Subject: fracture in flail lower limb in adult

Date: Fri, 30 Aug 2002 13:20:16 -0500


Would like comments and opinion on this femur fracture in an adult with a flail olower limb due to polio in childhood. very mobile with axillary crutches incl. driving a car etc. what would you do? avoiding POP would be advantageous to him in terms of mobility, convenience etc. thinking of a stacked Nancy type flexible IM titanium nail as an ideal choice. am I right?? any other ideas? am doing the surgery in about 12 hrs from now. has anybody got any special ways of putting them in?? do contribute your ideas.

hope everyone can see the image clearly, if not, it is a segmental fracture femur in an adult with a child's femur, 5mm isthmic diameter of the femur, soft bone due to paralysis and disuse. fracture is at midshaft and 5 inches below that in 2 places, small butterfly in midshaft and undisplaced transverse fracture in the other site. overall femoral length is about 40 cm or so.

With warm regards & best wishes,

Dr N V Girish Kumar

Trauma Care Specialist
O'Brien Bone & Joint Centre
RS Puram, Tamil Nadu State, India

Reply at: Orthopaedic Trauma Association forum

Date: Fri, 30 Aug 2002 13:00:23 -0700

From: Bruce Sangeorzan

I recommend standard locked intramedullary nail with immediate return to function. if patients like this have to be immobilized the lose function that does not come back. allow weight bearing as tolerated.


Bruce Sangeorzan, MD
Professor of Orthopedic Surgery and Sports Medicine
University of Washington
Harborview Medical Center

Date: Mon, 2 Sep 2002 11:33:47 -0400

From: James Carr

Dear Girish

Stay away from the Nancy Nails - although they can be custom fitted to this man's femur, the proximal fracture pattern is Winquist III, and therefore unstable to this type of nail without some type of external immobilization. I recommend templating to see the size of his canal, then use a humeral nail if a regular nail won't work. Standard femoral nail is my first choice.

Jim Carr

James B. Carr, MD
Palmetto Health Orthopedics

Date: Mon, 2 Sep 2002 6:30 PM EST

From: Bill Burman

James Carr says Nancy nails won't work "without some type of external immobilization". That, plus his mention of monorail ex fix in a recently presented case of pilon fx with segmental defect, brings to mind a combination of unreamed flexible nails (controlling bending moments) with a simple proximal/distal metaphyseal ex-fix (controlling length and rotation).

While not as rigid a construct as an interlocking nail, it seems that such a combination would be faster, less blood loss and less infrastructure-intensive than interlocking nailing and thereby make it an option for expedited polytrauma stabilization, less well-stocked operating environments and narrow medullary cavities. Femoral ex-fix is plagued with pin tract problems. Perhaps placement of half pins in the practically subcutaneous trochanteric and lateral femoral condylar regions would be less problematic.

Also, a clinical photograph of this limb may show it to be atrophic and shortened and therefore, not in need of the usual femoral IM fixation rigidity.

Bill Burman, MD
HWB Foundation

Date: Tue, 3 Sep 2002 18:33:45 +0600

From: Alexander Chelnokov

Hello girish,

I would use an unreamed femoral nail of smallest diameter (9 mm in my settings) with minimal reaming, only to fit.

Best regards,

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

Date: Tue, 3 Sep 2002 09:23:00 -0400

From: James Carr

Bill brings to mind a reasonable solution for the use of flexible nails + ex fix. The major drawback is medullary sepsis, which should be a fairly low %. Another variation from the Ender rod days was application of a unicortical plate. I think the ex-fix is a better option, as a number of the unicortical plates failed.

Jim Carr

James B. Carr, MD
Palmetto Health Orthopedics