UNITED STATES FLEET 
UNITED STATES NAVAL FORCES, GERMANY, 
TECHNICAL SECTION (MEDICAL) 
ROOM 124, EUCOM HDQTRS.BLDG. 
APO 757 
File: F-3 (5) 
Serial: 243-Med. 
22 April 1946 
From: Assistant Technical Officer (Medical) U*S. Naval Forces, 
Germany 
To: Chief, Bureau of Medicine and Surgery, 
(Attn: Chief, Publications Division). 
Via: (l) Technical Officer, U.S, Naval Forces, Germany 
(2) Chief of Naval Operations (•p-32-F2.). 
Subject: Marknagelung (Medullary Nail) - Additional Translation - 
Forwarding of. 
Enclosure: (A) Copy of Subject Translation (Project II, Folio IV) 
Fresh Fractures of Upper and Lower Limbs treated by the 
Medullary Nail. - by Prof. Dr. C, HAEBLER. 
1. Because of its bulk, Enclosure A will be forwarded under 
separate cover directly to each of the below listed recipients of a copy 
of this letter. 
2. This Folio contains a review of the treatment of fresh 
fractures of the upper and lower limbs with the medullary nail prepared 
by Frof. Dr. Haebler of Hannover. 
3. Subsequent Folios in this series will include a discussion 
of other uses of the medullary nail by Dr. Haebler.and a complete discussion 
of the subject by its inventor Prof. Dr. Gerhard Kuentscher of Schleswig. 
Production of these folios has been somewhat delayed by the difficulties in 
obtaining photographic material to make the illustrations, 
4* Attention is invited to the fact that this folio is from an 
unpublished manuscript prepared for the U.S. Navy and publishing rights are 
therefore a property of the Bureau of Medicine and Surgery, Navy Department. 
5. The reserve supply of these Folios is limited. It will be 
forwarded to Bureau of Medicine and Surgery, Publications Division on a 
Government Bill of lading. Requests for additional copies or further distri- 
bution should be addressed to that office, / 
HARRY J, ALVIS, 
Commander, Medical Corps, 
U. S. Navy• 
cc: 
Tech. Off, CNFG* 
CNO (•p-32-F2) 
BUMED (Publications Div.) 
BUMED (Professional Div*) 
BUMED (Research Division) 
National Naval Med*Center, 
Navy Medical School, 
National Naval Men*Center, 
Naval Med. Research Inst* 
Army Medical Library 
Department of the Army, 
©ffice Surg, Gen. 
Department of the Air Force, 
Office Surg. Gen* 
U.S. Public Health Service, 
•ffice Surg, Gen. 
U.S. Veterans Administration, 
•ffice Chief Med. Director* EXPERIENCES WITH THE MARROW NAIL OPERATION ACCORDING TO THE 
PRINCIPLES OF KUENTSCHER 
by 
Prof. Dr. C. HAEBLER 
Translation prepared bys 
U.S, Naval Technical Unit, Europe, (Medical Section) 
Office of Naval Advisor 
Office of Military Government (US) 1 
In my previous publication on the marrow nail 
operation (l) I had not evaluated the final findings 
statistically because the material in ruestion appeared to 
be too small. The experience obtained from 900 cases 
dies not say a great deal of course, nevertheless a prelimi- 
nary evaluation seems to be useful. The findings were 
obtained from my civilian practice in my own clinic and 
from the MUNICIPAL HOSPITilL at Ricklingen/Hannover of 
which I was the deputy in charge for about two years. 
On the other hand and to their greater part these ex- 
periences were gathered during my activities when I was 
a consulting surgeon of the Air Armada "RFICH" during 
which time I had the opportunity to perform nailing 
operations myself and to study the course of all the 
other cases by means of detailed reports and after con- 
sultations. A special department of the Air Force 
hospital at Braunschweig (Stabsarzt von Scanzoni), which 
was superintended by myself, made it possible to gather 
experience with particularly complicated cases principally 
with regard to the marrow nail operation in old gun-diot 
wounds, 
The indication and the technioue were previously 
published in detail. BOEHLF.R has also contributed to 
these problems (2). In the second edition of his pub- 
lication (1944) he is much more cautious as to the in- 
dications. finally KUENTSCHFR and MAATZ (3) have pub- 
lished their technioue in detail and given us a detail 
description of all fractures suitable for the marrow nail 
operation. It would be rather interesting to deal with 
the various antithesis of those authors and compare them 
with our own In view of the limited space, 
however, we have to deal only with our own findings and 
experiences gathered from our own material. 
On the one hand we must deal with the problem 
whether the results obtained by marrow nail operations 
are an advance in comparison to the hitherto known methods 
of treating bone fractures. On the other, however, we 
must study the problem as to whether or not the number of 
disadvantageous effects is greater so that they offset 
the better results. Furthermore we must study this 
method as to the cuestion of whether or not it may be 
generally used notwithstanding its difficult technioue 
or ffhether or not it must be reserved to special surgeons 
because of the danger connected with its use. Finally 
we must come to a conclusion whether the indications stated 
earlier (l) may be maintained. 
One general remark must be made: In general the 
healing of a fracture is determined according to the 
formation of callus as observed in the X-ray. A long 
time ago we had already pointed to the fact that the 
X-ray picture may be deceptive. From the clinical point 
of view a fracture may be solid and suitable for weight 
bearing even if the X-ray does not show ?/hat we consider 
to be a sufficient formation of callus (2)# We often 
observe, however, that even an abundant formation #f callus 
(without structures of lines of force) may not withstand 
the strain caused by gymnastics during the confinement to 
bed. At that time we came to the following conclusion: 
"Besides the rough mechanical examination the only criterion 2 
is the subjective statement of the patient as to pains 
encountered during weight bearing, bending or pressing 
the fragments together. 
All these symptons fail to appear after the nail- 
ing if a stabile osteosynthesis has been achieved. In 
case of a true stabile osteosynthesis painless weight 
bearing is possible at a time when a sufficient formation 
of callus is certainly not yet to be observed. In such 
a case, even X-rays are of no help. It is well known 
that especially in case of an ideally fixed fracture the 
formation of callus is particularly slight and it is 
restricted to the fracture cleft. In case of an inserted 
nail the dense shadow of that nail covers the callus to 
a great extent. But even if a sufficient ouantity of 
callus was formed the shadow of the nail will render it 
difficult - sometimes even impossible - to determine 
the structures of the lines of force or their stability. 
As an example it may be oointed. to the X-ray demon- 
strated by illustration 1, It is a nailed true pseudarthrosis 
of the arm above the elbow in which only the connective 
tissue cartilage was removed from the fracture planes. 
The patient, a regular sergrant, had served in the field 
army for two years with a nailed fracture of his arm 
above the elbow without any trouble. According to the 
clinical and X-ray findin s the fracture was considered 
to be healed. Therefore the nail was removed but the 
pseudarthrosis still existed. 
Therefore there is no sure symptom whether and when 
the nailed fracture ?/as healed. So it may happen that 
the nail is removed too early (BOEHLER, ref,(2), 111, 
3486/87) and vice versa we often have certa.inly left the 
nail in the bone longer than was necessary. As to the 
practical evaluati#* of the method it seems to be with- 
out significance, however, whether a bony healing is 
achieved earlj7- or late. As soon as the patient may use 
the broken limit without difficulty it does not make any 
difference whether the X-ray shows only a little or 
abundant callus and whether according to the X-ray the 
healing lasts 8 days or 8 months. We know that in all 
fractures even after the clinical healing, processes 
of reduction and reconstruction take place,which may 
last years. All this is of utmost 1 
greatest interest from the scientific pofnt of view but 
nobody will refer to it when evaluating this new method. 
Therefore in the statistics in cuestion we take as a 
basis only the duration of the treatment and the incapacity 
for work. 
The aim to be looked for was described by KUENTSCHER as 
a stabile osteosynthesis by which (just as in the nailing 
of the fracture of the neck of the femur) the fracture 
pieces are united by the nail in such a way that any dis- 
placement is made impossible and painless weight bearing 
and use of the limb in ouestion is possible. The 
mechanical peculiarity of the "lashing" (fixation) obtained 
with the nail allows a firm pressing together of the frag- 
ments during the weight bearing. In this way particular- 
ly favorable mechanical conditions for the stabilization 
and formation of callus are obtained. 3 
Illustration 1 
True pseudarthrosis of the arm above the 
elbow 2 years after nailing. A re- 
section was not made because the nervus 
radialis was lying in the newly formed 
joint capsule. So much of the fibrous 
cartilap*' was removed that the bleeding 
bone was exposed. The patient served in 
the field army for more than 2 years 
with the nail in place. From the clinical 
point of view the fracture is absolutely 
stabile. From the reontgenological point 
of view sufficient ouantities of callus 
have been formed. Slight rarefactions about 
the nail point. The wires we see here 
were applied during a previous unsuccess- 
ful operation. After the removal of the 
nail the pseudarthrosis is flexible again. 
According to my own experience gathered with the foreign 
body osteosynthesis we did not dare hope that the meyp pr e~ 
of the matallic nail would stimulate or favor the 
formation of callus and unfortunately all such hopes 
were futile. On the contrary it was observed that an 
abundant formation of "stimulated callus*' which is caused 
by rust or unfavorable mechanical conditions is of little 
value and may even be disadvantageous. Therefore it must 
be kept in mind that the marrow nail will further the 
healing process and the formation of callus only in case 
of favorable mechanical conditions. 4 
Unfortunately not all fractures are suitable for 
the marrow nail operation in the sense of a stabile 
osteosynthesis. This euestion cannot be dealt with in 
details here. The capability of appreciating the mechanic- 
al conditions of the marrow nail operation which is 
necessary for each healing of a fracture, and experience 
alone are the only means to get along with this prob- 
lem. 
All these experiences had to be gathered first and 
especially in the beginning, some fractures (especially of 
the leg) were nailed of which the osteosynthesis Yfas only 
’’relatively stabile” . In many cases an absolute stabil- 
ization could not be achieved, not only because of the 
relative unsuitability of the fracture but principally 
because of the techniaue applied (the nail was either 
too short or too thin). Just like myself many an 
other surgeon had to make the same experience. Among 
my patients are several cases of ’’unstab:'le osteosynthesis”. 
It is my impression, however, that also a relatively 
stabile osteosynthesis has some advantages and therefore 
nailing operations of that kind wore made intentionally in 
order to gather further nxperience. 
I. Fresh simple Fractures. 
It is characteristic for the marrow nail operation 
that the fracture cleft is not exposed. All dangers 
arising from the operative treatment of fractures such 
as infections, delayed formation of callus, etc. are 
eliminated. In fresh fractures such a "closed marrow 
nailing" should always be possible and I myself have 
always been successful. The difficulties may be very 
great, however, especially if the surgeon is not sufficiently 
experienced and therefore many surgeons decided to open 
the fracture after the application of the nail. Primary 
cause for these difficulties may be the possibility of 
soft parts entering the cleft (l) which was referred 
to also by HART (2) 
Previously the interposition of soft parts was 
frequently considered to be an insurmountable obstacle 
for the reduction and therefore the fractures were ex- 
posed. BOEHLER, however, has pointed out that that 
obstacle had to be overcome only occasionally. In 500 
cases of thigh fractures no single case of that kind was 
observed. He is of the opinion that in case of a dis- 
location soft parts penetrate the fracture cleft. But 
if the pressure is strong enough the bone ends slip 
back and the interposition disappears. This observation 
must be confirmed by my own experience. Muscles or 
fascias interposed between the bone ends are torn by 
the nail and after that they slip back. 
For reasons mentioned above HART’s (2) proposal is 
not acceptable according to which it would be better to 
expose the fracture if difficulties are encountered in 
setting a fracture. The danger of infection is consider- 5 
ably increased by the exposure. We therefore rather 
suggest stopping the operation in such a case and to 
treat the patient with wire extension. (After the 
shortening has been eliminated it will be possible later 
on to try a second nailing operation). The only indication 
for the exposure of the fracture is the suspicion that 
nerves or larger vessels may have been hurt but it must 
be kept in mind that this suspicion has always been an 
indication for the exposure of the fracture. 
A total of 463 cases of nailing operations of fresh 
simple fractures were performed, 171 of v/hich were frac- 
tures of the legs, 141 fractures of the arm above the 
elbow, 133 thigh fractures and 18 fractures of one or both 
forearm bones. 5 fatal terminations must be regretted 
all of which occurred in cases of thigh fractures. They 
will be dealt with in detail in a special chapter. 
In the first place, however, I would like to deal 
with the duration of the treatment and the results achieved. 
aJLThigJL .fractures 
It was possible to study the course of 118 of a 
total of 133 .thigh fractures until a healing was achieved. 
In 111 or 94% of the cases, it was possible to achieve a 
good healing without any shortening, bending or involvement 
of the joints, (See table #1). In a 58 year old patient 
suffering from arthrosis deformans of the knee joint, a 
limitation of flexion amounting to 20° could not be avoided 
(Table No,2). In a single case the shortening amounted 
to 3 centimeters and in another case a lateral distortion 
of 30° occurred (table #3). 
I have seen that patient a long time after the 
operation when the nail was to be removed. It was a case 
of a transverse fracture in the central third and the 
osteosynthesis was stabile. The distortion was probably 
not observed during the operation (it was the first case 
of a nailing of the thigh of that surgeon). This case 
was treated by transecting the bone above the fracture 
with the nail in place. Then a guide rod was inserted into 
the nail, the distortion eliminated and the nail introduced 
again. The final result y;as that the limb could be used 
satisfactorily. 
The two other shortenings of 3 an cl 2 cent:, motors could 
also have been avoided. In both cases thr osteosynthesis 
was only relatively stabile. In the first case (ill* 
2a-c) wc had to deal with a subtrochanteric transverse 
fracture which had been nailed by exposing the broken 
pieces because it was not possible to fix the bone ends 
correctly. After the insertion of the nail the fracture 
pieces were firmly pressed together. X-ray controls after 
the nailing revealed that "the nail was lying in the 
marrow cavity the tip of the proximal fragment, however, 
pointed to the front". These findings were obtained by an 
X-ray taken from the side (ill, 2a). In the proximal frag- 
ment the nail is not lying in the bone axis. After a lapse 
of •nlyi K « 
y * * 
111. 2a 
Subtrochanteric oblinue frac- 
ture after nailing., vh: ch xras 
an open operation because the 
reduction was not successful. 
The proximal fragment came 
to a displaced position in the 
anterior direction because the 
nail was not inserted in the 
correct axial direction. 
Primary healing. After a lapse 
of 12 days the limb is sub- 
jected to some passive exer- 
cises and exercises in the mam 
of walking while the patient 
was still confined t• bed. Thee 
exercises did net cause any 
trouble. After a lapse of four 
weeks the Ximb is subjected t© 
weight bearing . 
a 
111, 2b 
Same fracture 9 weeks after 
the operation. For eight 
days the patient has suffered 
from pains at the fracture 
site. Distinct protective 
limping. The fragments have 
slipped, the nail has 
wandered in the lateral 
direction. Medially from 
the nail the old nail bed 
is distinctly visible. 
