Surgical Clinic of the University of Giessen (Medical Director: Prof. Dr. Fr, BERNHARD) EXPERIENCES WITH MEDULLARY NAILING OF FRACTURES by Dr. med. K. KATZ Lecturer of the University and Dr. med. J. WEIS. Translation prepared by: U.S.Fleet, U. S, Naval Forces, Germany Technical Section (Medical) TABLE OF CONTENTS page Table of Contents ;; ■*=. ■■■> I Foreword by Commander Harry J, ALVIS, MC, USN II Introduction 2-3 Historical Development of Fracture Treatment 3-5 Range of Medullary Nailing within Operative Fracture Treatment 5-6 Superiority and Risks of Medullary Nailing General Indication 6-11 Indication for Marrow Nailing of Closed Fractures 12 - 14 a) Humerus 14 - 17 b) Forearm 17 - 22 c) Femur 22 - 28 d) Leg 28 - 33 Technique of Percutaneous Medullary Nailing of Simple Fractures 33 “ 38 a) Humerus * 38-45 b) Forearm 45 - 48 c) Femur 48 - 54 d) Leg 55 - 64 Some Errors and Risks Connected with Medullary Nailing 64 - 70 Personal Experience with Medullary Nailing of Simple Fractures 71 - 72 Open Medullary Nailing of Primarily Simple Fractures 72 - 81 Indication for Medullary Nailing of Compound Fractures 81 - 99 Medullary Nailing of Gunshot Fractures 99 - 101 Osteotomy and Medullary Nailing of Fractures Healed in an Unfavorable Position 101 - 11° Medullary Nailing of Retarded Fracture Healing and of Pseudarthrosii 111 - 138 Influence of Medullary Nailing upon the Formation of Callus 139 ** 143 Reaction of Bone Marrow to Medullary Nailing 143 - 144 v*> * Additional Fields of Medullary Nailing 144 - 149 Literature 150 - 151 II FOREWORD. This manuscript, prepared in 1945 just after the close of the war, presents the point of view of the Surgical Clinic of the University of Giessen concern- ing the use of the medullary nail. Admittedly their experience was not as extensive as that of other clinics but it was unique in that it included a number of cases originally nailed in a field hospital on the Finnish front by Dr, Kuentscher. The Giessen Clinic at that time was a general surgical clin- ic and was not predominantly concerned with orthopedic work. This manifests itself in the greater emphasis on basic surgical principles and less on the mechanical aspects of the use of the new medullary nail. • V Harry J. Alvis, Commander, Medical Corps, U. S. Navy. INTRODUCTION When studying the medical journals one sees at a first glance that the treatment of fractures, though an old and widely explored field of surgery, has been subject to con- tinuous change in the years before, during, and after the recent war. On the one hand this may be due to the con- siderable increase in the rate of accidents before the war in Germany, when the growing use of motor vehicles in wider circles of the population as well as the work on numerous large building projects (Autobahn) was particularly re- sponsible for the increased opportunity to injure bones - quite apart from the war casualties. On the other hand the development of new methods of treatment revived and maintained the interest of the physicians dealing with frac- ture treatment. The new method of treatment presently in the foreground of discussion is medullary nailing of tube bone fractures according to KILTJTSCHER a method which was first published in 1940. The procedure of the "stable osteo- synthesis” (KUSNTSCHER) is described as follows: At a place distant from the fracture site a small incision is made and a long/ strongt and appropriately shaped "nail" is driven in-. to the medullary cavity which forges the fragments so firmly together that, as a rule, the fractured extremity can immedi- ately be moved and after a short time can be used or subjected to weight-bearing without any additional external support. Here several problems, some of them of a theoretical, some of them of a practical and technical nature, resulting from me- dullary nailing shall be investigated as well as the clinical experience and the results collected with the patients of the Surgical Clinic at Giessen. So far there are only a few summarizing volumes on med- ullary nailing. The first book published on the matter was that of HAEBLER (l) which gave a very detailed and gratify- ingly outspoken report on a material comprising 250 cases. The author of this book also treated the details of the tech- nique and particularly discussed the problem of nailing gun- shot fractures. This study was published during the war and in many a respect bears its stigmata, a fact which frequent- ly may have been embarassing for its author too. In addition, mention must be made of the 3rd volume of BOEHLER*s (2) ’’Technique of Fracture Treatment in Peace and War" which through the plentiful material (more than 500 cases, of which 236 were observed in the emergency hospital in Vienna under the direction of BOEHLER), through the systematic des- cription, and through the evaluation of the single cases as well as of entire groups of patients treated with the same method is of extraordinary value, as it always makes the personal experience of BOEHLER the center of consideration. As a third study published in form of a monograph the "Tech- nique of Medullary Nailing" by KTJENTSCHSR and MAATZ (3) must be mentioned which, however, almost exclusively deals with technical problems. References to smaller studies of the Clinic of Kiel and other scientists who have investigated the method will be made in the course of this treatise. In publishing our material, consisting of 280 cases, we want to point out right in the beginning that not all of these had been treated in the Giessen Clinic in the first stage of their injury* Some of them were previously treated elsewhere and they were admitted at Giessen for expert ex- amination, and for the continuation of treatment. One or the other reader may believe that the number of cases, par- ticularly of those treated by ourselves is small and it e- ven may be that some who have a greater experience with mar- row nailing may deny our competence to judge and evaluate the method on the base of such a small number of patients* We do not share this opinion. The small number is due to the fact that contrary to other surgeons we did not apply the method to every fracture suitable for medullary nail- ing. On the contrary, right from the beginning - our first medullary nailings were made as early as 1942 - we main- tained the contention that only a very critical selection of those fractures for which the application of medullary nailing was permissible could be of value for the method. Nailing constitutes one of the most audacious of surgical enterprises. The superiority of the method was so obvious that it could be applied only with wellfounded judgement, if it was intended to promote its acknowledgement in sur- gery, rather than its rejection. So much for the views first held by the Giessen clinic. On the following TDages the attentive reader will observe the development of our attitude. HISTORICAL DEVELOPMENT OF FRACTURE TREATMENT To understand and to evaluate critically the origin- ality of the method and its difference from the previous- ly usual operative fracture treatment, a short survey on the historical development of the general problems aris- ing within the theory of fractures is necessary. Medul- lary nailing involves the problem of improving a certain technique and because the method calls attention to the principles of fracture treatment in general, even today one can see that quite a number of new problems have orig- inated from it. These problems not only refer to the me- thod applied for treatment, but also to the biological pro- cesses taking place during fracture healing. When treat- ing the fractures of the extremities two exigencies always have to be fulfilled. The restitution of the anatomical structure and the restitution of the function of the in- jured limb. It is not possible in every case to meet both requirements absolutely. Sometimes in the course of time the demand for overcoming the structural change, sometimes for restitution of function was a matter of pre- ference determining medical action. As always, also in the field of fracture treatment extreme advocates of the one and of the other aim were to be found. Although it almost seems to be a matter of course that the perfect solution is the•restoration of the normally built up ana- tomic structure, which is the principal basis for the un- hampered function of the extremities, the damages caused by prolonged immobilization prevail in many cases even with an ideal reduction of a fracture. This experience led to the result that some of the surgeons finally dis- regarded the correct anatomic reduction of the fragments and exclusively directed their attention to the preser- vation of the mobility of the joints even accepting a shortening of the long bones almost equal to crippling, if only the function of the extremity was preserved to the greatest extent by early exercises. Such a proce- dure can be regarded as obsolete in this extreme form. With fractures of the upper extremity and particularly with those of the humerus the renunciation of the per- fect reduction of the fragments is justified to a cer- tain degree, as for the hand as well as for the arm grasping and moving are of greater importance than cor- rect axial position and equilateral length of the ex- tremities. For the lower extremity including the foot the restoration of the axis bearing the weight of the body and an equal length of the sound and treated ex- tremity certainly are of a greater significance, as in this case the ability to bear weight and equivalent lengths mean more for standing upright and walking than the full mobility of the joints. It is particularly the occurrence of late impairments of the joints of the lower extremity due to inadequate static stress which must be taken into account. BOEHLER e.g. is of the opinion that a curvation of the femur by more than 5 degrees has a detrimentous effect upon the joints and he insists in it being straightened out. Thus we have outlined the principal problems to be solved by the various methods of fracture treatment and from these exigencies the practical basis of every me- thod of treatment can be deduced. This essentially con- sists of reduction and retention. The principles of the procedure to be followed for the reduction of dislocated fractures are firmly established for all kinds of frac- tures with the exception of single modifications and im- provements of the reduction technique. Since the intro- duction of wire extension the decision must be made in every individual case whether a fracture shall immediate- ly be reduced to the best possible position or whether reduction shall be achieved by traction and counter-trac- tion during a prolonged period of time. One may deduce from the development of the reduction technique that ef- forts have been increasingly directed to applying the re- ducing force to the bone, as the soft tissues enveloping the bones of the extremities never constitute such an adequate point of application as the fragments themselves, For this reason the development of technique from Schmerz's clamp and Steinmannfs nail to the Klapp wire was certain- ly to be expected. Formerly reduction and retention not only were two completely different procedures but also required different appliances. It was the method of wire extension which united the two stages in one single tech- nical and instrumental procedure, as the wire drilled through the bone not only was employed as a manubrium for the traction to be administered for reduction which, thanks-to R. KLAPP as well as KIRSCHNER and their dis- ciples, complied in the most minute technical details with this requirement. In addition, wire extension was capable of effecting retention. In this connection, wire extension takes a special place in fracture treatment. There is no need to discuss in detail the great advan- tages of the wire extension method. With medullary nailing in its perfect form reduction and retention are again divided into two separate stages, but in many cases the advantages of the internal immobili- zation without any immobilization bandage are so predomi- nant that the separation of the treatment into two stages is no longer a method of greater significance. Since the most early times of scientific fracture surgery one of the best founded rules was the principle that no closed fracture should be changed into an open fracture because of the hazard of infection. It is par- ticularly the debris, consisting of bone splinters, peri- osteum, escaped bone marrow, crushed musculature, and blood, which constitutes such a favorable culture medium for pus organisms that this rule must be maintained un- der all conditions. Presently even the reversed rule was valid according to which a compound fracture should be converted into a closed fracture as soon as possible if it is compatible with the general principles of wound treatment. These considerations were the reason why o- perative•reduction was taken up fairly late, only tatingly, and at no time without contradiction. Doubt- lessly there are situations which do not permit evading operative opening of the fracture site and the adjustment of the bones under direct control of the eye, if - par- ticularly with old fractures - none of the other methods is successful. However, it is particularly the experienced surgeons who constantly raised a warning voice demanding that the indication for operative reduction be confined to the utmost minimum, though it may be ever so tempting to gain really excellent anatomical results in this way. Warnings have also been expressed with regard to the in- troduction of metallic or other stable foreign bodies aim- ing to retain the fracture in position, because of the danger of infection and the disturbance of the healing of the fracture. Nevertheless it must be admitted that the fixation of the fragments at the fracture site itself by means of wire, bolts, pins, screws, or plates was only a natural step, if once it had been decided to open the frac- ture site. Even today this admonition should not be dis- regarded although some surgeons relying upon modern chemo- therapy may be inclined to compromise the principles valid so far. In this context we should like to call attention to the fact that with the introduction of sulfonamides and particularly of penicillin into fracture surgery ventures may be undertaken which in former times were not considered permissible. Therefore the surgeons are relieved of a great part of their responsibility by these drugs. RANGE OF MEDULtABY NAILING WITHIN THE OPERATIVE FRACTURE TREATMENT. So far medullary ceiling is the only method which meets satisfactorily the two most essential postulates of fracture treatment; The application of the immobil- izing force to the bone under optimal conditions and with a stability of immobilization which cannot be attained by any other procedure. It is a well-known fact that absolute immobilization is an especially important factor for frac- ture healing. Secondly, the insertion of the marrow nail can in most cases be effected from a place far distant from the fracture site. Therefore, when nailing a fresh uncom- plicated fracture, there is no need to establish a communi- cation between the fracture and the outside, not even for a moment. It is a characteristic feature of the peculiar technic of medullary nailing that it has to be considered among the operative methods of treatment, but that under normal conditions the opening of the fracture andthe in- sertkn of foreign bodies in the fracture area can be a- voided. This is in contradistinction to other operations made for the reduction or the retention of the fragments. Although in contradiction to KUENTSCHER (4)> we believe that medullary nailing should be considered among the me- thods of operative fracture treatment, not only because a small incision is necessary to insert the nail into the medullary cavity, but also because of the possible sum- mation of a certain number of perilous factors seeming in- significant at first glance. These involve the anesthesia - regional or spinal anesthesia, sometimes narcosis - the position of the patient, and the frequently prolonged dur- ation of the operation. GRIESSMANN and SCHUETTEMEYER (5) stating that "in general the duration of the operation does not exceed 10 or 15 minutes" certainly create a faulty impression for beginners, as very frequently much time is required for the operation including reduction, fluoros- copy, and X-ray pictures. To these hazards must be added the reduction, the hazard of fat embolism, of infection, traumatic shock, and probably still other factors, the com- bination of which may have the effect that the whole pro- cedure assumes the character of a major surgical interven- tion. However, since under normal conditions the opening of the fracture site is avoidable, one is in a position to maintain the basic rule and to avoid converting a closed fracture into an open one. At any rate, marrow nailing is far superior to the heretofore available methods in those cases in which there is an absolute indication for opera- tive reduction. This statement may be made, because med- ullary nailing permits reducing the risk of operation to a minimum. Exceptions occurring when medullary nailing is applied shall be mentioned below. SUPERIORITY 1NP RISKS OF MEDULLARY NAILING GENERAL INDICATION. The time has come now to outline more sharply the su- periority as well as the risks of the medullary nailing of fractures. Numerous publications permit one to survey the experience gained during the early years and to compare it with the results obtained with our patients. Some general advantages of medullary nailing are be- yond contradiction: In’most of the cases the patient is spared a long confinement to bed, as after the healing of the incision at the Insertion site and with the nail seated firmly, there are nc objections to permitting the patient to get up, and, with fractures of the lower extremity, to subject the broken limb early to weight-bearing. Concur- rently local damage of the injured extremity is avoided such as muscular atrophy, decalcification of the bones and above all ankylosis of the joints. As regards reducing con- finement to bed for old persons, the medullary nail is com- parable to the femur neck nail and it is at least possible to let the patients make extensive exercises in bed if for some other reason getting up cannot be permitted. Every physician knows how dangerous it is to keep older patients immobile in plaster casts, or confined to bed by extension treatment, as it provokes circulatory disorders, pneumonia, and decubital ulcers. One must add to this the immobility caused by the fracture pain even including insufficient respira- tory movements. In this connection the excellent success of systematic exercises in bed must be mentioned which were recommended ten years ago chiefly by KIRSOHEER. By the stable osteosynthesis - in every case a really firm seat of the nail is essential - the fracture pains are relieved im- mediately and continuously and thus the dangers arising from the lack of movement can be prevented. For this reason we also follow the principle to nail immediately every fracture of the femur neck. Hence the majority of the general disad- vantages inherent in fracture treatment as practiced so far, can usually be abolished with one stroke by medullary nail- ing. By no means, however is marrow nailing permissible if shock is present. As the fractured bone is sufficiently sta- bilized through the internal fixation it is seldom necessary to apply an additional plaster cast or extension bandage ex- cept in the case of leg fractures. And even in an unfavor- able case one can limit oneself to the application of a plas- ter cast which exempts the knee joint so that it can be moved at an early date. If one does not want to trust the fixation of the fragments to the nail alone one may employ an addition- al walking cast. This combined with the nail permits exer- cises and weight-bearing at an earlier time than would be pos- sible without nailing. In this case the walking cast can be kept smaller than could be risked without the medullary nail. This will be discussed together with the individual forms of fractures. Since the introduction of medullary nailing we are relieved to a great extent of the concern for the mobil- ity of the joints in the proximity of the fracture. Finally attention may be called to the economic factor, as in view of the shorter duration of hospitalization the costs are no- ticeably reduced for the patients as well as for the insur- ance company (HAEBLER (6)). In contrast to J'he apparent general superiority of the new method, as described above, some direct disadvantages must be mentioned although they are of a more local nature. It was pointed out already that medullary nailing is an oper- ative procedure, whereas the aim should be to exclude opera- tive intervention as much as possible from fracture treatment. In this case it is not. so much the operative reduction itself which should be avoided, but rather the hazard of infection connected with it. The zone of debris and the hematoma pres- ent at the fracture sirepresent an excellent medium for pus organisms so th.it i-he old principle of avoiding, the con- version of a closed fieoture into an open one is still valid even in the era of sulfonamide and penicillin treatment. Ref- erence to this fact was made above. Medullary nailing is a compromise between conservative and operative reduction and KUENTSCHEH (7) deduces from this fact that it does not constitute an operative fracture treatment. Even though with the ideal performance of the operation the fracture site is not exposed, the forcible insertion of the nail into the medullary cavity causes a communica- tion between the fracture and the outside which in one or the other case may give access to infection. There is no doubt that the more ardent supporters of medullary nail- ing are right in stressing the fact that the insertion of the nail at a distant place, which has to be considered as sterile, does not involve the same peril of infection as the exposure of the fracture site itself, provided t hat the operation is practiced with complete asepsis. This is particularly true if the operation is made at the site of the complicating wound. However, in spite of all precau- tions the opportunity is created for pathogenic organisms to invade the tissue, a fact which would be completely ex- cluded in the oase of entirely conservative methods. Me- dullary nailing causes a breach in the principle of keep- ing the fracture closed, even though it is applied at the place where danger is least. For this reason one must take into account that the method involves a certain risk of infection which, however, is not necessarily greater than that of any other aseptic operation. In practice with closed fractures the advantages of marrow nailing pre- dominate so that the decision to apply the method is not difficult as far as the risk of infection is concerned. According to HAEBLER's calculations the number of in- fections with the "percutaneous” nailing method amounts to 1.5 % while they amount to 11# if the fracture cleft is ex- posed. The cases of infection after medullary nailing of closed fractures were exhaustively described by MAATZ and REICH (8) whose unreserved discussion of the failures is of particular value due to the detailed presentation of the case histories. Therefore that study shall be subjected to a closer investigation here. -Its authors described 1A cas- es of traumatic osteomyelitis, some of which they observed themselves while the others were reported to them from neighboring hospitals, and the medical histories of cases of bone infection published earlier by A. W. FISCHER and MAATZ (9) were recorded again. We are of the opinion that for the judgement of the risk of infection due to medul- lary nailing in its narrower sense only those cases are real- ly suitable for evaluation in which a closed fracture became purulent after medullary nailing. This occurred in three instances. Suppuration of open fractures or after the ex- posure of the fracture site or after osteotomy cannot un- restrictedly be held against the method of medullary nail- ing as here infection theoretically could occur without the nailing. A closer study of the case history of these three closed fractures revealed that only in one instance nail- ing really was the cause of infection, and MAATZ and REICH uid erlined the fact G.r.at with regard to this the case stood alone among the 200 medullary nailings performed by them. In a 45 year old female patient (case 3) there was a closer], oblique fracture of the left tibia which was nailed without any difficulty, the incision site however showed drainage from the very beginning on* When after five weeks the medullary nail was removed, pus was evacu- ated. The fracture site became purulent after 10 weeks and foot-joint empyema al- so ensued. At the time of reporting ”a pyemic condition was distinctly visible”. Contrary to this single observation of infection of a fracture originating from the site where the nail was inserted, the two other cases of infection were easi- ly explainable. With an 18 year old male patient (case 1) a metastatic suppuration of a closed fracture of the left leg oc- curred which had originated from the in- fected right knee-joint and various other hematomata also began to suppurate simul- taneously. Amputation of the right thigh had to be performed. The patient died. In the case of a two year old child (case 2) with a closed fracture of the shaft of the f emur the fracture site became puru- lent subsequent to a very difficult nail- ing procedure after which the nail protrud- ed too far. Infection "apparently occurred via the medullary cavity after the forma- tion of a suppurating fistula at the nail insertion site”. The process could be con- trolled through incision and the final re- sult after 5 months was satisfactory. These observations show clearly that infection origin- ating from the nail insertion site is one of the most rare incidences occurring in the course of the treatment of closed fractures. If one were to express the observations of MAATZ and REICH in per cent, the figure certainly would remain below the figures for the infection hazard of strict- ly aseptic operations; this was also stressed by the above mentioned authors. With a total of 102 medullary nailings of closed frac- tures we have observed slight infection in three cases, which, however, did not substantially disturb the course of the heal- ing of the fractures. These infections occurred in the humerus and in the leg. In addition we were