallary natling is the unique uethod, ond is {amune to post-operative=3- soquelee of the fencral sheft fracture, If the operation is perforaod perfectly, Hagh Baith has edvocsted and praised this method categorically, and sliaded to epply to a great array of Anteresting cases - nanely fresh fractures, delayed and non union eases, melunion, the bridging of the fecects, patholo gical fractures, dyeplasio, and severe type of osteoporosis, Tt was # wrong inpression thet the nail 1s @ foreign doly in the medullary cavity, so it vill incerfere in the process of healing of fractures, Put tho plausitie proof ts ‘that, ailing does not interfere in the process of healing of the fractures, By other eethods, unton can be actieved but could hot collocate the requisite denims of @ noteal limb, On the contrary, the unton can be achieved with nome] proservetion of functions, and enotomical shepe of the Linb, by intra- Bedullery nailing, Tt also curtetls very mich the perted at Fecunteney leading to @ norms] 2ize of a pationt within very short tine it hss been postulated by Gerhard Kintscher that ‘he shearing strains imposing apon the fracture site, vill be Converted into conpression strain ss the nai? ltes in the ‘Tong exis of the bone, The nailing eliminetes all detrinentor factors, The conprossion strein exists, enhancing the fortia~ ‘ton of callus, In intrauedullary nsiling, velusble advantages ‘ere, the exteranl reinforcenent or support of the Lim 4s not necessary, ond early weight hearing brings the two ends of fracture sore accurately and perfectly, so the osteosynthesis4s discernible, Previously, 1¢ was believed that introduction of neil into uedullery canal neens, introduction of infection. But, sceneely,it,con materialize its influence, becsuse, surgeons are very much swore of taking all sorts of ster{las nessures end antiseptic precautions, Also, in this age, anti bioties pley s good role to preclude the infection, 80 Infection 1s not © protien, end nov, hardly infection can peep through this operation, Infection is deeuod to te one of the causative fectors of non union, But Watson Jones sta:os As complicstion of the past’ On the basis of rationslity, sepcis, after the plating is wore possible, because, the operation aay consune wuch time and sone tine for the better exposure of the shaft 4 long Incision is necessery, denanding more muscular exertion, In plating, two tables of cortex sre bored in and around the fracture, So, the stability and sonpectness of ‘the cortex sre disturted causing the cortex poraus, and weeks The plate occupies © Lerge sysce of cortex in @ close contact, atsrapting the periosteum end periosteal yesgele of that ere The srea is deprived of blood supply, Also, during serewing sone of the medullary vessels may te demged, If double plates ere used, then tiood supply of that erea of cortex will be throttled, Kow, the qucstion cones of disturbed healing process due to less blood supply causing delayed or non union and there wey be secondary fracture,Bho During intrenedullery nailing, the nutrient artery way be denaged, tut no evidence of hindrance is shown in eccumlae tion of callus, in our series, Besides thet, the ostoosyatheaie is not so stable and porfect.by plating and serewing in the fonoral. shaft Fracture, so the coupletion of osteogenie activity of the union ney te delayed, Thegosorts of internal fixations are els0 exposed to sctually trenendous contracting forces of powerfsl qusctés of the thigh’ end are subject to fetigues This fatigabiiity and powerful contraction of the msetes, in asay occasions, evoke tonding or breakage of the pletes and screws, Over and sbove, the neiling provents the angulation, lateral displacement, and, osteosynthesis vill te statle provided the quelities and quantities of the nail ere perfect, Zn comperison, the extraction of nail is aiso simple and ore easter process than the extraction process of plate end sorew. Prolonged splinting of the fracture may invite @elayed union, Tt often keeps the patient tn recumbency, and depredate the functions of the joint. The cause of this undesirable hindrance can te depicted in tw ways, These foctors are extra-articular adhesions and intra-articular sdhesions. This intra-articular adhesion inpelled the inee Joint more tovards stittnase;. Once adhesion is established, At 1s ridteu2ously impossitie to irradicate the stirmess. Just to overcome the resistones of the puseuler ‘spasm, and to tring the two fractured ends in appositionBits skeletal traction for fev deys has got lnsonse value, But prolonged period of traction causes overpull or distraction, If this is allowed to exist, loss of muscle tone or the interposition of non-ossifiable wsterial azy lead to non op delayed union, Chaney's view is that, good knee function wrly union, But, early active uovenent of the Limb and early union can following fenorel shaft fracture depends upon Fender the service vell, to bring beck the norms functions of the Joint, But under no ctreunstances it is possible to yield union to fenorsl shaft fracture within 9 very short ‘tine nor vith any other promiscuous method, But the appraised of intramedullary neiling can te determined, ty infliction on perfect stable osteosynthesis following early union, Fonorel shoft fracture reduced ty surface or skoletel traction or by sanipalotion followed by inuotilizetion in plaster vill not te compensating accurately, ond perfectly. It hes teen found, the end result 1s either uslunion on non lunton; sssocieted with restricted lace movement, and slnost every case eventuelly cones to open reduction --nawely the intrameduliery nesting, Osteosynthesis due to intramedullary neiling expe aites the callus formation, end this osteosynthesis encourages the potient to move lint actively. Tt is expedient to tell thet the intransdullary netting hea got clear expositions, and activities, Loren Buhler hes enmetated, "Neaullary nailing 19 vestly superior to oll previously knoun uethots for the treatnent of fractures of the femoral shart",TIT, AISTONY OF TRTRAMSDULLARY NATLING The schievenent of proper trestneat of the femoral sheft fracture is very painstaking, a story of perseverance of So uany who reached the destinstion by their intellectual excogitations snd aethodical efforts. Hippocrates and his followers used to redsce the fractures by wanusl aanipulations, Tt was practised for mony yours but could not achieve desired result, ‘The continous trction, for the tresteent vee introduced in 1305 by GUY DECHAULIAC, and henceforth, the ‘treataont hat beon adopted with its tremendous influences and refinenents. Sti12, this method has got sowe unavotdsble sequelse, joint stiffness, msouler atrophy, and general Gisetility, due to prolonged recumbency, It was widely used before the evolution of plaster of peria, Key, Convell heve advocsted this nothed with @ plea of some motilizetion of knoe ond full range of movement of