111, 2c 
Same fracture 17 weeks 
after the removal of the 
nail. The shortening amounts 
to 3 centimeters. The bed©f 
the dislocated nail is still 
distinctly visible in the 
trochanter massive. 
1b 
c 6 
12 days when still confined to bed the limb was subjected 
to active exercises after the manner of walking. By 
doing so he did not complain about pains and four weeks 
later he was able to get up. Two Weeks after that he 
complained about pain when walking and a distinct limping 
was observed. The X-ray control (ill, 2b) revealed that 
the bone ends had slipped. The smooth trabeculas of 
the spongiosa reacted upon the constant rhythmic strain 
by an a.bsorption and thus the nail moved in the outward 
direction. The old hail bed in the trochanter can be 
seen. The final result (ill. 2c) was a shortening of 
3 centimeters. 
A shortening will not occur in any case in which 
the nail is inserted in the proper axial direction if 
the fragments are not pressed together and if the bone 
is not subjected to weight bearing too early, All these 
experiences had to be made first. When for the first 
time such a fracture was subjected to weight bearing 
a fortnight later the X-ray control revealed that the 
nail had moved in the upward direction out of the trochanter 
and thus a shortening of 1 centimeter had occurred, 
(111. 3). 
We cannot agree with BOEHLER that spiral fractures 
in the upper third should not be nailed but treated with 
the wire extension "because they cannot be kept in place 
by the nail alone (l)”. Illustration 4 shows such a 
fracture wh:*ch was healed in good position without any 
shortening and without additional wire extension. 
The only thing to be taken into consideration is 
that the fracture must not bear weight too early and that 
in fractures in the upper areas the nail mu,ct be inserted 
medially from the trochanter major. Only in this way 
does it get sufficient hold and it cannot work its way 
out of the bone laterally. 
The shortening of 2 centimeters in a spiral fracture 
in the central shaft which showed a long splinter broken 
off (ill, 5) was caused by the insertion of the nail 
into the distal fragment and in this way the bone ends 
were pressed together. This circumstance was hot observed 
during the X-ray control after the operation because 
of the good general condition of the fracture. (Un- 
fortunately, this picture was lost). Because of the fact 
that only after seven weeks post-operative was the limb 
subjected to weight bearing, a further shortening was 
avoided, 
It seems to be unsuitable to use an additional wire 
extension or nail extension in cases of fractures with 
long spiral splinters or in eases of double fractures as 
recommended by BOEHLER. In applying his principles we 
would lose the great advantages the marrow nail operation 
grants us. It is only necessary to use nails which are 
long enough and which must be driven into the spongioses, 
of the distal epiphysis. It must always be kept in mind 
that this osteosynthesis is only '’relatively stabile". 6a 
b 
a 
c 
d 
Illustration 3a 
Pertrochanteric spiral fracture with separation of the 
chant or minor caused by streetcar accident ot a 6o yeai old 
woman. This picture was taken five days following iniury. 
Wire extension, followed by marrow nailing. 
Illustration 3b 
Same fracture after the nailing. Very good position- TN. 
separated piece with the trochanter minor is m good po- 
sition. The patient got up 2 weeks later, 
Illustration 3c 
Same fracture 4 weeks later. Under the influence of the 
weight bearing the fragments were firmly pressed together, 
shortening of 1 the nail has slipped out of tns 
trochanter above, because it jammed in the marrow cavity or 
the distal fragment. The nail was inserted medially to the 
trochanter (ana not through it), therefore a lateral displa 
ment ot curvature was avoided. The patient was able to lea: 
the hospital 32 days p.op. and to do all kinds of house work 
fhe nail was extracted 5 months p.cp. 
Illustration 3d 
9 months. p,op#>4 months after the removal of the nail. 
Healing in perfect position with a shortenig of 1 centimotc 
The nail bed is not visible anymore. At the upper part 
of the trochanter a little callus head is observed. All 
joints are freely movable and pains are not encountered any- 
more. 6b 
Illustration 4 
I11ustration 5 
Subtrochanteric spiral frae- 
tufe with Separated third frag- 
ment 22 weeks after the nail- 
ing, N» shortening, all joints 
are freely movable. After the 
nailing confinement to bed for 
5 weeks. After that the limb 
was subjected to weight bearing, 
9i weeks p.op, the patient was 
released from the hospital as 
fit for service. 
Healed long spiral fracture 
in the midd._c of +• he shaft 
with a separated spiral splin- 
ter, The shortening amounts 
to 2 centimeters. The picture 
taken after the operation 
(which was lost) shows the s...m 
position of the fragments. 
It was not observed that on: 
fracture had become snorter, 
probably during the insertion 
of the nail into the distal 
fragment (counter pressure fre 
the direction of the knee), 
further shortening did not 
occur because the limb was si' 
jected to weight bearing onij 
seven weeks p,4p, In frac- 
tures of this kind the frag- 
ments must not be pressed to- 
gether, it might even be 
necessary to diminish the 
counter pressure during the - a 
sertion of the nail so that t 
nail may push that fragment 
to the former position. 7 
In the beginning the nail finds sufficient hold 
in the spongiosa of the knee-joint- epiphysis so that the 
joint may either be moved or even bear '/weight. Under 
the strain of the rhythmic v/eight bearing the spongiosa 
spicules are absorbed very soon (4-6 weeks later) and 
probably even small chips break off the ends of the frag- 
ments. Thus the nail looses its hold. If in such a 
case the bone is subiected to weight bearing, shortening 
or bending will occur because the fracture callus is not 
yet strong enough. Its value is decreased by the constant 
bending and even a resorption in the vicinity of the 
fracture slot or a fracture of the nail may occur (see 111, 
7). 
From the clinical p»int of view the danger of dis- 
placement is ouite noticeable by the fact that the patients 
complain about pains even in those cases in which their 
fractures were subjected to painless weight bearing 
previously. Special attention must be attached to this 
fact and such a patient must be confined to bed again. 
X-ray controls repeated in short intervals are urgently 
required < Any bending that occurs must be counteracted 
and an additional cast is required. Shortenings must be 
corrected Uhder anaesthesia by medns of extension and 
after that a wire extension must bo applied. If a shorten- 
ing or a bending does not exist or if move rents even with- 
out weight bearing are painful a 11 zinc:t (Unna*s paste) 
bandage according to the traction method wi11 sufficei 
Therefore special attention must be given to those cases. 
By doing so even serious comminuted fractures may come to 
a healing in good position without having to use a wire 
extension from the very beginning. (Ill, 6), 
Distally located spiral fractures were not nailed 
anymore because in two cases an additional wire extension 
was required besides the nail. In those fractures a nail- 
ing is not indicated. If the right technioue is applied 
those fractures will come to a good healing with wire 
extension alone. 
Table I demonstrates the exact data of the treat- 
ment , 
Tqble I.L Time required for the treatment and re- 
sults with the marrow nailing of fresh simple thigh 
fractures, 
Number. 
_ .mm 
Period of 
Unfitness 
for serv, 
I 
Final re 
II 
suit s 
_III _ 
Hospital 
71 
n. j 
145 
, (64-248) 
198 
66 
— 3 
— -2 
Civilian 
hospital 
47 
55 
(19-98) 
109 
f38-171) 
44 
2 
Total 
118 
; 108 
(19-248) 
162 
(30-263) 
in 
=94$ 
5 
*4, 34 
2 
-1,74 7a 
b 
a 
Illustration 6a 
Comminuted thigh fracture after the nailing. The 
nail jams in the marrow cavity of the distal fragment. Th. 
osteosynthesis is stabile. The limb was subjected to 
active exercise 6 days later during the confinement oc 
bed and 6 weeks later it was subjected to weight bearing, 
Illustration 6b 
Same fracture 17 weeks pt»p. after the removal of 
the nail. All joints are freely mtvable5 no shortening. 
The unfitness for service lasted 137 days* 8 
I. Healing without shortening*.curvature or impediment 
of the joints, 
IX, Slight curvature, shortening or impediment of the 
joints (decrease of ability to earn a living less than 
20%) . 
Ill, Marked shortening, curvature or impediment of the 
joints (decrease of ability to earn a living amounts from 
20-50%). 
It is remarkable that the unfitness for service of 
soldiers treated in military hospitals lasts *uoh longer 
than in civilians. It must be kept in mind, however, that 
our patients cases originate from eleven military 
hospitals and several surgeons participated in only two 
to three nailing •porations. It is a matter of course 
that these surgeons wanted to observe the patients as 
long as possible. Patients treated in civilian hospitals, 
however, could easily be observed even after their re- 
lease from the hospital, and thus it was possible to 
permit them resume their work. 
Our data nearly corresponds to those of FISCHER 
and MAATZ (l) (length of time reouired for the treatment 
in the hospital: 58 days, unfitness for work: 170 days.). 
In table II we see the results obtained by BOT’HLER 
(conservative treatment). 
Table II. Duration of treatment and results obtained 
in cases of conservative treatment of fresh simple thigh 
fractures (according to BOEHLER). 
Average Time 
of treatment 
davs J 
Missed annuities 
ing days based on % dis- 
ability 
Pat. treated in 
emergency hospitals 
24» 
] 
627 ' 
10,2 
•tb«r than emergency 
hospitals 
390 
1819 
22,6 
L 
It must be admitted that in the • a9.-0 8 mentioned 
above we have not to deal with the same kind of fractures, 
for, the material of BOEHLER includes distully located 
fractures which were not nailed by us. It is a matter 
of fact, however, that »ven the longest period of 
medical attendance in marrow nailings is not longer than 
the average duration of treatment in the emergency 
hospital. The longest period #f incapacity for work 
is only one third of what it is with conservative treat- 
ment in BOEHLER*s clinic, which in this connection is 
one of the best. In this way the great advantages of 
this method - als» from the economic point of view 
are demonstrated. On the other hand the nursing of 
the patient is much easier and all those who have ever 9 
had a chance to observe the strain wh:ch is taken 
from the patient when, in most cases even one day 
after the operation, the patients are lying in bed 
without any pains and soon may move the limb or even 
may subject it to weight bearing* will understand 
that the physicians as well as the nursing personnel 
and the patients are. enthusiastic about this method 
and that unden the influence of this enthusiasm the 
indications were sometimes too widely extended* 
As demonstrated in the table above many of our 
patients were employed at hard labor sometimes as 
early as 5-7 later. This may be done even if 
the fracture has not yet come to bony healing be- 
cause the very strong thigh nail provides sufficient 
support in all suitable fractures. The patient must, 
however, be kept under permanent control, for, even 
in fr sh fractures the marrow nail may break (l)* 
If in such a case the patient consults a physician 
not acquainted with this method, such a physician 
may fail to extract the nail immediately and replace 
it with a new nail. 
A 20 year old parachutist suffered a closed 
transverse thigh fracture in the middle from a jump. 
This was immediately nailed. Ten days later he 
was able to get up without pains and a;as released 
from the hospital 8 weeks later. 11 days after that 
when carrying a sack weighing a hundredweight he 
suffered from pains at the fracture site. Despite 
this fact he continued walking but his th:gh is 
somewhat bent at the fracture site. Therefore, he 
was sent to a military hospital "/here a plaster 
cast was applied for a period of six weeks. After 
that he was transferred t» a special department 
of the hospital in order to have his nail removed, 
(December 1944). Now, the fracture has come to a 
bony healing in a slight varus position (111. 7)# 
An extraction hook are long that it could be pushed 
forward to the end of the nail tip was not available. 
The bending, however, was not so oronounced that an 
osteotomy with another nailing would have been indicated. 
Therefore only the uoper part of the nail was removed 
and the patient was released from the hospital because 
of the general conditions of war. After that we 
lost sight of him but most recently we learned that 
he is in good condition. It has not yet been pos—■ 
to examine him again. 
Late curvature or shortening in cases of thigh 
fractures - besides the above mentioned cases 
wero not observed especially not after the release 
from the hospital. Most of our nailing •perations 
(98) were in fact stabile and only in those cases 
were the patient granted an early release from the 
ho spital. 
Fractures less than 7 centimeters distant from 
the knee joint were not nailed in our hospital. 
Operations of this kind, however, were tried three 
times in military hospitals but in all cases great 
difficulties were encountered. Two of the pationts 9a 
Illustration 7 
Fracture of the callus and of the nail 10 weeks 
after the operation due to carrying heavy loads of 
50 kilograms. The o st cosynthesis was not absolutely stab.1' * 
because the nail was not inserted medially to the 
trochanter but through it and the nail head was lying 
in the bone. Around the nail head rarefactions of the 
bone which proved that the nail was ’’working” . The callus 
is of little use. It is cloudy and cannot take the strain 
which it is subjected to because of the movements at the 
fracture cleft. Instead of removing the nail immediately 
and counteracting the curvature a plaster cast was applied 
for a p riod of six weeks until the fracture was healed 
again. 10 
died and in the third case we declined to perform the 
nailing operation and the patient was treated with a 
wire extension which made a good healing possible. 
Fractures of that kind and spiral fractures in the 
lower third with a long spiral splinter are considered 
to be unsuitable for the marrow nail operation. Physic- 
Chaise not well acquainted with the technique of the 
/ire extension and who are not able to bring the fracture 
into a good position by this extension will probably 
not be able to perform a nailing operation without an 
exposure of the fracture site. Even if this process 
can bo carried through successfully an additional wire 
extension is required and therefore the advantage ob- 
tained is not so great. 
If by applying a wire extension satisfactory re- 
sults cannot be obtained and consecuently the fracture 
site must be exposed in such a case the fracture 
pieces should be united by putting a vire round the 
fracture pieces (in spirale fractures) or by applying 
a LANE1s plate (in transverse fractures) which will 
grant better results than the marrow nail. The nail 
can never find sufficient hold in the distal fragment 
and the protection against displacement is less than 
by an osteosynthesis with wire and plate. If an 
infection occurs, however, the nail will cause an 
infection of the entire marrow cavity and of the 
knee joint which may lead to a fatal termination or 
to the loss of the affected limb. 
il. r^ctures 
A final healing was obtained in 162 out of 171 
cases of nailed log fractures and the result0 obtained 
are demonstrated by table III, 
Table Duration of treatment and result 
obtained by a marrow nailing operation of fresh simple 
leg fractures. 
No, J Duration 
stav in hosp^ 
of 
scrv.disab* 
Final result 
I II III 
Mil, Hospital 
97 
122 
(30-220) 
nti 
(92-245) 
V 
86 
10 
l 
Ciyiiian 
Hospital 
65 
67 
(18-183) 
131 
(71-235) 
63 
2 
Trtal 
162 
102 
(18-220) | 
133 
(71-245) I 
149 . 
=92% A 
, 12 m 
1 7,4% 
1 ® i| 
0,6% 11 
I, Healing without any shortening, curvature or impedi- 
ment of tho joints. 