faced with two cases of osteomyelitis of the nailed tibia. One of these patients died from a knee-joint empyema which gave rise to a suppurative thrombosis of the pelvic veins. Quite a different yardstick of course must be applied to all complicated fractures. This will be considered in de- tail below when the indication for the medullary nailing of complicated and compound fractures will be discussed. In the chapter, dealing with the superiority and the risks of medullary nailing in general, the problem of fat embolism must also be considered, which becomes prominent for every surgeon used to anatomic thinking as soon as he commences to study lb-; marrow nailing method. A minor de- gree of fat embolism regularly found after every bone injury as was shown by ;he very thorough investigations of EEHR (10). Of course is possible that particularly in cases of older individuals whose bone marrow is rich in fat, fat or fat colls may bo pressed into the circulatory system by the pressure of the medullary nail, be it even I due only to an over-all rise of the pressure in the mar- row cavity. It must be said here that the pressure in- crease can be largely avoided, if the marrow is given oc- casion to escape while the nail is driven in. This is easy, as the medullary nail is no solid rod with a cir- cular cross-section, but is shaped like a tube in which the fat or the bone marrow is diverted towards the in- sertion site. The nail, therefore, does not have a syringe piston effect (KUENTSCHER). The expedient to avoid fat embolism is to withdraw the guide-rod from time to time before continuing to drive the nail further in, if, as in the case of the femur, a guide-rod is em- ployed. The fracture itself also permits the contents of the medullary cavity to escape and thus provides a certain pressure equalization (RAISCH 1943). Moreover, allegedly there also prevails a certain overpressure in the marrow cavity under physiological conditions (LAR- SEN (11)). On the other hand the fracture site too may be exposed to overpressure caused by a large hematoma and the ruptured veins may give access to fat droplets as far as they are not compressed. Experience shows generally that the hazard of fat embolism is not great and that it even is a particularly rare occurrence in the case of open fractures. MAATZ attempted to clari- fy conditions by means of animal experiments and with guinea-pigs and dogs he nailed as many as four long bones in the same animal without a fracture being pres- ent, so that the fracture cleft could not act as a decom- pression valve for the overpressure in the medullary cav- ity. The fat embolism found hereafter was so small that it was practically of no bearing. MAATZ, however, points out that patients who due to their fracture and its se- quelae are liable to embolism should preferably be ex- cluded from medullary nailing to avoid any additional fat embolism, as it' has the appearance that only the summation of the two factors becomes a real threat. HAEBLER, too, discussed this problem in detail and arrived at the same conclusion as regards practical action. One should not disregard the fact that the fatal hazard of fat embolism exists, though the figures for a fatal outcome due to fat embolism be ever so low, since only through a thorough in- vestigation of the causes will it be possible to meet it effectfully. For this reason the case histories published by HAEBLER shall be subjected to a closer scrutiny. They are particularly valuable because of the analysis he made of them. There were 6 deaths among 250 cases of medullary nailing. Two of them died from fat embolism, and a third case was also attributed to fat embolism by HAEBLER in view of its clinical picture, although the pathologist denied fat embolism as the cause of death. Unfortunately no histological examination was made. All these fatal cases were cases of femur fractures. Hence it results that particular care should be applied to the nailing of the femur. FISCHER and MAATZ found one case of death each with medullary nailing of the femur and the leg a- mong 200 marrow made before 1942. One of those deaths occurred after medullary nailing of both legs which was necessitated by fractures caused by a jump from a win- dow. Among our mat*.rial of more than 200 cases we lost on- ly one patient through fat embolism subsequent to medul- lary nailing. This was a 60 year old patient whose gen- eral condition was not good and who suffered from bilater- al oblique fractures of the femur. Both femora were trea- ted with medullary nailing in one session; this was one of our first cases of medullary nailing. With our present ex- perience one must conclude retrospectively that the fatal embolism could perhaps have been avoided if only one side had been treated first, and the other side at a later date after general recovery had ensued. Considering the conditions of mechanical pressure one should examine carefully whether it would not be advisable in case of a large fracture hematoma to immobilize the frac- ture by moans of wire extension until the hematoma is part- ly resorbed and thus the pressure of the hematoma upon the marrow cavity has lessened. Moreover one should consider that with old fractures whose cleft is filled with callus or cicatrized tissue the pressure valve can be restored artificially. In such cases it may perhaps be better to expose the fracture and to nail it after exposure (HAEB- LER) in order to avoid fat embolism, a procedure which has to be considered as an exception. This consideration how- ever should not lead to the deduction of a rule. A spec- ial decision must be made for every individual case. Data from the anamnesis, the-presence of adiposity, the condi- tion of heart and lungs, all must serve as guides in this decision. The sole example of fat embolism shows that the method of medullary nailing requires a very accurate evaluation in every individual case. But there is no reason to reject the method as a whole because of isolated failures. There is no doubt that the application of medullary nailing is rendered more complicated by such considerations and experiences than it appeared in the beginning, but it is particularly the ne- cessity to weigh the pros and cons in every single case which attracts the attentive surgeon as every fracture requires an individual operation. This is not the chief reason why me- dullary nailing ranges among the great operations of surgery. By all these considerations the whole field of indica- tion will be defined separately for every individual case, and our study shall contribute particularly to this end. In view of the relative newness of the method the same consider- ations make it advisable to restrict the method for the time being to hospitals in which all appliances are available, and which at least, 'as'regards technique, provide security by reliable asepsis and by the smooth applicability of all de- vices required for care... nl nailing and for the control of all possible complications. An X-ray apparatus is indis- pensable, and the best results are certainly obtained if the equipment permits operating with two roentgenoscopes simultaneously, as exact reduction must be accomplished un- der the fluoroscope in two planes at right angles before the nail is driven in. INDICATIONS FOR MARROW NAILING OF CLOSED FRACTURES. The indications for marrow nailing of closed fractures were classified by KUENTSCHER and MAATZ (12). According to their system the fractures of the long bones are classifiable in: fractures "most suitable”, "suitable”, "still suitable”, and "not suitable” for medullary nailing. Regardless of the opinion held about the classification of a complex biologic process it is obvious that in such a practical field as sur- gery, valuable hints are obtained by systematic classifica- tion and that this is the most appropriate method to present the observations and the results. In this way definite rules may be found and possibilities for comparison gained. It is natural, however, that the individual classes of the topio must be considered with the understanding that they refer to the typical form of the various types of fractures of the. long bones, that means after the elimination of all compli- cations. As it is not possible, however, to reduce nature to a rigid system it will hardly occur that the fractures admitted for treatment appear in their pure forms. Never- theless a certain simplification will always be of didaotic value and in this case it is left to the surgeon to use the schematic system for weighing the discrepancies and to clas- sify for instance a fracture as "not suitable” which accord- ing to the classification schema would be "still suitable”, and to exclude it from nailing and vice versa. In this field all of us still have to learn, and for this reason a certain system of consideration can only be of advantage. As yet no surgeon is compelled to nail fractures which he would rather like to treat otherwise according to his ability or audacity, and the non-performance of medullary nailing pres- ently can in no case be interpreted as malpractice. Far that reason KUENTSCHER and MAATZ (1945) stressed that every sur- geon who wants to become acquainted with the method should have an opportunity "to commence with a very limited range of indication". Experienced surgeons, among whom KUENTSCHER as the inventor of the method and his co-worker MAATZ have to be counted chiefly, may widen the range of indication. KUENTSCHER and MAATZ defined their opinion as follows: "Since its introduction the method has proven valuable to such a high degree that one is right to maintain that every "nail- able” fracture should be treated with the medullary nailing method". When studying in detail the indications for the medul- lary nailing of the various fracture types we rely upon the assumption that the general directives discussed above will be considered in every individual case. The local indica- tion principally depends on the mechanical conditions.^Af- ter an examination of the general condition of the patient and of all data recognized as important for the general in- dication for medullary nailing one will have to deliberate in the case of every closed fracture of the upper and the lower extremity whether or not medullary nailing is feasi- ble and in addition the question must be considered whether the reduction and retention of the fracture will be more successful with or without the medullary nail. This means that the surgeon must be capable of a critical judgement of his personal skill, his experience, and his dexterity, and that he must take counsel with himself whether he will be more successful when treating the fracture with a medullary nail or without it* Moreover it is necessary to consider after-treatment beforehand, as with an increasing experience with medullary nailing the result will turn out that one tends to use it more and more because it does not lead to muscular dystrophy and ankylosis of the joints. It is par- ticularly under the view point of early exercises that one is entitled to such a procedure also with those fractures whose reduction and retention would have been practicable with other non-operative methods. As outlined above in cases of closed fractures the in- dication for medullary nailing is definitely determined by the state of the injured extremity. If there is a very ex- tensive hematoma associated with a considerable swelling of the fractured limb or even dermal vesicles it is better to postpone medullary nailing to a later date when the swell- ing has subsided, the vesicles have dried, and the skin ab- rasions are covered with epithelium again, provided that it does not require more time than one can account for with re- gard to the reduction. In connection with the indication for medullary nailing, skin abrasions on principle involve a haz- ard of infection which must be considered as just as serious as the soiled wound of a compound fracture. Such a dilatory action and conservative treatment prior to reduction and the application of a plaster cast was usual so far in all similar cases. However, it shall be specifically stated here that for the choice of the time of medullary nailing the delibera- tions in the case of a compound fracture must be entirely dif- ferent from those in the case of a simple fracture according to recent experience. This will be given closer consideration below. With a closed fracture early medullary nailing is not the principal thing, and a dilatory treatment for a few days does not mean a waste of most valuable time, but it rather creates more favorable local conditions for medullary nailing. The local indication is largely determined by the proportion between the bone tube and the medullary nail and reversely by the possibility or impossibility to adapt the nail to the bone tube. Here motives originating from the theory of indication intersect purely technical factors so that it is not possible to describe each of the factors separately, since they are linked together. This was felt by all scientists who worked on the medullary nailing method and we regret that sometimes we will be compelled to repeat ourselves here. The width of the medullary cavity is not equal in all sections of the bone, but usually it is more narrow towards the middle. In consequence the nail to be driven in cannot be thicker than the most narrow part of the bone tube. This constitutes,a disadvantage as the difficulty of immobilizing a fracture by means of a medullary nail increases with the distance of the fracture from the most narrow part of the medullary cavity. We shall see later during the discussion of the various types of fractures that this disadvantage can frequently be compensated without causing noteworthy compli- cations by peculiarities of technical proceding which either refer to the nail insertion site or to the type of nail to be employed. Medullary nailing has excellently stood the test with multiple fractures. Here the single fragments can be thread- ed upon the-nail provided they still constitute whole parts of the tube, be they ever so short. ”A11 fractures involving the joints have to be excluded from medullary nailing as fragments which still are in a fair- ly favorable position may be driven asunder by the nail, as there is no sufficient hold for the nail, and as the joints ‘are endangered by its intrusion (KUENTSCHER and MAATZ 1945)• a) Humerus. Among the fractures of the humerus those of the middle of the shaft and the lower third are suited best, as here the cavity of the humerus has its smallest diameter. Amongst these it is the transverse fracture which can best be immo- bilized by the medullary nail (Illustration 1). The judge- ment of the situation is somewhat more difficult, if one is faced with fractures located very close to the shoulder or elbow joint, that means particularly in the case of frac- tures of the collum chirurgicum or with supracondylar hume- rus fractures. In the final analysis KUENTSCHER and MAATZ consider all humerus fractures as ’’very suitable” for medul- lary nailing, but we do not share this opinion entirely. The views of KUENTSCHER and MAATZ are based upon the fact that for nailing humerus fractures one can proceed from the prox- imal end as well as from the distal end. When the medullary nail is driven in from the proximal end, that means from a spot immediately below the humerus head with the supracondy- lar fractures close to the elbow joint, the nail at least acts as a bolt and prevents dislocation of the distal frag- ment even if it does not find a firm hold in the distal fragment because this is too short,If in addition the supra- condylar fractures are bedded upon an abduction splint or in a plaster cast, they can be held in an appropriate or fair- ly appropriate position. This frequently is really diffi- cult without the medullary nail. In this case the plaster cast and the splint need not remain for a longer time than until enough callus had formed to hold the fracture in place. EHRLICH (13) and HAEBLER (14) point to the fact that with the nailed humerus a distension of the fragments may occur due to the weight of the arm alone, that means that the fragments are forced asunder. We also made this ob- servation (Illustration 2). According to the observation of HAEBLER (15) distension of the fragments chiefly occurred with complicated fractures when, due to the impairment of the muscles, muscular traction was reduced. In such cases the danger of pseudarthrosis is imminent. One must antici- pate it and make the proximal or distal nailing dependent on whether the nail will find a firm hold in the peripher- al fragment. This will not always be the case. Therefore early roentgenoscopy is more important here than in any other case. The best evidence of instability of the frag- ments is the pain felt when they move. In many cases the pain reveals more than anything else whether or not the fracture is sufficiently immobilized. If there was a dis- tension the fracture must be reduced again by jolting, and this condition must be maintained by the application of a splint or a plaster cast. BOEHLER prefers to exclude from nailing fractures less than 8 cm distant from the elbow joint, as he does not con- sider them suitable. We do not believe that every case of fracture of the collum chirurgicum is ’’very suitable” as the 1 a 1 b Illustration 1. a) Before treatment b) Condition after medul- lary nailing from the distal end (a small piece of bone was cracked off on the nail insertion site)• Distension of the frag- ments# c) Condition after healing of fracture and removal of medullary nail* 1 c nail to be driven in from the dis- tal end only in rare cases finds » such a firm hold in the spongiosa of the humerus head that one could say that it is not preferable to immobilize the collum fracture with conservative methods rather than with the medullary nail. Just be- cause the retention of this type of fracture is usually successful even without medullary nailing we would like to regard medullary nailing as feasible but not as absolutely indi- cated. As with the fractures of the upper extremity there usually is no general indication for medullary nailing with the purpose of avoid- ing prolonged confinement to bed, treatment with the medullary nail- ing method i s not necessary in such cases. BOEHLER also holds that the fractures of the collum ehirur- gicum may be nailed, but this word- ing reveals that it is not absolute- ly indicated. It is advisable to divide the humerus according to KUENTSCHER and MAATZ into four parts instead of the usual three; division in four parts is apt to prevent misunderstandings. HAEBLER stated that he recently ap- plies medullary nailing from the dis- tal end "only to fractures in the low- m er third”. This opinion is easy to defend as the nail driven in laterally through the corticalis will find a firm hold with its head there as well as the lon- ger part of the nail in the long tube of the proximal fragment which is the case particularly when the most narrow part of the humerus is located in the proximal fragment and when the nail becomes securely stuck in it. If the distal fragment is very short, that means if the fracture is located in the dis- tal quarter of the bone, the lateral insertion of the nail is difficult unless one comes so close to the elbow-joint that this Is imperilled in its turn. Moreover with distal nailing one is bound to proceed very obliquely in a shallow curve through the corticalis to the medullary cavity. This may cause the cracking off of small bone fragments, an occurrence which as a rule does no harm though it is undesirable (Illus- tration 3)* This will happen all the more easily, as when nailing from the distal end one is compelled to insert the nail very close to the fracture site, since there is no al- ternative if the fracture is located in the distal quarter of the bone. Although no sufficient fixation of these short frag- ments can be expected from nailing from the proximal end in view of the above mentioned disadvantage we would like to give preference to nailing from the proximal end in such cas- es, because it permits the retention of these types of frac- tures so easy to dislocate and because it prevents lateral displacement'. When discussing the technique of medullary nailing we once again shall deal with the decision on whether Illustration 2« Distension of frag- ments of a humerus fracture. proximal or distal nailing should be applied. An addi- tional bandage insures fix- ation* b) Forearm. KUENTSCHER and MAATZ are very liberal as regards the width of indication for the medullary nailing of forearm fractures. This is revealed by Illustration 4 taken from the book of these authors. The typical radius fracture of the distal end'needs no medullary nailing, as treat- ment with the conservative method generally employed so far is usually sufficient,If this does not yield a satis- factory result, nailing also cannot improve the condition, since the distal fragment is too short to provide suffici- ent hold for the nail- Like- wise the use of the medullary nail in cases of olecranon fractures has not proven suc- cessful as the bone which is spongy there does not hold the nail (KUENTSCHER and MAATZ), Only a few cases of olecranon fracture with a particularly long fragment are suitable for medullary nailing (Illustrations 5 and 6)- BOEHLER considers all those forearm fractures as not suitable, "which with their distal end are less than 6 cm away from the joint", KUCNTSCHER and MAATZ ex- press it in a somewhat different manner but the result is prac- tically the same when they state that "all those fractures are suitable for medullary nailing" the shorter fragment of which still has a medullary cavity long enough to permit the medul- lary nail to stick in it. "Very suitable" are the transverse Illustration 3. Cracking off of wedge- shaped piece of bone dur- ing insertion of nail. Illustration 4. Width of indication for forearm (from KUENTSCHER and MAATZ, Technique of Med- ullary Nailing). All fractures within the shaded areas are suitable for med- ullary nailing* 5 a Illustration 5» a) Olecranon fracture and frac- ture of radius head. b) Condition after medullary nailing of olecranon fracture. 5 b 6 a 6 b Illustration 6. a) Olecranon fracture b) Condition after med- ullary nailing c) Restoration after removal of the nail. fractures of the forearm which are located in the middle of the shaft of both bones. Moreover we would like to consider treatment with medullary nailing as particularly indicated in the case of oblique fractures of the middle of the shaft of the forearm, as it is a common experience that their re- duction is difficult and that it is still more difficult to retain them in a good position by means .of a plaster cast. This will then lead most frequently to an operative reduc- tion, that means to the exposure of the fracture and to an operative immobilization of at least one of the fractured bones by means of one of the foreign bodies available for treatment so far. Infection and a delay of callus forma- tion, however, are in the background as dangerous incidents. No other method but medullary nailing is able to im- mobilize those fractures without an exposure of the frac- ture. HAEB1ER too considers medullary nailing superior to such methods as e.g. the double-wire plaster cast. Operative reduction is not avoidable in every case; but if one is suc- cessful in accomplishing medullary nailing while the frac- ture remains closed, the hazards are reduced to a minimum. If the nails are firmly seated exercises may be taken up early; in a case published by MAATZ this was feasible after 10 days. If only one of the bones of the forearm is fractured it should be nailed, if the two bones of the forearm are fractured it is advisable to nail both of them. Forearm fractures do not occur so frequently that every surgeon comes into a position to form his personal opinion about the suitability of the medullary nailing method for their treatment within a short period of time and with many cas- es. Therefore the literature shall be discussed here more thoroughly. Above all it had to be decided whether in the case of forearm fracture it is sufficient to nail one of the fractured bones and which of the two, radius or ulna should be subjected to medullary nailing in this case. B0EH- IER e.g. applied medullary nailing in the case of a green- stick fracture of both forearm bones, first only to the ra- dius and he obtained a satisfactory result of reduction of the ulna too. At-first the callus also developed well on both of the bones, as the X-rays (16) show. After 5 weeks,* however, the callus of the not-nailed ulna fracture was re- sorbed, while that of the radius remained excellent as re- gards shape and extent, and after 13 months there was a com- plete pseudarthrosis of the ulna while the radius fracture was consolidated by bone. This incident certainly is not the only case of that type and most probably it must be traced back to the fact that in the case of the not-nailed fracture the bone was resorbed v/ithin the range of the frac- ture cleft, as it can be frequently observed on X-ray pic- tures. The gap formed this way was not filled by callus and the nailing of the adjacent bone prevented the auto- matic union of the reduced fracture planes. Later on we shall have to deal several times with the problem of dis- tension. With such a condition no stimulus for the form- ation of callus can be expected from the medullary nail- ing of the pseudarthrosis bridging-over the gap, as the firmly healed neighboring bone acts as a "distending bone”. HAEBLER (17) employed other means, and he nailed the ul- na, probably because the performance of medullary nailing with a straight nail from the tip of the olecranon is sim- ♦ pie.and easy. His experience, however, brought forth the decision to nail the simultaneous radius fracture as well in spite of its being in a favorable ix>sition, because the proper objective of KUENTSCHERTs method, the stable osteo- synthesis, can only be achieved when both bones of the forearm are nailed. One must aim to attain this final re- sult if one desires to start early exercises. If one were to renounce it and were to oontent oneself with plaster cast, in most of the cases medullary nailing even of one of the fractured forearm bones would not be necessary• If 7 a 7 b Illustration 7* a) Forearm fracture b) Medullary nailing of both forearm bones c) Condition after healing of fracture and removal of med- ullary nails. it 1b possible, however, to subject both bones to medul- lary nailing, KUENTSCHER*s method in cases of forearm fractures doubtlessly yields better results