ankle joint, The disadvantages are, prolonged period of Fecunteney, constent supervision, and frequent adjustaent of weight, ond lint. The end recult of many cases caue out 82 @ non or delayed union case, Non union due to distraction is blamed by "Bohler"s and infection at the site of traction way be the source of menace, Since the advent of plaster of poris, orthopecdisty ‘ried the treatment with this new light of suecess. Sut this sethod alone wos very cumbersono and very difficult toe- maintein the proper alignaent, causing many hesords, 4n allied wethod, by the conbination of continuous traction till the callus 1s accumlsted at the fracture site, followed by reinforcement vith plaster of paris vas tried for @ perdod, but failed to have satisfactory results, Originaliy, the external skeletal fixation vas introduced by BOMET in 1870, followed ty Parent and Tonbottes eround the turn of contury. It was alao difficult fo maintain the exact weight for proper traction, and other Porophernalias, ond conplicetions also aid not spare this method, After thet, meny devices have cone into ection but ‘the Haynes, the Roger Anderson, and Stader apporatas hove Given wore useful service for the sdjustuent of this method, Russell apparetas, Thooas splint, end Béhler's odd fteation of Breun splint have given soue contritutions to this acthod, This externel skeletal fixation method hes teen tried vith the collaboration of plaster of peris, and still this ecabine- ton aethot ts prectised, but not mee tron couplications, Roger, in 1827, had attempted open reduction and wire sutore fixetion, but, this method did not gein acceptance ‘411 the concepts of entisepsis and azopsis ore improved sn sargery, No aothod was in perfection, so endeavoung Were Going on with full sving for better method, tn 1905, LIB tirst instituted the interned Fuation, by plate snd serovs, aupericrity had teon proved fe wire suture, Those plates and scrovs vere asting mtsohiveously-~9- by resorption of bone, around the plate and serevs, followed by the ost unvented complication for the surgeon ~ the Anfection, Being perturbed and onnoyed he had uttered, ‘rerefying osteitis, in plain English means, dirty surgery’ So he tegen to follow the "Non-touch" technique which gave Vetter result tut could not stop resorption, But, at last. the dsr’ comer of treatuent was pierced and focussed by the new Light of unprecedented method, “TEE INTRAMEDULLARY NAILIN", Tn thé letter pert of nineteenth century the new chapter of treataent of fracture opened, In 1897, NICOLAYS2N published one pazer about intramedullary hailing, followed ty DELBZT in 1906, end LAMBOTTSE in 1913, Delbet practised the internsl fixation of the neck of the femur. Lanbottee's performance was to fix the sell fragments of tone by seens of thin nell, He olsc treated subtrochentertc fracture of femur ty means of a long screy, Leubottee also prectised the exiel method of osteosynthesis of clavicle sinee 1907, The intremedulley neiling inspired the surgeons of every corner of the world, to practise thia method and to find out the pros snd cons of the sethod, In the second decade of this century different terials vere used ase nail - ivory, beef bone snd human tone (iiuglend, 1927), tut none could render appreciable result, For sone pericd nailing wee in cold storage, But in 1918, HEY GROVES eItuded to tt and revived this method, He had oponed the curtain of secret of nailing, by using10 - Hasdive mole in the medullary cavity, This procedure vas criticized bitterly as tony union was aot sood, due to resorption of the bone, MENEGAUS in 1934, ODISTLE, ond MOE gavocated ‘that probably the bone reserption was due te electrolysis of metal, VENABLE, STUCK, ond BEACH (1937) conquered this Problen, Three years after thoy proved it and consistently enunciated that electrolyticslly inective satel can preciude ‘the resorption of tone, So the research was goine on to find | out metal, which wi2l be benign to tone ond other tissues, Ab last, biologicolly inert sLloy, steel and vitalliam vere selected, This echtevenent again brought hope in despair, In the year 1937, snd 1939, in Anorica, LeVsRUGI end HL. RUSH presented entirely 9 new technique of longitu Ginal fixation of wins by means of steinmann's pin, They Geliberstedy used to keep the end oF the pin off the akin, with # uotive of extracting 4% out after few weeks, The efficacy of this aethod was criticized by Watson Jones, TANGRIWUDS of Snglend, tn 1940 used Kirschner vire in intranedutlery nailing, Ke Followed the sane procedure of Tush. Tt ws followed ty Joly end Devis of Belgium, to 190, conta riimscuen of Kten, cerauny, trtomphed ovor thts antter and ostabiined the superiontey of tntresedullacy nating, Sintacher dtsplayed the unique Ness of tmtroneacliary netting — one of the contronevetoa Gsstioult promen which ves svinging 16ke « pedutun how toca felvod by hit avgnttteentiy,His first paper was published ta March, 1940, "Deutsche Kongress fur chirurgie", He performed the operation by longitudinel fixation extra-srticuleriy, and used strong metallic. rod, occupying the full length of medullary cevity of the femur, AG first, Klintscher's provedure wes criticized "ants phystologice] wethod", tut soon the reality end Fotionslity of intramedullary neiling encouraged Scendinsvien, Dutch and Gernan eurgeons, and later, surgeons of other countries to perform intramedullary nailing in shaft fracture of the femur, In the World Wer IT, this intramedultory hailing sceptically perforaed by other surgeons in selected oases of femoral short fractures, but tts adracte performances and its end result chermed then itmensely, They adwired this intramedullary nailing with acceptance and recognition, Xantscher end soae other surgeons sre in favour of closed method, because, to avold infection and fovour- able callus formation, But, it 1s experienced by other surgeons that lerge nunber of disadventeges of the closed method out-veighed its snail nunter of advantage: So, Kintscher's closed method suffered bitter criticism They also postulated that those couplicstions of closed nethod are preventable. by open method, AUSTIN HOORE reusried, "I have cone to the conclusion thet T wil expose the fracture site in ell cases in the future",-~R- IV,AWATONICAL PECULIARITIES OF THE FENUR ‘The romux 1s the strongest, the longest bone in the body. It is also a weight bearing tone. The tone has got forward and outward curveture of its staft, so do-the ‘thigh, Those curvatures help for propulsion and for the maintenance of posture snd equilitriun, The posterior consavity 2 supported by » strong ridge, Linea aspore, The eck has uade on eagle of about 128° with shart, nemed heck sheft angie, The above wentioned pecullarities are inportent in ‘the trestaont of shaft frecture, Failure of restoration of this enatonteal contour will result deformisy and distur- bance in trensaisaton of body weight. The