II. Slight curvature, shortening or impediment of the 
joint Is • less tJL0% 
III, Marked shortening, curvature or impediment of tho 
joints 20-50%, 
Also in these cases the time renuired for the treat- 
ment in civilian hospitals is considerably shorter than 
in military hospitals due to the above mentioned reasons, 
The duration of service disability, however, docs not 
differ so much, 
Comparable statistics for the conservative treatment 
are not available. The kind and duration of treatment 
of the different types of fractures differ considerably, 
(transverse and spiral fractures etc.) and according 
to the extent of the displacement all varieties are 
possible. favorably located transverse fractures 
require an additional wire traction for about three to 
four weeks. Patients treated with a marrow nail, how- 
ever, may be released from the hospital two #r three 
weeks later and the wire extension will in no case be 
required. As to the incapacity for working WOEHLER 
estimates a time of about 3-6 months which certainly 
will not be required by the marrow/ nail rarthod. BOEHLER 
(l) has proved that in most simple fractures of the leg 
an unimpaired healing can be obtained with a conservative 
treatment by expert application. Three years after the 
treatment 85,26% of his 346 patients no longer received 
any pension. In comparison to that, an absolutely 
satisfadtory healing obtained in 92% of the cases must 
be considered as a real progress. In this connection 
it must be borne in mind that in none of the cases marked 
as II, (Table III) would the patients have received a 
permanent pension (i.e. 20% reduction of earning one's 
own living). 
In all these cases we have to deal with si1ght valgus 
positions or slight recurvations without impairment of the 
joints or slight shorteningsof less than 1 centimeter. 
On the other hand it must be taken into consideration 
that the mat rial published by BOEHLER was gathered in 
a clinic which is well-kncwn for its great experience and 
the good results obtained. 
Our own two unsatisfactory cases originated from 
the very first time when the marrow nail was still in- 
serted laterally from the tuberositas tibiae. In this 
way a recurvation is avoided, but in oblioue fractures 
a slight valgus position may iccur especially in case 
of an early weight bearing. Both of the patients were 
compulsory members of the sick fund and did not receive 
any pensions. 
In comparison to the above cases the case demon- 
strated by 111, 8 must be considered a bad result w hich, 11a 
a 
b 
c 
Illustration Ba 
Simple oblirue fracture of the leg in the cast. 
Illustration Bb 
Same fracture aft or the nailing, Tcpi.hnicalamis~ 
takes: The nail is too thin and too short, the valgus 
position was not corrected. An infection of the nail 
insertion site occurs wh:ch, because of the instabilo 
osteosynthesis spread to the fracture cleft later (the 
nail acting as a drain. 
Illustration Be 
Despite a long lasting treatment in the plaster cast 
the valgus position is somewhat increased. 12 
however, is not due to the method but to the technique 
applied. In this caso only one nail (the thin nail) 
was applied (which in addition is too short for such 
a distally located fracture), and the valgus position 
was not eliminated. Therefore the osteosynthesis was 
only relativoly stabile and the valgus position increased 
later on. Besides all that an infection occurred at the 
point of insertion of the hail and at the fracture cleft and 
that is why an additional plaster cast had to be applied. 
The iaone was subjected to weight bearing after a good 
formation of callus* studying the picture with 
the plaster cast before the nailing it must be admitted 
that the physician would better n#t have nailed this 
fracture, 
For comparable purposes 111* 9 shows a similar 
fracture. In this case a long double nail was applied 
and a healing in perfect position achieved. 
ono exception (slight recurvation which was not 
counteracted (2)) the osteosynthesis was only relatively 
stabile in all cases which did not show satisfactory 
results. Considering the shape of the marrow cavity 
of the tibia and the necessity to use only curved nails 
only a few cases may be considered as Hsuitable" when 
bearing in mind that a stabile osteosynthesis should bo 
obtained by the double nail (transverse fractures located 
at least 8 centimeters from the upper and 10 centimeters 
from the lower ends of the tibia, furthermore oblique 
fractures and spiral fractures in the central third). 
Therefore KUENTSCHER and MAATZ have constructed double 
nails which spread in the distal end of the tibia and 
thereby obtain sufficient hold also in distally located 
spiral fractures and green stick fractures (turn-sproad- 
nails, nails with an inclined plane). One disadvantageous 
fact, however, must be taken into consideration: A 
special nail is renuired for each fr cturc and sufficient 
quantities of nails were not and are not yet available. 
Due to this fact very little experience was gathered 
with these nails so that we are not in a position to give 
a final evaluation concerning these special types of 
nails, 
In case of distally located spirnl fractures and 
oblique fractures, best results are obtained with the 
simple double nail. First condition, however, is that 
the nails are long enough, so that they may find sufficient 
hold in the spongiosa of the distal fragment. In this 
case it must be taken into consideration, however, that 
the osteosynthesis is only relatively stabile and that 
early weight bearing is not indicated. If necessary a 
plaster cast or a U-splint must be applied as an 
additional protection for the fracture. 
In 16 cases of leg fractures with a r'latively 
stabile osteosynthesis which were treated in my civilian 
practice the period of stay in the hospital came up to 23 
to 183 days or 77 days on an average and the inability 
for work came to 68 to 196 days, i.e. 134 days on an 
average. When considering those figures it must be said 
that a considerable gain is obtained in comparison to the 
treatment with the traction method, This is demonstrated 
bj?* ■ «!• '&* 12a 
a 
D 
Illustration 9a 
Fracture of the same kind after a technically correct 
nailing with a sufficiently long double nail. The 
osteosynthesis is only relatively stabile therefore a 
short cast was applied f*r 4 weeks. After that a moulded 
splint was applied with which the limb is subjected to 
weight bearing. The splint is removed 14 days later. 
8 weeks p.op. the patient was released to his unit. 
Illustration 9b 
4 months p.op. after. the removal of the nail. Com- 
plete restoration. Treatment in the hospital and time of 
unfitness for service amounted to 74 days. 13 
by Illustration 10-12, 
As in all cases of bone fractures the nailing of 
distally located or complicated leg fractures repulses 
technical understanding and skill. Fr0m the technical 
point of view the nailing of leg fractures is very simple. 
It is perhaps the simpliest nailing operation possible, 
™hcre must, however, be taken into consideration that 
incidents may occur, v/hich the physician must know in 
order to avoid failurcs(l)i 
In cases of proximally located fractures the nail 
may slip behind the distal fragment if it is inserted 
too steeply and too distally (111. 13). In such a 
case the fracture must be brought into an anticurved 
position. Contrary to this the nail tip may slip behind 
the distal fragment in distally located fractures, if an 
anticurvation exists. In such a case a recurvation may 
be successful. In conformity with thoMdategorid imperative 
of the fracture treatment1' it may be said: "The distal 
fragment must be brought into that direction in which 
the nail tip points”. 
In one case the nail jammed in the corticalis of the 
distal fragment so much that it was impossible either 
to drive it in completely or to extract it. The surgeon 
reacted in the right way. He pinched the nail off and 
applied a blaster cast until a healing was obtained. 
After that the nail could be removed easily. 
If the situation is so complicated that it is impossible 
to open the fracture during the operation it seems not to 
be advisa.ble to, apply a marrow nail. The danger of 
infection is imminent and increases during needless and 
long lasting attempt. Therefore in such a case conservative 
treatment will show better results. 
Novertheless only in rare cases of leg fractures will 
difficulties arise during the operation. They must, 
however, be expected during the after treatment because 
in leg fractures the osteosynthesis can nev-r bo as stabilo 
as in thigh fractures. 
In tile cr.se of the groen*fti«k fracture demon- 
strated by 111* 14 the fragment which had turned 180° was 
expected to slip back so that it would not endanger the 
skin anymore. Despite the fact that the skin above the 
fracture site was extended due to a slight valgus position 
which intentionally' was not counteracted necrosis 
occurred 4 days later. Therefore the fragment which 
was not covered by periosteum anymore was removed. After 
that the plaster cast was applied, because the osteo- 
synthesis was only relatively stabile. The valgus 
position was not counteracted which could have been done 
easily, (result II was avoidable). 
In the c?.se of the comminuted fracture demonstrated 
by 111. 15a the fracture was absolutely stabile after the 
nailing. Therefore a U-splint war applied and the fracture 
was subjected to weight bearing two weeks later. In spite 
of the fact that the patient' complained about pains at the 13a 
b 
a 
Illustration 10a 
Spiral fracture of the leg with a fissure of the 
distal fragment extending in the downward direction, 
during and after the end of the nailing operation. The 
limb is subjected to painless weight bear ng 19 days later 
with an adhesive bandage. The patient is released fro. t b ■ 
hospital three weeks after the injury, 
Illustration 10b 
Three months after the operation, a ter the renov.il 
of the nail. All joints are freely movable. 
Illustration 11a 
Spiral fracture of the log 
with a long third, fragment 
a 16 year old, apprentice 
clerk. The fracture is only 
slightly displaced because 
the periosteal tube is not 
damaged. 13b 
Illustration lib 
Same f r a c t u. r o 16 d ?. y s a f t e r 
the nailin'-. 
Illustration 11c 
Same pa1lent same dayi thc 
damaged riaht 1 ca is absolut 
iy stabile and frcely m.ov~ 
able. Release from the 
hospital. From the third day 
on the log was sub looted to 
active exorcise and on the 
11th day the pationt got up 
b 
c 
Illustration lid 
6 weeks p.op. Good form- 
ation of calius. Pationt 
does hard labor. 8 days 
later serious hematoma in 
the right log due to a 
sudden fall. The frac- 
ture was not harmed. 
d 
Illustration lie 
10 weeks p.op. The fracture 
healed, the nail going to be re- 
moved. Extraordinarily strong 
formation of callus oxtending 
from far above the fracture 
site to far below, which is no' 
due to the nail but to the 
separation of the undamaged 
periosteal tube which probably 
granted additional support. No 
rarefactions in the vicinity 
of the nail tip, i,c., the nailr 
have not"worked", 
o 13c 
a 
a 
Illustration 12a 
Double fracture of the leg with simult .ncous fracture 
of the same thigh eight weeks after nailing. The patient 
got up on the 29th day p.op. with the plaster cast in 
place till the end of the 8th we k p.op. Despite the fau 
that the formation of callus is very poor, the patient is 
able to subject his leg to painless weight bearing. The 
leg nail is removed 3-g- months p.op., 14 days later the 
th?gh nail is removed. 
Illustration 12b 
The fractures after the re- 
moval of the nails. Negli- 
gible impairment of the ankle 
.joint which did not exist any- 
more 12 weeks later when a 
follow up o x a. mination took 
place. During the operation tl 
leg was nailed first and then 
the thigh* 
b 13d 
111u rtratio n 12b 
(Second part, Explanation see 
page 13c.) 
Illustration 13 
The nail slipped behind the 
distal fragment in this 
proximally seated leg frac- 
ture which is due to the 
fact that it was inserted 
distally from the tubero* 
sitas. The fracture is 
not sufficiently enough 
distracted and should have 
boon brought into an anti- 
curvature position. 13e 
a 
b 
Illustration 14 
a) Groonstick fracture after the nailing. The third 
fragment is turnod round 180°. Slight valgus position 
which was not corrected because oth rwise the skin 
would have been under tension above the separated frag- 
ment, Nevertheless a necrosis of the skin was observed 
4 days later, Excision of the necrosis and removal of 
the bene splinter which was not covered with eeriest* It 
was forgotten to counteract the valgus position (}). 
Primary healing. 
b) Same fracture 3i months later. The defect is well 
bridged over with callus. Four weeks after the nailing 
the patient subjected his leg to weight bearing with 
an ambulatory cast. The patient has been without a cast for 
6 weeks. The nails will bo removed. 14 
fracture site weight bearing was continued. 8 days 
later the patient complained also about pains in the 
knee joint and therefore an X-ray (111. 15b) was taken 
in order to determine 7/hether the already very far 
protracting nail had worked its way out of this frag- 
ment. Unfortunately it was not observed that a shorten- 
ing had occurred. The final result (111, 15c) is a 
shortening of three quarters of a centimeter. The nail 
had moved into the spongiosa of the distal fragment 
because it had jammed in the corticalis of the proximal 
fragment . From the very beginning it would have been 
better in this case to drive it in more deeply and to 
subiect the limb to weight bearing only after some 
time and if so only with c. plaster cast. The pains com- 
plained about during the process of weight bearing 
should have been a warning signal. 
In case of a proximally located fracture the nail 
mtvos in the upward direction during the compression 
process and may cause troubles as demonstrated by 111, 
16. Due to negligence in thiscaso the bone ends were 
not compressed after the •peration. 
If in prcximally located fractures the fibula is 
intact the compression will be hinderod and even in 
transverse fractures a bending may occur if the fracture 
is subjected to early weight bearing (ill. 17). The 
smooth bone spicules of the spongiosa and the very thin 
corticalis cannot stand the constant slight pressure. 
They are resorbed and the nail begins to”wander” which 
may be distinctly detected by the rarefactions in the 
vicinity of the nail head end (ill. 17c). 
In cases in which the osteosynthesis scorns to be 
stabile in the very beginning and the fractures may be 
subjected 'to weight bearing without difficulties, nailfl 
which are too short may cause a blocking of the freshly 
healed fibula and in this way may load to disturbances 
of the formation of callus. 
Despite the fact that in a transverse log fracture 
near the junction of the middle and distal third the 
nails were too shert and the fracture was not comprossed 
(ill. 18a) the patient was given permission to rise after 
a lapse of two weeks. ”Ho had, however, to use crutches 
in order to examine to which extent the fracture could 
be subjected to weight bearing”. 8 days later an X-ray 
was taken and it was observed that a lateral displacement 
of the fragments had occurred six weeks later the patient 
could walk without a stick and therefor' was released 
from the hospital to do garrison duty. In the X-ray a 
good formation of callus was observed at the fibula and 
tibia, the slight valgus position, however, was not 
noticed (111, 18b). 3 months later he was sent bask 
to the hospital because of • increasing pains at the 
fracture site and edema of the log. The X-ray showed 
a healed fibula and cloudy callus on the tibia with 
formation of flanges and the fracture slot remained open. 
Clinically a distinct springiness of the bones is observed, 
i.e. an unhealed fracture. In the vicinity of the nail 
tip a rarefaction of the bones is observed v/hieh oroves 
that the nails are not at rest. Therefore the nails must 14a 
a 
b 
c 
Illustration 15 
a) Spiral fracture of the le~ with a marked splitting of the 
tibia after the nailing in good position, The nail length is 
correct but it was not inserted deeply enough. Therefore, the 
osteosynthesis is only ‘’relatively stabile”. Nevertheless, 
the limb is subjected to weight bearing with the U-splint 14 
days later. The patient suffered pairs at the fracture cleft* 
b) Apart from this the patient complains about pains when bond- 
ing the knee joint. Therefore, 3 weeks p.op,, an X-ray is tea - • 
which proves that the nail did not move in the upward dirocti > i 
It was nrb'observed, • however that the fracture had become somewhat 
shorter in the distal fragment due to the moving of the nail in 
the downward direction* Therefore, the patient was permitted tc 
continue subjecting the limb to weight bearing. 14 days later 
the U-splint was removed, 
c) Three months p,op. the fracture comes to a bony healing. 