than the other methods* The Giessen clinic was reluctant at first to ap- ply medullary nailing to both forearm bones (Illustration 7) simultaneously. This is quite natural as formerly conserva- tive fracture treatment was exercised in the clinic, and we shied from the use of met- 7 c * allic foreign bodies of such a big size. The tendency to be satisfied in cases of forearm fractures with a purely conservative method is an explanation for why today only few experiences with medullary nailing of closed forearm fractures are available. The majority of cases represents open nailing with slowly healing fractures, with fractures healed in an unsatisfactory position, and with pseudarthroses after forearm fractures. At first we used to nail the radius. Ulnar pseudarthrosis as observed by BOEHLER, did not occur among our oases (Illustration 8), but in view of the small 8 a 8 b Illustration 8. a) Fracture of the shaft of the forearm. b) Condition after nailing of radius c) Condition after healing of fracture of both bones and after removal of medullary nail. number of forearm nailings performed in our clinic,. this does not mean anything* For a critical evaluation of the method one failure is mere important than many successful treatments, be they ever so satisfactory, 8 c as it reveals the possibility of failures and suggests the measures of prevention. This observation and the opinion also held by HAEBLER that only by medullary nailing of both bones of the forearm a stable osteosynthesis is established induced us later to apply medullary nailing to both fore- arm bones. We should, however, like to warn not to enforce this goal under all circumstances, if there are technical difficulties or counter-indications of another nature. c) Femur. Medullary nailing was first performed on the femur. This is a natural consequence of the fact that the medul- lary cavity of the femur alone among the marrow cavities of the long bones resembles a straight tube. One can em- ploy an absolutely straight and rigid nail. The insertion site which is located medially to the tip of the trochan- ter major permits the insertion of the guide-rod and of the nail right in the final direction. For this reason very favorable technical conditions prevail for the per- formance of the procedure. Nevertheless we must consider carefully what fractures of the femur shall be treated with medullary nailing (18). It is particularly BOEHLER who points out explicitly what hazards of operative fracture treatment too freely employed so far can be avoided by the KUENTSCHER method particularly in the case of the fe- mur. The literature references about incidents including the death of the patient reported by BOEHLER (19) which have occurred in the course of operative fracture treat- ment involving the exposure of the fracture site are tru- ly frightening. By means of KUENTSCHERfs medullary nail, which is inserted far distant from the fracture site,this hazard can be eliminated in the majority of the cases. With the nail firmly seated the opportunity to take full advantage of the method is so great that it is worthwhile in every case to consider whether or not it is permissible to renounce this favorable outlook for treatment. BOEHLER is justified in raising objections against an uncritical operation of the femur fracture whon there is only lateral displacement of the fragments the reposition of which ac- cording to his experience is not as important as to per- mit or indicate the exposure of the fracture. Lateral dis- placements will be easily corrected by medullary nailing as well. If, therefore, with closed femur fractures considered with a view to the site of the fracture, doubts are raised whether or not medullary nailing may be applied, that means if one is convinced that one is able to yield as satisfac- tory results by conservative treatment as by treatment with medullary nailing, the general indication is decisive. Age, general health, shorter or longer confinement to bed, and all other considerations of this kind will very frequently speak in favor of medullary nailing and with an increasing experience the decision to apply marrow nailing will become easier, as observed by ourselves and other surgeons. A matter of greatest import is to accurately follow the rules for the reduction which in any case - here as well as with other bones - must be performed prior to med- ullary nailing. The marrow nail is no reduction appliance, but it merely serves for the purpose of retention; it con- stitutes a splint which is applied inside the bone instead of outside.# Reference to this was made above, but it is just with the femur fracture that these elements must be observed with particular care, and it is for this reason that we would like to call attention to them once again when these fractures are discussed. The technical performance of the medullary nailing of the femur sometimes may be easy und under favorable circumstances may be accomplished within ten minutes. But that should not lead to extend in the case of the femur the indications for the medullary nailing of fractures farther than with other bones, because if difficulties of technique occur it is particularly here that they cause complications involving even danger to life. The marrow cavity of the femur is larger than any o- ther and in older persons it, therefore, has the greatest fat content, so that here the hazard of fat embolism is greater than with other bones. This finds its expression in the fact that the majority of fat emboli associated with the medullary nailing were observed particularly with the femur. Shock, position of the patient, spinal anesthesia, size of the nail as a foreign body, all these circumstances assume importance with the medullary nail- ing of the femur fractures which influence much more the whole organism than it is the case with fractures of the smaller bones. Therefore, with the femur fracture cau- tion is advisable in every regard. After critical examin- ation of the failures FISCHER and MAATZ (20) arrived at a similar opinion, and they wrote: "The deaths occurring af- ter medullary nailing of the femur and the leg reveal that this operation which really is not great may be the deoisive factor for the fatal result when there are other simultaneous injuries. This does not mean that some of the patients would not have died if marrow nailing was not performed". HAEBEER goes so far as to contend that medullary nail- ing of the femur is more difficult than any other type of medullary nailing. This fact, however, is traced back by him to the difficulties of reduction. More recently with increasing experience his opinion might no longer be valid in this pointed manner. The technique of reduction will be discussed in detail below. The technical difficulties may be set aside to a great extent, nevertheless there remains the question of what is the indication for the medullary nailing of the various types of femur fractures. Particularly suited for medullary nail- ing are the transverse and the oblioue fractures (Illustra- tion 9, 10, 11). According to KTJENTSCHER and MAATZ the most suitable range for medullary nailing of the femur shaft fracture is located at least 6 cm below the trochanter ma- jor and at least 8 cm above the condyles. Medullary nail- ing was extraordinarily successful in case of multiple frac- tures (Illustration 12) the fragments of which can be thread- ed upon the nail (see also BOEHLER (21) and EHALT (22). For the treatment of the subtrochanteric fractures a specially shaped nail is required (see Technique). The long spiral fractures are less suitable, as with these the medullary nail frequently does not find sufficient support, and as it is not 9 a 9 b Illustration 9. a) Short oblique fracture of femur shaft b) Condition after medul- lary nailing c) Condition after heal- ing of fracture and re- moval of medullary nail. possible to avoid the danger of rotation. Nevertheless ex- cellent results may be obtained with the spiral fractures (Il- lustration 13 and 14)• As soon as additional supports such as plaster bandages or wire exten- sion are required for the re- tention of the fracture, the medullary nailing method is de- prived of its most essential advantage: immobilization while movement is unimpeded. Here it becomes a doubtful procedure a- gain, as in such cases the ques- tion arises whether it is per- missible to apply medullary nailing if its superiority cannot be fully exhausted, and whether one rather is not obliged to renounce its use and to spare the patient this operation which under favorable 9 c 10 a 10 b Illustration 10. a) Short oblique fracture of femur b) Condition after medullary nailing. Cracked off bone piece c) Condition after healing of fracture and removal of medullary nail. conditions, however, eliminates all disadvantages of the conser- vative method. A type of femur fracture whose treatment, as is well known, may cause considerable inconvenience is the supra- condylar fracture. With this type of fracture one constant- ly has to oppose the tendency of the peripheral fragment to deviate at an angle from the longitudinal axis and it is par- ticularly here that many methods were suggested endeavoring e.g. to accomplish treatment with several wires pierced through the bone. Due to the shortness of the distal frag- ment with these fractures a satisfactory mechanical fixation of the medullary nail will be possible in very rare cases on- ly. Here the conditions are somewhat similar to those prevail- ing with the supracondylar fracture of the humerus. But par- 10 c 11 a 11 b 11 c Illustration 11, a) Transverse fracture of femur b) Condition after medullary nailing c) Condition after healing of frac- ture and removal of medullary nail. Formation of bone resembling exos- tosis above fracture. 12 a 12 b 12 c Illustration 12, a) Multiple fracture of femur b) Multiple fracture of femur threaded upon medullary nail c) Condition after healing of fracture and removal of nail. 13 a 13 b Illustration 13, a) Spiral fracture of femur with frac- ture line extending to knee-joint (leg of same extremity amputated) b) Condition after medullary nailing and progressive state of fracture healing.Five years after medullary nailing the nail is still in place without oausing discomfort, 14 a Illustration 14* a) Long spiral fracture of femur b) Condition after medullary nail- ing and progressive state of fracture healing. 14 b ticularly with those fractures medullary nailing is very helpful as it prevents the distal fragment from angulation* There is no other method to effect it with the same security* Here the nail acts as a pin or a bolt. KUENTSCHER and MAATZ therefore consider the supracondylar femur fracture as "very suitable” for medullary nailing* Even though an additional support (plaster bandage extending over the whole extremity) is indispensable (after KUENTSCHER and MAATZ for k weeks) the favorable outlook for a satisfactory result and for the pos- sibility of early exercises leads to the decision to perform medullary nailing in the case of this type of fracture too* Extending the width of indication we purposely go beyond HAEBIER*s postulate to nail the supracondylar femur fracture only in those cases "in which one does not succeed in retain- ing the reduction by a plaster bandage or permanent extension". d) Leg. The indication for the medullary nailing of the leg fractures to a great extent depends on mechanical factors* One may begin by stating that only the tibia has to be nailed, while medullary nailing of the fibula can always be omitted and no other surgeons practicing medullary nail- ing perform it. The medullary cavity of the tibia varies in width* As usual the nail fits best in the most narrow part which is locate the borderline between the middle and lower or this reason osteosynthesis is most successful 11 it is applied to the transverse fractures oc- at this level# EHALT. considers medullary nailing .urie most appropriate treatment of this type of fraoture. As the diameter and the shape of the nail must conform with the medullary cavity a really stable osteosynthesis cannot be accomplished with those fractures of the tibia which are located in other parts of this bone. The experience gath- ered with the so-called spread-nail is not wide enough to permit final opinion on it. KUENTSCHER and MAATZ attempted to give a yardstick for the indication for medullary nail- ing of the leg. As in many cases their hints are very use- ful for the decision of whether or not medullary nailing should be performed, they will be given here onoe more: "The minimum length of the shorter frag- ment cannot be given in centimeter values, as the shape of the medullary oavity is in the de- cisive factor. If there is a great discrepancy between the smallest and largest diameter of the medullary oavity, that means if there is a considerable disproportion between the thick- ness of the nail and the width of the marrow oavity, the r ange of the fractures "suitable for medullary nailing" moves towards the middle of the length of the shaft. The borderline be- gins where the difference between the diameter of the medullary cavity (m) and the diameter of the nail (n) is equal to or greater than the di- ameter of the bone cylinder (k), so that the fragments no longer are compelled to stand upon each other, but rather that one fragment can topple off the other " (Illustration 15)* We shall be faced with this problem once more when we discuss the selection of the nail. Illustration JLLi For fractures of the leg the proportion of the dia- meter of the medullary nail (n), the diameter of the med- ullary cavity at a level with the fracture (m), and the di- ameter of the bone mantle (k) is decisive. Here the equa- tion is valid: m-n = orone and the delay of the healing of the tibia after medul- ary nailing which is linked to that. Slowly healing though tailed fractures of the tibia, therefore, should not be con- idered as a drawback of the method, as the mechanical con- ations implied in the presence of two bones or the biologic- .1 fact of the consolidation of the fibula fracture frequent- .y setting in earlier, cannot be eliminated. As regards the indication for medullary nailing of leg ractures, therefore several clear directives of a general 16 a 16 b Illustration 16, a) Low transverse fracture of leg b) Condition after medullary nailing c) Condition after healing of fracture and removal of nail • and local nature can be estab- lished. i?he general consider- ations refer to the age of the patient, to the condition of his circulatory system, and to the hazard of fat embolism, for which the period of time elapsed since the injury may play a cer- tain role (obstruction of the pressure valve through a big pressurized fracture hematoma or by formation of callus which has already set in); the local considerations depend on the type of the fracture, whether simple of compound, or the tech- nical possibilities originating from the mechanical conditions, and on the hazard of infection. As in every difficult oper- ation a certain play must be given to'the skill, the experi- ence, and the temperament of the surgeon. 16 c This is a purely individual or psychologic factor and it must seriously be taken into account, because it seems to have a decisive influence upon the views held with re- gard to medullary nailing. This has been mentioned sever- al times, and any surgeon about to apply medullary nailing should consider this factor as much as any other as decisive for the indication for medullary nailing. With almost all surgeons examining the method the observation may be made that from initial doubt their attitude gradully changes to acceptance and the same happened to us. From now on opinions will differ. There are surgeons wha become'enthusiastic a- bout medullary nailing and increasingly fond of it. This shows in the choice of the alternative beginning with the question which fracture must be nailed by all means and progressing to the other extreme which fracture cannot be nailed as yet under the present circumstances. The more, critical surgeons who are less enthusiastic form an opinion on the positive and the negative sijle of the problem. This does not mean that they are able to weigh the advantages and disadvantages of the method systematically but rather that their decision is accompanied by never ceasing doubts and the concern about the right means to be applied. It certainly is not incidental that such an expsrienced emer- gency surgeon as LORENZ BOEHLER devoted a special chapter to the psychology of the surgeon in the third volume of his book on the technique of fracture treatment which deals exclusively with medullary nailing. The technique of medullary nailing may be easy and it may be performed quickly and elegantly, but every person with experience knows that incidents may occur which can be controlled or predicted only after long surgical prac- tice. This has nothing to do with surgical dexterity but it may occur in every operation. lust as during an.appen- dectomy one may be faced with unusual situations which can- not be overcome by a less experienced surgeon though thorough- ly in coiomand of the typical operation, medullary nailing as. belonging to the major operations frequently may be accompanied by difficulties which for their elimination require the skill and a certain undeterminable factor of mastership that can only be acquired by extensive professional experience. There- fore medullary nailing should not be considered as an inter- vention which is always easy and in no case should it be as- signed to an insufficiently trained assistant. The surgical clinic at Giessen as one of the first to take up medullary nailing was fully aware of its responsi- bility for the injured and it first began within.very con- fined limits to check and develop the method. Since the ex- perience gained was favorable the clinic was able to widen the indication gradually in the course of the last.years. This was done under critical evaluation of every single case and under regular comparison of the current reporting of other surgeons, particularly of the Kiel school which, as the inaugurator of medullary nailing, "naturally was very liberal in the use of the method in order to test it" (FISCHER and MAATZ). In the beginning we therefore subject- ed only simple fractures to medullary nailing and among these preferably those of the femur, since the superiority of the new method over all others practiced so far was par- ticularly obvious here. The experience permitting the widen- ing of the range of application of medullary nailing and the particularities with regard to the selection of the case as well as tha increasing security and refinement of the technique leading to the same result, are revealed best by the publication of our material and the success and the failures obtained with it* Medullary nailing of the clavicle is only indicated if/there is a considerable dislocation of the fragments and if reduction cannot be accomplished with conservative methods. This is rarely the case* Sometimes, however, the pressure upon the brachial plexus urges operation (Illustration 17)* a Illustration 17* a) Fracture of ciavicula b) Condition after medullary- nailing* Formation of callus sets in* b TECHNIQUE OF PERCUTANEOUS MEDULLARY NAILING of1 Prior to any discussion of the special problems associated vith medullary nailing the technique shall be described as em- ployed in all the cases of the Giessen clinic and as it has leveloped there in the course of the last years. This will De preceded by an account of all those matters and appliances vhich are fundamental for every medullary nailing. The finer sechnical development which has proven necessary or useful 'or some types of fractures shall be demonstrated when the respective section of the extremities and the treatment of its fractures will be discussed. Concerning the numerous variations of the technique !armamentarium etc.) special reference is made to the des- iription by KUENTSCHER and MAATZ. We are not so much con- cerned with an exhausting description of the appliances md instruments and their use, but rather with the demon- stration of our personal procedure, and although it is not ‘ree from subjective judgement we hope that it will be use- •ul for those surgeons who like ourselves are compelled to- .ay to rely on a minimum of technical devices, due to the ;reat difficulties in the procurement of instruments and ppliances. The technique of medullary nailing is still in the stage of development. If we add another technical chap- ter to the literature on the Kuentscher-nailing despite the fact that there are already several publications by several outstanding orthopedic surgeons, we are guided by two considerations. The emergency of our time has made us particularly conscious of the shortage of tech- nical equipment and the inability to manufacture special devices for this very technical method in Germany. This urges the restriction to a very simple technique in the field of medullary nailing. This may even be considered as an advantage* Thus attention is focussed on the har- mony between physiology and technics, biology and mechanics. On the other hand one-should not forget that particularly in fracture treatment, where there is a preponderance of the mechanical requirements, a specified technical outfit simplifies the execution of the tasks even for those tech- nically less endowed, improves tie results, and thus best serves the patient. Seen from this angle we must regret many a gap in our equipment as being a considerable dis- advantage. When describing our experiences and results, however, the description of the methods by which they were obtained is a matter of necessity. The lack of a practical reduction appliance was al- ways considered a particular handicap. The exact anatomic reduction of the fragments should always precede medullary nailing, because only in this way does the operation re- main a relatively minor procedure. One must postulate that such an appliance secures retention of the fragments at least during the Insertion of the nail. This postulate is apparently met by the reduction appliance of MAATZ (23)(2k)• We do not dispose of this "Kiel model" and we had to rely on auxiliary devices. Other reduction appliances have been designed specially for the leg and the humerus by LINSMAYER (25) and by WITTMOSER (26). We always had excellent re- sults with BOEHIER's screw extension apparatus which was of special use for the medullary nailing of the leg fractures. BOEHLER (27) also described special devices. Another difficulty lies in the manufacture of special types of medullary nails. We, as well as most surgeons, are dependent upon using machined marrow nails available commercially. It is ouite obvious that the nail really should be specially shaped according to the bom for which it is intended. The ideal condition would be that for every bone an appropriately fitting nail could be chosen or manu- factured. Apart from the fact that today there are no means as yet to transmit the dimensions of the bone onto the med- ullary nail, as the shape of the foot is transmitted onto the foot support, there are, nevertheless, certain cases in which the special manufacture of the medullary nail determined in its shape by the bone or by the shape of the fracture would be desirable. It would at least be an advantage to dispose of a stock of specially shaped medullary nails in addition to the nail sets presently available. Such nails were recommended by KUZNTSCHER and MAATZ for particularly wide medullary cavities. Moreover it is desirable to dis- pose of nails armed with saw-teeth for the perforation of those sections of the medullary cavity which are obstructed by solid callus. They are required when rofractures or fractures with a delayed callus formation are to be nailed. An indispensable requirement for medullary nailing*is an extension table or an operating table with an attachable extension applianoe. It is quite out of the question to undertake medullary nailing without extension appliances, and no surgeon should be allowed to attempt such an enter- prise relying on his technical skill, and it should be con- sidered as an obvious lack of responsibility if such a thing were to occur. For the medullary nailing of the low- er leg something like BOEHLER's screw extension apparatus also is indispensable. Lacking the special apparatus, ex- tension appliances for all directions must be available for reduction. A further basic requirement moreover is sufficient as- sistance . This refers to a lesser extent to the operation itself which with the so-called percutaneous medullary nail- ing is a minor operation only. Only medullary nailing com- bined with an exposure of the fracture and operative reduc- tion necessitate the presence of one or two assistant surgeons. This does not go beyond the practice employed in all other operations. When commencing even the seemingly most simple medullary nailing operation, one must be prepared in case un- foreseeable circumstances suddenly require operative reduction. In this case the operation is considerably more extensive. In cases where unsuccessful efforts force one to extend the oper- ation, the procedure should be concluded as .promptly and care- fully as possible. Such action should not be handicapped by insufficient assistance. One therefore can only give the urgent advice not to begin by underestimating marrow nailing as an operation and little service is rendered to the patient, to the method, and to the reputation of the responsible surgeon by a failure. This may also be considered as a hint to the fact that no medullary nailing should be undertaken in hos- pitals with an insufficient number of medical personnel. The special role of the fluoroscopist shall be mentioned below. One of the most important requirements is a suitable X-ray apparatus. It should be possible to screen the nailed extremity on the operating or extension table as well as to take X-ray pictures of it. It would be most appropriate, of course, to have two X-rays at hand, as fluoroscopy should al- ways be available in two planes and as the readjustment of a single X-ray tube requires some time during which the reduced fracture may be disturbed. Reduction, therefore, is always checked with the fluoroscope; it even would be preferable to accomplish it under fluoroscopic observation, at least as far as the final adjustment is concerned. Then it usually is easy to introduce the medullary nail. The length of the medullary nail may also be determined before the insertion by simply laying it along the injured extremity with simul- taneous fluoroscopy. From these