diemeter of the medullory canel 1s not symme- ‘teieal throughout its length, There is one constetetion called tsthaus, ot the Junction of upper and middle third | of the shaft. The aieueter of the upper and lower part of ‘the medullary canal is greater than the other part, The mm surenent of the medullary cons] plays an importent role in nating, Tn cross section, the cansl 49 ovel ia most cases, ‘The sagittal disnoter is greater, on the average, ty two to three nn, anciber peculierity is thet, young athletic tnaividuals Sonerally, have rather narrow cenel with thick cortex, On ‘the contrary, elderly people may have large medullary cane with thinmercortex,-2- | ‘The femur is covered by strong muscles and fosotae, Mesolea ero in three groups, Anterior group of muscles are exerting their actions upon hip and Ineo, causing flexion end extension respectively, Antero-nediel group is for the adduction of thigh and posterior group trings the tmee in Flexion, The chief function of the thigh i to keep the pelvis spproxinstely hontzontal, Muscles of the thigh are richly supplied with arteries, the bone is also htghly vascular, Femur receives its Blood supply fron the nutrient artery = the artery enters the one and bifurcatea, one for each end of the bone. Moh one enters the netephysis efter dividing into sote of braliel vessels, Periosteun has got @ very rich blood supply. These periostesl vessels elso supply the bone. These ve sols have got iumense velue for the union of the frectured bone. In fracture of the shaft, shock is usually present ue to profuse bieeding from the soft tissues and tone,=e Vs INDICATIONS FOR INTRAMADULIARY WATLING TH FEMORAL SHAFT FRACTURES Severe violence i@ the prime factor to cause fracture of tho sheft of the fomr ot any site, Tt mey be in upper, middle or lover third of the shaft, len are mostly vietins of this frecture, Eecouse of the fact, they are ore exposed to stre~ yous’ vorks, In out sories 83 are uele patients, Now days, intrenedullery nailing hes got wide field of tndteations, The indication is not limited within the Line of densrestion, Previously, nobody coulé think of comminuted fracture that can te treated vith intrenedallery nasiing. Bat it was show by K.P, HIRZOG and others that the comminuted fracture can be treated in s tefitting mennor with this ne‘ling, At present it is practising abundantly, The dein Mundenentel idea is thet, intranedullary neiling can be performed. where stable osteosynthesis can te achteved, In Kintscher's version, “intranedullary nailing should Ye used in 911 ceses in which © stable osteosynthesis can be achieved, providing thet no contraindication ts present", Transverse, oblique end spire) frectures of the fonoral shaft in edultare in clear indlcatiorof intramedullary ailing, But most suitable places in the upper and middie third of the shagt, In our view, frecture in the uprer pele of the lover third a2so gives excellent result with intronedullary nailing, Fresh closed fracture exhibits excellent result with= out sny residual complicstion,-~we The so called double frectures, eomninuted fracture, , srely cominuted can be treated with wedullery neiling. But se fracture elvays renain in vulnersble position for every-posaibi lity of rotation and shortening, Meny surgems view to apply additional support in comninated fracture by etreunferential viring , but we are not in favour of this additional support, because, it will cause necrosis of the bone, Intranedullary nailing, in conpound fracture should be deferred until the wound is completely healed up. Intromedullary nailing 1s s1so epplicetle to the shaft fracture of humerus, wine, radius ond titia, Chiléren ave not suftatle for intranedullery nailing, because of the Gsnger of seute ostecuyelitis, Operable pathological fracture of fenorel shart shovs better result with intronedullary nailing then any other treateent. We operated tvo cases of shaft frecture of femur, ono wes 8 case of Feget!s atsease, another ves fibrous dysplasia, toth the casos have shown Good result vith intramedullary neiling, Intramedullary nailing is the best possible treat= sent of welunton, delayed union and non union eases, Sonetineg, Se sedullery cane f= non union eases or tn other cases oxy be widers for stable osteosynthesis, double netls are to be inserted, In this respect, Kintscher's clover leaf nail serves the purpose test. John Charney once faced the sene Giffieulty with wider diometer of the canal, in » aon union case and he impacted doutle Klintscher's clover leaf neil, Then he told, “this useful trick would seen to be another reason to support the superiority of the clover leaf pettern nataries over the solid type nail", Due to wider girth of the canal of the lover third part of the shaft, neiling 1s not so suital Ae the nail can not fitted snughy,. so there is possibility of rotation of the distel fragnent, But nailing ean be done, being voll supported ty tone inpection the canal of distal fregnent, Supracondyiar fracture of femur can te treated with duel cedullery pinning, Arthtodesis of the Ince Jotat can be performed by intra~ meaullery nailing. (Figure 1). Generelly 1¢ 1s Gone in psintua arthritis deformens, tumours, in arthropathte conditions and in intractetle nralgies Subtrochanterie fracture of femar an also te treetea with intronedultery nailing. 21 should be inserted through more medial to greater trochenter 5 arthrodesis tranedullary to avo verus defcraity, 8 Intramedullery neiling is slso very useful in jortening and lengthening of the t nur, considerable sharte- ing of the femur dus to ges ity can be corrected by tarre. medullary nailing, and the remnusitty shoes, But if the shortening is too mich, beyond reach, then to emancipate this problea, the sound side is to te shortened for the syanetiy-- of the links, It is © controversial point, how mich 8 Liab con be shortened without having eny side effect . the opinion varies, We have shortened sbout 8 ems, in one case, but, shortening should te considered eccording to height, Weight end volune of the patient. The junstion at the level of upper and middie third is selected deliterately for the shortening, just to get rid of isthmus, The lengthening of the feaur 4¢ gaining popularity: now deys for cosmetic purpose,+15 - Va, ASSESsvEt oF ra Partai 0D OPERATIVE: PECHNIEQUE A ~ ASSISSNENT OF THE ATTEND: Potient with fenorel shaft fracture should be exenined thoroughly, If the pstient is in shock, #11 possibie measures are tobe taken for resuscitetion, ti21 the patient As cut of danger. Tt ts wise, not to take any risk of per- forming intramedullary nailing in open fracture t111 the vound heals, Meny surgeons are in feveur of nailing in fresh open fracture of fenoral shaft, efter proper detridenent, According te their opinion,the end result 1s nore or less satisfactory, For the intramedullary nailing, proper assessnent of type of fracture, and site of