The shortening amounts to of a centimeter. The nail has 
moored furt.hcr in the downward direction. 14b 
a 
b 
Illustration 16 
a) Oblioue fracture in the upper third of the leg after the 
nailing. The position is good, the fracture cleft is gaping. 
10 days later the patient starts subjecting the limb to weight 
bearing. A very short time later he complains about pains 
when bending the knee joint. 
b) Fight weeks later: Due to the effect of the weight bearing 
the fragments wore firmly pressed together. Conscouontly 
the nail which was jamming in the distal marrow cavity moved 
in the upward direction. 
Illustration 17 
a) Projcimally located transverse 
fracture of the tibia after the 
nailing. 14 days p.op. the limb 
is subjected to Y/oight bearing 
without any additional bandage. 
The patient complains about 
"slight pains !at the fracture cl d 
when stepping on the foot", 
b) Five weeks later: "still exist- 
ing distinct limping and moderate 
disturbances of the circulation cf 
the leg. Distinct formation of 
callus, (The valgus position 
which had developed in the mean- 
time was not observed). Zinc- 
gelatin bandage and plenty of 
active exorcise". 14 days later 
the patient wont on leave. After 
that removal of the zinc gelatin 
bandage, physiotherapy and half- 
day labor. 
a 14c 
Illustration 17c 
Three months p*cpi Healed under a 
slight increase of the valgus 
position. The rarefactions of the' 
bene prove that the nail had moved* 
c 
a 
» 
Illustration IS 
a) Transverse fracture of the leg at the junction of the distal 
and middle thirds after the nail ng. The fragments were not 
pressed together. The nails arc too short. 
b) Six weeks after the nailing the limb which was not proi ctod 
by a plaster cast was subjected to weight bearing too early. Due 
to thjs fact the fragments were pressed together but at the same 
time they came into a valgus position (wh"1 ch was not observed). 
Distinct formation of callus. Patient released to the unit for 
garrison duig* 14d 
Illustration 18c 
Three months later: The fibula 
has come to a healing. A slit 
running through the cloudy 
callus of the tibia is obscrv 
Rarefactions round the nai1 
tip. From the clinical point 
of view the fracture Is spring 
ing. Pains and edemas. Ex- 
traction of the nails, oblicue 
osteotomea of the fibula, 
BECKfs drilling. Plaster cast 
Secretion of the drilling wourv 
for 14 days. Once again the 
varus position is not corrected 
c 
Illustration I8d 
After a lapse of three further 
months an ambulatory east 5s 
attached. The fracture came 
to a bony healing. It would 
have been better to leave the 
nails in place and to resect the 
fibula and to correct the varus 
position. 
A 15 
be removed and the fibula Separated obliquely. After 
that multiple drilling must bo accomplished according 
to the principles of BFCK during which BFCK’s wire 
must not Mcut itself free and got very warm”, A plaster 
cast is required. A serous hemorrhagic secretion is 
ejected from the drill-hole for a period of 14 days, 
a serious infection, hiwever, docs not occur. A bony 
healing is achieved three months later after an ambulatory 
cast was apolied (ill* 18d), The removal of the nail 
as well as the drilling according to BFCK's principles 
was not necessary, the latter causing only an increase of 
the danger of infection. If in this case a piece of bone 
2 centimeters long' had been resected from the fibula and 
if the varus position had been comoensated, which could 
have been accomplished easily, the patient would hive 
been taken care of better. 
In case of an early healed fibula and delayed formation 
of callus the physician should not hesitate to resect 
the fibula (not only to separate) and. to apply a plaster 
cast. In this case the nails are kept in place. rven 
if they are too short they grant an additional support 
and the fracture will soon come to a bony healing, 
(111. 19). 
In leg fractures it will hardly be possible to determine 
whether the osteosynthesis is stabile enough to make 
weight bearing possible. This is contrary to findings 
in thigh fractures (See 111. 9 and. 10, which by no means, 
seem to be If there is any doubt, hov/ever, as 
to the stability of the fracture with regard to the X-ray 
and the special kind of fracture it will be better to 
apply an additional plaster cast. It is a matter of 
course that edema is alway a' an insufficient stability. 
According to my own experience the only sure criterion is 
the subjective statement of the patient. If the patient 
complains about pains something must be wrong even if an 
additional plaster cast was applied. This is demonstrated 
by the following example: 
111. 20a shows a spiral fracture in the lower third. 
The nails applied were relatively short. After the tjpplica- 
tion of a small ambulatory cast the fracture was subjected 
to painless wtight bearing 8 days after the operation. 
A displacement did not occur. 4 weeks after the operation 
the patient was released from the hospital and given 
ambulatory treatment with a plaster cist in place. 10 
weeks after the operation the fncture was clinically 
healed. The formation of callus observed in the X-ray, 
however, is not yet strong enough (ill. 20b). Therefore 
the nails were not removed. The fracture was subiected 
to weight bearing without a cast and. 8 days later the 
patient started working, 6 months after the operation 
the fracture was bridged over by good callus (ill. 20c) 
and subseouently the nails were extracted. Minor rare- 
faction about the nail tips proved that the nails were 
semewhat loose. 15a 
a 
Illustration 19 
a b 
a) Fracture of the leg with fracture of both ankle bones. It 
is n»t possible to get the fragments into the; right position 
because of the fracture of the ankle bone. Therefore the 
surgeon decides to nail the fracture using the open method, 
primary he ling. Plaster cast, 14 days later application of 
a U-splint with which, three weeks p.op., the limb is subjected 
to weight bearing. 12 weeks p..op., removal of the u-splint. 
The fracture of the ankle bone came to a healing. Massage and 
gymnastics. Three weeks later the- patient suffers pains and rod 
ness at the insertion site. After a confinement to bed for 
eight days these symptoms disappeared. 
b) 3 months p.op., the fibula is healed. The fracture cleft of 
the tibia is gaping. The skin above the fracture site is 
flushed and distinc tly warmer than the surrounding skin. Re- 
section of the fibula and application of a U-splint, 15b 
Illustration 19c 
5 Weeks later the fracture is 
bridged over with bone and is 
stabile. The nail is removed. 
Fractures of this kind are 
better treated conservatively 
because of the danger of in- 
fection if the closed nailing 
is not successful* 
c 
Illustration 20a 
Spiral fracture of the leg 
after the nailing in a 50 year 
old woman. The nails are rather 
short; they should have been of 
such a length that they reached 
the epiphyseal line. Neverthe- 
less the patient was able to sub 
ject the limb to painless weight 
bearing 8 days later with a 
short walking cast. She was re- 
leased from the hospital 4 weeks 
later for ambulatory treatment. 
a 15c 
b 
c 
Illustration 20, , 
bt c 
Same fracture 10 weeks later. The fragments were firmly 
pressed together by the weight bearing and angulation did 
not occur. The callus is not yet stabile enough and there- 
fore the nail is kept in place. Weight bearing without the 
plaster cast. The patient resumed her work 8 days later in a 
factory, 
a) 10 months after the nailing the fracture is healed and a 
good formation of callus is observed. The nail may be removed. 
Slight rarefactions surrounding the nail tip prove that the 
nail has become somewhat loose. 16 
111; 21a shows a similar fracture of another patient 
who in the first Y/eight bearing with a walking cast com*- 
plained about pains at the fracture site. After a tem- 
porary observation she wo.s considered hypersensitive. 
14 days later the X-ray revealed a slight valgus position 
which was counteracted by the plaster cast during its re- 
pair. The patient was confined to bed for a period of 
8 days and after that the bone was subjected, to weight 
b'aring; Once again her complaining about pains was 
not taken seriously and three weeks later the fracture 
had. slipped into the former valgus position and a slight 
curvature was observed, (ill, 21b). Once again tho 
position was corrected and then the patient was kept in 
bed with a cast. Three months after the operation the 
X-ray (ill* 21c) shows a beginning formation of callus* 
At the so.me time it was observed that the bone of the 
distal fragment was somewhat poor in calcium. From then 
on the patient did not complain about pains anymore and' 
because of the terror air raids sh6 was released from the 
hospital* 8 weeks later the ambulatory cast was removed 
by the family-doctor. 6i; months after the nailing the 
patient came to see us. The examination revealed that the 
fracture had come to a bony healing in valgus position 
(111, 21d), Tfie patient testified that in tho first 
weeks after th* removal of the cast sho had suffered from 
pains and edema, 
Therefore one should not trust so much in the nail. 
On the contrary all warning symptoms well-known from the 
conservative treatment of bone fractures should be ob- 
served. 
KUFNTSCHER and MAATZ (l) Y/rite in their publication 
on the marrow nail operations: " It is useless to insert 
a nail in a fracture of the tibia so far that the point 
of the nail gets a hold in the distal spongy portion of 
the bone. This hold is negligible and unreliable," 
In their explanation they point out that a tissue 
(and also a bone) which is subiected to a rhythmic pressure 
reacts with absorption at the spot of impact. This is 
certainly true, but, if in a leg fracture the nail is in- 
serted deeply enough, i.e., if it is driven in as far as 
near the epiphysis this hold, will suffice to stabilize 
the fracture so much that the patient may expose the 
broken limb and the fracture will come to a bony healing 
before the resorption begins. 
This is proven by the spiral fracture demonstrated by 
111, 22 a in which the fracture cleft extends considerably 
in the downward direction. The patient used the broken 
limb without any additional cast 10 days after the operation 
without encountering pains and 4 weeks after the operation 
he started working. 111, 22b which was taven three months 
after the operation does not show any rarefactions in the 
vicinity of the nan 1 point. This proves that the nail 
had forged a stabile union with the bone. Thus it must be 
concluded that the deeoer insertion of the nail saves us 
the trouble of using the more complicated leg nails. 16a 
a 
b 
c 
Illustration 21 
at bt c 
a) About the same fracture as in 111. 20 aft r the nailing with 
the cast in place in a 5B year old woman. Also in this case 
the nail should have been longer. She was allowed up after eight 
days with a walking cast. She complained about pains which were 
not given any consideration. An X-ray, taken two weeks later, 
proved that the fracture was angulated which pG immediately 
corrected. Confinement to bed for one week, after that, weight 
bearing. Once again the patient complained about pains at the 
fracture site, 
b) 9 weeks p.op. The fragments have slipped in the cast and a 
slight recurvature in a valgus position is observed. This po- 
sition of the bones is corrected by wedge shaped excisions of 
the cast, 
c) 3 months p.op. Beginning formation of callus. The fracture 
is somewhat shorter and a slight lateral displacement is ob- 
served, The axial direction, however, is correct. Painless 
weight bearing with the cast. Release from the hospital. 16b 
Illustration 21d 
6-g- months p.op. The fracture 
healed with a slight recurvature 
in valgus position. Five weeks 
after the release from the 
hospital the cast is removed bj 
the family doctor. In spite of 
the fact that the patient suff 
pains when walking another cast 
was not applied. 
d 
Illustration 22a 
Spiral fracture of the leg which 
extends 'far into the distal third 
K he nails extend to the vicinity 
of the epiphysis. They are some- 
what spread but not to such an 
extent as spread nails so that 
they could find sufficient hold 
in the corticalis. Patient 
starts subjecting the limb to 
painless weight bearing 10 days 
n.op,, without any additional 
cast and resumes hard labor 4 
weeks p.o p, 
a 16c 
Illustration 22b 
Same fracture 3 months p.op,5 v' eh came to 
a bony h aling. No rarefactions round the 
nail tip. The strong formation of callus on 
the bent side is not stimulated cal1us but 
due to the periosteal separation. 17 
de never wore ‘obliged “t© apply an*'additional wire trac- 
tion, Even in spiral fractures m which the nails are too 
short and too thin the fragments will not shift in the 
cast if an early weight bearing is avoided, (ill, 23). 
According to my own experience, made in 21 cases of 
such fractures, the isolated shaft fractures of the tibia 
are particularly suitable to the nailing operation. Frac- 
tures of that kind, particularly transverse fractures, take 
a very long time to heal in case of conservative treat- 
ment (according to BOFHLER eventually 1-2 years). They 
show the tendency to heal in faulty position because of the 
blocking effect of the fibula. kith the marrow nailing, 
however, a cuick and unimpaired formation of callus is 
obtained and the employability is cuickly restored (111, 
24)« These fractures may and must be exposed early so 
that a good compression of the fracture is obtained. This 
is especially true as to the isolated tibia fractures in 
the distal third, in which, howovo5:,the nail must be driven 
into the Vicinity of the epiphyseal line (ill* 25). 
The statement of RAISCH (l) that fractures of that 
kind are unsuitable for the marrow nail operation "be- 
cause the fibula acts as a blocking bone, which effect 
is accentuated when getting up with the nail" must cer- 
tainly be rejected. In the case mentioned by him the nail 
is too short and too thin. Therefore the nail is useless 
and conseoucntly we must not be surprised that in this 
case the formation of callus is as bad as without the nail. 
With regard to my own exprri ence I cannot a re© -with 
B0EHLERfs restrictions (second edition of this public .tion) 
as to the nailing of fresh simple leg fractures. On the 
contrary our indication is rather extended, for, the 
operation is simple from the technical ooint of view and 
it does by no means cause an additional strain upon the 
patient. Those physicians, however, who do not know the 
fundamental laws of treating bone fractures should not 
be allowed to make use of the marrow nail operation. Such 
a physician will not achieve good results even in case of 
a conservative treatment. All this may be proved by the 
records of the cooperative associations (insurance companies). 
an the Arm above the Elbow 
131 cases of a total of 141 cases of nailed fresh 
fractures in the arm above the elbow could be studied as 
to their course until healing was achieved. The duration 
of the treatment and the results achieved are demonstrated 
by Table IV, 
Table IV. Duration of treatment and results achieved 
by marrow nailings of fresh simple upper arm fractures. 17a 
a 
b 
Illustration 23 
a) Spiral fracture of the- leg in a 40 year old woman 8 weeks after 
the nailing. Despite the fact that a thin nail was used which 
extended to only one centimeter beyond the spiral fracture 
the patient was able to subject the limb to painless weight 
baring with the cast in place and was released from the hospital 
for ambulatory treatment. The nail was inserted, laterally from 
the tuberositas tibiae and consequently the slight varus position 
ccurred, 
b) 5 months p,op,5 the fracture is bridged over by bone and the 
nail is removed. A walking cast was applied for 3 months. After 
that the patient was able to subject the limb to painless weight 
bearing, 17b 
a 
b 
c 
Illustration 24 
a) Isolated greenstick fracture of the tibia in a 40 year 
old soldier after the nailing. Clinically the fracture is stabile 
but the fracture cleft is still somewhat gaping, despite the 
fact that the fragments were pressed together. Patient starts 
subjecting the limb to weight bearing without any cast 6 days 
'‘.at er. 
b) 14 days p.op. The fragments were firmly pressed together by 
weight bearing. 5 weeks p.op., patient released from the 
hospital as "fit for service" except for assignment reouiring 
marching. 
c) 15 weeks p.op. the fracture is bridged over by bone. The 
nail will be removed. 17c 
a 
b 
Illuatration 25 
a) Isolated fracture of the tibia in a 52 year old workman with 
oblique fissures in the distal fragment. 
b) Same fracture 16 weeks after the nailing bridged over by 
)one. The nail will be removed. On the fifth day p,op, the 
uatient started subjecting the limb to weight bearing. He was 
"eloased from the hospital on the 26th day. He resumed working 
°n the 46th day. 18 
m mm™* -Xvt- 
Nr±J 
Time reouired 
Treatment in 
i^S_i|os£ital_. 
for the 
Restoration 
of employab. 