conditions the question emerged repeatedly who really is the more important person during medullary nailing, the surgeon operating the fluoros- cope or the surgeon driving the nail in, because there is no doubt that the most important part of medullary nailing is reduction for which the screening surgeon is responsible. The maintenance of asepsis seldom permits the operating surgeon to check the result of reduction himself. There is nothing more disastrous during medullary nailing than in- sufficient asepsis. Though the most important part is as- signed to the fluoroscopist, and the operater has to rely fully on him, we always maintained that the full respon- sibility for medullary nailing lies on the shoulders of the operating surgeon who accomplishes the operation pro- per, be it ever so small and easy to perform* Screening is a matter of the assistant. However, one may also pro- ceed otherwise, making it more easy for the operating sur- geon tobear the responsibility: he is to reduce the frag- ments first and immobilize them by an appropriate appliance or by reliable extension appliances, to prevent the frag- ments from re-dislocation while the nail is introduced. Only after reduction is performed are the hands to be scrubbed and the medullary nail driven in. In this case the screening assistant is charged with the task of check- ing the fitting of the nail in the medullary cavity, the passing of the fracture site, and of checking the lower limit to which the tip of the nail may or shall be hammered in. Little time is lost when such a procedure is employed, and through the certainty about the position of the frag- ments as well as the personal knowledge about the conditions prevalent in the fracture obtained during reduction, as well as by the recognition of the tendency of the fragments to dislocate, this loss of time is amply balanced for the operat- ing surgeon. Such observations sometimes exert a consider- able influence on the introduction of the nail. Thus, for instance, in some instances successful passing of the frac- ture site is only possible, when the tip of the nail is pointed downwards or to one side. These are details of tech- nique which may be decisive for the practical performance of the operation. Medullary nailingshould not be performed without a port- able roentgenoscope, the so-called cryptoscope (Illustration 18). Roentgenograms are no substitute for the control of the Illustration 18. Cryptoscope according to BRAUN, For operation and reduction the surgeon looks through a "noephan” glass (speci- ally smoked glass) without taking off the cryptoscope (after B0EHL3R: Tech- nique of Fracture Treatment). mobile fragments and it may frequently happen that unfore- seen difficulties of reduction occur requiring so many roent- genograms in two planes that the whole operation becomes ex- pensive and dangerous to the patient and the staff. When proceeding with the aid of the cryptoscope strict attention has to be paid that neither the roentgenologist nor the en- tire operating group are exposed to the damaging effect of the X-rays. The medical personnel should endeavor to pro- tect themselves against the X-rays, the effect of which adds up with frequent medullary nailing. The roatient is exposed to the irradiation only for the short period of the surgical part of the intervention. BOEHLER devoted a short but im- pressive chapter of his book to the problem of protection a- gainst irradiation. There is not much to be said about the basic stock of instruments (Illustration 19)* It does not require mention- ing that the medullary nails should be available in all usual lengths and diameters. Illustration 19. Instruments for nail- ing. Experience has shown, however, that some surgeons were so eager to begin with medullary nailing that they commenced it without even having an extraction instrument (28), This, however, is just as important as the nail and hammer, be- cause it is by no means the rule that the first nail will fit correctly with the first insertion. If in such a case one is compelled to extract it again, one will be astonished in the beginning of the great amount of force necessary for this and all other solutions will either not lead to the de- sired result at all, or only after prolonged attempts. All this can be avoided by using an extraction instrument. We have always obtained very good results with the so-called ex- traction-hook and the slotted extraction-hammer. We had un- satisfactory results with the construction of a traction pul- ley, in which a wire threaded through the nailhole was wound up on a windlass and pulled the nail out of the medullary cavity. The wires broke, or the windlass pressed into the bone and caused inconvenience by tissue damage (29)* Never- theless it may occur that no force is able to move the nail forwards or backwards. Then the only means is to saw it off level with the wound. Therefore a metal saw which can be sterilized also belongs to the standard set of instruments. In such oases one must wait until the bone atrophy setting in around the nail in the course of time permits the removal of the remnants of the nail after a few months. The frac- ture then of course cannot be treated by medullary nailing, and the conservative methods must be used* After this short discussion regarding the appliances and instruments which are the same in all types of medullary nail- ing, the special details for each type of fracture will be des- cribed. In accordance with the purpose of this treatise we shall confine ourselves to our own method. References con- cerning discrepancies from the general literature shall be given wherever necessary. We will assume that we have to deal only with simple fractures and for better survey we shall at first describe only that part of the technique which is typical. a) Humerus. The technique to be applied on the humerus shall be des- cribed in all details with the purpose of outlining our tech- nic as completely as possible, as many particulars can be shown which are repeated with every medullary nailing so that one can refer to them when the remaining extremities are dis- cussed. For the medullary nailing of humerus fractures we either employed general anaesthesia or plexus anaesthesia. The lat- ter makes the intervention as a whole less trying, but we con- tend that it is not permissible to insist on the performance of medullary nailing under plexus anaesthesia. When the pa- tients are very anxious or nervous, general anaesthesia is more convenient for the surgeon as well as for the patient. Finally one must consider whether or not reduction can be ef- fected without the complete elimination of the muscular ten- sion. Local anaesthesia was employed in very rare cases on- ly, and even KU3NTSCHE3R and MAATZ have recommended it only with the forearm. BOEHLER shows more liking for local anaes- thesia, but for the humerus he prefers conduction anaesthesia, while for the lower extremity he is more fond of spinal anaes- thesia. Generally speaking local or conduction anaesthesia offers the advantage of facilitating the bedding of the pa- tient. A matter of the greatest importance for any kind of re- duction is the position (Illustration 20) of the body and of the extremity and three requirements must be fulfilled: One of them is to accomplish the reduction of the fragments as smoothly as possible, another to take care that the nail- ing procedure can be performed without a second change of the position. The third requirement is that the fluoroscopy which is indispensable for the two above mentioned procedures should not be impeded by the position of the patient. During the medullary nailing of the humerus the patient is to be laid in dorsal recumbent position and the shoulder of the in- jured side should slightly project over the edge of the opera- ting table. BOEHLER used to put the injured extremity in his screw extension apparatus. The thorax has to be fixed to the operating table with a large unpadded belt which is applied closely below the axilla. The shoulder joint as well as the elbow joint are bent to 90 degrees. Thus it usually is easy to accomplish the reduction of the humerus fractures by ex- tension and counter-extension - if necessary by moans of a wire pierced through the proximal end of the ulna. KUENTSCHER and MAATZ recommend traction with a cuff applied to the hand while the arm is extended and abducted by 45 degrees in the houlder joint. If there is no extension apparatus care has o be t aken that a sufficient number of assistants are present ho are strong enough to ke-op the reduced fracture in the osition desired. a b c Illustration 20. a) Position for humerus nailing in the screw extension apparatus after BOEHLER b) Position for humerus nailing after LINSMAYER c) Position for humerus nailing after WITTMOSER (From BOEHLER, Technique of Fracture Treatment) d) Position for humerus nailing after KITE NTS CHER and MAATZ (From Technique of Medullary Nailing) a ThQ medullary nail has to be selected of appropriate I length and diameter. Its length does not depend on the | length cf the fractured bone, but it rather must be taken !into account that the medullary nail will have to extend from the insertion site to the upper or lower portion of the bone; it therefore has always to be shorter than the 1 bone. The length of the medullary nail, however, may also be determined after the area to be operated is draped by |placing the nail upon the covering sheet, and then its jlength can directly be compared by fluoroscopy with the (bone. The determination of the correct diameter of the medullary nail causes more difficulties. Its thickness has to depend on the most narrow part of the medullary cavity. Too thin a nail does not provide a stable osteo- synthesis. In this case the fragments will be loose and the operation will end as a failure. If the nail is too |thick it may not be possible to drive it beyond the most ;narrow part of the cavity. Still more harm is done by forceful insertion of too thick a nail vA th the final re- jsult that the bone bursts asunder. Although this seems to be a rare occurrence it means a hazard involving an injury which should be avoided by all means. Sometimes smaller parts of the bone are cracked off in the area near the fracture. Even though it does not result in an irreparable damage it means a lack of care chargeable to the operating surgeon. KUENTSGHER and MAATZ recommended a "metal scale” to be laid alongside at a level with the bone before the first roentgenogram of the fracture is taken. If the focal ray is directed through the scale land the center of the bpne, an equivalent perspective is obtained upon the X-ray film. Every step of the scale is 2 mm. long. The steps are valid for the longitudinal axis of the extremity and thus it can be avoided that the tor- sion of the measuring scale acts as a source of errors. Thus the width of the medullary cavity can be read off with the first roentgenogram taken. BOEHLER, as well as our- selves, so far has had no reason to use this auxiliary. With the usual focal distance of SO cm., which must remain the same for all pictures, 1 mm. must be subtracted from the medullary cavity shown on the roentgenogram of the humerus, because of the enlargement of the proportions caused by the distanws: The thicker nail was driven in laterally into the med- llary cavity until its tip had safely passed the fracture Ceft. For this purpose the insertion hole had to be bored Hh special obliaueness and depth. During introduction the Cncave.cross-section of the nail should not point in post- al0** direction as usual, but in medial direction. This is to achieve by putting an instrument (forceps or elevator) Ito the eye .of the nail, by means of which rotation in post- Qior direction is prevented. Before the thinner nail is in it must be bent appropriately by hand so that the ourva- tion of the lower end of the nail is almost eliminated, the nail assuming a slightly S-shaped profile as a whole. Now, this nail must be driven in in such a way that the two con- cave sides point against each other and that the seoond nail slides with its hollow upon the V-shaped arm of the first nail as upon a rail. (Illustration 29)• As long as both Illustration 29» Schematic design of how to use a double nail for the tibia as a spread nail. nails project by 3 or 4 cm. over the bone, the tip of the thinner one shows no tendency as yet to deviate from the rail . The desired spread of the nail tips still is par- alleled by a certain spread of the upper nail ends. If in the course of further proceeding both nails are hammered in together, the upper ends approach each other, because they are pressed together by the insertion hole. Their tips spread to the same measure. This involves no danger, as the two nails already have passed the fracture site. In this way a firmer fixation and a larger total cross-section of the nails can be obtained by the spreading of the nail tips and thus a better filling of the distal medullary cavity is achieved (Illustration 30). After satisfactory experiments on skeletons the procedure was practiced on patients. Illustration 30. Modified double nail, (after WEIS) Medical history: 18 year old male patient with a transverse fracture in the lower third of the leg (Illustration 31)• Medullary nailing was performed with a double nail employed as a spread- nail. A clinically satisfactory stable osteosyn- thesis was obtained. After 1 week the limb of the patient was subjected to weight-bearing. Dis- missal three weeks after medullary nailing. The gait was normal and caused no pain. a b Illustration 31• a) Transverse fracture of leg b) Medullary nailing with modified spread-nail c) Weight-bearing one week after medullary nailing. c This method was used in another 4 cases with the same good result. In none of the cases was an additional external immobilization necessary. Nevertheless we would not con- sider the method as more than an improvized auxiliary pro- cedure. Satisfactory results are to be expected only in particularly suitable cases. The eligibility of a fracture for this method does not only depend on the sfte of the frac- ture which has to be at the most narrow part of the medul- lary cavity of the tibia, but also on its type. Only trans- verse fractures and short oblique fractures are suitable, as the surfaces of their fragments fit well upon each other, and as the medullary nail is not expected to prevent lateral sliding off or longitudinal dislocation. ( In exceptional cases KUeNTSCHER and 1,'IAATZ per for filed, me- dullary nailing of the tibia from the medial malleolus, that means in the inverse direction from the distal end towards the proximal end, while the medullary cavity was very narrow (6 mm.) and while there was an oblique fracture located be- tween the middle and lower thirds. In this case the turn- spread-nail would not have been sufficient for immobilization. We, too, performed medullary nailing from the distal end towards the proximal end in one case and the final result was really good. The double nail,-however, was not driven in from the medial malleolus, but from a place located in the lower third of the tibia. Thus it was possible to take advantage of the internal friction for a firm hold of the nail along the whole length of the short proximal fragment. Typical medullary nailing from proximal to distal would have encompassed less than one half of the proximal fragment, and as the X-ray pictures revealed later (Illustration 32) it would have had to be considered as not suitable for medullary nailing. We believe however, that this mode of proceeding is beyond the limits of the capacity of the medullary nailing method and that treatment by wire loop (see below) is more conservative if one has decided to rely on operative treatment. A particular disadvantage of proceeding from the distal end is the danger of penetrating into the upper foot-joint. Only a little experience could be collected with the modpilary nailing of the fractures of the clavicle,as it rare- ly Occurs that it must bo performed. It does not make any difference whether the nail is driven in medially or laterally (Illustration 17). The width of the medullary cavity is the decisive factor, as it may be so narrow that even the thinnest nails are too thick. In this case they may be replaced by Kirschner wires, but it hardly is possible to achieve a stable osteosynthesis with them. They may provoke an abundant formation of callus (callus luxurians) which involves the danger of compression of the brachial plexus. In such cases a i wire loop is preferable,' possibly in concurrence with a steplike freshening of the fragments. T.j3 retraction of the medullary nail is effected not earlier than 'when the roentgenograms display a completely organized callus and when the fracture cleft has disappeared. It causes no particular technical difficulties. BOmHLhR recommends the wire grid of JhhCHKE which is laid upon the i extremity in the region of the nail head and roentgenographed I together with the bone. It sometimes may facilitate the lo- i calization of the nail head of the bone has grown over it or if the nail has wandered deeper into the medullary cavity resulting in the disappearance of the nail head into the insertion hole. Usually an incision in the old scar under local anesthesia is sufficient to discover the nail. Due to the atrophy of the bone around the nail formed in the course of time, it usually can be extracted without any special appli- ance. In some cases the nail head must be exposed by means of gammer and chisel. During the extraction of the nail pain is felt and for this reason w© prefer to give a short evipan or bthyl chloride anesthesia. After the removal of the nail the small incision is sutured again I When double nails wore inserted and if they coincide on the roentgenograms so that they appear as one single nail it is recommenddfcto take X-ray pictures after the extractio'Fof the nail, as it has that the second nail escaped notice and remained in the medullary cavity. This may particularly occur if one is compelled to remove nails which were put in long ago in another hospital and if the patient neither is Informed about the details nor in the possession of Slevant medical documents. a b Illustration 32 a) Log fracturu with short proximal fragment. b) Medullary nailing from distal with double nail. c) Satisfactory adjustment of fracture. Advanced stage of callus formation. c In our hospital an incident occurred during the extraction of a double nail of the tibia which shall be mentioned here. While a rather firmly seated nail was removed the double nail located below it penetrated with its head into the knee-joint (Illustration 33). It was not difficult to remove it through a small incision which, however, opened the knee-joint. No infection set in and the joint was freely movable afterwards Csee also OPITZ Illustration 33 Double nail penetrating in- to the knee-joint during ex- traction. SOIIE ERRORS. AND RI3N3 CONNECTED WITH lEDULlARY NAILING. Subsequently I want to refer to several complications which usually result from a faulty technical procedure. We shall limit ourselves to personal observations and to the more significant literature references. There are numerous publica- tions about minor incidents (usually published in the Zbl.Chir. or Chir.). One of the most frequent errors is to use too short a medullary nail. Due to the lever effect of the longer part, the shorter end may be subjected to bending and this not only involves the nail alone, but also the whole fracture (Illustra- tion 34). If the nail is strong enough to resist bending in such cases, it may in turn become the cause for the splintering off of bone splinters within the area of the fracture (Illustration 35), so that the nail tip protrudes from the medullary cavity laterally and penetrates into the soft tissue. If too thick a nail is introduced with great force, it may happen that' the bone is forced asunder as if a wedge was used (Illustration lo). Such an incident was described by SPRLNGEIIi (35). Illustration 34 Cur vat ion of a humerus fracture caused by too short a nail. Illustration 35 A large piece of bone is splintered off as a result of too strong expansion while bending, the medullary nail being too short. Other complications have their source in the use of too long nails and may be classified under the heading of wandering of medullary nails. T"e observed them after nailing a sponta- nous fracture of the femur, where the nail moved upwards, so that it had to be replaced twelve months after the first nailing (Illustration 36 and 37)• If the nail extends to the distal fragment for a short stretch, wabbling movements of the nail tip may occur enhancing loosening and ascending of the nail. In the lower leg there is the danger that very long nails perforate the upper foot-joint (Illustration 38). Apart from the possibility of articular infection an arthritis and defor- mity of the joint may result. After the madullary nailing of longdrawn oblique or spiral fractures the nail itself may remain immovable. The shortening of the fragments over the medullary nail may be sufficient to force the articular cleft of the foot-joint towards the tip of the nail, even though a b c Illustration 16 Wandering of a femur nail in proximal direction. Spontaneous fracture with sarcoma (A.E., 29 years old). a b (Text see next page) c d Illustration 37 a) Pseudarthrosis close to the knee-joint after gunshot fracture of the femur. b) Resection of pseudarthrosis and medullary nailing. c) Migration of medullary nail into knee-joint. d) Pseudarthrosis is healed, medullary nail is removed. • Illustration 38 Wandering of nail into the upper foot-joint. it originally had the correct length. Finally it may occur that the tip of the nail perforates the corticalis »nd pene- trates into the soft tissue in consequence of an angulation of the distal fragment (Illustration 39)* a b Illustration 39 a) Medullary nailing of tibia fracture. b) Perforation of nail tip through corticalis and penetration into soft tissue. Further incidents may from a disproportion between the guide-rod and. the medullary nail. If the guide-rod chosen is too thin, the nail may deviate from it and be hammered through the wall of the bone. Some of the failures may be traced back to deficiencies of material. SPEENGELL (36) observed a guide-rod breaking off in the medullary cavity of the femur. He hammered the medullary nail in nevertheless and he left the broken tip of the guide-rod in place. This caused no disturbance of fracture healing. The medullary nails themselves may corrode if the metal is defective and if the nail is in place for a longer time (SPEENGELL), and finally the nail may break. These nail fractures may be interpreted as due to a deteriora- tion of the metal, if they are a level with the fracture cleft. An article about these so-called fatique fractures of the medullary nail was published by STOTZ (37) of the Giessen hospital. These fractures are most inconvenient as it may be im- possible to extract the peripheral remnant of the medullary nail. BOEHLER (38) helped himself by introducing into the peripheral remnant of the nail a guide-rod, the tip of which was smoothed and rounded and bent at an angle of 0° for a length of 4mm. "As soon as fluoroscopy revealed that this nail had surpassed the nail tip, it was turned by 180° so that the angulated piece caught the nail. Thus it could be extracted• " Refractures over the medullary nail while still in place occur not infrequently. They may be due to the fact that the patients are allowed to subject the extremity to weight-bearing at a time at which the fracture is not united as yet by organized callus over its whole extent. Thus, if the patients suffer a new accident which need not be great, the bone is fractured *gain at the old site. We observed such refractures predominantly at the tibia (Illustration 40 and 41). Usually it is sufficient to straighten the fragments together with the nail and to apply a plaster cast subse- quently. Conditions are different if the nail was already removed and a new accident severed that bone. If at this point of time the first fracture was completely consolidated, the new fracture frequently does not appear exactly in the line of the old fracture, but closely above or below it. . / a b Illustration 40 a) Freshly healed tibia fracture. b) Refracture while double nail is still in place. This is due to the callus being more resistant than the bone in the immediate vicinity, particularly if it is poor in calcium as a result of previous prolonged treatment. In such cases a new fracture due to a new accident must be assumed in the expert opinion for the insurance company. Treatment may again consist of medullary nailing. a b Illustration 41 a) Healed leg fracture shortly before extrac- tion of medullary nail. b) Refracture after extrac- tion of nail. c) Medullary nailing of re- fracture, advanced stage of callus formation. c PERSONAL EXPERIE?JCE TWITH MEDULLARY NAILING OF SIMPLE FRACTURES. During the period of time embraced by this report 102 1 simple fractures were treated with percutaneous medullary nailing at the University of Giessen hospitals. The majori- ty of these fractures were femur fractures (45). Besides, there were 32 leg fractures, 18 humerus, and 7 forearm fractures. Our results are demonstrated in the table (Illustration 42). It reveals that bony healing without any complication was ob- tained in 82 cases corresponding to 80 %. Complications were observed in 18 cases. They usually consisted of a delay of solidification of the fracture (12 cases), while slight in- fections were observed in 3 cases. Osteomyelitis was observed Percutaneous Medullary Nailing of Closed Fractures Bone in- ; Number of, No Compli- volved ! Cases |cations ; 1 Complies-! Reason for tions 1 Failure i » Number of Complica- tions or Deaths Humerus 18 13 5 4 delayed healing, 1 slight infection — ; Forearm 6 1 1 "* ■ 1 :— j 1 delayed healing Femur 4? 