fracture of the feaur should Ye done corsectly, so thet neiling would not fait, If the patient hes any other lesion, that should te consulted with the speciolist of thet tranch. Above a11, petient should te in good health, ond hes got no other contraindication for the intramedullery net ling, B PREAOPRRATTVE MAG MENT: As 2 routine wethod, ve apply skin or skeletal fraction to the injured 2imp,tut mostly skeletel trection, Aust to overcone the muscular spasa and to bring the fractured ends tn apposition, and altgnsent. This process helps the ‘enipulation in future nesling. The length of tite of traction is stout 1-2 weoks, Malunton cases are treated in tvo phases. In the-firat stage, ostectony 1s done, folloved by skeletal traction,-39- In the second stage, actual operotion ic, intranedullery nailing, © = OPSRATTVe TECHNIQUE: We prefer open method to closed uethod for its Justiftetie advantages, Previously, ve used aiamond shaped. neil, but due to heving mechanical and other Loop-holes, we prefer Kilntscher's clover leef nail to that ones Patent should te placed in sterel position on ‘the sound side, The injured extrenity should te sterilized fron wid Jeg to d1tse crest or a bit up, folloved by draping, (Fig. 2), & + After stertitzetion and draping, the fractured lint 1s shown, 4 Lengitudinel postero-Letersl incision of ebout 6" has teen civen at the fracture site, After incised the fascia lata, tone can te approsched ty splitting the muscles ot by following the intermusouler geptun. (Fig, 3),3, Faseia late is being tneised and the Buscle £8 exposed, It is better to follow the latter one, retracting the soft tisies sntertorly, Mow, the ol@ heenstom, grana~ Istion tissues or fibrous tissues should be denuded. After exposing the fracture site, the fragnents are exposed with Little periostes] stripping. (Fiz. #) Fig: ', Froctured ends are being exposed, Feriostes! attachaent is carefully pregerved.os: fax as practicable, just to avoid asepticnecrosis; + + Now, the # eted thigh te flexed on hp ond addueted. The greater trochsnter is being prominent, an incision of stout 2% has teen given over the tip of ity-u- Now the greater trochenter and its small adjoining area is exposed. The area over the tip of the greater trochanter can ‘#lgo be exposed by an incision over the protruded end of the guide pin, vien it vill be introduced throuzh the fractared end of the proxinal fragnent ond will energe out sateuta- Reously through the aediel side of the greater trochanter, The guide pin tas got double edge focilities, First one, it acts as # guide for its successors, secondly, Jength of the vedullsry cenal con be determined. That Jength will be the length of the desired nail, This 1s done by introducing a guide pin into the distel freguent ané iato 2 the proxinel froguent through the respective fracture ends. The neasuresent in the distel freguent vould te froa the fractured end upto the upper end of the pstella or at the level of adductor tuterele. In the proxinel tregaent upto the tip of the greeter trochenter, The neasurement should te confirmed by compariay vith a second identical pin, placing outsite the Let along with the iner one, Let the forcer one De vA! and the letter one be '5!, Nov the totdl-aength of the canal is 4+B, ‘The neasurenent of the nail cen also be determined Wre-operotively by sesnogren (Fig, 5) or ty assuring the unaffected Liab with a tape fron the tip of the greeter Srochenter upto upper border of the patella, Fron the x-rey of the sound side, the length, and the dieneter of the setullvyy canal ean te ascertained ty scale or by orsineter,~22- Fig.5: Sconogran of the normal Lint, Avout 2-3 ous. should be more in ectual length of neil than the length of the medullary conal, That portion Wil reuoin under the soft tissues and sin, atove the tip of the greater trochanter, The guide pin hes teen introduced through the fractured end of the proxins! fraguent and it bas euerged throush the medial side of the greater trochante (Rig, 6), Fig.61 The guide pin is being introduced through ‘She fractured end of the proxins! Hagaeat,=23- The guide pin at the first instance oan eso be inserted through sedis] side of the greater trochenter into ‘the proxinel halt. ‘eter boing enorged through the greater trockenter, the pin agai shoo1é te pushed tack upto the fractured end of the proxina! Yalf, Now the distal feagnent is celivered and efter manipulation the two ends heve been troaght in apposition, correctiag the rotation, seintainiag the on is retained with the help of bone snatorical plane. (Piz. 7) This apposit: holding 2areepe end by assistent, ext, the guide pin te driven h the aister init As determined Tig. 75 Tho guife pin hes bron driven, agep ge, aise, oagment, with the lelp of second identical ghide plecing owtsite the Liat elongwith the inner one, Dae to inequelity of the medullary canal, during nefling, many forcheoning complications including obstruction ey be ing2leated, To be assured ogainst th hazards, intramedullary reemem for ceasins tre canal ore used Seneretiy it ie started with the snaller size of the reamer, At Works inside tte esas by gliding over the gufde pin 4a sito (Fig, 8),'the réener need not to pass upto. the loverFig. 8: The process of reoming 1s shovn hors lover half of the lover third of the feaur, tecause of having wider diaaeter, When the resisting portions of the cena] are cleared up, assuring the censi of Ymoun equal diameter through= out its length, reaming should te stopped, The reaner ond ‘the nail should te of sane Atanetar. This procedure of reaning cen also te done through ‘the fractured end, without prior reduction of the fracture. After this manoeuvre, the guide pin is passed through the fracture ends into the distel helf, bat,atter the crecture 4a being reduced correctly, considering the enatoatcal eligatent. ‘The correct desired nail should te selected in respect of Jength end dlaceter of the medullary canst, It will neither ve snelder, nor bigger, and neither loose nor tight. Tho neil will fit snostyy In every step of the operstion surgeon vill keep his vigtlant eyes, not to entertain any mishap, exercise of ax neil, the position of the Liab with the position of the patella, t care can avert mishap, Before the insertion of the= 5 = and the position of the reduced tone, also mst be checked. e guide A slowly over ow, the neil ie ince! pin. (Pig, 9). In driving the nail further, caution should : The Kiintscher's clover lear naiz is being introduced into the sedullery canal, be talon, If the noid ogress by Light homering, pounding hessertng 5I 1d not te applied, nay esa inpingenent into the cortex, 1 gement occurs, the ail. drawn, followed ty se~insertion, by slightly Fotating the neil, If {t fails, it means nai: ts bigger, so swaller size nail can te tried or the canal can te en- lersed ty further reaxing. If the driving nat. atruptly resists for further oa ® enaden the friction ce of the nail ts diatnished, it se>ns,either © natl bas stuck Gown in the cortex intruded tnt the sort the nati shou2t te paties out insertion vith great care. ‘he: 8 of eatastrop! 