I 
Final re 
II 
suits 
III 
Hospital 
78 
108 ; 
(38-238) 
177 
(93-346) 
76 
2 
0 
Civ,Hosp» 
- 53 
41 
(14-11*) 
78 
(43-183) 
52 
0 
1 
Total 
L31 
.... i 
78 
(14-238) 
112 
(43-346) 
123 s 
97,7% 
2 a 
_1,5%_ 
1' « 
0,8% 
I. Healing without any shortening, curvature or impe- 
diment of the joints. 
II. Slight curvature, shortening, or impediment of the 
joints (decrease of employability of less than 20%) 
III. Harked shortening, curvature or impediment of the 
joints, (decrease of employability from 20 up.50%) 
Once again we see a considerable discrepancy bet- 
ween the duration of treatment in civilian hospitals and 
military hospitals. This discrepancy may be explained 
by the same facts mentioned before. 
Comparable statistics as to the duration of the 
conservative treatment are not available. The kind of 
employability as well as the stay in the hospital is 
not substantially shorter on ah average. If necessary, 
however, fractures in the arm above the elbow may be 
treated as ambulatory patients. There is no doubt, 
however, as to the great advantage that in general an 
abduction bandage is not rceuired. As to our own 
patients it must be taken for granted that in fact 
an early employability was obtained. 
The results obtained are by all means better: 
BOEHLER (1) has observed that 82% of the patients treated 
in emergency hospitals and 22,2% of the cases treated 
as ambulatory patients did not receive any annuities 
after three years. In all the cases treated in our 
own hospital only ono patient got an annuity of 20%, 
In this case out first nailing of a fracture in 
the arm above the elbow was performed. An infection at 
the nail insertion site occurred but it did not cause 
any general reaction. Later on, however, it caused 
the formation of secuestra, also in the fracture site 
because the osteosynthesis was not stabile enough. Con- 
scouently an impediment of 20% in extension and a 
slight impediment of rotation of the forearm •ccurred. 
In the case ?fhich showed result II we had to deal 
with a transverse fracture in the upper third. After 
the nailing the fracture was in good condition from 
above but the nail was inserted too far distally and it 
was bent laterally (ill. 26a). Therefore it did not find 18a 
a 
a 
Illustration 26a 
Transverse fracture of the arm above the elbow in the 
upper third after the nailing. Satisfactory position 
•f the fragments. The nail was inserted too far distal- 
ly. The only hold the nail finds in the marrow c vity 
which extends in the upward direction is the thin corti- 
calis of the insertion site. The hole drilled in there 
by means of an awl is in most cases larg r than the dia- 
meter of the nail. 
Illustration 26b 
Same fracture 3i months later with a typical 
angulation in the direction to the extensive 
side. Fracture is healed lat rally. The 
limb was subjected to some active exercise on 
the sixth day. Conseciuently the fracture came 
to a displacement until the nail finds suffi- 
ci nt hold on the opposite corticalis. The 
nail should have been inserted somewhat more 
proximaily and its bending should have been 
stronger, so that it might find some hold on 
the opoositc corticalis (correct position of 
the nail). Otherwise such fractures must be 
nailed distally and the nail bo driven into 
the spongiosa of the head. 
b 19 
sufficient hold in the proximal fragment (in the arm 
above the-elbow the marrow cavity extends to the 
vicinity of the surgical neck). £ his condition 
was not observed and consequently the. patient subjected 
the 3.imb to wqight bearing six days I'.tcr. An A.-ray 
was taken 8 days later because the oati~nt had suffered 
from pains and because a “diffuse swelling of the arm 
above the elbow'1 was observed. This X-ray showed’that 
a lateral and backward angulation had occurred. An 
attempt to correct them under anaesthesia failed and 
thus the fracture healed in the described oosition 
(ill, 26b), An impediment of the joints and of the limb 
was not observed. 
Proxinally located fractures reouire an Insertion 
of the nail in the vicinity of the tuberculum majus. 
The nail should be bent at the head end so that It may 
jam at the corticalis of the opposite, side as demon- 
strated by 111, 26b (even if so done the osteosynthesis 
stays only relatively stabile and therefore early weight 
bearing must be avoided). The nail will never find 
sufficient hold at the insertion site. The hole in 
the bone was drilled with an awl and therefore it will 
always differ from the nail as to size and shape* 
Besides this the corticalis is so thin that it may break 
easily when the sharp edges of the nail cause a pressure 
on it (111, 29). 
It is better to nail fractures of this kind from 
the distal end particularly in those cases in which the 
proximal fragment is shorter. In thrs way an opening 
of the hemorrhagic soft parts is avoided (increase of 
the danger of infection). The nails must be driven 
in beyond the line of growth into the head. In this 
case it is useful to insert the nail somewhat above 
the middle of the arm above the elbow (if the hematoma 
does not extend that far). The thicker nail gets a 
stronger curvature, the inner thin nail is bent at its 
point in tho opposite direction. Thus it has the 
shape of an S. The nails spread (similar to the 
system of turn-sproad nails)in the head and find suffi- 
cient hold there (ill, 27a). The fractur' must bo 
strongly pressed together. If one forgets to do this 
tho nail point may perforate the head (ill. 27a). The 
nails jam so strongly in the distal fragment that they 
meet the least resistance in the spongiosa of the head 
end. If this perforation occurs outside the joint 
plane it is of no significance. An injury of the Joint 
cartilage, however, would cause serious disturbances which, 
are well-known in connection with the nailing of the 
neck of the femur. Therefore the nail must not be driven 
too closely to the joint plane. 
For a long time fractures in the neck of fehe. tsuarerus 
were only exceptionally treated with the abduction flpllmt 
and the traction bandage. After those fractures have 
been well set it will be possible to obtain such a strong 
jamming effect in most of the cases that 8-10 days 
later a DFSAULT-bandage can be applied. After that the 19a 
a 
a) Fracture of the collum chirurgicum of the arm above the elbow 
in a 53 year old workman - after the nailing. The exterior nail 
got a stronger curvature, the inner nail was somewhat S-shaped 
at its top. In this way the nails spread in the head and find 
sufficient hold. The fracture cleft is still somewhat gaping* 
The arm is put in an arm sling for three days, after that it 
is subjected to active exercise. After a lapse of ten days the 
•patient is released from the hospital for ambulatory treatment. 
Illustration 27 
b) Same fracture 8 weeks lat r. Due to the exorcise the frag- 
ments were pressed together. The nails are jamming in the marrow 
cavity of the distal fragment and consequently they worked them- 
selves farther into the head. In doing so the outer nail has per- 
forated the bone because it had been driven in rather deeply. 
Sliding along at the inner nail this nail has worked its way into 
the distal fragment. The inner nail,.however, which had found a 
better hold stayed in its firmer position. The patient cannot take 
his arm up higher than 9i° because of the irritating effect of the 
nail tip. Therefore, the nails are removed despite the fact that 
the callus seems fcot to be compact enough. 
c) Same fracture 12 weeks p.op. The impediment of the shoulder 
joint has decreased and is only slight at this time. (Three month 
later no impediment at all). 20 
limb may be subjected to movements. This kind of treat- 
ment is considered to be the most simple and well tolerated 
treatment possible. Therefore we do not want to nail 
those types of fractures on principle just like fractures 
of the neck of the femur. That is the reason why so 
far only three fractures of that kind were nailed be- 
cause a jamming effect could not be attained. The ex- 
periences made so far are so good thst we decided to 
prefer the nailing operation to the use of an abduction 
splint, 
In the distal third of the humerus the marrow 
cavity is often narrower in the sagittal section than 
in the frontal section. The outer nail of the double 
nail is broader than higher at the point and therefore 
in such cases the front edge of the nail must lie in the 
frontal plane, This means that the nail must be inserted 
at the rear edge of the tuberculum majus at such an angle 
that the opening of the transverse section points to the 
bent side. the nail may rotate or break, 
(111. 28). 
The nail should project at the insertion site fore 
one centimeter at a minimum. If it is driven in too 
deeply it will not get sufficient hold at the insertion 
site and the weight of the arm will distract the fracture 
and the nail head will slip into the marrow cavity. In 
this way a stabilization does not exist anymore because 
the marrow cavity is very broad in the proximal frag- 
ment, When using the limb rhythmic waddling movements 
at the fracture site will occur and in this way the form- 
ation of callus will be disturbed (111, 29), 
The patient suffered from a commotio and con- 
sequently was confined to bed for 4 weeks. An arm sling 
was not applied and movements of the limb were avoided. 
In this way a distraction was favored, When using 
the limb the patient constantly complained about 
pains which were considered to be duo to the nail, 
for, in the vicinity of the nail head a distinct form- 
ation of spicules was observed in the X-ray. Unfortunately 
it was not observed that the formation of callus was 
absolutely insufficient. If the fracture pieces had been 
pressed firmly together and if a oluster cast had been 
applied with the fracture in abduction, the fracture would 
have come to a healing, even with the nail, and an 
angulation would have been avoided (Result II). 
If the fracture is stabile after the nailing the 
arm must be held in an upward direction by means 
of a sling. The shoulder joint may be moved 3-4 days 
later, the elbow joint, however, only after a lapse of 
one week. The sling must be kept on for at least 14 
days, 
Motion should by no means cause any pains* The 
osteosynthesis must always be considered to be not suffix 
ciently stabile if pains and swellings occur during or 
after the use of the limb. In such a case the arm must 20a 
a 
b 
c 
Illustration 28 
a k b -t c 
a) X-ray in order to determine the length of the nail in case of a 
transverse fracture of the arm above the elbow between the middle 
and the lower third. The nail is lying laterally and not at the 
extensor side. Conseouently its distance from the film is smaller 
than that of the bone in the frontal picture. So we are deceived 
as to the relation of the nail to the marrow cavity, which in this 
case is particularly narrow. Besides this the nail was brought 
into a distal position whereas the operation must bo made from the 
proximal side. 
■) It was not observed that the marrow cavity was narrower in the 
frontal direction than in the sagittal direction. Conscnucntly 
the nail was inserted with the front edge in lateral position 
(or: too far in front). In this way the nail cracked a piece of 
the bone on its flexor side. Due to the fact that the length of 
the nail(for purposes of the operation) was determined from the 
distal end it projected too much and consequently it had to be re- 
placed by a shorter nail. It turned so much in the distal frag- 
ment that its diameter equals that of the marrow cavity. When 
inserting the nail into the distal marrow cavity the fracture had 
to be bent off in the direction of the angulation because the nail 
tip had left the guide wire in front. This angulation vjas cor- 
rected only after the complete insertion of the nail which had 
caused an additional angulation of the nail at the fracture side. 
In this way it was impossible to insert the thinner inner nail. 
c) Same fracture 5 weeks after the nailing. Four weeks p.op,, th: 
arm could be subjected to painless manipulation. Due to a sudden 
strain the arm was subjected to, the nail cracked at the site of 
the fracture. (In the picture taken from in front the distortion 
is distinctly visible). 20b 
The broken nail is removed (the distal piece 
of the nail is extracted through a hole made 
into the bone above the fossa olccrani) where 
the new nail is immediately inserted distally, 
Nov/, the nail is lying in the correct plane 
and consequently do oh nails can bo used with • 
out difficulty. The ost osynthesis is so 
stabile that ten days later the patient may 
do some exercise. Six weeks after the sc cor. 
operation the patient is released from the 
hospi tal as "fit for garrison duty11. The 
nail was removed three months after the secor 
operation. 
Illustration 28d 
d 
Illustration 29a 
Transverse fracture of the arm 
above the elbow 8 months after the 
proximal nailing which was made 
in another hospital. After the 
nailing the patient was confined 
to bed for 4 weeks without any 
bandage because of a commotio. 
After that the limb was sub- 
jected to some exercise for a 
long period of time which was 
harmful. Again and again the 
patient complained about pains 
when using the arm for a long 
period of time. From the clini- 
cal point of view the fracture 
appears to be stabile. 
a 
The nail head slipped into the 
bone and consequently did not 
find any hold there. The rare- 
factions in the X-ray prove that 
the nail is "working". The de- 
layed formation of callus is due 
to the constant waddling move- 
ments at the fracture cleft. All 
this was not observed and therev*: 
fore the nail was removed because 
of the irritated margins. 20c 
Illustration 29b 
After the extraction of the nail 
a distinct springing (effect) was 
observed clinically. A slight bending 
occurred which was due to the firm- 
ly pressing together of the fragments* 
The fracture which war immobilized oi 
an abduction splint healed in six wool 
The delayed formation of callus is ncy 
due to lues but to the instabile ostoc 
synthesis. 21 
be held by an abduction splint during daytime and motion 
exercises must be made as soon as painless move- 
ments arc possible. In those motion exercises the 
bending of thfc elbow is especially valuable. Motion 
exorcises by means of the pulley-traction method should 
be avoided because they favor a distraction of the 
fracture. 
In casb of an insertion from above the nail 
should be'long enough and driv-n into the diatal marrow 
cavity very firmly (strong counter-press’--ra fro." the 
elbow). It is not easy, however, to deter in© the 
exact length of the nail. The diameter of the distal 
marrow cavity must be measured thoroughly during the 
X-ray with th nail lying dose to the bone (l). The 
diametersmust be compared with one another and during 
the operation it must be taken care that the nail is 
lying in the proper plane. In doubtful cases it is bette 
to insert the nail somewhat more distally from the 
tuboreulum (if the fracture.is suitable to this kind of 
treatment). If necessary the nail may stick out a little 
bit more and a harmful effect is not to be expected. 
This procedure is not so harmful as is too deep an 
insertion of the nail, (ill* 30 and 31). 
Spongy transverse spicules may permeate the marrow 
cavity (111* 32) so that the (blunt) nail cannot pene- 
trate them. These spicules may not always be observed 
on the X-ray. If the fracture is in the distal third 
the nail does not get sufficient hold and complications 
of all kinds of an "instabile osteosynthesis" must 
be taken into consideration (late angulation, ball- 
callus and delayed formation of callus); 
Therefore we nail fractures in the distal third 
from below (contrary to BOEHLFR and KUENTSCHER), A 
possible exposure of hemorrhagically infiltrated soft 
parts seems to be less dangerous than the lack of 
stability (ill. 33). Transverse spicules possibly 
hindering the insertion of the nail may be pierced by 
means of a drill awl or an electric drill. 