40 5 n 4 delayed j 1 death healing, through 1 pseudar- ; embolism throsis j after doub- ! le nailing Leg 111 ’ 1 i 32 i 23 i 1 ! ; i 7 3 delayed healing, 2 slight in fection 2 osteomye- litis 1 death through em -pyema of knee-joint and throm- bosis of pelvic veins Total: : f 102 j 82 j 18 — — Illustration 4-2 in 2 cases, both of them involving the tibia. Pseudarthrosis of the femur was observed in 1 case in spite of treatment by medullary nailing. Among these lo2 closed fractures treated with percutaneous medullary nailing fatal outcome was observed in 2 cases, one of the patients dying from fat embolism after medullary nailing of both legs, the other one dying after the development of a knee-joint empyema originating from the me- dullary nailing of the tibia and causing a septic thrombosis of the pelvic veins. This latter case induced us to choose a place lateral to the tuberositas tibiae as the insertion site, since the perforation of the ligamentum patellae pro- vokes the danger of infection for the knee-joint. At this time no penicillin was available. The success obtained with regard to the adjustment of the fracture and above all the excellent mobility of the joints as well as the possibility to dismiss the patients early for ambulatory treatment with the medullary nail in place, determined us to continue with the method under con- sideration of the indication which was thoroughly discussed above. In the course of the last years we sometimes extended the field of indication, and sometimes reduced it according to the experience made. There is no doubt that the sulfona- mides and principally penicillin are drugs which have a decisive influence upon the indication for the medullary nailing even of the compound fractures. This shall be men- tioned here beforehand and with all due caution. OPEN MEDULLARY NAILING OF PRIMARILY SIMPLK FRACTURES. The preceding chapter outlining the range of medullary nailing within the conservative and operative fracture treat- ment, its general advantages and disadvantages, and some dan- ger sources of a similar general nature, could treat their subjects with finality, as the principal problems of the me- thod have been settled today to such an extent that vital pints of a general nature no longer are a matter of discussion. The treatment of the indication for the medullary nailing of simple fractures could also proceed along similar lines: fundamental rules were established which most likely will not be subject to significant changes in the near future. These chapters were then followed by the description of the technique of the medullary nailing of simple fractures. The discussion of technical modifications as they were necessi- tated by the medullary nailing of compound fractures or by a simultaneous operative exposure of the fracture site, be it for reasons of reduction, or of osteotomy of old and un- satisfactorily healed fractures, was purposely disregarded. The description of the easiest technique employed in the ideal case of a simple fracture suitable for percutaneous nailing was to give a model of the typical procedure for every bone and its various types of fractures. This is to be considered as the basis of the technique and as an unalterable frame for the following discussion of the other possibilities for the application of the medullary nail. In every case of medullary nailing the operating surgeon must endeavor to adapt the operation to that schedule representing, if one might say so, the ideal technique, or with other words: the technical concept of the method. The topics of the following chapters, however, are still subject to change as the literature shows, and so far it has not yet been possible to establish a strict dogma in all paints. We therefore deem it correct if in accordance with the varia- bility of the procedure and of the results a greater space is reserved to the subjective character of the literature references and to our personal observations. We believe that it is only of advantage for the method if the success and the failures observed within our range of observation are put in the foreground, as finally it is only the.free communication of all experiences which gives a rounded picture of the width of the field of medullary nailing as well as of the counter-indications. It sometimes happens that notwithstanding all manipu- lations and reduction appliances a fracture cannot be reduced satisfactorily. Then, of course, it is not possible to in- troduce the medullary nail. These are the fractures which before the introduction of the medullary nail method necessitated operative reduction. The question ist whether such operatively reduced fractures should be nailed or not. By the operative exposure of the fracture site one abandons the most important advantage of medullary nailing, that is a diminished risk of infection and the preservation of the biologic complex which is encompassed by the term “fracture focus”. Strictly speaking operative reduction renders me- dullary nailing senseless. If, however, one is compelled to perform operative reduction, it is essential for the further course of fracture healing to select the correct ; method of retention. It rarely is possible to unite the fracture planes so securely by simple cogging that there is no hazard of dislocation after the application of a ; plaster or extension bandage. Therefore, we have to rely upon foreign bodies to retain the fragments in place. We have i almost completely abandoned the use of Lanefs plate as its ; application resulted -in failures which could have been ; avoided with other methods. They usually consisted in loosen- ing and bending of the screws, or a matter of greater con- sequence , in the formation of pseudarthrosis, because the splint apparently acted as a distension mechanism wnich pre- vented a close contact of the fracture planes. In the chap- > ter dealing with pseudarthrosis such an example will be given. A wire suture applied through drill-holes in the longitudinal axis of the bone usually contradicts the most primitive laws i of mechanics, and it is not able to provide a satisfactory ; fixation of the two fragments upon each other. One repeated- ly however, observes fractures in which a wire loop applied in longitudinal direction attempts to unite the fragments firmly, an enterprise which is successful in very rare cases :only and with bones of a small diamaeter (forearm). When regarding the way a joiner would proceed to fix two laths : together, one will appreciate the inadequacy of these wire sutures. We are not quite sure as yet whether or not they Hexert'an inhibiting effect upon the formation of callus as bodies. It is, however, quite possible that this was sometimes the case. In the case of long oblique fractures , and of spiral fractures a wire loop around the circumference of the bone (cerclage)is practicable. There is no principal c objection against this method and later on we will be able to show that it can be used to advantage. But it is particu- larly these transverse fractures, eligible for operative reduc- tion which cannot be treated by a wire loop slung around them. In these cases we several times employed medullary nailing for the purpose of retantion and it yielded good results. Regardless of the risk or the inoffensiveness, the po- sitive or the negative value of the introduction of foreign bodies, one should always endeavor to disturb as little as possible the fracture site in which complex bioligic pro- cesses take place. During discussions of the problem of buried foreign bodies the medullary nail was frequently rejected, be- cause the medullary nail allegedly constitutes the biggest of all buried foreign bodies known so far and because it allegedly disturbs and impairs the progress of fracture healing. This reasoning most certainly is not correct. If foreign bodies dis- turb fracture healing this effect usually is due to faulty application. The numerous experiences made by the surgeons’ all over the world with the fastening of bone grafts during the treatment of pseudarthroses sneak against damages caused by simple wire loops. VON ERTL(3v) certainly gfces to far in generally rejecting the wire suture and the wire loop. An insufficient immobilization resulting in the disturbance of fracture healing, or other mechanical deficiencies such as the distending effect of Lano*s plate may be a factor of much greater importance than the fact that the nail is a foreign body. One should not expect one or two wire loops to produce an absolutely stable fixation of a fracture with- out an additional external support, particularly if, as is the case with the femur, one has to deal with extremities of considerable weight constituting long levers. We believe that these factors frequently are responsible for the technical deficiencies, but that they are not the effect of the foreign bodies alone. As for the medullary nail it must be said that it has no contact with those tissues in which the healing of the fracture takes place, that means with the periosteum and the muscular The medullary nail constitutes no foreign body in the fracture. Its effect upon the bone marrow also cannot be the reason for its rejection as a means for retention after operative reduction, since it became ©bvious by innumerable percutaneously nailed fractures that this factor plays no essential part. In facu the medullary represents the best instrument far the fixation of the transverse fractures after they have been reduced operatively and no better method is available (SCANZONI (40)). Moreover, the operative reduction using the medullary nail Is much more conservative than the use of foreign bodies, as the intervention at the fracture site itself is limited to a minimum, to reduction exclusively, and as no further damage is caused particularly as regards the periosteum. This also eliminates any debate as to whether or not transverse fractur- es can primarily be treated by a locking bone graft. In ad- dition the medullary nail frequently can be inserted from the fracture site after exposure and this increases the security and the speed of the intervention. Furthermore all the other general advantages of medullary nailing are positive factors, above all the short tine of confinement to bed, and the possibility to begin exercises early.. As regards technique the open medullary nailing of the femur offers several peculiarities and there- fore, it shall be described separately. The fracture is exposed by a longitudinal incision at the lateral aspect of the thigh. The best position of the patient on the operating table is a slightly oblique one. The use of the extension apparatus is only necessary in the case of a considerable longitudinal shortening but it is advisable in any case to apply the extension sleeve to the foot before the operation, as it may become necessary to ronly strong traction during the operation. If the obstacle to reduction is eliminated the long guide-rod is introduced from the fracture site into the medullary cavity of the proximal frag- ment, and it is pushed upwards immediately. At the proximal end of the bone the tip of the guide-rod protruding beside the trochanter major is exposed by the same short cutaneous incision as is practised with the percutaneous medullary nailing* Now, the medullary nail determined as to length and thickness is guided over the rod from above as usual, and it is hammered in until it appears in the fracture cleft. Subsequently the guide-rod is withdrawn through the lateral incision, it is turned round and inserted from above into the nail which now guides the rod. The guide-rod also appears in the fracture cleft, the fragments are united by single-pronged hooks, and the guide-rod is inserted into the distal medullary cavity. From no\v on medullary nailing is per- formed as usual. The wounds are sutured and the extremity is bedded, or a plaster cast is applied if necessary. If it is not possible to unite the fracture planes despite extension, which may occur with old neglected cases, one may be successful if one angulates the fragments to a great extent (There is an instructive illustration of this proceeding on page 13 of the monograph prepared by KUENTSCHER and MAATZ on the Technique of Medullary Nailing), By no means, however, should one extend the femur too abruptly in one session, as there is the danger of a rupture of the intima of the arteria femoralis. The hazard.of infection is not greater with the medul- lary nail tharPIriy other operative reduction. If one has reason to worry about the aseptic performance of the inter- vention it is recommended to powder the wound vjith sul- fonamide (marfanil-prontalbin) and to give an Injection of sulfonamides or penicillin subsequent to the operation. Here, too, the approved principle is valid that an absolute immobilization is the best means to prevent in- fection. This purpose is served in the first place by medullary nail, but one should not forget that the immobi- lization of the soft parts is of just as great importance. In addition to the fractures which due to difficul- ties of reduction are reduced operatively, the’long oblique and spiral fractures also are eligible for operative treat- ment, as wireloops put around the fracture planes lying obliquely upon each other offers the safest means for an exact reduction and retention of these special types of fractures. In such cases one, therefore, will frequently decide in favor of a primarily operative treatment involving the exposure of the fracture. In consequence of the opening of the medullary cavity which mainly runs in a longitudinal direction, medullary nailing is not always capable of immo- bilizing the fracture sufficiently. The fragments may separate as well in a lateral direction so that the medullary nail finds only an insufficient hold in the short parts where the bone is intact and a longitudinal displacement and rotation of the fragments over the inserted nail is to be feared with long oblique fractures and with spiral fractures (dislocatio. ad peripheriam). On the thigh and on the leg DECKER(4l) used to expose the fracture and to perform simple looping with catgut or silk threads. He did not employ med- ullary nailing in such cases for fear of the additional operative strain for the patient. His concern as regards the immersion of foreign bodies was so great that he applied only one single looping (cerclage) possibly not consisting of wire, and that for elimination of any further disturbance of the condition of the fracture he performed these opera- tions in bed for many years. Additional fixation was accomplished by means of wire extension which remained in place even after the operative fixation, or plaster cast was used for this purpose. Even short oblique fractures which can just be held by the loop, were treated in this way. The result of such a treat- ment was satisfactory and since 1934 there was no case of infection. For the operable oblique and spiral fractures to be se- lected in every individual case we chose a compromise by com- bining the wire loop with medullary nailing. In this case one may restrict oneself to one or two wire loops and thus take care that the fracture is spared, while the remaining part of the fixation is left to the medullary nail. Wire looping,‘there fore, restores so to speak the continuity of the osseous tube re- quired for medullary nailing, and the conditions are created for the use of the nail with all its well known advantages. A medical history and several illustrations may serve as an example; Medical history: Lucie H., 67 years old, slipped and fell on an even floor on 10 January 194-8. She suffered a long oblique fracture of the right femur shaft; the hip-joint was completely stiffened in consequence of a previous arthrosis deformans. On January 12, 1948, the fracture was reduced operatively, and the fragments were immobilized by wire loops. The medullary nail was inserted at; the site of the operation ;;oand 'spinal anesthesia). The wound healed without any complications after it was bedded upon a Volkmann's splint. Walking was resumed first on February 1943, and the patient was dismissed for ambulatory treatment on February 28th 1948. The joints were mobile to the same degree as before the accident (Illustration 43). (Text see next page) a b Illustration 41 a) Long oblique fracture of femur. b) Condition after wire looping and medullary nailing. The therapeutic result obtained with another case ;reated in the same way is shown in Illustration 44. a b Illustration 44 a) Spiral fracture of femur. b) Condition after wire looping and medullary nailing. For some of the oblique and spiral fractures of the leg no medullary nailing was required in addition to the wire loop (Illustration 45). In such cases the method suggested by LAGNUS, the so~called MGNUS-tube has proved useful, so that we shall employ it again in suitable cases. It seems a Illustration 45 a) Oblique fracture of leg. b) Fixation of fracture by wire loops and Magnus-tube. c) Condition after healing of fracture and removal of wires. b c that the method presently has been forgotten, a fate it really does not deserve. In our cases the fixation of the tibia fragment was so stable that we could abstain from additional medullary nailing. The application of splint and an early walking cast yielded excellent results even with regard to the mobility of the joints.in these cases medullary nailing would not have offered a note worthy advantage. One always must be aware of the fact that schematized fracture treatment is by no means ideal* The choice of the most adequate method for every individual fracture should be based on the multi- tude of the available methods and if after the examination of all advantages and disadvantages one is under the im- pression that less severe interventions lead to better re- sults they must be given priority before medullary nailing. Although it is a fundamental feature of the medullary nailing method that it renders operative reduction of not primarily complicated fractures superfluous in fresh cases, there are nevertheless older fractures or such fractures which are on the border between fresh and old, which cannot be reduced to a satisfactory position by conservative measures. They are usually fractures which even with the application of the usual types of treatment would have required operative reduction particularly when attempts for conservative treatment no success. In a certain number of such medullary nailing may be a profitable means for retention subsequent to the operative union of the fragments. As an example I would like to mention the case of a suboapital humerus fracture which in another clinic already been the object of a futile attempt to unite it with wire sutures (Illustration 46). 79 a b Illustration 46 a) Old subcapital humerus fracture after wire suture performed in another hospital. b) Condition after operative reduction and medullary nailing from the distal end. In this case reduction was achieved operatively it was kept stable by the medullary nail. The conditions required that here the nail was hammered in from the humerus shaft towards the proximal end which is not the typical procedure. When discussing the indication for the medullary nailing of the humerus fractures we contended that the subcapital fractures are suited for medullary nailing though not without restriction. We still hold the same opinion and the above mentioned case of medullary nailing used for the treatment of such a fracture is no proof of the contrary. It only shows that in special cases medullary nailing may success- fully be used with a subcapital fracture too. One may even contend that any other method would hardly have been able to achieve retention of such a fracture which for mechanical reasons is very difficult to treat so satisfactorily as was feasible with medullary nailing. The fractures of the forearm shaft range among the types of fractures which also most frequently offer considerable difficulties to reduction. Some of the obstacles observed in these cases may certainly be overcome by medullary nailing if one only is successful in reducing at least one of the two bones and in fixing it with the medullary nail. Here an attempt at medullary nailing is also permissible if reduction prior to medullary nailing was not successful, as sometimes a medullary nail introduced into one of the fragments pro- vides the possibility of controlling the bone in such a way that finally the nail tip stands opposite the medullary cavity of the other fragment, so that the nail can be driven into it. If reduction fails even though such a stratagem was employed, the operative reduction of such fractures is Indicated. Here medullary nailing renders the operation very sparing and economic, as in many cases there is no need to nail more1- uhan one bone, because the other one rassumes a good position automatically after a good anatomic adjustment of its neighbor. Thus, for instance, in the case of a 4 week old forearm shaft fracture only the radius was reduced operatively and nailed with th final result of an ideal adjustment of the ulna the fracture of which was soon conso- lidated subsequently, while the nailed radius took more time for bony consolidation (Illustration 47)* a b Illustration 47 a) Transverse fracture of forearm. b) Medullary nailing of radius. Healing has set in on both bones of the forearm. c) Healing of fracture and removal of medullary nail. c These few hints may be sufficient to throw a light upon the actually rare necessity of exposing a primarily closed fracture for the purpose of reduction and medullary nailing. Considerably more significance must be attributed to the oper- ation in fracture site for the trl%ment by osteotomy of fractures healed in an inadequate position and also for the elimination of pseudarthroses. INDICATION FOR MEDULLARY NAILING OF COMPOUND TRACTUBES. The decision of whether or not in the case of compound fractures medullary nailing has to be considered as indicated is grave, unavoidable, and of fundamental importance. So far the basic principle to be applied to the treatment of a compound fracture was to convert it first to a closed fracture, and even this was only practicable if the wound had not to be considered as seriously infected. In cases of serious infection or contamination the excision of the wound (FRIEDRICH) is not reliable and open wound-treatment must, therefore, be taken into the bargain. Although medullary nailing does not' break with these principles to a large extent, it cannot be denied that it causes a breach in the wall of this thousand- fold approved principle. This was mentioned above, when the range of medullary nailing within the methods applicable for fracture treatment was discussed. It may be appropriate here to say a few words about the significance of the term’Compound fracture1’. It is necessary to narrow the meaning of this term, that means to outline it more precisely, and one should not count every fracture com- bined with an additional wound among the compound fractures as is frequently done. Rather, it is absolutely clear that only such fractures can be considered as compound fractures where the fractured bone came into communication with the outer world. In most of the cases this happened in such a way that one of the broken bones pierced the soft tissue from within. It is most important to know this fact, as such a mechanical process is less apt to cause soiling of the wound than a complication of the fracture the result of direct force acting from without. This is important for the particu- lar reason that in the former case rather than in the latter one may hope to restore aseptic conditions by operative wound treatment, and to nurse the wound after closing it. An additional soiled injury which does not communicate with the fracture cannot be classified as a compound fracture. The surgical treatment of the complicating as well as of the non-complicating injuries has to follow the lines of general surgery. The investigative work of the genera- tion of surgeons subsequent to FRIEDRICH has developed the eight-hours limit. These principles are also valid for the medullary nailing of compound fractures which will be shown as really possible and the only matter of importance is, whether these "principles permit "surgical wound treatment with primary suture and a transmutation of the open frac- ture to a closed one or loot. If this is not the case, the compound fracture cannot be treated by modu 11 ory~ naiilngT If these approved principles are considered, skill and ex- perience will succeed to keep the breach broken into them as small as possible. It is of great value that during the first years of medullary nailing a current and unrestricted record was kept about the success and the failures of the method. Thus it was possible to recognize the true amount of the failures and particularly of the infections which sometimes took a fatal course. The number of failures is by no means so great as to hove a negative effect upon the validity of the method. Rather, the analysis of the cases of infection gave suf- ficient clearness about the range of indication for the medullary nailing even of compound fractures (FISCHER and REICH (42)), EHALT (43). Nevertheless BOEHLER (44) shows some reluctance against the nailing of fresh open fractures. "The prerequisite for a satisfactory result is a thorough wound excision and a dermal cover free from tension.” - "The open medullary nailing of the open leg fractures was a failure, and I therefore forbade it in my sphere of work." Even though infections of the medullary cavity occur, theyusually are easy to control, as the medullary nail it- self, so to speak, acts as a drain, and as in addition one must take into account that the fracture is immobilized by the nail to such an extent as might ever be desired. A phlegmon of the whole marrow cavity is an extraordinarily rare occurrence, as revealed by the literature and personal experience. Conditions were considerably improved during recent years by the possibility of administering sulfonamides and above all penicillin to the patients. It was mentioned earlier and we would like to repeat it here that with the help of penicillin one is entitled in many cases to make a primary suture and to perform medullary nailing of complicated fractures. This was not permissible prior to the penicillin era. We even believe that this kind of treat- ment, if applied in the right manner, no longer constitutes a risk or a heroic attempt, but that our ideas regarding the treatment of infected wounds and complicated fractures may even become subject to fundamental changes. Under the right manndr we understand the responsible combination of the operative wound treatment with the immediate administration of penicillin in a sufficient dosage within the eight-hour limit. To the same measure to which the indication for the primary wound suture of infected wounds is extended, the field of application of medullary nailing is enlarged. It therefore is not true that the principles valid so far and outlined above could or should be disregarded, but it is rather this enlargement of the field of indication which evokes and requires the sense of responsibility of the sur- geon. FISCHER and REICH (4?) are in favor of the medullary nailing of compound fractures, and they believe that the medullary nail may remain in place in spite of suppuration, as with their cases the process of inflammation was restricted to the fracture site and to the bone marrow, and as no diffuse phlegmon of the bone marrow and no progressive osteomyelitis developed. EHALT (46) recommends the medullary nailing of open fractures, while FISCEliH and KAATZ (47) have abandoned medullary nailing of severe com- pound fractures. They "Iso underline that compound fractures must be nailed immediately if one wants to avoid the hazard of infection. MATS and REICH (48) gave detailed records about the course of a bone infection after medullary nailing, and they drew the same conclusions as FISCHER and REICH. However, camong their patients there were several cases of serious sepsis which in the final analysis had to be charged to medullary nailing. The thorough description of these coses was very instructive. In accordance with these directives the Giessen clinic attempted the medullary nailing of compound fractures with great caution. This is also the reason why we do not yet possess so numerous material ~s to be able to give percentages with regard to success and failure or complications. We must, therefore, restrict ourselves to five medical histories as examples. We believe, however, that the study of this delicate chapter of the Kuentscher Nailing :s better made in the form of accurate reports on individual cases, than in the form of greater statistical compilations, which cannot give indication of the difficulties and problems to be overcome with the medul- lary nailing of compound fractures to an extent as it is pos- sible with the aid of the individual case history. We are not so much concerned with showing a large number of fractures healing smoothly and without complications after being treat- ed with medullary nailing, but rather with stressing what must rand what may be done. As regards the technique of the medullary nailing of compound fractures, the following method proved useful* The position to be selected should be the same as with percutaneous medullary nailing of closed fractures. Then wound excision should be accomplished first, but the wound should not be closed yet. After the excision of tne wound the medullary nail is hammered in with a clean s-. t of .instruments until it arrives at the fracture site. If one is not immediately successful in passing the fracture site -uid in introducing the medullary nail into the cavity of the distal fragment, one had better keep the wound gaping open by hooks the insertion of the nail into the distal medullary cavity is performed under direct vision. One goes through the wound already present, while for the open medullary nailing of primarily closed frac- tures a particular incision is made to expose the fracture site. When medullary nailing is terminated, the wound is powdered with marfsnil-prontalbin sulfonamide powder and sutured. Medical history: A.W., 27 years old. Comminuted fracture of the right femur due to pistol shot on June 11th, 194-7 (Illustration 48). The patient was operated on immediately, the entrance and exit wounds were excised, a b Illustration 48 a) Gunshot fracture of femur. b) Condition after medullary nailing. and percutaneous medullary nailing from the trochan- ter major was performed. The wound was sutured per primam and 1 million units of penicillin were given subsequently by administering 30,000 units every 2 hours. On August 2, 1947, the patient was dis- missed. The fracture healed in a satisfactory posi- tion without any complication. 