8 dxys, specislly in open method with resning are very.= 2% rere and ve did not face in our series, 1A end the peculiar vil ‘he driving s ting sensation of the neil during hemnering will be the zood guide for an experienced surgeon, Any change of sound of aviving tho nail and the sensatsoa,will te sppazently core- ning to the surgeon against further inpection ox intrusion, Grest care nust te teen for the msintenance reduction without any rotation, Otherwise, 1 split the distel fraguent or nay ‘apinge upon the cortex of msy perforate the cortex due to rotation of the fragments! Niaintenancs of the reduction correctly, during noting, is onother secret of su of Intranedutiery nedting. t pert of the ne is driven in ty the tonping tool. (Fig. 10), About 2 exs. of the neil is rept clover tear neit stove the greater trochanter, will rengin unée> the sub: extansous ¢ As porta: 5 8 sodistor for sed in layers, (Fiz, 12),Fig.11: After the completion of intramedi apiting the woend 23 being elo: It is wis: to take x-ray of t! cheeling the nailing. In ceses of naluaton, delayed and non union, fracture enés should be trim off, to freshen the ends, nailing followed by tone sreft at the site of fracture, gives sat-sfactery result, We do not advocate circunferentie ted fracture, tecsuse, to avolé tone tive sessures, estinetion Tength and diameter of the canal, with the correct selection o: ‘the nail, and 811 other correct procedures ore strictly observed, the catast irophe hes zot no place ta open method D = POST-oPsRATTV? scastRIs. for the an anedullary nailing opere n any externel reinforcement is not requited,whereas all other netheds luding plating will te suppt uentod ty oxternal ebilizetton,- 28 = arly novenent of the Linb ond joints wil tring back mscle tone, strength, end elso the normal functions. This mascular exercise and eorly partis] veight-tearing will ake the osteosyathests more stoble and stinulate callus fend unton, After the operstion, 1f the patient is confined to bed for weeks es post-overetive extre-precautionary peasure, then there ts every chance of being restricted knee overeat, muscular strophy, ond nay cause distraction. Too early ful weight-bearing say also tring cals ities, beading or treaking of the nafl or propulsion of neil into the Ive joint. So the patient will te worned very teginaing, not to develop false feelin: of confidence on the of the limb, - “pin euphoria”, before the solié union occurs, Becouse, the 1ieb my not sustainundye and unwarrented streia 0 eorly, resulting tending or brenkage of the neil, Atter the operation, below knee surfoce traction is applied far one week. Sunebody precers to apply compression Yendage, Quadriceps exerctse is encouraged frou the next dey of operation, After one week, petiont is advised for ective ovement of the knee joint slowly. ‘hen the stitehes are taken off, petient is allowed to walt with crutches, ity without any weight-bearing. As soon s@ callus tegins to accumilote radiologically at the fracture site, patient 4a pernitted fo walle on erutehess credvally with portial weight-tesring wader the guidance of @ physiotherapist. Clinicsl and x-ray evidences of consolidetion of cellus attritute thet the cratches aroto te discarded, slloving the patient's velctng vith ult weight-tesring,VEZ,COMPLICATTONS AND DAGBRS OF NATLING Before the perfection of the nailing, many pitfalls and complications bsd teen faced, tut now a days perfection hhae overshadowed those dravtacks. (2) Shook is not » protien only in intraneduliary sailing, tut elso in other major operations, even tt nay ensue tn other operations of femur as for, in osteotony, pleting ond 4n énsertion of the prosthesis ta hip or ‘nee: Joint, correct pre-operative sssessnent of the patient; and the progress of ansesthesis, tiood transfusion, end aodicine, have siminished the incidence of shock, Weither wo have faced ony difficulty in nailing die to shock of the patient ner we have ost s single potient due to post-operative shock efter Antreueastiory naiting. (42) Long neil say encrosch upon the knee joint, and Bigger size neil ney inpings tn the cortex or aay split the Yone, Sneler thin neil vill allow the distal sragoent to Totate outuerdiy, disturbing the osteosynthesis, If the cross Section of the nail does not edlneide with fosur, the force Vill be exerted nore ageresively upon the site of fracture cousing Bending or breolage of the nail, ent deformity of the link, But, pre-operetive asscsenent, resning of the cons] with correct selection of the nal] and ueticulous performince, a11 are alnost equally responsitle for the elimination of these conplice tions and dangers, In our series ve heve not face such difttesity,-1- (444) Fot enbolisa, as a complicsticn of nailing was terror to the surgeons. Modifications of Kintscher's nail land open sethod have trenendoasly decreased this incidence. We have not encountered @ single case of fat outolisn in our nailing Lists, (4y) Thronbopbletitig,; pulmonary and renal compli- cations though are in the list of complications but we have ot encourtered in nedullary nafling, (o) An sdventitious bursa ney develop at the protruding end of the nail end sometines an ossified cap aay develop, We have got one case of ossified cap at the protruding end of the nail,=e VII, MATERIALS The records are proclaining that fro 1961-1969, eighty-nine adult cases of fenorel shaft fractures of verious types have teen treated in HACEPTERS HOSPITAL, Thirty-four eases out of eighty-nine heve been treaved by intraneduliery nailing, and the rest, by stelete? ‘traction folloved by plastering or ty closed reduction folloved by plastering, or by plating and serewing, reinforced by plester of paris as an external support, Among thirty-four eases, two eases are cocpound froctures, eight coses are couninuted, two cases spiral, five obLique and the rest are transverse troctures, Acniasion of 921 thirty-four coses, at this hospited, are not in the sane day ofter injury. Tt cen te studied fron the following date - Tatle 1, TABLE-4 TDSTSSIOW THE Tr tHe HOS GF Cis SOFA APEER TSURe rE Stee doy-arter wise TF cases ORE 27 days ater —— a ease —— TE eons — as ins 235 wee oteE——— ee — Bean Tor meats atta a Shit a3 amen aE A so mentee oa wie fee seis tone area Tae She day aE —-R- ALL the stove thirty-four cases vere treated with intra- nedullery nailing, the profundity of sdventages of nailing has been charted in Table IT, If the Teble IT ts carefully studied, 1t ts erystel clesr that the end results of intramedullary neiling aro excellent and unperelioled, Those patients got adnitted themselves in the hospital withost much deley ané not essocieted with other injuries, have been discharged within 4 very short tice