If the marrow cavity is very narrow at t'*o 
distal end the double nail may burst the bone (111.34)• 
In such a case the only thing to do is to use a thinner 
nail, It must by all means be driven into the opongiosa 
of the head beyond the line of growth. 
This is especially true as to fractures situated 
farther proximal. Beyond the .junction of the m: ddlo 
and the lower thirds, the marrow cavity is consider- 
ably enlarged so that even a double nail may sometimes 
not find sufficient hold if it is not driven into the 
head. Otherwise disturbances of the formation of 
callus may occur (ill. 35). In such cases an abduction 
splint should be used so the nailing treatment in com- 
parison to the conservative treatm nt) is not consider- 
ably easier. 21a 
a 
b 
a 
b 
Illustration 30 
Illustration 31 
.) Transverse fracture of the arm 
above the elbow which was nailed 
proximally. The nail is too short. 
It does not find sufficient hold 
in the distal marrow cavity. Ten 
cays later the patient starts sub- 
jecting the fracture to some exer- 
cise without the arm sling which 
cause pain. 
b) Three weeks p.op.,The fracture 
was distracted due to the weight 
of the arm. The distal fragment 
slipped from the nail, Consc- 
ouently the arm was put on an ab- 
duction splint on which the elbow 
was movable. The splint was re- 
moved 4 weeks later and the patient 
could be released from the hospital. 
His employability has been re- 
stored after a lapse of eight 
weeks p.op. The nail was removed 
4 months p.op. 
a)Transverse fracture of the 
same kind in a 41 year old 
workman. The nail jams in the 
distal fragment of the very 
narrow marrow cavity. It as im- 
possible to insrt at any fur- 
ther. The fracture cleft is 
somewhat gaping. The arm 
had to rest in an arm sling 
for eight days. After that 
the arm was subicctcd to some 
active exercise with the arm 
sling. Release from the hos- 
pital 3 weeks p.op. 
b) Four weeks p.op. The frag- 
ments were pressed together by 
the strain put on the arm and 
conscoucntly the nail moved 
upward and slipped somewhat 
out of the bone. The ab- 
duction is not hindered. 
Distinct formation of callus. 
The employability was restored 
6 week p.op. 21b 
Illustration 32 
The distal end of the marrow cavity 
shows a framework of spongy spicules 
which hinder a furth r ins rt: on of the 
nail. 
Illustration 33a 
Spiral fracture of the arm just 
ibove the elbow after the distal 
Insertion of the nail. The double 
sail found sufficient hold in the 
broad proximal marrow cavity. The 
drain to relieve the hematoma in 
the wound was removed 2L hours later. 
r?*o was put into «rn sling far 
:iffht days and after that it was sub- 
jected to sor.c exercise noY©rio<nts 
I- -lieh did not cause- -the patient -any 
ir:ne Release 'iron" tfc*p 4-ospital 12 
s p.op. xxsoured Ih&eiffefrg as an 
-'pprentice locksmith 3 weeks p,op. 
a 
Illustration 33b 
Seven weeks p,op,, the fracture 
is healed and the nail will 
be removed. a 
b 
Illustration 34 
a) Transverse fricture of the arm above the elbow in the middle 
third which was nailed distally without exposure of the fracture* 
The distal marrow cavity showed strong spicules which made it 
impossible to insert the thicker nail any further. At the in- 
sertion site a piece of the bone was split off. Therefore, we 
used only the thin nail which was driven into the spongiosa of 
the head. The hold the nail finds there was so good that after 
a lapse of eight days the limb could be subjected to some exer- 
cise movements, which w re painless. The existing paralysis of 
the radialis was improving after a lapse of three weeks. 
b) Same fracture 3 months after the nailing. The nail was re- 
moved. The paralysis of the radialis does not exist anymore 
5 months p.op. 21d 
b 
a 
Illustration 35 
a) Fracture of about the same kind (without damage of the 
radialis) which was nailed distally with a double nail. At the 
fracture site the marrow cavity broadens so much that the nails 
do not find sufficient hold there. Besides this the nails are 
too short and consequently the osteosynthesis is not stabile. 
An abduction plaster cast must be applied. Only nine weeks after 
the operation could the limb be subjected to exercise movements. 
a) 12 weeks p.op, The fracture cleft is wide open. Callus 
flanges may be observed, which unite the bone ends to a slight ex 
tent. Only 18 weeks p.op. cpuld the nail be extracted. 22 
In one of the above chapters it was pointed 
out that a possible damage to the radial nerve is 
an indication for the exposure of the fracture. 
As demonstrated by 111. 34 we are very cautious also In 
this respect. If after a thorough clinical and neu- 
rological examination it must be supposed that the 
possible damage may be compensated, the nerve should 
not be exposed at that time. If, however, the paralysis 
does not subside the exposure and an eventual nerve 
suture may still be done even if 6-3 weeks have al- 
ready passed. 
A primary injury of the radialis was observed 
five times which in 4 cases subsided after the closed 
marrow nailing. In the fifth case, six weeks after 
the nailing the nerve was exposed and successfully/ sutured. 
Contrary to the findings of HART(l) a jamming of the 
nerves betw n the fracture fragments was not observed 
and therefore it must bw oejaeludcd that this does not 
ofton occur, 
c Fracturcs_of_tho forearm 
Tho course of 15 out of 18 cases of closed 
fractures of thv, forearm was observed until a final 
healing was achieved. It is a matter of course that 
it is impossible to g.,t final conclusions out of this 
small number of eases. 
SCHNEIDER asserts that for anatomical reasons it 
is impossible to nail th ulna. This is incorrect, 
BOEHLER the clinic at Kiel and myself have always 
success-.*—jly nailed the ulna, 
isolated shaft fractures »f the ulna seem to 
be espcial’y suitable for the na:ling operation. From 
the technical point of view the operation is not diffi- 
cult and the straight ulna nail grants a true stabile 
osteosynthesis with good mechanical conditions for 
the formation of callus. Kith the conservative treat- 
ment, however, the fractures show a tendency to cause 
faulty positions or a delayed formation of callus be- 
cause of the blocking effect of the radius, 
Five out of seven uncomplicated ulna fractures came 
to a good healing and disturbances were not observed. 
4-5 weeks later the patients were able, to resume working. 
The fracture clcft$fhowever, were ruitc visible for a 
relatively long period of time and conscoucntly the nails 
¥cr» removed only 3-5 months later. 
In two eases the nail was too short and conscoucntly 
wo observed either a formation of stinulated callus or 
a delayed formation of callus (ill. 36 and 37), 22a 
Illustration 36 
a) Transverse fracture of the ulna 
after the nailing. Good position. 
The nail is too short. The patient 
started subjecting the limb to 
exercise movements 6 days p.op,, 
8 days later he was released fro in 
the hospital and after a lapse of 
throe weeks he was able to do 
all kind of work. 
b) 10 weeks p.op. It was not 
possible to obtain a stabile 
osteosynthesis with the nail. 
Constant movements at the fracture 
site which w re due to this in- 
stabile osteosynthesis caused a 
bridging over by stimulated callus , 
Distinct rarefactions round the 
nail point has caused some ero- 
sion of the corticalis on the 
radial side. Due to the f a c t t h - r. 
the patient constantly uses the or 
a slot occurred in the (bri go) 
callus so that he rotary move- 
ments are not ’ ndcred. 
a 
b 
Illustration 37a 
Jagged transverse fracture of the 
ulna after the nailing, by 
the open method because the 
operative reposition was not 
succeeful. The position is 
ideal but the nail is too 
s hort, 
a 22b 
b 
G 
Illustration 37^ 
b) Four months p,op. The patient is able to use the arm and in 
doing so he docs not suffer pains. Stimulated callus with form- 
ation of flanges which arc not yet united, because of the con- 
stant movements of the fragments which are due to the instability 
of the fracture. Rarefactions round the nail tip which in the 
direction of the radius has nearly completely penetrated the 
corticalis. Periosteally we see here a now formation of bone. 
c) 2-g- months Inter. The fracture cleft is bridged over by bone, 
Nov/ the nail point is firmly slated and conscoucntly the rare- 
factions round the nail tip are less marked. The periostrally 
formed bone structure is much better now. In one case we had to deal with a fracture which was 
complicated because of damages of the plexus and luxa- 
tion of the radius head (ill. 38a). Apart from this 
a transverse fracture of the other arm above the elbow 
had occurred which was nailed at the same time. The 
nail was sticking out of the bone considerably (.111* 38b) 
and an inflammation at the insertion site had occurred 
which was due to an exposure of the limb four weeks after 
the The physician failed to immobilize the 
arm or to remove the nail and thus an abscess appeared 
at the fracture site which had to be opened. When after 
a lapse of 10 weeks the nail was removed the wounds came 
taa quick healing and an infection of the marrow cavity 
or a formation of seouestra did not ocr.ur (ill. 3$c), 
At the olecranon the nail may stick out 3 mil'i- 
meters at the most and therefore it must be inserted. Up 
to the eye. If the nail is teo long or if it jams in 
the distal fragment and conseeuently causes a widening 
of the fr cture cleft the nail must be pinched off and 
t jie_s eqti orjal_arjga_.be..smoothed_by_means_pf_a-_f ij.^• If 
the patient suffers from pains at the insertion site be- 
cause the nail was not inserted deeply enough or because 
the nail has w-orked its way out of the bone in su«h a 
case the arm must be immobilized in an extended position 
and the nail removed as soon as possible. 
The nails should be as long as possible. Otherwise 
the fracture will not get sufficient hold. In the ulna which 
is relatively soft, the nail will soon get loose. Ifiiuetich 
a case the nail is too short, rotation at the fracture 
cleft wil occur and stimulated callus and delayed form- 
ation of callus etc. must be taken into consideration. 
It seems to be unsuitable to use a simple piece of 
wire for then nailing11 operation. The wire is not strong 
enough to prevent lateral displacement* of the fragments. 
If the marrow cavity is really too narrow or if a corre- 
spondingly thin nail is not available it will be better 
to treat the fracture conservatively or (especially in 
fractures in the upper third) to apply either a La HE 1 s 
plate or a wire loop. 
Due to mechanical conditions isolated shaft fractures 
of...ihe_radiu.s also show a tendency to a delayed formation 
of callus. 
An intact ulna will render it more difficult to bring 
the fragments accurately one upon the oth~r. The con- 
ditions are more complicated if a physiological absorption 
of the ends of the fragments occurs. Even in the padded 
plaster cast (after a good reduction ) movements of 
the limb are no sure help. In cases of that kind the 
ulna acts as a spring so that the fragments are not pressed 
together by the muscles but they are rather moved one 
against the other in a lateral direction. Therefore we 
have to deal with movements which are especially dis- 
advantageous for the formation of callus. These move- 
ments cannot be completely compensated by means of the 
circular plaster cast because of the relatively thick 
pad of muscles. It is only possible to "buffer51 them. 23a 
a 
b 
c 
Illustration 38 
a) Transverse fracture of the ulna with central luxation of the 
radius, 
b) After the reposition and nailing of the ulna. At the ole- 
cranon the nail projects considerably. The patient begins subjecting 
the limb to some exercise after a lapse of ten days. Four weeks 
later an inflammation at the insertion site is observed. The 
fractur is not yet healed and consequently the nail is not re- 
moved, but, at the same time, the arm is also not immobilized. 
3 weeks later an abscess at the fracture site is observed. 
Immobilization of the arm in a half flexed position. 
c) 10 weeks p.op. The nail is removed. The wounds healed 10 
days later. The limb is freely movable. 24 
The introduction of the marrow nail method was 
expected to cause a change for the better. We must, 
however, keep in mind that the thin radius nail is 
not absolutely stiff but evidently somewhat elastic 
which was proved'by our first marrow nail operation 
of that kind. 
Within four weeks after the nailing the patient 
was aTle to move his arm freely. The fragments were 
not firmly pressed together, however, and the fracture 
slot seemed to be somewhat broader due to resorption. 
The patient assumed his former activities and com- 
plained about pains at the fracture site only when 
doing hard labor. Swelling did not occur and the 
fracture was clinically healed. X-ray pictures, how- 
ever, did not show any formation of callus. Nine 
months after the operation a slight bony bridging- 
over seemed to exist, (ill, 39a). The patient did 
not complain about pains anymore and therefore the 
nail y/as removed. Distinct plastic movements of the 
fracture were observed. Therefore a plaster cast 
was applied which was removed 6 weeks later by my 
assistant because the fracture seemed to be clinically 
and roentgenologically healed (111. 39b). 10 days 
later these fragments were firmly sticking together and 
a slight bending had occurred. U fortunately it was not 
observed that this was only due to a sub-laxation in 
the distal radius-ulna joint and conseouently this 
position was not corrected. A bony healing was achieved 
but an impairment of the movements of the wrist could not 
be avoided (ill. 39<). 
The nail had forged a stabile union but the bone 
did not show any reactions. It prevented a luxation in 
the distal radius-ulna-joint but nevertheless the frac- 
ture cleft was somewhat gaping and the intact ulna pre- 
vented a pressing together of the fragments. Therefore 
a healing could not be obtained. The fracture should 
have been bent in the direction of the ulna after the 
nailing so that in this way at least the split up 
part of the bone touched the distal fragment. 
Illustration 40 that in the above 
case a healing could probably have been achieved. ,lso 
in this case Till. 40a) the fracture cleft is somewhat 
gaping but at the radial side of the fracture the frac- 
ture teeth touched one another. also this patient was 
able to resume labor 4 we ks after the operation and the 
nail was removed 3 months later. The fracture is bridged 
over by bone on the radial side. On the ulna side, how- 
ever, the fracture slot still exists and the slight 
flange cal us indicates that despite the presence of the 
nail slight shearing movements must have taken place. 
After the first unfavorable observation (the cause 
of which viras found out later) we were rather cautious as 
to the nailing of those rare cases of radius shaft frac- 
tures. Only in one single case we decided to nail a fresh 
fracture of that kind because it was impossible to keep the 
fracture in the proper position by means of the plaster 
east. The patient was released from the hospital 8 days 24a 
a 
b 
c 
Illustration 39 
a) Greonstick fracture of the raddus 9 menths after the nailing* 
The patient resumed working four weeks p.op, He is able to move 
the limb freely. When doing hard work, however, he complains about 
pains. From the clinical point of view the fracture is absolutely 
stabile. Poor formation of callus. Only at a small spot besides the 
nail docs the fracture cleft seem to be bridged over by callus, 
The nail is removed, after that a distinct springing at the frac- 
ture site is observed and therefore a plaster cast was applied. 
b) Six weeks later the fracture seems to be healed and therefore 
the cast was removed, 
c) 14 days later the fragments are firmly standing together in a 
slightly anguln.tcd position. It was not observed, however, that a 
subluxation existed in the distal ulna-radius ioint and conscouently 
it was not corrected. The fractur comes to a healing in this 
position with an impediment of the movements of the wrist. a 
b 
Illustration 40 
a) Shaft fracture of the radius after the nailing. The gaping 
of the fracture cleft is due to the jamming effect of the ulna on 
the ulna site. Radially the fracture teeth are firmly standing 
togeth r. The patient resumed working four weeks later, 
b) Same fracture four weeks after the removal of the nail. The 
fracture of the radial side came to a bony h aling, The giping 
cleft of the ulna site, however, did not heal. 25 
later* Three weeks after that he was able to resume work- 
ing and the nail was renoved 3 months later (ill. 41). 