4 months after the gunshot fracture, on October 13, 1947, the condi- tion of the fracture was good, as shown in the illustration. This case reveals that even gunshot fractures may be treated with medullary nailing, if excision of the wound and medullary nailing are performed within the eight-hour limit, and if penicillin is available. We shall give a separate record about the gunshot fractures when the compound fractures will be discussed. Medical history: A.R., 28 years old, was the victim of a traffic accident on November 26, 194? whereby he suffered a femur fracture on both sides as well as a compound fracture of the right leg. Both femora were treated by percutaneous medullary nailing. The complicating wound on the leg was carefully operated on, and it was sutured under the ample use of marfanil-prontalbin powder, as the eighth-hour limit had already been exceeded. The tibia too was treated with medullary nailing. The wounds had healed on December 7, 1945* Later on a slight suppuration was observed on the wound of the leg, although in the beginning there were no signs of disturbed healing. Because of the distending effect of the fibula, a'fibular resection was made on February 14, 1946. The spot beside the tuberositas tibiae, where the medullary nail was driven in, began to secrete slightly during the month of February 1946. At that time as a precautionary measure (March 9, 1946), the medullary'nail was extracted from the tibia, and a circular plaster cast was applied. The suppuration decreased in the course of time. Later on (June 27, 1946) an abscess was formed on the right leg, an incision was made, and two medium-sized bone sequestra were removed. Subsequently suppuration ceased, and the patient was dismissed on October 3, 1946, to ambulatory treatment. During the following period of time several incisions were necessary as circumscribed abscesses had formed several times. The suppuration was always easy to con- trol. The medullary nail of the left femur was removed on January 8, 1947. On January 21, 1947, the patient was readmitted because of a refrac- ture of the left femur. Medullary nailing was performed again and then a satisfactory callus formation set in. The femur was readjusted satisfac- torily. The medullary nail of the left femur is still in place, because on the roentgenograms the fracture cleft is still visible in outlines (Illustration 49). The various incidents had the result that the medullary nail in the right femur was not removed either although it would have been practicable according to the condition of that fracture; but there was no need for precipitate action. The joints of the two legs are freely movable in spite of the prolonged treatment with the exception of a slight impediment of the right upper foot-joint. This case showed that medullary nailing of several simultaneous fractures is quite possible, and here it was the only means to obtain a free mobility of the joints. The transitory secretion of pus did not prevent a satisfactory final result. It is, however, quite possible that the course of healing would have been much more favorable if penicillin had been available. Medical history? P.H., 1? years old, suffered a compound fracture of the right femur on April 1?, 1946, when he was run over by a tractor. Operation was performed immediately. The wound was excised and a medullary .nail t:as introduced from the exposed fracture. Marfanitprontalbin powder was sprayed over the wound, which was sutured, and only a thin subcutaneous rubber drain tube was laid into the wound. This drain was removed on April 17, 1946. The progress of healing showed no complications, the leg was first subjected to weight-bearing on May 5, 1946, and the patient was dismissed for ambulatory treatment on May 18, 1946 (Illustration 50). a b c d e Illustration 49 a) A.R., 28 years old, transverse fracture of left femur (simultaneous fracture of right femur and leg). b) Medullary nailing with too short a nail. c) Condition after healing of fracture and removal of medullary nail. d) Refracture of left femur. This was due to insufficient fixation during treatment, the nail being too short, e) Condition after second medullary nailing be- cause of refracture. Good progress of callus formation. f g Illustration 4-9 (cont*dr\ f) Oblique fracture of right femur (simultaneous fracture of left femur and right leg). g) Medullary nailing. Good progress of callus formation. 1 11 111: jration ' 2 :Jiont * h) A.R., 28 years old . -rjm fracture, leg treated with a double rail (simultaneous femur fracture on both side;. V. l) Condition afte- a >f fracture and removal of medullary noijs* Ir Che course of treatment resection of -fthi:la v’f c necessary. The tibia fragments wer( shifted by half the width of the shaft, as the fracture was not very suitable for medullary nailing because the distal fragment was too short. h The latter case shows the course of a femur fracture which was immediately treated in the correct nay. Illustra- tion 51 shows the undisturbed healing of another nailed compound fracture of the leg, as well as Illustration 52. Today we would immediately commence with penicillin treatment for security reasons together with simultaneous medullary nailing. But in the case described above this was not necessary. We dispose of a larger number of compound frac- tures, which had healed without any complications after reduction and medullary nailing within the eight-hour limit. An early, most preferably prophj'lactic administration of penicillin is apt to soothe all worrying, which is always in the background when complicated fractures are nailed. Under the protection of penicillin which in this particular case was immediately available, we excised the considerably soiled wound of the complicated leg fracture and we sutured it per primam, while there was a considerable tension. Medullary nailing was accomplished within the eighthour limit. The undisturbed course of the wound healing per primam and without any rise of temperature is particularly apt to demonstrate the great gain which is represented by this for the time being latest form of fracture treatment. As early as 4 weeks after the injury, the patient could get up with a walking cast and as regards the fracture, this would have been possible earlier, if there had not been a simultaneous cerebral concussion prolonging the period of confinement to bed. Conditions are somewhat different in the following case which shows that even severe injuries which at an earlier time almost certainly would have necessi- tated the amputation of the limb can in an excellent way be treated with medullary nailing and penicillin, thus enabling the preservation of the injured extremity. a b (Text see next page) c d Illustration 50 a) Compound fracture of right femur. b) Condition after medullary nailing. c) Weight-bearing and mobility 2 weeks after medullary nailing. d) Condition after fracture healing and removal of medullary nail. a b (Text see next page) Illustration 51 a) Compound leg fracture. b) Condition after medullary nailing and primary wound suture. c) Healing of fracture. Removal of medullary nail. c a b Illustration a) Compound leg fraotme and fract u.r e o f me. d i a i ma 1 - leolus. b) Medullary na ria ng after healing of complicating wounds, 3 weeks subsequent to injury. Illustration 52 (confd) c) Healing of fracture and removal of medullary nail. Medical history; P.D., 15 years old, suffered a compound fracture of the left humerus with a large com- minuted wound (Illustration 53 a), as well as a com- pound fracture of the forearm on the same side. The wound was treated operatively and it was sutured per primam after it had been powdered with marfanil-pron- talbin powder. The humerus fracture was treated by medullary nailing from the proximal end and due to the small caliber of the medullary cavity, the fore- arm fracture could be fixed by Kirschner wires only. Subsequently sulfonamides and penicillin were given. The wounds healed per primam. The accident had occurred on March 12, 1947, and the patient could be dismissed on April 3, 1947, for a period of 2 weeks. The further course of healing also was undisturbed as far as the healing of the wound and of the fracture was concerned, apart from an incomplete paresis of the radial nerve and an impairment of the median nerve. The radia.l nerve was not visible in the large wound caused by the injury. In the course of treat- ment restoration of the nerve function was slowly established (Illustration 53, b~g). On the humerus, however, no bony solidification occurred, and a pseudarthrosi'. developed over the medullary nail in place. After one year it was consolioated within 3 weeks as the result of t he transplants cion a tibia graft according to PEEOdTur. (see chapter dealing with pseuua^threols), Another case among tre compound fractures treated by us, who came under- treacment after the eight~hour limit was exceeded, could not be nailed per primam. a b I±1 ustr3tioL a) P*D. s 1? years old. comm:' uubed wojnc and compound fracnue of 1-.ff bumeius and forearm. b) Compound fracfure ei lefc humerus and forearm (hare h f:, 1 °4 7, c d lllustrat i. on.J^(_ytL'JS.L c) and d) Medullary nailing of humerus from the proximal rend, and medullar; nailing of both forearms (March 12, 194?) e) Condition after healing of forearm fracture and removal of medullary nails (September 17, 1947)* f) Pseudarthrosis of humerus while medullary nail is in place, probably resulting from distension of fragments (February 11, 194o) e g Illustration 53 (contfd) g) Condition 3 weeks after bone graft according to PHEMISTER. Commencement of bony solidification of pseudar- throsis. Medical history: W.H.. 47 years old, was run over by a car on August 29, 1942, and suffered a compound fracture of the left leg. The wound was treated by counter-incision, and a drain was inserted. The fracture was reduced and wire extension was applied through the talus, the extremity being bedded upon a Braun*s splint. After the wound had healed, medullary nailing of the tibia was performed on September 22, 1942, that means 3 weeks after the accident. No com- plication occured subsequently. The patient rose as early as on October 24r, 1942, after a U-shaped plaster cast had been applied. On October 28, 1942, the patient was dismissed for ambulatory treatment. The plaster splint was removed on November 11, 1942, when the fracture was consolidated; medullary nail was extracted on March 6 , 1,943, The final result was excellent. The patient las incapacitated by about 15 %* The medical case history reveals that the medullary nail remained in place for a long period of time, but unfortunately we are not able to give a satisfactory explanation for that fact. However, we frequently made the observation that the medullary nail caused so little inconvenience to the patients that they themselves put off the remo- val of the nail, if once the fracture had healed. The case described above shows that capacity to work was regained while the medullary nail was in place, and this was the case on January 2o, 1943, that means about 5 months subsequent to the injury. The medullary nail was removed more than 1 year later. This case, therefore, shows that with correct observation of the principles of wound treatment medullary nailing performed even after the compli- cated wound had healed, may yield an excellent re- sult. In this connection we should like to mention particularly that it is not necessary to let pass such a prolonged interval between the healing of the infected wound and the adjusting operation of the bone, as is required in the case of osteotomy or of the operations of speudarthroses since with percutaneous medullary nailing the previously in- fected wound need not be opened. In these cases too, we hatfe a feeling of security through the aid given by the sulfonamides and penicillin. Medical history: P.K., 31 years old, suffered a motor-cycle accident on March 22, 1945, leading to a compound fracture of the left femur. Medullary nailing was not performed until the day after the injury. A serious osteomvelitis developed which caused the formation of seaoestra as well as an extremely dangerous condition or? the patient in the course of the sickness a t.ar.si.tory sepsis developed. There is no nccv. to gir'e all particulars (Illustration 54). Finally we were successful in preserving the leg. The nail was removed on Sep- tember 8, 1945* Later on there all'll was a condi- tion of chronic osteomyoljtis and sequestra were formed. Today the leg is shortened by 12 cms, the knee-joint is stiffened in extensor position, and the mobility of the hip and of the foot-joint is considerably reduced. This case shows clearly what dangers may oc- cur if one deviates from the safe way of the above described principles performing medullary nailing after the eight-hour lim.rl is over, and before the infected wound is h^a 1 ed, a b Illustration 54. a) Compound fracture of the femur, treated at first with wire extension. The wound is drained, b) Medullary nailing on the next day together with the opening of the fracture and additional wire loops. Primary wound suture. c) Condition after fracture healing and removal of medullary nail. Cf. clinical data in the text. c We abstained from describing in detail those cases of med- ullary nailing of compound fractures in which health was re- stored without any complications. We just stressed some re- markable case histories which demonstrated the principles to be maintained by all means. No fatal case and no case of am- putation occurred during the period on which we gave this re- port (until the end of 1947). After this time, however, there was a fatal case of a leg fracture with ad- ditional soiled wounds. By a mistake these wounds were not sufficiently appreciated as a counter-indication, the tibia was nailed without regard to the eight-hour limit, and a severe phlegmon originated from the nail in- sertion site which resulted in a septic con- dition and finally in death. Here, some consideration must be given to the medullary nailing of infected fractures. In the oreceding chapters we made clear our fundamental point of view within the frame of general surgical principles, and the majority of the authors also reject medullary nailing in such cases, but it shall not be forgotten, that voices were raised in favor of the medul- lary nailing of infected purulent fractures (49) (50). As a principal argument for proceeding in such a way the immobilization secured by the medullary nail was mentioned, as it always was recognized as a vital factor for the control •of the infection. BGSdLBR also had observed such cases taking a favorable course afbei* they had been nailed in another hos- pital. In the Giessen university hospitals NUSSELT (51) treated a case of infe-ted gunshot fracture of the femur. In the case of this patient ri a bone graft was made elsewhere a few weeks after the wound had healed because of a pseudar- throsis after gunshot fracture. This kind of treatment had an unfavorable outlook from the very beginning on. Marked suppura- tion ensued which was associated with severe septic symptoms, chills, und jaundice. The temperature was very high for a b G d Illustration 55 a) Gustav A., 34 Years old, pseudarthrosis after gunshot fracture of femur, 4 weeks after bone- graft. Septic suppuration. b) Condition after removal of bone-graft. c) Condition 6 weeks after percutaneous medullary nailing. d) Commencing growth of bone bridge. Local osteomyel.it is. many weeks, and the patient was admitted to our hospital for amputation. After thorough consideration we decided on me- dullary nailing in this almost desperate case, as good re- sults were yielded with some similar cases of medullary nailing during the war. Here, too, full success was obtained (Illus- tration 55)* The suppuration ceased fairly rapidly, the wound shows only slight fistular secretion now, and the injured extremity can be used again to a certain extent. It therefore is permissible to assume that in this case the immobilisation of the pseudarthrosis by means of the medullary nail played a decisive part in the fight against the infection...." LIEDULLARY NAILING OF GUNSHOT FRACTURES. As soon as the pdssibility of treating compound fractures with medullary nailing was recognized - this was the case in the course of the war years 1939 till 1945 simultaneously with the development of the Kuentscher nailing - it was only logical to include the gunshot fractures in the method. There were only a few theoretical objections as one could not expect that any other method for the immobilization of gunshot fracture of the long bones would be more successful than medullary nailing. Moreover, neither extension or plaster bandages nor a combination of both are able to immobilize a gunshot fracture during trans- portation to the same degree as medullary nailing. The exact and stable fixation of the fragments applied to the bone itself necessarily was as important for the prevention or the control of the infection not only of the bone, but also of the injured soft tissue, because every gunshot fracture had to be considered as contaminated. In addition it is an advantage of the method that the access to the injured extremity was easier when there were neither plaster casts nor extension bandages constituting an obstacle to observation and treatment. KUENTSCHER ( 52) himself strongly recommended in 1943 to apply medullary nailing to the gunshot fractures and he gave an account of more than 28 relevant cases showing all the advantages he had expected. There is indeed no fundamental difference between the compound fracture after an accident in peacetime and the gunshot fracture in war. This consideration necessarily must lead to the consequence that the same prin- ciples are applied to the medullary nailing of gunshot frac- tures as they were worked out for the medullary nailing of the compound fractures acquired in peacetime. They principally consist in the strict abservation of the eight-hour limit and the control of wound infection by all means or in the correct judgement of the seriousness of the infection and in the ex- clusion of the fracture from medullary nailing if infection had occurred. This is nothing new, and I repeat it to stress the responsilibity involved. HAEBLER ( 52) •» too, assumes a positive attitude with regard to the medullary nailing of gunshot fractures, and he is of the opinion "that it is wrong to warn against m rrow nailing of open infected fractures or of gunshot fractures on principle, be- cause it had occurred once upon a time that osteomye- litis ensued upon an open fracture. In such a case osteomyelitis may occur, but then it is due to faulty technique. If a really stable osteosynthesis was performed, no osteomyelitis will be found even with a suppurating fracture." Contrary to his reserve as Wo the question of the medullary nailing of fresh open fractures, BOEHLEB (54-) is in favor of the nailing of gunshot fractures, provided that some conditions of a general and local character arc fulfilled on the part of the patient as well as of the surgeon and his armamenta- rium. As regards the details, information may be obtained from BOEHLEB's book. His recommendation of the medullary nailing.however,is limited to the gunshot fracture of the femur. For the remaining long bones BOEHLEB docs not employ medullary nailing, because these fractures can be treated so well with the older methods that they constitute no urgent indication for medullary nailing, or because se- questra may be formed subsequently as is the case with the lower leg. The fact that the invention and the development of the method of medullary nailing coincided with the years of World War II constituted an enhancing as well as an inhibiting fac- tor. An enhancing factor, because the method could be admi- nistered in the immense field of treatment of gunshot fractures and because in this way an opportunity was created for the method to prove its value to such an extent as would never have been possible in peacetime; an inhibiting factor, because the conditions of war brought it about that the new method was given into the hands of inexperienced surgeons and thus could not yield its optimal eifect, and as the varying con- ditions of war prevented its organic development in logical succession. It, therefore, war certainly an appropriate measure to forbid medullary nr-j.ling In hospitals near the frontline. RAISCH (5/) war an against medullary nailing in the advanced medical units, fro reasons for this warning not only were the danger if infection, but in addition the lack of the minimum technical equipment such as fluroscopy and other things. Lloieo/er, it should not be overlooked that it is of importance that medullary nailing and its after-treatment are carried oil fcv the same surgeon, a postulate which under war conditions is practicable in very rare cases only. No roentgenogram mid no report, be it ever so detailed, is able to give the full number of the many significant details and their real character known to the first operating surgeon only, and which as a whole are no datails, as they influence the treatment during the first days and weeks subsequent to medullary nailing insensibly, and as they may be decisive for the preservation of the in- jured limb or even cf life. The postulate made above that even today the percuttooous nailing of closed fractures should be limited to hmse hospitals in which all necessary appliances and instruments arc ayaliable, not to speak of the training and the ability of the physicians in charge, is particularly valid with ragard to compound fractures, and among these to the especially difficult conditions present with gunshot fractures. The prerequisites permit;-:ing the medullary nailing of gunshot fractures war- principally complied with in the Navy during the war, and here particularly on the big battleships. On these, the appliances required for operation were on hand, no transporta- tion over large d is tone,... was necessary, there were always the same surgeons who could rely on the help of well-trained medical orderlies. Thus a smooth performance of medullary nailing and an adequate after- treatment were guaranteed. (HEIM (56)). We had no opportunity ourselves to use medullary nhiling for the treatment of fresh gunshot fractures during the wai*i In the chapter dealing with the medullary nailing of compound fractures one will find the medical history of a patient with a comminuted fracture of the femur due to a pistol-shot. This accident happened 194-7, and the injury was cured in a very satisfactory manner by wound excision, medullary nailing, and the administration of penicillin. However, in the military hospital attached to our University Hospitals during the war (under the direction of Professor BERNHARD) a certain number of gunshot fractures treated with the medullary nail in hos- pitals near the frontline were admitted for expert opinion and the course of these cases and the success obtained with them enable us to give our independent opinion. It is not possible to give an exhaustive description of the