Date: Wed, 12 Oct 2005 20:08:14 -0400

Subject: Femur fx healing

From: Charles M. Blitzer

Pt is 27 yo construction worker now 5 months post fx. He has tenderness localized over distal locking screw heads. CT confirms bridging bone posteriorly. How much healing is necessary? Suggestions for further management are appreciated.

Thanks.

Charles Blitzer

Date: Thu, 13 Oct 2005 16:48:45 +0600

From: Alexander Chelnokov

Hello Charles,

CMB> posteriorly. How much healing is necessary? Suggestions for further management are appreciated.

I don't think the distal screws really are the source of pain. The image doesn't show proximal screws - is the nail dynamized or statically locked? If the latter i would remove the proximal static screw and leave the patient for 4-6 months or forever if he becomes asymptomatic.

Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia

Date: Thu, 13 Oct 2005 12:05:00 +0100 (BST)

From: David Oloruntoba

I would suggest 2 things

1. If the # is not dynamised dynamise by removin the distal lockin.
2. Consider bone grafting the gap in the distal femur where the spiral looks displaced.

D.O. Oloruntoba

Date: Thu, 13 Oct 2005 20:04:04 +0800

From: Sam

Sorry,I can't agree with Dr. David Oloruntoba .

I can't dynamise the nail by removing the distal locking because of its spiral fracture line. Dynamise will be unstable to the fracture. And the case has tenderness in the distal locking region . It may be refracturearound the distal hole . I don't want to use bone grafting because it will disturb the soft tissue and may not be good to fracture healing.

So I think it will be better to identify whether there is refracture around the distal hole .If so , I think it will be better to remove the nail and a LISS can be used.

Dr. Sam.Shen
Dept. of Othropaedic and Trauma
Xin-hua hospital
Shanghai , P.R. China
Mthatha, South Africa.

Date: Sat, 15 Oct 2005 12:20:16 -0400

From: Peter Trafton

Hi Charlie,

From what you say, I'd be slow to do anything fast - certainly not remove screws or bone graft yet - 5 months is not very long since injury, especially if he's still healing. I'd review serial, better quality x-rays. Not just AP & Lat, but both obliques as well. I'm assuming he's fully weightbearing a, has good motion and is progressing satisfactorily with rehab, and that his "locking screw head pain" is tolerable. If he fails to progress, or has significantly limited activity, then perhaps suspect nonunion or structural insufficiency. Does the anterior bone prominence bother him? Knee motion ok? Isn't there some new bone in the anterior gap?

PGT

From: Charles M. Blitzer

Date: Sat, 15 Oct 2005 15:25:30 -0400

I did get CT which confirms union along the posterior cortex.
He is sore enough over the distal lateral screw head to use at least one crutch.
He has excellent knee ROM with no ant thigh pain or tenderness. Minimal ant new bone.

From: Bill Burman

Date: Sat, 15 Oct 2005 23:04 EST

Maybe the distal locking screw head irritation is good - promoting partial weightbearing while waiting for the gap to close as PGT suggests and as seen in another case.

Date: Sun, 16 Oct 2005 10:06:27 +0600

From: Alexander Chelnokov Hello Charles,

CMB> I did get CT which confirms union along the posterior cortex.

Was the nail dynamized? Or it remains statically locked?

CMB> He is sore enough over the distal lateral screw head to use at least one crutch.

The crutch means that the pain depends on loading of the limb. So it must be cyclic motions somewhere in the nail-screws-bone interface during walking.

Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia

Date: Sun, 16 Oct 2005 22:24:52 -0400

From: Peter Trafton

I doubt that locking screw pain would lead one to use a crutch.

This suggests that fx is not healed, or that union is tenuous.

I'd still follow him with 4-view x-rays Q 4-6 weeks, and consider further surgery only if he fails to progress clinically & radiographically.

In my experience, CT's can be deceptive; interpretations of CT's by radiologists even more so.

/p