Two out of three fractures which wcre:Haitled from the 
outside showed goed results In the thi rd. case the nail 
jammed in the proximal fragment so much that it was im- 
possible to insert it to the eye. In order to bo able 
to close the skin without tension the hand was immobilized 
in dorsal-flexion. In cases of that kind it would bo 
better, however, to pinch the nail off. Otherwise the 
great advantages of the nailing method will not come into 
effect, 
Fractures in both forearm bones were nailed only 
in those cases in which, after reduction and application 
of a cast, the fragments could not be held in the proper 
position. In the beginning wc renounced the nailing of 
the radius under the condition that the fracture was 
in good position after the nailing of the ulna. A 
plaster splint was attached reaching to the arm above the 
elbow. A disturbance of the healing process in radius 
fractures was nit observed but a distinct decalc ific \tion 
of the wi*ist bones was observed despite the fact that the 
patients froouently moved >the limb with the cast, 
i 
Recently we have nailed two Cases in which both of 
the bones were nailed and thus a plaster cast was not 
rccuired. 
Both patients were able to uSe the arms freely 4 
weeks later and the healing did not show any disturbances. 
Atrophies of the wrist joint were not observed. In com- 
parison to the conservative treatment the advantages gained 
by the nailing method are so great that we have decided to 
nail both bones from now on, if they are suitable for the 
nailing method. 
L TJh.e_Dang.Qrs...if ..the . covered nailing, 
The possibility of infection was one of the main 
reasons why many authors did not want to operate fresh 
simple fractures of the long shaft bones. It is im- 
possible to deny that in many cases the indication was 
not strict enough and the insufficient technioue showed 
terrible results. With the closed nailing operation, 
however, only a small incision was necessary to insert 
the nail and therefore the danger of infection must be 
loss. In the first place, however, a suppuration 
in the fracture cleft must be avoided. 
According to the statistics at hand in 453 cases of 
closed nailing operations primary sup urations occurred 
in 3 thigh fractures, 2 leg fractures, 1 fracture in the 
arm above the elbow and in 2 forearm fractures. During 
the extraction of the nail an infection was observed in 
1 thigh fracture, in 1 fracture in the arm above the elbow 
and in 2 leg fractures. 25a 
a 
Id 
Illustration 41 
a) Radius shaft fracture with 
luxation in the distal radio- 
ulnar joint, 
b) Same fracture after the nail 
ing. Ideal position. The lux- 
ation was corrected. The frac- 
ture cleft is somewhat gaping 
because of the jamming effect 
of the ulna. The patient was re 
leased from the hospital 8 days 
later. The resumed working 
three weeks later. 
o) Same fracture 11 weeks after 
the nailing. The fragments were 
firmly pressed together by the 
weight bearing effect. The nail 
head slipped somewhat out of the 
bone. In this way a subluxation 
in the radio-ulnar joint occur- 
red which, however, does not im- 
pede the movements. The frac- 
ture is bridged, over by bone. 
The nail is ready for removal. In 4 out of 8 cases of primary infections the frac- 
ture cleft was impaired and 2 fatal terminations were ob- 
served in the cases #f thigh infections. All these cases 
arc of course a serious set back for the nailing method. 
We; must take into consideration, however, that all of the 
inf ctions could have been avoided, particularly those of 
the fracture cleft. 
I am myself responsible for the following fatal 
termination. 
A 20 year old pilot Suffered from a transverse 
fracture of the right thigh in the mid 1e third from 
a serious concussion and burns 6f first and third de- 
gree of the face, both arms, right leg and of the buttocks, 
14 days after the accident I decided to use a marrow nail 
because it was practically impossible to immobilize the 
fracture due to motoric unrest and all movements of the 
patient caused unbearable pains in the fracture. I was 
well aware of the danger of infection considering the 
presence of suppurating wounds, nevertheless I htped 
to be able to prevent an infection by the immobilization 
of the fracture because the vicinity of tho trochanter 
was unimpaired and a good granulation of the wound of 
the broken legs was observed. The experiences made with 
marrow nail operations justified this opinion. A further 
reason why I decided to nail this fracture may lie that 
shortly before I had a chance to observe a fatal termination 
of an infection of a closed thigh fracture with suppurat- 
ing wounds of the leg which had boon treated by wire ex- 
tension. After the nailing the body temperature decreased 
considerably and the patienfr did not suffer from pain any- 
more. 5 days after the operation an infection of tho in- / 
tentionally unsutured operation wound occurred which was 
immediately opened. 14 days after the operation an abscess 
at the fracture cleft was observed which was also wide- 
ly opened. After that we observed a serious suppuration 
of the burns especially at the buttocks and septic tem- 
peratures, 7 weeks after the operation the kneo joint was 
infected and the leg had tt be removed in conseouence 
of which the patient died. 
The amputation preparation showed ring sequestra at 
both ends of the fragments and grey-blackish granulations 
around, the nail bed, Harrow phlegmon was not observed. 
The infection of the knee-joint was due to a tube abscess 
on the extensor side. 
Let us leave the question undecided whether or not 
the infection of the fracture might have been prevented 
without the railing. There is no d»ubt, htwever. that 
the new unpreventable injuries of the soft parts at the 
fracture site caused by the reduction are causing a con- 
siderable increase of the danger of infection. As_long 
£S_suppuratin£_wounds_exist .i n_the_body_asej>tic_f racturejs 
.be..nailed even if the nailing decreases the pains 
of the patient and facilitates his nursing. 
In a similar case BOFHLFR has also observed, an in- 
fection of the fracture hematoma. He is of the opinion 
that an infection can Ttc avoided if the nail is applied 27 
before an infection of the burns occurs. It is very diffi- 
cult, however, to decide whether his theory is right or 
wrong bccau e, so far at least, further experiences have 
not been made. It is our opinion, however, that an 
operation of that kind should be made only in emergency 
cases and if so the hematoma should bo drained (l) (in the 
dependent direction in the septum intermusculare fibula) 
just as in nailed compound fractures. The hematoma is 
particularly endangered by hematogenous infections. 
The second fatal termination was due to the insuffi- 
cient technirue applied and the wrong indications; 
A 20 year old pilot was sufferin' from a transverse 
fracture located in the distal third, of the left femur, 
from wounds of the soft parts of the left leg, from 
a basal skull fracture and concussion. Immediate de- 
bridement of the wound was made and. a wire extension 
applied at the calcaneus because excoriations were 
observed in the vicinity of the tuberosita tibiae, after 
that an abscess of the left fracture and at the same- 
time an infection of the calcaneus wire occurred. Never- 
theless we decided to nail this fracture 8 days later " 
in order to obtain a good fixation of the fracture ends 
and because the patient appears to bo very unrestful''. 
The length of the nail was determined on the sound thigh 
because an X-ray apparatus was not available with which 
a picture of the entire thigh (with the nail laid over 
the fracture) could be made. ’'The longest available nail 
just about fit". During the operation, however, it was 
observed that "the nail is a couple of centimeters too 
short". Therefore the operation was stopped and the nail 
was left in the marrow cavity. A wire extension was 
attached to the tibia (ill, 42a). The operation wound 
healed primarily. 8 days after the operation " a cast 
must be applied with the traction bandage on the extension 
splint", because the patient is delirious. A decubitus 
occurred at the hollow of the kn»e and the temperature 
rose. The x-ray control showednapproximately proper axial 
position of the fragments". The decubitus in the hollow 
of the knee increased. Three weeks after the wounding we 
came to the conclusion that the permanent unrest of the 
patient reruires a repetition of the nailing operation 
in such a way that the first nail which was inserted 
previously should be driven in that much by means of a 
second nail so that both of the fragments are bridged over". 
After this operation was carried through (ill, 42b) a 
pelvis cast was applied. One day after the second operation 
the temperature rose up to 40° C and an infection of the 
operation wound occurred which was opened on the second 
(l) According to the proposal of FE LSFNRFICH we use with 
best results a long drain which is to be led to a small 
sterile bottle outside the bandage. In this way the form- 
ation of a humid chamber saturated with blood is avoided 
which would be a good medium for bacilli. a 
b 
c 
Illustration 42 
a) Transverse fracture of the femur near the knee with accompany- 
ing infected wounds of the same leg, after an unsuccessful nail- 
ing with too short a nai1, in wire extension. 
b) The nailing operation was repeated despite the fact that a 
iccubitus existed at the knee joint and a longer nail was not 
available. The patient was suffering from a seri ous comaot:* o end 
vas very restless. The nail was driven into the proximal fragment 
by means of a second nail. Nevertheless the nail was still too 
short and conseouently did not find sufficient hold in the soft 
spongiosa. Wound infection at the trochanter, abscess at the frac- 
ture cleft, sepsis. Three weeks later the limb had to be ampu- 
tated. Fatal termination, 
') Amputation specimen. Marrow abscess at the nail point. 2 8 
day. 4 days later an abscess at the fracture site was 
observed by which 600 cubic centimeters of pus are drained 
off. Previous time was lost by blood and urine tests and 
by fighting the sepsis with sulfonamides and blood trans- 
fusions. i;hen, finally, three weeks latc-r the surgeon de- 
cided to amputate the limb the patient could not resist 
this strain. 
The marrow nail does not get sufficient hold in a 
fracture which is located so distally and a stabile osteosyn- 
thesis can never be obtained. Therefore an additional 
plaster cast was reouired anyhow. A nailing operation 
should never be made if the surgeon does not have a complete 
armamentarium at his disposal. Otherwise technical diffi- 
culties will arise. The first condition is to det~r ine 
the length of the nail as preciseljr as possible. After 
the first operation passed without any infection on no 
account should the second operation have been made after 
a decubitus was observed under the fracture site. The 
unavoidable injury of the soft parts caused by the re- 
duction of the three weeks old fracture must under those 
circumstances lead to an infection. The nail was not in- 
serted deeply enough and conseauently a marrow abscess 
around the nail point occurred. (ill* 42c). Let us 
leave the Question undecided whether or not the life of 
the patient would have been saved by amputating the 
limb in which the sepsis had started. When considering 
that a wire extension could not be applied to the tibia 
the best thing to do would have been to set the fracture 
as accurately as possible (eventually using an extension 
apparatus) and to apply a large plaster cast to the thigh. 
In case it was not possible to attain a go ~>d positic® 
of the bones such a malposition could have been corrected 
4-6 weeks later after a. danger of infection no longer 
existed. Surgeons who do not kn»w well enough the princiv 
pies of the conservative treatment of fractures should less 
than ever be allowed to "nail". 
An early repetition of the fruitless nailing seems to 
be particularly dangerous for infection. In case of a 
thigh fracture which was described in detail earlier we 
could not remove the nail which was not in good position. 
When the nailing was repeated 9 days later an infection 
of the wound occurred. It did, however, not extend 
beyond the fracture site because of the stabile osteosyn- 
thesis. 
KUENTSCHER asserts that in simple fractures the 
infection is restricted to the insertion site. In the 
two leg fractures (ill. 43 and 111. 8,) and the fracture 
in the arm above the elbow, however, the fractur clefts 
were infected though the wounds at the insertion site were 
immediately opened. In all these cases a stabile osteosyn- 
thesis 'had not been obtained. Also in the case of a chron.f 
leal ofllteomyelitJU* after a thigh nailing and the serious in- - 
fectioh after a leg nailing in none of those cases could 
a stabile osteosynthesis be achieved, and this circumstance 
is probably due to the extension of the infection. If the 
nail is not firmly seated in the marrow cavity little dis- 
placcments take place which are due to the movements of 
the limb. The empty spaces originating in this way absorbed 
the infectious sccretum either by pressure or soaking. 
The stimulating effect of the shifting foreign body favors 
the process of inflammation. a 
b 
Illustration 43 
a) Double log fracture after the 
nailing* The nailing operation 
■/as delayed for 14 days after the 
njury because of an abrasion and 
•as done only after the wound was 
loalcd. The distal fracture is 
immobilized by the nail, the osteo- 
synthesis of the proximal fracture, 
however, is not stabile. Five 
days p,op. infection of the nail 
insertion site and of the other 
fracture hematoma, which soon ex- 
tends to the distal fracture he- 
matoma. Broad incisions, drainage 
plaster cast. An infection of the 
bone is prevented, 
b) Same fracture 3 months later. 
The fracture came to a bony healing, 
an ostitis is not observed. The 
wounds are considerably healed, 
8 days the patient has subjected the 
limb to painless weight bearing. 
c) Same fracture .2 months later. 
The nail was removed 3 weeks before. 
The wound was kept open with the leg 
in elevated position. 10 days later 
the wound was healed. The gait was 
unhampered, no edema was observed. 
The shortening amounts to i centi- 
meter , 
c 29 
If an infection occurs in cases of relatively suitable 
fractures (particularly in leg fractures )- in which the 
nail forges a stabile union in the beginning because 
it was long enough and because it was driven into the 
spongiosa, in .su$ch a case the infection is restricted to 
the insertion site if the wound is opened immediately and 
broadly enough, so that the pus may drain off. In case 
of such a relatively stabile osteosynthesis 2-3 w ebs later 
the nail becomes loose because of the absorption of the 
spongy spicules and as soon as some strain is ->ut on the 
limb (as long as the wound has n*t yet come to a healing) 
a "late abscess" may come into existence at the fracture 
site. Therefore it is absolutely necessary to open the 
wound immediately (especially in cases of leg fractures) 
and to put the limb to rest by a cast as long as an infection 
exists. It is unsuitable to remove the nail before the 
fracture is healed, for, by doing so, the nail bed will 
facilitate the spreading of the infection. 
In case of a true and stabile osteosynthesis an 
immobilization of the limb is not indicated. After the 
acute symptoms have subsided the limb may be freely 
moved and the patients may even get up. This was clear- 
ly proved by the experiences made with the nailing of 
infected fractures. If after the healing of the frac- 
ture the nail wound continues secreting, the nail must 
be removed. After that the limb must be kept in such 
an elevated position that the insertion site is lowest: 
otherwise a gravity abscess will occur in the marrow 
cavity. 
It stands to reason that an Infection or an in- 
flammation may occur because the nail (just as in fract- 
ures of the forearm ) is projecting too much and thus 
causes damage to the skin or because it was projecting 
out of the wound. All this may be prevented if we cut 
the nail off and smooth its edges by means of a file. 