after being trested with intrauedullory neiling. Following steletel traction, open method of intramedullary nailing nos teen performed upon tho patients, We axe not in support of closed method, Recent cases enjoyed for better end result ty intronedallary nei2ing than old cases, hen patient cones late, it has teen observed, generally, they com with defornity of the Limb and joint. However, in our series ( tn Tete II), wo heve teeated the following fresh feacrel fracture ceses, wre not associated with any other inuries, ty intrenedullary nailing. bs, 13, 20, 25, 28, 29, 30 an 33 ), one spire] fracture ( case These were eight recent transverse fractures ( case i Yo, 2), two eases of conmimuted fractures ( case los 12 end 34), and one cose of compound conminuted tractare ( ease Fo, 24), In ei2 the above esses, the end results of intra nedullary nailing ere marvellous except that cospound frecture case, Besides thet, the mumter of fresh fracture cases with other isfurtes vere; six case of treneverse fractureao (ease ifo, 1, 3, 6, 8, 9 and 32 ), one oblique fracture (case No. 19 ) and three conminuted fracture cases ( case No, 7, 10 and 27). Two cases of bileteral fenoral shart fractures {case Ho, 7 and 29 ) tn cur series have teen tre: red by Anteonedllary nailing. Both the cases were fresh fractures One cose ( case Fo, 7) was btleteral connimted fracture associsted vith other injuries, tut the other one ( case Nos 29 ) vas a cose of bilateral transverse fracture, not accompanied by other injuries, If we consider the Teble IT, then old ceses withoat other Anjuries were, three transverse fractures ( cose ‘fo, 11, 23 and 26), one case of spiral fracture ( case No, 26 ), ‘two oblique fractures ( case Zo. 14 and 23 ) and one wos Sonminuted fracture ( ease Ho, 22), Bat, old eases of fracts es, associated vith other injuries vere five in amber; one transverse cose ( e999 Ho, 21 * two oblique fractures ( ease Ho. 4 end $ ) , one case of Seosinuted fracture (cess Fo, 27 ), aud ane vasa case of conpound fracture ( case Yo. 32), Al? the old nasea had. derormtet following conservative treatnent. Ta tyo coseg fut length of the femr could not be achieved, and only tuo cases regsined fully their lost functions of the imee joints,-3he IK R380LTS The successful result of fonerel shaft fracture ‘treatnent in adults, depends upon may factors. The keystone, to solve 211 these factors {s the type of treatuent, No other wetiod of treatment can stride over the femorel shert fracture fe ntcely es tho tntrapecultery na‘ling does, The results of Antranedullory nailing of our series, given tn Tetle It, as Follows:~ Tuo patients ( cese with intrauedullery nailing tut they hed patells frecture of the sawe side, In tvo, one ( case io, 17) hed ma2-union io. 17 end 27 ) vere treated of the fomur end knee stiffness, who received conservative treataent in other hospttel, Mel-anton wes corrected fully, following natiings peteliectony had teen done upon thoze tvo cores, after neiling, In toth the cases, knee flexion soveneat are restricted folloving pete2lectony, otherwise, unton of the fractures are excellent witho:t ony other defernity. Seneraliy;, wien patients come late, it means thet they are coning after being diseppcinted vith other treatuonts and nost of the patients present thenselves with defora ty, Such cleven pottents ( case No. 4, 5, 11, 13, 26, 17, 22, 23, Sty 26 and 32.) case for further treainent, with nel-unton, shortening, oversiding or angulation, Tt wes obvious, and sito foma thet they ceoe with appreciable ‘mee atitiness, These are the end resultso® prolonged and improper inngbtii- zetion end toproper reduction, following conservative treat vente FSS Fp 3840-5- Once stiffness is develoced in the joint, it teccaes ® tooth and neil protien to irradicate the refractory stifmess, in two stages, In the Usually, we trest these nal-unton ca first stage, osteotomy will te dong followed by skeletel ‘traction for two to three weeks. Jn the second stage, intra medullary nailing will be performed. For the rehabilitation of the Unb, nce joint, the patient chould attend physiotterany departaent, Of the eleven cases, two patients ( case io. 4 ond 11) regained nornal functions of the knee Joint, others Improved @ lot. but could not reach the targets Only An two eases ( io, 4 and 24 ),in our series, shortening of the Lt could not te corrected fully. tn one case ( osse To, ), pre-nailing shortening wos eight centigetres, after intramedullary nailing six end @ half centinetros recovered, In enother case ( exse No. 24 ), four centinetres cane dovn to one centinetre, The letter one vas a case of compound and severely conninited fracture, Sooetines, 1t 1s very difficult to correct ell the Shortening deforatty nutty, ty the dint of merit of nailing, Fresh and recont the cases, test will be the end result of intrenedullory neiling, leest vit be the sufferings of the patients, Ta our series, one case ( esse Ko, 10), wos » cous of Wlatere] tibiel fracturessiong with fenorel short fracture, 7s other four femora? shaft fractures, two of then hed sone filed Fibie fracture ( oase Fo, 6 snd 31), and tvo had oppooite Sided ‘bia fractures ( case Wo, 3 and 21). All tne toex cases were ‘eokled with nedling} but tibia, conservatively, One caseof opposite sided titie fracture ( case Ko, 3 ) regeined full range of movenent of the knee joint, but other cases could not recuperate norms] Tinetions of the “nee joint, for prolonged recumbency, due to concomitant fracture of tibia 4nd other fracture injuries. The end result of intranedullery nailing wos good in all the eases, One case ( ease No, 24 ) of non-union with pseudo~ erthrosis was interferea with intranedullery nailing, slong With bone grafting ot the fructure site, Te end result 1s exceltent. ilo other trestnent can conquer this sort of deformity so menificiently, Two other cases ( ese wo, 8,284 19 ), conconitantly had frecture of toth ischiun snd pubis, and hip distocation of the opposite side respectively. The case with dislocation of hip could aot escape from knee complications bat snother ease 4id, But the union of the feuoral shaft fractures took | place sdniratiy excellent in koth the eases; without eny other untoverd effect, ‘Three nore cases ( case Ho. 1, 7 and 9) vere | associated vith injuries, 921 of then vererevarded vith sound union of the fracture, by the outstonding perforasnce of the intrasedatlery netling, Two of then enjoyed full range of novenent of the knee joint, Two cases are not tncluded in Table IT. Botl: the ceses vere nslled by intranedaliery neil in enother hospitel, One case had neck fracture of the femur ani pstelle fracture of the seue stae, They did not interfere tre neck fractures their first endeavour wes netling of the sxart, nthe patient-H- como under our care, the wound ves highly infected acconpented by osteomyelitis of the femur, The nail vas taken out end sequestrectony wes dono, ‘This wes folloved by Winnett arr cethod. Yow, there is coxa vera defornity, the Liab 1s short ty six continetres with stiff kneo, Other one cane to this hospital for further treatment, efter one yeer of neiling. angulation deforaity developed vith tending of the dianond ghiped pail, The Hab wos short ty four and a nal? continetres, with cons vara deformity of the centiguaus nip, The neil ves taken cut and velgus osteotomy was done with restoration of two ands helf continetres length of the Limbs Considering the stove to cases, ve can confer thet the nerit of the case in 811 respects, should te eticulosly seratintzed before nas2ing size, shape, length of the na{l should to voll conputed considering the length and dleneter of the The nedullary conaly operative end post-operative stages should te well regarded, Advice should be given also to the patients which are to be observed, otherwise, misfortune will come in dtsgris The phctogrephic sequences of intraneduliary nailing of Table II, are given on pages.4l-'g.