problem within this book. That would require a study of its own. Besides one of us has not been in the position to observe such cases nailed in the advanced medical units, and nearly the whole material was lost by the events of war. However,summing up we may draw the conclusion that in a few selected cases medullary nailing is undoubtedly able to yield excellent results with gunshot fractures too, while the majo- rity is not suitable for this kind of treatment. It is the proper selection which in the final analysis determines success. This decision, therefore, can only be placed into the hands of a fully trained surgeon who not only is thoroughly acquainted with the technique of medullary nail- ing and the whole course of the treatment, but who in addi- tion disposes of a great general surgical experience. If this requirement is not met, there is the danger of great damage being done. It is of particular significance to take into account the zones of comminution by the gunshot injuries of the long bones. According to FRANZ (57) their extent ranges between 8 and 10 cns. with fractures of the humerus caused by a rifleshot, and over 12 to 14 craswith fractures of the femur. With shell splinter injuries and injuries due to explosive bullets the zone of comminution may be even larger. Along the extent of the zone of comminution the bone is destroyed to such a degree that the medullary nail finds no hold and therefore provides no fixation. In all such cases, therefore, a plaster cast or an extension bandage should be applied and it is quite clear that it is not possible to subject such fractures to early weight- bearing, as the fragments would telescope over the medulla- ry nail causing a considerable shortening of the injured extremity. One of the surgeons of the hospital who was well trained in medullary nailing employed the method for the treatment of a gunshot fracture of the fe- mur, but he did not take into account the effect of the extensive zone of comminution, and as a result the extremity was shortened by 6 cms. OSTEOTOMY AND MEDULLARY NAILING OF FRACTURES HELLED IN AN UNFAVORABLE POSITION. During the years subsequent to the war an increased number of fractures healed in an unfavorable position was observed which necessitated osteotomy for correction. This not calways was the fault of the previous surgeon in charge of the treatment, but it frequently was the result of the fact that extensive injuries of the soft tissue in the case of war injuries, or severe infections prevented an undis- turbed fracture treatment. Not infrequently the unfavorable position was due to the lack of the required appliances and to similar incidental causes such as prevailed during the last months of the war. With war experience the knowledge of the possibilities for the treatment of such bone frac- tures was increased, and the introduction of the Kuentscher nailing contributed to a substantial enlargement of the therepeutic methods in this field too. The most varied tar- gets may be set for osteotomy ranging from simple refractur- ing of fractures consolidated in deformity to extensive re- constructive operations of the long bones deviating from the axis in all directions. Experience has taught that the reten- tion of bones re-aligned by operation is the very field of medullary nailing. The indication for such a proceeding is given more frequently in the case of the lower extremity than of the arm, as the anatomic accuracy of axial adjustment is more important for the function of the lower limb than of the arm. One must add to this the danger of late joint damages. The weight of the body resting in a faulty axial position very frequently one even may say regularly, causes secondary arthrotic alterations of the hip, knee, and foot joints, so that for this reason alone it is absolutely necessary to correct the axial oosition of the upper and the lower leg. The osteotomies performed on the arm involved predominantly the fractures of the forearm bones, which due to an un- favorable position cause a restricted mobility and an arthrosis of the wrist joint. While preparing osteotomy the condition of the soft tissues, particularly of the skin, must be the subject of special attention. Particularly as a sequela of war injuries or as a result of infections and of phlegmons extensive scars are often found within the area of the fracture, as well as defective soft tissue, areas of skin atrophy, cica- trization, and an inadequate vascularization, a condition which, when neglected, endangers the success of any operation of the bone by provoking suppuration or necroses of the ex- ternal skin cover. This is the reason why no osteotomy should be performed before a sufficient period of time has passed since the end of suppuration or fistulation. It has become fairly common knowledge that a minimum period of six months has to be observed. However, in many cases where no quick action was necessary, and in which one would have risked the loss of the extremity we have waited as long as one year. But even after such a long period it may happen that small abscesses filled with pus are formed in which small foreign bodies, silk threads, bone splinters etc. are found. It, therefore, is absolutely necessary to make a thorough local and general inspection of the patients prior to the operation and to obtain information about the presence of hidden sources of infection by examining the blood sedimentation rate and the leucocyte count. In addition the condition of the soft tissues, particularly of the skin, must be improv- ed prior to osteotomy, and it may even be required to per- form an autodermic graft prior to the operation. This means that it is more practical to restore the soft tissue before the bone is built up again. Medullary nailing doubtlessly is the best method for the fixation of the extremities after osteotomy. Mention was made above of the deficiencies of other stabilizing foreign bodies having a purely mechanic effect. The tech- nique of medullary nailing after osteotomy is easier than that of percutaneous nailing, since the difficulties of re- duction are eliminated by the exoosure of the bone and by the realignment under direct vision , and in the majority of cases there is no better way than to introduce the medullary nail from the site of the osteotomy. The technique of femur nailing from the fracture site described above may serve as an example. But even in cases in which the medullary nail is inserted at the typical site, the tip of the nail appear- ing at the site of the osteotomy can be inserted into the other fragment under direct vision, a procedure that repre- sents a considerable technical facilitation rendering the operation more sparing and rapid. .For osteotomy the patient need not be bedded in the ex- tension appliance. If there is a considerable shortening of the extremity involved it is recommendable to attach a sleeve or a loop to the hand or to the foot prior to the operation. By means of this sleeve vigorous traction can be exerted by hand if during the operation such a necessity should arise* Usually, however,*the bone ends involved can be controlled and adjusted by elevators or by singlepronged hooks in the operation wound. In most cases the medullary cavity is ob- structed by callus and the best thing to do is to bore a hole in both directions at the site of the osteotomy using the pointed awl prior to the insertion of the nail. If this is not practicable, hammer and chisel or the electric ball drill may be used. The diameter and the length of the nail are determined during the operation in the same way as described before. FISCHER and MAATZ (£8) in 194-2 gave a report about 14 osteotomies on the femur and about 1 on the leg performed because of an unfavorable position of the fracture. All of them took a satisfactory course with one exception requiring amputation because of infection and deficient healing. In 1947 GRIESSMANN and SC HUE T TELIA EYER (59) described two other osteotomies one of which, a 63 year old male patient, suffer- ed a post-operative shock and died after femur osteotomy. The other case showed a satisfactory result and the previous shortening amounting to 5*5 cms. could be reduced to 1.5 cms. In the Giessen University Hospitals 68 osteotomies combined with medullary nailing were performed before the end of 194-7* The experience gained thereby encouraged us more and more to employ the medullary nail as a means of retention for fractures realigned by operation. Our results are shown on the following table (Illustration 56). In the majority of cases we had to deal with fractures of the lower extremity healed with deformity. Only several typical examples out of the ample material available shall be dis- cussed here (Illustration 57 to 62). Treatment by Osteotomy combined with Medullary Nailing rf 6P> Fractures healed in an unfa > tm.e Position. Bone 'Number: Bony ! j Conso- | lidation Complications Osteomyelitis j Pseudarthrosis ) Humerus 3 3 . 1 purulent fis- tula on nail insertion site Forearm 12 12 1 osteotomy on ulna and ra- dius, pseudar- throsis on ulna Femur 43 43 1 severe osteo- myelitis in operation area 2 bony consoli- dation as a result of additional bone graft Leg 10 —-J 10 1 infection of f soft tissue on; nail insertion! site Total 68 68 i Illustration 56 a b Illustration 57 a) Femur Iran bura healed in an unfavorable position. b) Condition after ostotomy, realignment and medul- lary nailing.. Advanced formation of callus. a b c Illustration 58 a) Femur fracture healed in an unfavorable position. b) Condition after osteotomy, realignment and medul- lary nailing. c) Healing of fracture and removal of medullary nail. I tlustrati on ljL; a) Femur fracture ed ir* an unfavorable position. b) Condition after osteotomy, realignment and medul- lary nailingo a b c d Illustration 59 (cont’d) c) Fracture is healed and medullary nail removed. d) patient 6 months after the ooeration. 1 [ JL.: V' tration 60 a) Femur fracture healed in an unfavorable position and shortened by p.5 cms. b) Patient before tne operation. a b c d Ill us trail 011 _ 6 0 (c ant'd) c) Condition after ostootorn;/ and medullary nailing. Shortening is compensated up to 1 cm. d) Advanced formation of callus. Patient 9 months after the operation. a b illustration 6l a) Multiple guns'hoc fracture of femur healed in an unfavorable position. b) Condition after osteotomy and medullary nailing. Illustration 6l(cont rf tn c onsideration given to the particular aituation of tine par lent and to all eventualities of the fur- ther course. This w- s already stressed above and as a matter of fact these are matters known to every surgeon conscious of his responsibility. Disturbance of fracture healing or of bony consolidation after osteotomy occurred in two cases both of them involving the femur only. Infections subsequent to osteotomy were ob- served in 3 cases. MEDULLARY NAILING OF RETARDED FRACTURE HEALING AND OF PbEUDARTHROSIS. The elimination of pseudarthroses always played a spe- cial part in the field of fracture treatment and this is due to two reasons: Continuous attempts were made to obtain information on the process of fracture healing and on its disturbance through studying the mechanism of the formation of pseudarthroses. The treatment of the pseudarthroses had to aim at giving as physiological an assistance as possible to the natural process of the undisturbed fracture healing. In this context it is intended to refer only to the treatment of the pseudarthroses. Here an exact and sufficiently pro- longed immobilization after bone grafting proved to be the most essential factors. Problems are similar in the case of delayed consolidation of fractures whose difference from pseudarthroses is in many cases considered as a gradual variation only. However, we believe that there is a sub- stantial difference between these two forms of failure of bony consolidation in fractures, since in the case of delayed fracture healing mechanical factors may usually be considered as causative, while the development of a pseudarthrosis is due to the faulty progress of a biologic process of development. This differentiation also is of practical significance for the prognosis and the choice of the operation to be performed. The two conditions can be recognized to a lesser degree by the period since the occurrence of the fracture and by means of the clinical examination, than on the basis of roentgenoscopic inspection. Both of them, delayed fracture consolidation as well as the fully developed pseudarthrosis, require operative treatment. In the case of delayed fracture healing one sometimes succeeds to obtain consolidation wita a less strenuous procedure. This consists of drilling according to Beck and a simultaneous resection of bone from the fibula, if there was a distending effect preventing the extensive union of the tibial fracture planes able to bear weight. In all other cases the fracture site must be exposed by operation, the cicatrized tissue removed, the ends of the fragments freshened, and the fully developed pseudarthrosis resected. If necessary, bone grafting should be performed ; the bone graft either being taken from another region of the body or formed from the fractured bone itself in the shape ; of an interlocking plastic. In any case an exact and prolonged immobilization of the fractures treated in this way is one of the most esseq- tial requirements for success. This is where medullary nail- ing comes into its rights. Every exoerienced surgeon knowI, for instance, the difficulties encountered when attempting to immobilize absolutely an ooerated fernur oseudarthrosis by pla ster cast rnd in a favorable position. The weight of the leg, the long levers and the thick masses of soft tissue constitute considerable obstacles. Moreover it is the de- sire of the surgeons to avoid the introduction of larger foreign bodies into the fracture and its environment particu- larly during the treatment of a pseudarthrosis and subsequent to bone grafting. ERTL (60) attributes the sole responsibi- lity for the failures occurring sometimes to the wire loops by which the bone grafts are usually fixed. Even though experience revealed that this view certainly is exaggerated* one should take advantage of every opportunity to avoid the use of foreign bodies and to take the biologic conditions into account. This will be discussed later. "In the case of delayed callus formation medullary nailing constitutes "a causal therapy’*, as the cause for the slow consolidation of frac- tures in the majority of cases is of a mechanical nature. The medullary nail eliminates the injurious shearing forces and it promotes the effect of the pressure forces enhancing bony consolidation.” (KUENTSCHER and MAATZ) The importance of medullary nailing, however, not only is due to the fact that the fixation is established on the bone itself and that it solves the problem of immobiliza- tion better than any other method. The relative harmlessness of the medullary nail as a foreign body was discussed earlier. In addition, however, it has shown that in the case of delayed fracture consolidation one not infre- quently succeeds in "obtaining healing by medullary nailing alone without any other additional operation, This may be achieved by percutaneous medullary nailing as it is applied to the fresh simple fractures. This, however, can only be accomplished when the fracture planes are already in a state of satisfactory adjustment, as the coarse cicatrized tissue between and beside the fracture planes permits closed reduction without operation in very rare cases only. If, however, the fragments are adjusted in a satisfactory position, medullary nailing -dLone may be sufficient to bring the delayed fracture healing to a close. This, no doubt, means a progress and an amplification of our method, as it not only permits avoiding an operation in the fracture site itself, but also offers a strict immobilization in a perfect position. The latter may be maintained indefinitely, More- over, there is the advantage that to fractures of the lower extremity walking casts may be applied early and exercises of the joints may be taken up much earlier than with any other method (VOGL (6])). Experience has shown that in suitable cases percutaneous medullary nailing is capable of terminating delayed fracture healing (Illustration 64). The conditions for success are the adjustment of the fragments so that medullary nailing can be achieved without greater manipulations for reduction, moreover a configuration of the fracture planes permitting as broad cos possible a contact, and a very narrow fracture cleft, as one cannot expect that thicker masses of callus or cicatrized tissue can be bridged over by medullary nailing alone. On the leg, medullary nailing most suit- ably should be combined with a resection on the fibula in such cases in which the latter bone acts "as a distension splint" (GULEKE (62)). If percutaneous medullary nailing is not practicable, which frequently is revealed not earlier than during the operation, and if it is caused by an immobility of the fragments forbidding even small manipulations aiming at reduction, it is preferable to perform operative reduction, On the leg a small incision over the fracture is sufficient in such cases, and through this incision the cicatrized tissue found between the fragments may rapidly be removed without requiring the freshening of the bone ends, as the fracture usually is wedged together by standing upon it. After the removal of the cicatrized tissue we never had difficulties in performing medullary nailing. Our proceed- ing, which, so to speak, lies between operative reduction of a fresh fracture and osteotomy spares the fracture in a most favorable way. This operation is hardly more strenuous than drilling according to BECK. If in the one or a b Illustration 64 a) Femur fracture consolidated in an unfavorable position causing shortening by 5 cms. b) Delayed callus formation (pseudarthrosis). Condition 4 months subsequent to osteotomy and wire suture made in another hospital. c) Condition after percutaneous medullary nailing without any other additional intervention. d) Condition of fracture after healing and removal of medullary nail. c d the other case this method yields no results a bone graft nay be applied later on to bridge the fracture over, while the medullary nail remains in place as a retention appliance. The pseudarthroses may be divided into two large groups, the contact pseudarthroses vith or without the formation of a typical pseudo-articulaii )U, and the gaping pseudarthroses which can be observed particularly frequently as a consequence of gunshot fractures. Another classification according to the degree of functional disorder was recently suggested by GULEKE (63 ) who makes a difference between rigid, waddling, and gaping pseudarthroses. These types of pseudarthrosis were discussed in many publications during and after World War I, and they were studied thoroughly so that their causes as well as their treatment is generally clear. Among the leading German surgeons it was particularly GULEKE (64) and LEXER (65) who discussed in several studies the origin, the prophylaxis, and the treatment of the various types of pseudarthroses. Within this study it is not possible to give a detailed des- cription of all problems incurring in this connection. We refer to the monograph prepared by G. BRANDT (66), but it is necessary here to discuss the principal points whose knowledge.is required for the practice of medullary aniling. The following faults made during fracture treatment proved the most essential factors provoking the development of pseudarthrosis: A frequent cause is the insufficient immobilization of the fracture including the precipitate subjection to weight-bearing. In addition, exaggerated and prolonged extension treatment resulting in a distention of the fragments may be responsible for the development of pseudarthroses. In the case of compound fractures, particu- larly of gunshot fractures, too extensive a removal of splinters should be avoided, as in this way elements re- quired for fracture healing are eliminated. Finally the interposition of soft tissue or foreign bodies (sequestra, drain tubes) and prolonged severe suppuration have to be eonsidered as causative factors. In the case of gaping pseudarthroses the large size of the gap between the fragments prevents bony bridging over. Finally it can be prevented by the distending effect of a neighboring bone (fibula, radius, ulna). Once pseudarthrosis has developed it can only be cbn- solidated by operation. Recently resection of the throsis combined with an extensive freshening of the bbne fragments and the transplantation of a bone graft was com- monly recognized as the only method. This means that $he pseudarthrosis is to be converted again to a fresh fracture, similar to the procedure practised for osteotomy of the fractura male sanata, and the biologic process of fracture healing is adecu&te by released and supported by the grafted bone. It is easily possible that in many cases there would be no need for a bone graft, and BOEHLER regards it as a ’’considerable simplification” that the operation of pseudarthrosis is terminated as soon as the fragments are freshened and the medullary nail introduces. Contrary to this we would like to stress that we do not transplant the bone graft to effect a fixation of the fragments, but for the only purpose of stimulating the healing process in a biolbgic manner, that means to stimulate the formation of callus. This is the- characteristic feature of the pseudar- throsis that no callus is formed and that the healing pro- cess takes a faulty development towards pseudo-articulation. After the resection of the pseudarthrosis there is the necessity to provide a secure immobilization of the freshened fragments. As we have seen during the discussion of the osteotomies, this can be achieved best by means of the medullary nail (RAISCH (67)). The medullary nailing therefore serves as a tool for the realization of the stable fixation which is one of the principal postulates of fracture treatment and thus it serves particularly to prevent the formation of pseudarthrosis. Especially in those cases in which a pseudarthrosis had developed previously, one should endeavor all the more to eliminate all factors liable to cause pseudarthrosis once mere. The following case will show that a pseudarthr sis can be cured by resec cion end medullary nailing alone without the transplantation of a bone graft: Medical history: W• ?., 60 years old male patient, suffered a fracture of the right tibia in May 194-5 end was treated in another hospital with Lanes plate. A pseudarthrosis developed. The patient was admitted to the surgical Hospitals of Giessen University on September 19, 194-6. The pseudarthro- sis was resected and medullary nailing was performed with a double nail. A fibula resection was accomplish- ed on September 23, 19-4-6. Bony consolidation ensued and the medullary nail was removed on October 15, 194-7 (Illustration 65)* Other such examples are demonstrated in Illustrations 66 to 69. The question remains to be discussed whether medullary nailing alone is able to achieve the healing of a pseudar- throsis. In theory this is quite imaginable, as the medul- lary noil pierces the tissue layers lying between the frag- ments establishing the communication of both parts of the medullary cavity. In the literature one constantly finds the contention that one of the principal requirements for the operation of a pseudarthrosis is to open the medullary cavities. *) This is a question one can answer today by the evaluation of several observations. These leave no doubt that under favorable conditions it is possible to bring about the consolidation of pseudarthroses solely by the introduction of a me -ullary nail without any addi- tional operation ana without an exposure of the pseudar- throsis. GERHARDT (68) was under the impression that the medullary nail stimulated the formation of callus when introduced for the treatment of pseudarthroses. *) See for instance BUNDSCHUH during the discussion of the lecture of NUSSEL1: Chir. 194-7. 