Date: Sat, 4 Dec 1999 17:43:04 -0000
Subject: infected nail
Dear list members,
Please give me your views on the following. A 40 year old man referred in May this year with a very comminuted femoral shaft fracture with a big middle third butterfly fragment having been treated in the previous weeks by open AO nailing and 2 partridge plastic bands around the fracture.
Unfortunately, the nail was too long and was poking 10cm out of the top of the femur. It wasn't locked so there was no rotational or axial stabiliy. We discussed the options,including the conservative one, with him and then elected to renail it.I removed the bands,grafted the frcture and put in a Smith &Nephew Richards nail, locked at both ends.
The Xray was very good but the mid-thigh wound became infected and formed a sinus, growing Coliforms. We finally decided that the nail was probably infected but waited intil the fracture looked healed and last week we took it out. There was lots of pus, which has grown an anaerobic coccus, in the IM canal.
We reamed and washed it out but did not reinsert a nail. Subsequent xrays show a healed butterfly segment but the upper part not healed, effectively giving a mobile transverse fracture between the proximal and middle thirds of the femur. He is now onskin traction. ESR is 90, CRP awaited. Normal WBC.The bug is sensitive to Flagyl. Xray cannot distinguish between a recently nail femur and an infected femur. No point doing a bone scan at this stage.
Your thoughts on further management,and in particular on the timing and type of further fixation, would be greatly appreciated.
Here are images of:
Date: Sun, 5 Dec 1999 10:07:44 EST
From: T DeCoster
Subject: Re: infected nail
suggestion for infected nail case
consider placement antibiotic impregnated beads down the medullary canal for 2 weeks with culture. Exchange as needed for positive culture. Then replace IM nail. Steve Henry of Louisville has published on this technique.
by the way, why did you remove the Parnham bands? I would think most of their damage had already been done. Did you obtain a culture at time of exchange nail?
Date: Sun, 5 Dec 1999 19:10:08 -0000
Cultures taken at the time were negative. I sincerely wish I hadn't bothered removing the bands but it seemed a good idea at the time to get rid them and to graft the fracture site. Of course, I now wish that I'd just left this chap on traction for his 3 months!
Date: Sun, 5 Dec 1999 15:23:17 -0500
From: E. Frederick Barrick, MD
Renail it with interlocking. No bone graft. An infected nonunion is best treated by sold fixation and lots of antibiotics. Do a closed nailing to retain the reamings at the nonunion site.
E. Frederick Barrick, MD, Director of Orthopaedic Trauma, Inova Fairfax Hospital, Falls Church, VA
Date: Mon, 6 Dec 1999 06:54:24 +0100
From: Peter Schandelmaier
Do you know if third fragment is vascularized _ after the banding and nailing it is probably not AND INFECTED, you might need to take it out.
Peter Schandelmaier, Hanover
Date: Sat, 11 Dec 1999 20:11:56 -0000
Many thanks for the responses.
CRP and ESR are coming down and he is 3 weeks post removal. Next step? Would list members have revised the first nail (which gave no control but was not infected) or kept him on traction? Thanks
Date: Thu, 16 Dec 1999 17:43:45 -0700
From: T DeCoster
Now 3 weeks status post removal infected femoral nail presumably on IV antibiotics, clinically improving. What is the sed rate (you said it is coming down). What organism grew? What antibiotic? Any drainage currently? Traction currently? Activity status now?
I would consider 3 more weeks of very limited activity (no ambulation) with IV antibiotics. If reliable then discharge to home with pivot transfers for a month and po antibiotics. Then progressively increase activity with some sort of hip thigh orthosis and very limited weight bearing.
Date: Fri, 17 Dec 1999 20:50:53 -0000
Thank you for your interest. Present status is that he is on skin traction of 15 lb with a very mobile unhealed fracture at the junction middle and proximal thirds as seen on last images posted. ESR is 60 (was over 100) and C-Reactive protein is 6 (was over 60).
Date: Sun, 19 Dec 1999 13:08:22 EST
From: T DeCoster
Mobile nonunion of the infected femur shaft fracture now with no gross sign of infection : I would consider waiting 2 more months. If above persists then consider repeat nailing, perhaps 2 stage.