~33- eveaae Pestricted Nermat nerenant, rat evenent 20" viexten revemeat Beseltent Bcellent Gee RroeLlent,50° Flaten Serosent, 70° siexten Soromene nan serement, lightly. ectrioled naa ‘nevement ‘restricted ‘90? fhezten evenent 20 ftaxien ‘Serene’ 15° flexion ‘aevenent Merma ‘noveneut Gomt Gove Beoelleat BroeLlant eed ea ExcellentBoellent Boeliet Beelient ‘Beellent Bweldentta ath this xray is take Sad rosult 1s excellent, Yt cone vith sp RSneaMiet gpieet treet, snd half tonths after nailing fo sc yen etFig. 16 Seatonminal fo| + Qks (Mahe side) Fig.25 (eft site) ora} closed ‘ctines. Treated ty nailing, ‘as ate taken after beinlatathis series, tvo cases of bilateral fenoral, shaft fractures were treated with intranedallezy neilings Jsch side of the bilstersl cose vas operated in separate sitting, Difference of opiniersare existing among the surgeons conceraing the exact tine of natl extvaction, Tt is very difficult to profess the exact tive of callus Formation folioving soltttty of the callus of 2 specific petient, Averoge tine of union can te drawn, tat not the portieular one.Hoaling tine of fractures of two pationts of ay factors. Many aze in favour of extracting the ast] between four to etght months, sane age vill vary, depends apon But considering the reconctltation of elinisal and redio~ logical evidences, we, sencretiy, extract the nail after one yeer. 4503 00 STUDY OF bf AND W.B.C. COUNT Ti TATRA OULLANY WATLING opera tive BC. count er eran,= 50 - Table II continued. 8, 14.50 13,25 9600 7800 = Fy BBO T0500 i. Bee ay OO Tis 9.96 7500 Te Te “13.56 600 5.1360 8600 Th ahg0 «3.005800 805800 G.iz20 15.00 2, RB. In the atove teble, the chenge of HLM in intr: bedullay nailtng bas teen foousged, The rercentage of bk , kefore operation and 2 few days after the nailing hes teen oxtlined, Total count of W.3,C, also found oat. Tt is evidently Proved that the variations of Hbg aac .B.0, count ore not=m Tonarkable before ant efter nailing. So neiling has got No cetrinental effect to Hb percentage, PERCENTAGE OF HELIN me : ; AB FQ) 28. Avézase vaniarion oF MAemesicarn LeveL aeRes Avo AFTER. Wrtkrinotdshby WaiLine Fig, 28: A Ayeros: PROV TAGE of S76: sw me a 5 a AB FIG. 29. vaziation OF HemosseBN LeveL Atree 'WTRAMEDULIARY NAILine Fig. 295 A. Level of HUE of tte petient Rs! tever of those pee aedullery nstlings Tt 4s seen that in sone petients 8 before operation. patients artor intra: Hb have ine sed after oiling, following blood trenstuston during operation,SG. TABLEW STUDY OF HES AND ¥.3.C, COUNT IK OTHER ORTHOPARDIC OPERATIONS S.No, re=Fost=—Pre=_——Fast=—singery Wise” gpera- opera- opere- opera- dase Give fixe Piece RE Bilin Hein HB. wbsc, Ga," count’ count ror gunn fer en < 1, 10,50 10,00 55005100 = Pasting Trarsfusea 11000-10800 ‘Plating 2 10,45 17800 10400 Plating Trensfused %. 12,30 10.80 5800 ~—«BMOO—~C*en—~S*S* amused Toyo 200 SSSR rasatioer 18.80 Sh 8560" 5200" 7 5400 eitiag “> Piloting = 2.05 aw B00 Gen OTe —g600 — gaa 2.81 135 eo eae —— wea Fee se00 : BIS 390 20- — sarE— i he T2307 — see setae SEF er rene 5 ae ese S700 a “Tremere — TT 5 560056 a yn begets Banstanie— _—_prosthesia= Table TV continued, 2.154200 00. 2%, 13.47 113542004000 27.5. Has a0 We 2. Wooo Uke 1130-5600 _su00 ‘Plating 29, 12,20 «10.35 ~~ od «500. 30. 15.57 ‘Open Pedvetion = 7h W300" “4800 “Hip gros- Trensfused A eats BL 14455 10,85 7006900 Paating etady of bs to keforg, and after other interne2 ftaations, ostectony, orthrogesis,insertion of prosthesis, and other operations upon hio, thigh and ara cf adult patients, PrRcenTace ce He SS w ome AB FS avon met se cem wet Fig. 30: A, level of overs, operations other than intramedullary nailing, B, Average level of Et of those operations as nentiones stove, intranedultery nailing. Fron the atove grash (fig. 30),end deta (tele IV), ve can safes that the Gifterence of tf terore and efter other , operations, is relatively core then intrauedutlary astling as Gelinested in tate TIT and graph (fig.2),ae TADLEY RSCORD OF DIURNAL YARIATION OF B.P, DURING INTRAMSDULLARY MiiING, Evo. imma oienes Verte tise Shima — vari of S.Pein mmHg of B.P. during chenee pulse rave during intreneduliory of pulse intramcullssy nailing, rete. nailing, 130-100-140 85-10-80 120-110 320-140 130-110 1s-110 | 95-15-60 40-205-75 80-70-80 9O-105-90 95-100.85 120-120-170 225-150 130-110-120 130-100-220 100-80-105 _90-105-85, 50-60-75 30-85-50 35-100-80 90-100Soya ‘Table ¥ continued, 95-100-90 80-35-80 90-100-80 1085-10087 “300-353-360 0-105 0-56 90-80 10-120 38, 1ad-aho “3 105-420 Hare the study of veristionsof blood pressure and pulse Fete of the patients, Those ere naxiain dturral vertetions and during actual intraneduttory noiting operations. The flactustion Of B.P, and pulse during nailing are not at alt contradictory points for which nailing shonld te in skevence, Bape Peesvee ne surbaeeiser sw mannionty sang ae aS Fite 34. Avene vations of ood Piatt wae Fig, 31. T& is shows in geape the Fiuctuatlan oF Elcod pressure duriar tnecasasotees 2eitf oe ele ie, mtting ee action, arthtodests) and ipsa tio insert ‘Average variation ot Set alline {3 20 na Ke‘ ahd 30am oe,oS TABLEW REGULIS O> FMRIOMAL Suiy reACIRES “ATH cCOUSRVATVE Time Lim, Suet tt Riese aT = Setrioted Tada. ary a at SRE Stans Uoper lees >> resto Texto. 6. 