4-29. a b c Illustration 65 a) W.P., 60 years old. Pseudarthrosis of tibia. b) Condition after resection of pseudarthrosis, medullary nailing, and fibular resection. c) Pseudarthrosis is healed and medullary nail removed. a b c 111us tration 66 a) Pseudarthrosis of femur. b) Condition after resection of pseudarthrosis and medullary nailing. c) Pseudarthrosis is healed and medullary nail removed. a b c Illustration 67 a) Pseudartnrosis of femur. b) Resection of pseudarthrosis. Medullary nailing nnd drainage of wound. c) Beginning formation of callus. a b c Illustration 68 a) Pseudarthrosis of femur after failure of previous bone craft. b) Condition after removal of cicatrized tissue from fracture cleft and after medullary nailing. c) Pseudarthrosis is healed. The x-ray shows the condition during an examination after three years subsequent to operation. a b c d Illustratlon 69 a) PseudarthroSa.s of left femur. Extension band- age and plaster cast aoplied in another hospital. b) Condition after bone grafting and the application of wire loops. c) Fracture of bone graft and bending of the fractured f emur. d) Bone graft is resorbed and a contact pseudarthrosis has developed. o f g Iili urt ration 69 (cont1 a) e) Condition after resorption of bone graft and removal of v;Are loops r f) Osteotomy and transverse freshening of the pseudarthroeis. Fixation by medullary nail. Beginning of callus formation an the nail tip. g) The fracture cleft is bridged over by bone. Increased formation of callus at the nail tip. The consolidation of pseudarthroses after percutaneous medullary nailing alone is demonstrated here by several roentgenograms (Illustrat j o- r/t'-r72) • b c* 111 us, . at ion 7 0 a) Pseudarthrosis of leg which despite fibular resection is not consolidated. b) Condition after percutaneous medullary nailing. b Illus tra tion_ 71 a) Pseudarthros is of humerus after gunshot fracture. b) Condition after percutaneous medullary nailing. Because of unfavorable conditions relating to the soft tissue no osteotomy was performed. a I1lustralien 71(conttd) oj Advanced formation of callus 4 months after percutaneous medullary nailing and without any a dditiona1 intervention. b Illustration 72 a) Pseudarthrosis of leg.Condition after percu- taneous medullary nailing with double nail. This was preceded by.fibular resection as the only measure orirr co nailing. b) A d va nc ed f or me 11 on of ca 11 us . a J- ~r —' w As to that problem we should like to outline our ex- perience and our points of view as follows; Under special conditions it may be possible to achieve healing of a contact pseudarthrosis by medullary nailing alone. This method however, does not represent the method of choice, but we use it with preference, if the exposure of the pseudarthrosis to an increased degree is linked to the hazard of infection, caused either by foreign bodies still present within the area of the pseudarthrosis or by pro- longed suppuration in the case of a compound fracture. This, however, also means that the treatment of pseudarthroses resulting from suppuration may be commenced much earlier than when the pseudarthrosis would have to be exposed. Reference to this fact was previously mace by NUSSELT (69)* A further indication for percutaneous mec uilary nailing may be the condition of the soft tissue, particularly of the skin; if the operative elimination of the pseudarthrosis involves the danger of dermal necrosis it is suitable to perform percutaneous medullary nailing as a first attempt. This can not be done unless reduction is practicable with- out which no percutaneous medullary nailing can be performed. It remains to be stressed that the percutaneous medullary nailing of a pseudarthrosis in any case can bu only regarded as an attempt to cure the condition by a measure which is as sparing as possible. If this yields no results medullary nailing constitutes just the first act of planned treatment. In such a case the transplantation of a bone graft follows as the second act which then inflicts considerably lesser damage on the tissue around the pseudarthrosis, because the medullary nail stabilized the bone thus saving the preceding bone grafting. The fixation by the medullary nail has a particularly favorable result when pseudarthroses located close to the joints are operated, as the fragments which frequently are very short give no hold to the bone graft and thus prevent the simultaneous fixation of the bone fragments as a whole. It will then not be necessary in every case to resect the pseudarthrosis according to a scheduled operation. A small freshening is sufficient, no precisely fitting bedding need be prepared for the graft, and the operation really represents not more than the introduction of a bone graft to bridge over the pseudar- throsis and to act as a biologic stimulant of the factors enhancing the formation of callus. In a study which has appeared recently HELLNER (70) classified the pseudarthroses in genuine or "ordinary", and in gaping pseudarturoses. As its title "Medullary Mailing and Free Bone Graft" indicates and as the text reveals two methods are compared with each other in this study, a proceeding which in our opinion is not permissible. This may also explain why HELLNER had to admit a number of failures among his operations of pseudarthroses, a fact which aroused his pronounced dislike for medullary nailing in connection with the treatment of pseudarthroses. In the first pages of his study HELLNER overlooks the fact that medullary nailing is only a method for retention just as is the plaster cast, while, however, the bone graft is not a method for fixation with homologous material - this is also revealed by the cases reported by HELLNER where extensive use of wire loops is made to fix the bone graft - but a biologic method for stimulating the callus formation. Far logic reasons it therefore, is not permissible to compare the results of medullary nailing and of bone grafting with each other. None of those who became familiar with these problems will be surprised that some of HELLNERTs pseudarthroses healed with bony consolidation solely after resection and nailing. *) The failures found, however, were not due to deficient fixation by the medullary nail and by the plaster cast, as HELLNER believed. If it was possible to cure pseudarthroses by bone grafting, then this was not achieved because the short graft effected a really stable fixation of the freshened fragments, but principally because of the biologic stimulation of the callus by the graft, possibly even indirectly by the removal of the bone substance. One really should not believe that a bone graft attached to the bone by means of a few wire loops is better able to achieve immobilization than the long medullary nail driven into the marrow cavity. KELLNER certainly is right in stating that due to atrophy of the bone the medullary nail soon will lose its capacity of providing »n absolutely fitting stable fixation. But it is only in very rare cases that we rely exclusively on the fixation provided by the medullary nail alone, since we add a plaster cast after the operation of pseudarthroses as was done by HELLNER too. After bone grafting, the bone and the bone graft suffer an alteration caused by the process of metamorphosis, and thus it happens that an absolutely stable fixation can be guaranteed in no case.**) There! >re the conclusion is justified that with regard to the problem of immobilization the medullary nail and can additional plaster cast are at least equal in value to the combination of bone grafting and plaster cast immobilization the medullary nail and an additional plaster cast are at least equal in value to the combination of bone grafting and plaster cast immobilization, if ever one is ready to accept HELLNERfs thesis of the stabilizing r$le of the bone graft which seems to be shared (see above, BOEIILER) by other authors too. We repeat once more that such a comparison provides no basis for discussion. These considerations were enlarged and essentially supported by the experience of decades collected by PHEIviISTER (72) with the method practised by him for the treatment of the pseudarthroses. PHEMISTER employed one or even two bone grafts usually taken from the area adjoining the pseudarthrosis and he attached them alongside the pseudarthrosis without preparing a bedding for the graft. Only bony process! were removed by chiseling, if necessary, to establish as large a contact of the bone graft as Dossible with the two fragments touched by it. These bone grafts were neither grooved nor bolted, nor were they kept in place by wires or other material. If the shape of the bone graft permitted a more *) Some of the experiences made in the Giessen University Hospitals the treatment of pseudarthroses by medullary nailing were described by NUSSELT (71). **)This was clearly shown by Illustration 8 in HELLNER1s s t udy. w w adequate attachment to the bone if it was reversed, so that the periost pointed inwards, PHEEISTER pro- ceeded in this way. This did not disturb the process of healing *). Only the soft tissue was sutured and a plaster cast was applied. The pseudarthrosis was not resected or freshened and it was left as it was. The pseudarthroses treated in this way resulted in a bony healing, as was shown by PHEEISTER in a great number of roentgenograms. For such a procedure, of course, only those pseudarthroses are suitable the position of which requires no correction. It is interesting to know that PHEMISTER underlined the metaplastic metamorphosis of the cicatrized tissue of the contact pseudarthroses which is converted to bone tissue and here we find the experience pointed out by HELLNER too, that bone may be formed by connective tissue cells. In a case showing vertebral fracture and simultaneous paralysis of the legs demonstrated by PHEEISTER not even a plater cast was applied as the legs remained immobile due to the paralysis. The successfull proceeding of PHEMISTER shows clearly that a bone graft is no retention appliance but a means for the stimulation of the metaolastic osseous metamorphosis of the zone of the pseudarthrosis (see Illustration 53 g)• It is possible that PHEMISTER was not conscious of this predominantly biologic role of the bine graft, but his instihet for the healing process of the bone showed him the right way. The immobilization after bone graft certainly is indispensable, but as PHEMISTER*s cases show, it nay be accomplished by a plaster cast quite as well as by the medullary nail, as we were able to observe. As to its origin the metaplasia pointed out by PHEMISTER is closely related to the crystallization process of HENSCHEN quoted by HELLNER. It shall be stressed once more that after all one knows today about pseudarthroses and medullary nailing, there can be no doubt that medullary nailing alone is no method for the treatment of pseudarthroses, but only a mechanical auxiliary, which should be used without hesitation with or without a bone graft. One of the great advantages of medullary nailing consists in the fact that it enables us to stop using the wire loops rejected by so many surgeons for the fixation of the bone grafts. Therefore, if the bone graft is fixed by a groove this is not made to forge the fragments together in a joiner!s way (HELLNER) but quite on the contrary to prevent the bone graft from shifting without the use of foreign bodies. *) Ve do not fully understand why HELLNER subjected the bone grafts in the "aseptic workshop" to such a radical"joiner's fashioning", so that even the periosteum was rasped off with a file which was particularly underlined by HELLNER. Even if one is ready to acceot the concept originating from VON ERTL that not the periosteum but its cambium layer sticking to the outermost corticalis accom- plishes the regeneration of the bone, it is not necessary to remove the periosteum and to rasp the transplanted bone graft "on all sides". The medullary nail gains its greatest importance for the retention of the fragments after the operation of f aping pseudarthroses. Here it is necessary to bridge over he gap by bone grafts and for the purpose of avoiding shortening which would impair particularly the function of the lower extremity, to inr. bilize the fracture ends at a great distance from each other and in an appropriate axial position* If one does not want to bridge over the gap with a bone graft, but instead wants to introduce small bone pieces or spongiosa particles according to MATTI, no other fixation than that by medullary nailing is suitable (CELLARIUS (73)). ZENKER (74) w°s several times successful in employing the method of spongiosa transplantation. The stabilization is a task which not always can be accomplished by the bone graft alone (Illustration 73), particularly on the femur, where fractures of the bone graft all too fre- quently annihilated the favorable original result of the restoring operation. Even the use of two strong bone grafts (BATEMAN (75)) cannot always prevent such an incident. For this technical necessity we dispose of no better auxiliary than the medullary nail, and it may be said that the stabili- zation of the gaping pseudarthroses similar to that of the osteotomies constitutes the very domaine of medullary nailing. a b Illustration 73 a) Gaping pseudnrthrosis after muitiple gunshot fracture of humerus. b) Condition after exposure*of psoudarthrosis and fixation of fragments by two wire loops without any bone graft, medullary nailing from the distal end. c) Psoudarthrosis has healed, medullary nail and wires are removed. c The technique of our proceeding was to prepare a bedding for the bone graft in the fragments of the bone by means of the circular saw and a chisel after the resection of the pseud** arthrosis. Then the bone graft was taken from the tibia, atten- tion having to be paid to all layers adhering from periosteum to bpne marrow. To reduce the number of wire loops required far the fixation of the transplanted bone we beveled the ends of the bedding as well as those of the bone graft in such a way that they could slide in as in a groove. This method was described by BRUN (76) as early as 1917 (Illustration 74). Then usually a wire loop attached to each side is sufficient (Illustration 75)? but sometimes we attained our object with- out any looping at all, provided the bone graft was exactly Bone graft fitted into groove Remnant ;f pseudarthr osis Illustration 74 Schematic design of how a bone graft is fitted into the groove for the purpose of bridging over a pseudarthrosis (after BRUN: Zbl. Chir. 1917, 969). and firmly fitted into the groove (Illustration 76). This certainly is desirable and it is only feasible with the aid of the medullary nail which insures the fixation of the extremity* Valuable as medullary nailing is for the operation of gaping pseudarthroses it nevertheless must be admitted that in some cases the presence of the medullary nail has a dis- turbing effect in so far as it takes uo part of the space necessary for the bone graft. Unfortunately we made the ex- perience that primarily thick and strong tibia grafts had to be reduced in size considerably if it was intended to insert them in the bedding prepared for the bone graft, as the medul- lary nail took too much room. It is worth considering whether in such cases it would not have been better to abstain from the preparation of a bedding and to attach the transplantation simply alongside the freshened fragments to avoid reducing its valuable components. a b c Illustration 75 a) Gaping pseudarthrosis of radius treated with bone graft and medullary nailing. b) Infection within the operation area resulted in a sequestration of the bone graft, part of which is detached. c) Favorable final result despite infection. The gaping pseudarthrosis is bridged over by bone. The medullary nail is removed. a b Illustration 76 a) Pseudarthrosis of femur caused by distending effect of a Lane’s pirate attached to the bone in another hospital. b) Condition after removal of Lane’s plate, reduction, bone grafting, and medullary nailing. On the lateral aspect the grooving of the bone graft without any additional fixation is clearly visible. Illustration 76 (cont'd) cj Condition after healing of pseudarthrosis and removal of medullary nail. c Recently LEZIUS (77), most likely on the basis of K.H. BAUER's (78) studies recommended a procedure by which the gap on the forearm bones can be bridged over by a bone graft containing a medullary cavity. For this purpose part of a rib or fibula must be used. The stability of the bone is guaranteed by Kirschner wires inserted in the medullary cavities of the frag- ments and of the transplanted bone. The principle of medullary nailing is therefore maintained. The trans- planted bone is threaded upon the wire as in the treat- ment of compound fractures". Actually, the use of whole bone segments for transplantation is nothing new. GULEKE (79) as early as 1916 pointed to the bolting of bones with parts of the fibula covered with periosteum according to LEXER. Merely the fixation of the transplanted bone segment by foreign bodies inserted into the medullary cavity shows a similarity to the Kuentscher Nailing. For the treatment of large tibia defects LEZIUS (80) recommended transplanting a circular tibia segment from the healthy leg to the log with the pseudarthrosis* In the course of this operation the pseudarthrotic tibia must be lengthened by one half of the length of the gap after accurate measuring, while the healthy tibia must be shortened by the same amount. Of course it is neces- sary to shorten the fibula of the healthy leg to a corresponding extent. Both tibiae are provided with medullary nails so that excellent results with regard to position are yielded. By this procedure, however, the whole individual becomes shorter so that even with a shortening by few centimeters extremely inconvinient disproportions in the length of the extremities are created. Such operations are permissible almost ex- clusively after gunshot fractures with their large bone gaps, and particularly these injuries ore menaced to a high degree by infection. A failure of the tibia graft to heal into the bone caused by suppuration is particu- larly grave, since then the valuable material was spoil- ed by the useless shortening of the healthy leg. It is most questionable whether one is allowed to perform such an intervention in view of the possibility of a failure. At any rate those cases which were examined by us in accordance with LEZIUS defied this method of treatment of gaping pseudarthroses. Recently I learned that LEZIUS himself has become decidedly more cautious recommending his method only for femur fractures. The method is only practicable if the wound is not contaminated and if sufficient penicillin and supronal rare available. Our proceeding in relation to medullary nailing and bone grafting shall be shown by roentgenograms (Illustration 77 to" 80). The results obtained with medullary nailing of pseu- darthroses are given in the table (Illustration 8l). More- over, TUERK (81) compiled a survey on the results of the treatment of 38 pseudarthroses admitted to the Giessen University Hospitals. It reveals that in the case of contact pseudarthroses of the tibia the average amount of time required for full consolidation after resection and medullary nailing with and without bone graft was 8 months. A bony bridging of the pseudarthrosis was to be observed on an average 4 months. Moreover, it is of interest to observe the difference between the treatment of pseudarthroses in peacetime before and after invention of the nailing method. This is demonstrated by the comparison of the number of days spent in hospital* Before medullary nailing 3>824 days were spent in hospital, in contrast to 1,722 days spent after the introduction of this method of treatment. In 12 cases contained in this survey the re- duction of capeacity was 0%* Most of those cases which were still measurably restricted in their working capacity after the successful treatment of their pseudarthrosis showed an immobilization of the joints as a reason for their in- validity, but the stiffening had already been present before the pseudarthr osis accretion thus constituting an irrepar- able sequela. a b c Illustration 77 a) Gaping pseudarthrosis after gunshot fracture of humerus. b) Resection of pseudarthrosis, bone graft and medullary nailing. c) Condition after healing of pseudarthrosis and removal of medullary nail. a Illustration 78 a) Gaping pseudarthrosis of humerus near the shoulder joint. b) Condition after resection of pseudarthrosis, bone graft, and medullary nailing from the distal end. c) Pseudarthrosis has healed and medullary nail removed. b c a b c Illustration 79 a) Gaping pseudarthrosis after gunshot fracture of left forearm. b) Condition after resection of pseudarthrosis, bone graft, and medullary nailing of both forearm bones. c) Pseudarthrosis of ulna has healed, medullary nail and upper wires are removed. The medul- lary nail of the radius is still in place, as the bone graft not yet healed in definitely. a b c d 111uatrntion 80 a) Pseudarthrosis of forearm. b) Condition after resection of radial osoudar- throsis, bone graft, and medullary nailing of radius alone. c) After the radial bone graft has healed in, the pseudarthrosis of the ulna also was con- solidated. Stimulation of callus formation by the adjacent bone graft (cf. PHEMISTER) d) Condition after removal of wires and of medullary nail, 1-J- years after operation. 5one. , Fibber of! Involved . cases j i 1 » i i i Pereiitartr i Bony Con- t ecus ■ai’l- | ,olMatton| ! | ! j | ■Resection ;Bony Con- j and **edul- jsolidatlon | : larv j i i i i : jResectlon j Bony Con- Bone aft j solidation land nedul- j lary Fall- , line ! Complications f t | Humerus: 11 t * t j ! ; cm CM i 7 i 7 |] 3 ! L i Ji T 1 1 local osteo- myelitis, se- questration of bone graft ! ! Forearm' VS \ \ I ! i i i ! ! 1 n i i - ii ! i 9 j 9 jj 6 | 6 i 5 slight local jj | | osteomyelitis, !{ [ t bone graft healed J 1 i . ‘ in ... i ■Perrrar 12 i . jj i 3 . jj j H j 1 3 I 10 ; 10 ji ; ; - 1 j ! ; 1 .. . . U. . .. i Li i i i i • In. But this is also justified if one bears in mind that it possibly spares the patient a prolonged confinement to bed with all its consequences of mental depression and general physical reduction, and. that we are at laest able to relieve him of the pains caused by the fracture by immobilizing the fragments. The rare occur- rence of such cases is the reason why we dispose only of one relevant observation. It refers to a 16 year old boy who had suffered a spontaneous fracture in the area of a Ewing- sarcoma of the femur (Illustration 90). Even though we were not able to influence the progress of the malignant bone tumor, we nevertheless were successful in enabling the patient by medullary nailing to rise and to walk without discomfort. The subjective complaints and the nursing of the patient could be considerably facilitated by this operation. Kedullary nailing is also of advantage for the ad- justment and fixation of the leg after knee-joint resection. In this case it is best to rive in the medullary nail from the middle of the tibia towards the proximal end up into the femur. No damage of the further course of healing due to the spread of ous germs into the medullary cavity was observed by us or by other authors (HONECKER (1QL)). Illustration 90 F.Z., 16 years old, sponta- neous fracture of left femur due to Ewing-sarcoma, treated with medullary nail. This form of medullary nailing also permits the purpose- ful stiffening of .joints destroyed by comminuted fractures whose restoration is beyond expectation. In such cases too the knee-joint is particularly suitable to be stiffened by means of the medullary nail, as the straight axis of the leg per- mits the use of straight femur nails (Illustration 9l), a b (Text see next page) c Illustration 91 a) Pseudarthros is of femur in the case of a stiffened knee-joint. Resection of pseudarthros is and medullary nailine from the dis- tal end through the stiffened knee-;j oint in upwnr 1 direction. b) Beginning f orna ti m of callus. c) Condition P years after medul- lary rial line. LITERATURE 1) HAEBLER, C.: The stable Osteosynthesis etc., I.F. Lehmann, Munich and Berlin 1944 2) BOEHLER, L.: Techniaue of Fracture Treatment etc., Maudrich, Wien 1944 3) KUENTSCHER, G. and MAATZ, R.: Technique of Medullary Nailing, Thleme, Leipzig 1945 4) KUENTSCHER, G.: Zbl. Chir. 1942. 1837 5) GRIESSMANN,H. and SCHUETTEXMEYER, W.:Chirurg 1947, 316 6) HAEBLER, C.: Zbl. Chir. 1943. 374 7) KUENTSCHER, G.: Zbl. Chir. 1942, 1837 8) MAATZ, R and REICH, H.: Beitr. Klin. Chir. 174, 358 (1943) 9) FISCHER, A.”', and MAATZ, R.: Arch.Klin.Chir. 2O3. 531(1942) 10) FEHR, A.: Beitr. Klin.Chir. 174, 25 (1942) 11) LARSEN quoted after MAATZ: Zbl. Chir. 1943, 383 12) KUENTSCHER, G. and MAATZ, R.: Techniaue of Medullary Nailing, 13) EHRLICH quoted after HAEBLER l.c. 14) HAEBLER, C.: The Stable Osteosynthesis etc. p. 153 15) HAEBLER. C.: Zbl. Chir. 1943. 734 16) BOEHLER, L.: l.c.p. 146-147, III. 391-398 17) HAEBLER, C.: l.c.p. 189 and Chir. 1943. 278 18) KUENTSCHER, G.: Zbl. Chir. 1940. 1145 19) BOEHLER, L.: l.c. vol. 3, p. 21 ss. 20) FISCHER, A.W. and MAATZ, R.: Arch.Klin.Chir. 2C£, 531 (1942) 21) BOEHLER, L.: Zbl. Chir. 1942. 1294 22) EHALT, W.: Zbl. Chir. 1942. 1296 23) KUENTSCHER, G.and MAATZ, R.: l.c.p.25 24) FISCHER,A.w. and MAATZ,R.: Arch.Klin.Chir.203.531(1942) 25) LINSMAYER, H.: Chirurg 1943. 48 26) WITTMOSER, R.: Chirurg 1943. 52 27) BOEHLER, L.: Chirurg 1943. 5® 28) In addition to the Kiel instruments special extraction instruments have been described by J. PFEIFFER (Zbl. Chir. 1943. 1659) and O.STOEHR (Zbl.Chir.1043. 754) 29) Von BRUECKE, H.: Zbl. Chir. 1043. 387 30) K.T. HERZOG: Zbl. Chir. 1943. 865 designed a special U-shaped guide-rod whose exterior arm currently indicates the position of its interior arm introduced into the medullary cavity. 31) MAATZ, R.: Zbl. Chir. 1943. 1641 32) KUENTSCHER, G. and MAATZ,R.: l.c. 33) MAATZ, R.: Zbl. Chir. 1943. 1641 34) OPITZ, W.: Chir. 1948. 142 35) SPRENGELL,H.: Zbl. Chir. 1942. 271 36) SPRENGELL,H.: Zbl. Chir 1942. 911 and 271 37) STOTZ, W.: Zbl. Chir. 1944 38) BOEHLER, L.: l.c.p. 106 39) Von ERTL, J.: Regeneration and its Use in Surgery, Johann Ambrosius Barth, Leipzig 1939 40) SCANZONI: Zbl. Chir. 1943. 1000 41) DECKER, P.: Schweiz.Med.Wschr. 1947. 733 42) FISCHER, A.W. and REICH, H.: Zbl. Chir, 1943. 299 43) EHALT, Zbl. Chir. 1942, 1849 44) BOEHLER, L.: l.c. p. 89 45) FISCHER A.’", and REICH, H. : Zbl. Chir. 1943. 299 46) EHALT, W.: Zbl. Chir. 1942. 1849 47) FISCHER, A.W.,and MAATZ, R.: Arch.Klin.Chir. 203, 531(1942) 48) MAATZ, R. and REICH, H.: Beitrag Klin. Chir. 174, 358 (1943) 49) EHRLICH, W.: Zbl. Chir. 1941, 1378 50) HAEBLER, C.: l.c. 51) NUSSELT, H.: Chir. 1948 (not published as yet). 52) KUENTSCHER, G.: Zbl. Chir. 1943, 1700 53) HAEBLER, C.: l.c.p. 6 54) BOEHLER, L.: Technique of Fracture Treatment etc., p. 197 ss.- Chir. 1943. 8 151 55) RAISCH, 0.: Zbl. Chir. 1941. 390 56) HEIM, H.: Chir. 1943.~W 57) FRANZ, C.: Textbook of War Surgery. Springer, Berlin 1936. 58) FISCHER, A.W. and MAATZ, R.: Arch.Klin.Chir. 531(1942) 59) GRIESSMANN and SCHUETTEXMitEYER, W.: Chir, 1947. 316 60) Von ERTL, J.: l.c. 61) VOGL, A.: Zbl. Chir. 1943. 1649 62) GULEKE, N.:- Beitr.Klin.Chir. £8, 66l (1916) 63) GULEKE, N.: Chir. 1948. 89 64) GULEKE, N.: Literature see BRANDT, G.: Delayed Healing of Bone Fractures and Formation of Pseudarthroses. Thieme, Leipzig, 1937. 65) LEXER, E.: See BRANDT 66) BRANDT, G.: Delayed Healing of Bone fractures and Formation of Pseudarthroses. Thieme, . , Leipzig, 1937. 67) RAISCH, 0.: Zbl. Chir. 1943. 390 68) GERHARDT, F.: Zbl. Chir. 3 942. 1858 69) NUSSELT, H.: Chir. 1947. 429 70) HELLNER, H.: Chir. 1948. 241 71) NUSSELT, H.s Abstract in Chir. 1947. 429 72) PHEMISTER, D.: See p. 126 *) 73) CELLARIUS, Th.s Zbl. Chir. 1943. 745 74) ZENKER, R.: Chir. 1947. 339 75) BATEMAN, J.E.: Am.J. Surg. 1947. 423 76) BRUN, H.: Zbl. Chir. 1917, 969 77) LEZIUS, A.: Chir. 1947. 208 78) BAUER, K.H.: Zbl. Chir. 1943. 254 79) GULEKE, N.: Beitr.klin. Chir. 28, 661 (1916) 80) LEZIUS, A.: Chir. 1947, 162 81) TUERK, w.: Diss. Giessen 1948 82) Von LANZ, TH. and WACHSMUTH,W.: Practise of Anatomy 1/3 p. 158, Springer, Berlin 1935. 83) GULEKE, N.: Chir. 1948. 89 84) STOTZ, W.: Zbl. Chir. 1942. 1418 85) OBERDALHOF, H.: Chir. 1946. 123; Arch.klin.Chir. and Dt.Z.Chir. 207 - 260, 109 (1947)-Chir. 1947, 428 86) Von ERTL, J.: l.c. 87) KUENTSCHER, G.: Klin.Wschr. 1940. 6 and 833.- Zbl.Chir. 1941.857. - Zbl.Chir. 1942, 1837 88) BOEHLER, J.: Zbl. Chir. 1943. 1833 89) HAEBLER, C.s l.c.p. 21 90) ROTTER, W.: Klin.Wschr.1948, 279 91) SCHNEIDER, E.: Zbl. Chir. 1942, 1854 92) KUENTSCHER, G.: Zbl. Chir. 1942. 1837 93) RAISCH, 0.: Zbl. Chir. 1943. 390 94) SLANY: Arch. f. O”thop. und Unfallchir, 1944, 43 95) -"ALTERHOEFER and SCHRAMM: Arch. Klin.Chir. 119, 766(1922) See also A.W FISCHER: Arch.Klin.Chir. 200. 72 (1940) 96) FISCHER, A.W. and MAATZ.: Arch.klin.Chir.2O3, 539 (1942) 97) HAEBLER, C.: l.c. p. 190 98) BOEHLER, L.: l.c. p. 238 99) SCHUMANN, G.: Zbl. Chir. 1942. 1861 100) HAASE, W.: Zbl. Chir. 1943, 1266 101) HONECKER, K.: Chir. 1947. 356