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.
Date: Thu, 13 Oct 2005 16:48:45 +0600
From: Alexander Chelnokov
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.
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.
Date: Thu, 13 Oct 2005 20:04:04 +0800
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.
Dept. of Othropaedic and Trauma
Shanghai , P.R. China
Mthatha, South Africa.
Date: Sat, 15 Oct 2005 12:20:16 -0400
From: Peter Trafton
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?
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