64 Stipe Lover ee 95° rextm proconte ted Tate = = Rasisietas Texion. pisster. RG Siople aide shetetay ~~ otto emetion plasters 10.39 Wissle Tease Seale triction pveente et plattersP57 Table “T ematinueds => Hissin praeest 36 Stele adie "Staple Uavor_Thalatal + ss Teabifetd aovmments esetion Te ts understood fron the skove date thot complications have yot 9 very goo place in the conservetive treatzent o% removal shaft fracturesin adults, Sleven cases of na2-anion sad one case of on-uaton as given in 4 le IT sre not ineluéed 1a the above Totle, These axe the symbolte recurring interpretations of conservative tresteent, TAS LEU cours 2:2 T.TROTaD PULLY Te csoRtY SR Use er Waicvaten——Gstnotans sat asia Wisnta Selsey aad piste mice Getentery ad Eta atta Toquastmsetay Teliewt F oli tee~58- Tn this data, it is only shom thet the conplicstions following skeletal traction tn collaboration cn plaster of parte or vith other conservative methods, again pursued ty other surgical interventions, but, none of the patients could regain ners knee functions, + thera Tee ren pasos By hasten of os rea msonLtAey mane File 32, Conners eam oF excunsency essicn wm Nahar Batc OO Fig. 32: Comparative graph of recustent period of different nothods of trestnent in adults of femoral shaft fractures,panne ene ef cuses eee ppean8 Fle 23, Copan me ae tee te a ma Fig. 33: Conparetive study of reterdetion of mee functions of adults in different methods of ‘treatoent of fencral shaft fractures, The recantent period of intrenedullary nailing is very negligitle and the occurence of knee stiffness efter intraredullary nailing is alnost 41, provided no other concomitant fractures o> injuries ere present, If so, petiont will tave to stay in ted for a long tine, end early ovenent of the Lint ts not possible,-60- DISCUSSION AND coNCLUSTON DISCUSSIONS A ~ INTRODUCTION Frog the statistical onalysis of treatnents of fencral shaft fracture in adults, in the previous chapter, At ts proved thet intramedullary nailing has got imaense command end suprensey over fenoral shaft fractures, aso on eformities caused ty other nanagenents and factors, TL, Unton 1s not the only criterion of successful frecture treataent, tut to restore the anatomical contour of the Lieb and normal functions of the joint, Intreneduilary sailing is the oaly method by which perfect ond effectual union of the fenorel shart fracture con te achieved vith Feconeilistion 0° stove mentioned factors, srovided the integrities are not tediy distorted previously by other tanagenents, The success of other methods are not commensurate with the suecess of intramedullary nailing, 2 ~ MATERIALS Daring the lest nine years, from 1961-69, eighty- ine edults patients of feucrel shaft fractures sere adaitted into this hospitel for tresteent. Thirty-four cases out of sighty-nine, were treated with intranedallary netting, ALL the cases were not fresh or recent, and the tine of sdmisston Anto the hospita2, efter injury, has teen charted in patie I, Rest fifty-five ctses hed teen tried with skeletal traction incerpotated with plaster or skin traction followed by plaster or closed reduction folloved ty plastering,or by- 65 pleting, But, here also, every patient could not neko convenient. to ke ednttted in the hespitel on the sane fey. after injury, T1s.tieasons ere, firstly, 212 standerd hospitals are charged, so all the patients could not sffora the hospital trestnent, The economic condition impelled acay petients too less experienced hand for treetuent. liost of ‘the cases cone beck with defornity. Atter being éise ppotated Som of the patients sain cone to the specielist in a Eee hospital t er trestuent, But it tecoaes a burden for then to bear the Lospitel expenditures, Secondly, avater of beds in the hospitel cen not eet up the desands of patients,2s nunter of well equipped hospitals are less,’So the-deserves patients cova not find Better ospitel eetlities et their prine sours of neceset chance ts be Auong fifty-five cases, only eizht cases vot, if penitted in this hosatte2 on the sane day after insvry, Due to chortage of beds, tuanty-one soace got adutssion within one weelts three ceses within one to two weels; eight eases within two to three weels; tvo eases within one to tvo months; ‘ight esses in tetween two to three conths after injury; two ceses in betwen three to>rour months and lest three vithin 8% months to one yeor following injury. This late coving of the patients ere due to shortage of ecconnadetio: in the hospital, and on secoint cf finsneiel condition of the patients and to Soue extent due to callousness of the patient ond negligence of the patientd relatives,~62- (414) In Turkey, pettern of road accidents out- nustered other types of accidents, According to our statistics stout 80f cases were injured due to traffic acciden etehty-aine cases 83% are mele patients, as they axe exposed Tn to strenaous ond-qultigarious or’ (iv) Dus to rush, the patisnts, in sone occasions, are discharged serlier then scheduled tine with proper aérections and sdvices, ut nany patients do not coaply with the doctar’s advice, as they are non cooperative netients fond do cot turn up dn tine for control, Tt is also found that 1 the post-operative progress of trestoont goes steadily vith bentgn effect wezy patients aa not turn up for finel check up. We Tecuested patients of our series, through letters to cone for fine] check ap, bat only 58.96 of patients came for that, (~) Yoiety-four cases out oF eighty-nine cases thrived with intrenedullary asiling, tebulated in ttle Tr. 421 the fractures vere not recent one. In or series tvelve enoes ( case Yoh, 5, U1, 13, Th, 16, 17, 22, 23, 2h, 26 ana 32) out of thirty-four eases cone with deformity for further ‘treetnent, leven cases vere sssociated with other injuries (case Ho.1, 3, 6 7) B, 9, 10, 19,21,27°€31), ana eleven cesce vere vith recent fmetures withot any other injuries (case Ho, 2, 12, 15, 18, 20, 25, 28, 29, 30, 33 ant 3b Je Tn Totle VE, five cases ( case io. 4, 8, 9, 12 and 13 ) vere involved in deformities ond complications, by s’elebeh traction folioved by plastering or with other conservativeoe nethods es mentioned, also evoked restricted knee movenents in all the cass, In Tobie VIT,ten cases associated with complications, sry bvt norms] Inge fanetions could not be revived sin any one of the cases. again tried with other surg Tn Toble VI & VII, unfortunately a2 other cases could not te included es history sheets are aot in order ~ Anconpletes. (vt) Tt 1s reckoned that in our series averege period of staying of car patients with feaorel shaft fractures, injury, is only 16,5 days in the hospital after introuodallary natling. ve coula discharre not releted with ott the patient nore ea‘ier after neiling tut generally patients are being tought hov to welk with oratches after renoval of stitches. After thet patients are being discharged grea the hospitel, The everage period of Sospitelizetion of the petiont of recent fracture associated with other injuries, after nailing, is 18.6 éays, and those of old cases with defornity is 22 days ( according to Table IT ), Tie letter ezoup ts the subject to operetion in two stages. In the first phase we hove done osteotony, faileved by skeletal treetion, In the second shrse, the main operstion - nonely intramedullary nailing, The duration of traction is atout two to three weeks, Zhis 1s our regular eptsode thot privertly ve epply sleletel traction to the tnjured Lint of fenoral shaft fracture. In uncomplibated cases, the