In o.ll 4 cases of infections occurring after the 
extraction of the nail, complications arose because 
either adequate instruments for its removal were not 
available or because the nail had slipped into the bone, 
limb was not kept in a good resting position and 
therefore in one case of a leg fractur a gravity abscess 
occurred at the fracture site which, however, could be 
brought to sound healing aft r an incision had been made, 
I daresay, however, that after the closed nailing of 
fresh are avoidable if the indication 
ed_ tec hnioue_ a re_ correct A 
Only in six cases was the method of the open nail- 
ing of fresh simple fractures used in which either a re- 
duction was impossible or because the nail could not be 
introduced into the distal marrow cavity. Infections 
of the fracture cleft never occurred. Only in one 
case of a thigh fracture was an inflammation of tho nail 
wound observed. In this case the nail was projecting 
too far out of tho wound and this projecting piece of 
the nail could not bo removed because a metal saw was not 30 
available # 
In spite of this we cannot agree with HAST to open 
the fracture as soon as difficulties arise for there is 
no doubt that br doing so the danger of infection is con- 
siderably increased. This was proved bv experiences made 
with old fractures. If the technieue applied is correct 
(the fragments must be distracted) good results will 
always be achieved. In no case frfe6>uld b.her:‘«per$LtiI6n be started 
before the operating suraeon has determined that it is 
possible to bring the fragments firmly one upon the 
other. If it is impossible to do that a wire extension 
should be applied. If a satisfactory position of the 
fragments cannot be obtained by this process the operation 
may be repeated one to two weeks later anyhow. If the 
necessity comes up to perform an open nailing an operation 
at this later time will in any case be more successful than 
to open the fr cture cleft after needless attempts which 
only disturb the asepsis and damage the tissue. 
One out of the three above mentioned fatal terminations 
has no relation to the nailing method. 
An 84 year old Wdman who had suffered from a sub- 
trochanteric transverse fracture of the thigh was treated 
with a 'wire extension after the closed nailing had failed, 
5 weeks later she died of debility of circulation and 
pneumonia(1). 
In the two other fatal termination;*! (thigh fractures) 
the post-mortem examination showed a fat cmbolfc£«* 
In one of the cases the fat embolus was due to 
the insertion of a second rod into the nail which had 
jammed with the first rod. Thus the pressure upon 
the marrow had become so strong that a massive fat and 
air embolism occurred (2), 
Tho other patient collapsed while under the in- 
fluence of a lumbar anaesthesia. Nevertheless the nail- 
ing operation was performed after he had recovered and, 
according to the records ”rather strong forces'1 had to 
bo used to insort the nail. The patient died 2 days 
after the operation. The post-mortem examination 
showed an extensive pneumonia and a slight fat embolus 
to which the fatal termination could not be ascribed, 
according to tho findings of the pathologist. 
In other nailings three further cases of fat 
embolus wore observed at post-mortem examinations. 
A 12 week old thigh fracture wh‘ch was in bad position 
was mobilized under anaesthesia and after that a wire 
extension was applied. 8 days later a closed nailing 
operation was performed because of the danger of infection: 
Duo to tho difficulties encountered with this operation 
a debility of circulatory difficulties were encountered and 
4 hours after tho operation tho patient died. The post- 
mortem examination showed a massive fat-embolism in both 
lungs. The fracture ends were closed by callus in which 
the nail was firmly seated (l). 31 
In a 2“2 months old thigh fracture which was 
nailed by the open method the (thinnest) thigh nail 
was jamming so much in the proximal fragment that re* 
peated attempt* were necessary to remove it and to ro* 
place it bv a .leg nail. KifENTSCHER*0 tackle and pulley 
whieH wap u*ed far thi* purpope caused a cr»eking 
#f the *cck tf the femur. Efea the ipcertian of the leg 
mail wa» difficult pp that the aporation last d mere than 
twe hour*. Tfco tollappo aopurred during the operation 
which pauPei the f3tml terminatian. The post-mortem 
examination rowealod the oxixtefice of a fresh fracture 
• f the neck of femur and the trochanter ma i or was torn 
off (by the tackle and pulley). Besides this a slight 
fat-embolism was observed to which the fatal termination 
could not be ascribed - according to the findings of the 
pathologists. findings were not available (2). 
The ideal that a displacement of fat might be caused 
by the marrow nailing is obvious, for, vrith the ineertion 
af the nail large auantities of marrow and at the same 
time also numerous rcssclp are damaged. 
MAATZ(J) proved by animal tests that a fat dis* 
plac cment does occur - but” it is so little that it 
is of no importance even if 4 large tube bones are nailed 
at the same time”. 
Aft r all the danger of a lethal embolus is little 
because the insertion hole is larger than the cross 
section of the nail. Thus the bone marrow may drain ©ff 
by the nail wound and a considerable over pressure is 
avoided (KUENTSCHER). 
It is striking that in all of our cases fat-emboli were 
observed only in thigh fractures. 
Clinical symptoms (as for instance: collapse of 
circulation, increase of pulsation) which are indications 
of a fat release were observed only in two cases of com- 
plicated thigh nailings. 
All this may bo explained by the fact that the 
"emergency valve" at the insertion spot 'becomes rather 
small with the thigh nailing because of the presence of 
the guide rod in the nail. As long as the marrow cavity 
is open at the fracture cleft it may suffice in general 
but not in old fractures in which the marrow cavity is 
closed by callus or connective tissue. 
Furthermore it is striking that in all cases, 
difficulties may arise with the insertion of the nail. 
When in this case especially tkibqg and repeated strokes 
arc necessary in order t® drive the nail in, the jamming 
nail will transfer the strokes to the bone. A prolonged 
striking upon a bone may cause a release of fat from 
the bone into the circulation (LARSEM), Those "hard11 
strokes will probably show similar dangerous effects. 
In order to prevent these dangers the nail should bo 
driven in by moans of strong "long" strokos and it should 
be replaced by a thinner nail as soon as jamming occurs 32 
(in thigh fractures it will always be better to use nails 
which are too thin instead of their b.ing too long). 
Besides this the guide rod should be removed for some 
time after the insertion of the nail into the proximal 
marrow cavity in order to facilitate an easy outflowing 
of the compressed marrow. 
In all thigh fractures it seems to bo better not to 
perform a nailing operation as soon as symptoms arise 
which are indications of shock, a bad general condition 
of health, or general symptpms which point to an endanger- 
ing of the operation. Aftef all the nailing represents a 
relatively large operation and even a small displacement 
of fat may lead to a fatal termination as a conseciucnce of 
injuries which already exist or which may come up during 
the operation. 
If all this is taken into consideration a dahger of a 
lethal fat embolus scarcely exists in practice. In 
no case, however, should, this possibility be the reason for 
abstaining from nailing thigh fractures* 
Damages due to metal mpy occur if stainless steel 
(V2A-steel)is not used for the manufactoring of the nails 
especially for the double nails. Indications of damages 
of this kind are rarefactions aroUnd the nail (which, 
however, may not yet be mixed Up with rarefactions caused 
by mechanical conditions) and periosteal deposits* They 
will not cause any delay in the healing process. Never- 
theless it will bo pfefarablo to femov. the nail as 
soon as possible; 
A number of physicians have observed that changes of 
the blood picture and of the sedimentation l*ato settle 
take place. All those findings ire rather interesting 
from the theoretical point of view, they arc of no 
significance, however, for the practical value of this 
method. 
SUMMARY 
In frosh simple fractures the stabile osteosynthesis 
achieved by means of the marrow nail sh»ws the following 
advantages: 
In comparison to the conservative treatment the 
healing process shows much better results. 
The time required for the treatment in the hospital and 
the duration of unemployability is considerably shorter. 
The nursing of the patient is very much facilitated. 
The danger of infection, the possibility of dislocation 
of fat and damages due to metal arc avoidable In case of 
thorough indication, correct tochnicue and good asepsis. 33 
These dangers are so insignificant that they are of no 
importance considering the advantages of this method. 
It must be kept in mind, however, that in fresh closed 
fractures a marrow nail operation should be performed only 
if that operation can be made without exposing the fracture 
site. 
If the osteosynthesis achieved by the nail is only 
"relatively stabile” its advantages are much greater in 
comparison to the conservative treatment. The danger of 
infection and the dang r of a late displacement are, 
however, considerably greater and therefore special con- 
sideration must be given to the after-treatment, 
Counter indications against the nailing of fresh 
simple fractures are: burns, blisters due to pressure on 
the skin, suppurating wounds or ether cotters of infection 
in the body, shock, bad general condition of health and a 
general endangering of the operation. 
In these cases the method of is the closed 
nailing for all simple fractures of the thigh between the 
trochanter minor and seven centimeters above the knee 
joint. 
Spiral fractures in the upper third and shaft 
fractures with a long spiral splinter may also be nailed 
and in these cases an additional wire traction is not 
reouired. The nail which should be long enough must be 
inserted at the proper spot and an early weight bearing 
must bo avoided because the osteosynthesis is only 
"relatively stabile". 
In distally located spiral fractures the nailing is 
of no advantage and therefore it is better to abstain 
from nailing those fractures. 
In leg fractures the nailing is particularly easy 
from the technical point of view but a true stabile 
osteosynthesis will be obtained only in transverse frac- 
tures, short oblioue and spiral fractures in the middle 
third. 
Even oblique and spiral fractures in the lower third 
may get such a strong hold by means of the usual double 
nail that the application of an additional wire traction 
is not always indicated. In these cases the nails must be 
driven into the line of growth (epiphyseal line) and 
sometimes an additional plaster cast or a U-splint will 
be reouired. In these cases and in fractures in the upper 
third the osteosynthesis is only relatively stabile and 
therefore special attention must be paid to weight bear- 
ing and thorough observation. Nevertheless the nailing 
method grants considerable advantages. 
If the fibula has come to an early healing it should 
be resected without delay in order to prevent a blocking 
effect upon the formation of callus first of in 
those cases in which the nails are too short. In those 
cases the nails are to be kept in position. Isol^i£d_fraptures„pf_the_tibia are particularly 
suitable to the nailing method* They must, however, be 
brought to an early weight bearing; 
The danger of a spreading of infection to the frac- 
ture cleft is rathr imminent if the osteosynthesis is 
only relatively stabile. Therefore the counter-indication 
should bo especially strict in leg fractures because of 
the imminence of infection. First of all fr ctures with 
considerable swellings of the soft parts, blist-rs or 
injuries of the skin should be excluded from the nailing. 
The closed nailing is the method of choice also for 
simple .sjhaf t_.fr t ur_s_of _t he_arm_abpv e_t he_ el bow. Frac- 
tures in the upper and middle third should be nailed proximal- 
ly, fractures .in the lower third, however, distally. 
Fractures which are less than 7 centimeters distant from 
the shoulder joint should be nailed from the middle part 
of the arm above the elbow. The nails must be driven into 
the nail head and the inner nail should be somewhat S- 
shaped, 
Fpacturos of the c<jjllum cfiirurgi cum of the arm above 
iiiiL.elb.22 should bo nailed only if it is not possible to 
fix the fragments and firmly press thefa together, 
Isolat.d_shaft_fractures„of_tho_ulna_and„radius should 
be nailed on principle if they are distant enough from the 
joint ends. In these cases the bone ends must be thoroughly 
fixed together because of the jamming effect of the second 
bone, 
If both forearm bones are broken thrv should be nailed 
only if the fragments cannot be fixed and firmly held to- 
gether by »e ns of a plaster cast. It is suitable to nail 
both bones. If an infection occurs the. wo nd must be broad- 
ly opened and the limb immobilised until the acute symptoms 
have subsided. If the osteosynthesis is relatively 
stabile the cast may be removed only when the wound has come 
to an aseptic healing or when the fracture is bridged over 
by bone. Otherwise an infection of the fracture cleft may 
occur. In such a case the nail should be removed otily after 
the healing of the fracture. 
If after the extraction of the nail an infection occurs 
the limb must be immobilized in such a way that the nail 
insertion spot is at the deepest point, otherwise a gravity 
abscess may occur at the fracture cleft. 
Fresh compoqnd__Frgorges 
In ope* bone fractures the healing result deponds 
largely on the ruestion whether a primary wound excision 
is possible or not. Due to the war the conditions are 
very unfavorable even in the home territory so that wo 
can refer to only 76 nailed fresh compound fr.ctures. The 35 
technique and the experience of the surgeon, however, 
are decisive. 
In this connection I would like to point to the 
insufficient data given in the piticats records in other 
hospitals. In most of the cases wo barely find the 
word "wound excision" and even the supplements we very 
ften misleadingly worded. 
It may be admitted that the radical wound excision 
with primary suture of the skin as recommended by BCT'HLER, 
is ideal but we must recognize the limits of this 
method and first of all it must be kept in mind that 
groat experience as well as mastery of the technique 
are necessarily required for it. If it was not possible 
to remove the injured tissue completely or if germs are 
still in the wound and consequently an infection occurs, 
in that case the suture of the skin must be especially 
endangered. The wound margins come to an early agglutination, 
the infectious secretum cannot drain off sufficiently - 
even if drainage is applied - and consequently the secre- 
tions will be pressed into the soft parts and into the bone. 
If symptoms of a wound infection are not observed an in- 
cision of the skin 2 mil limetors distant from the margins 
in the sound part of the skin is indicated. This is in 
accordance with the practice of my o?/n clinic. In this 
connection I would like to point out th :t we do not 
necessarily observe the 6-8 hour limiti Without regard 
to a later covering of the wound we remove all areas which 
seem to have their blood supply disturbed (dislocated lobes, 
scratched skin or contusion centers). All pobkets must be 
broadly opened. All dirty, contused, torn out or any other 
injured tissues are thoroughly cut away until finally fresh 
wound margins appeal** Bleeding vessels must inured:?. tely 
be pinched off. Special care must be given to a thorough 
removal of all damaged parts of the sinews and fasciae. 
All dirty sheaths of nerves and large ves els must bo re- 
moved. Dirty surfaces of the bones must be removed by 
means of the !1Luern rongeur but we re* ov only those bone 
particles which are completely loose. All the other ones 
are kept in position because they may be helpful for the 
formation of callus. After that the wound gets a temporary 
tamponage, the instruments, gloves, the linen and the 
wound covering are changed. Hemorrhage is controlled by 
trimming the wound margins once again near the clips. 
After that the bleeding vessels are tied,off and the nailing 
may begin. Only in thigh fractures the guide rod is in- 
serted from the fracture cleft into the proximal marrow 
cavity, In all other cases the procedure is the same as in 
simple fractures. A drain is applied to the fracture 
which must be led through the sound skin (and not through 
the wound) at the physically suitable spot. At the frac- 
ture site the soft parts must be stitched together as 
economically as possible but in such a way that the bon© 
is completely covered. Special drains must be inserted into 
larger pockets in the musculature. If with regard to the 
general condition*of the v/ound, a primary healing may be 
expected the skin should be closed by means of 3 millimeter 
wide adhesive tape (not by sutures). 36 
I would like to underline once again that contrary 
to the opinion of BOEHLER the suture of the skin 
especially endangered and therefore it is better to 
abstain completely than to obtain a closure by the trans- 
plantation of lobes, etc. The healing of the fracture 
takes a longer period of time anyhow and therefore there 
is no difference between a healing per primam and a he .ling 
per granulationem. Only in leg fractures a transplantation 
of lobes of the skin seems to be indicated because there 
is no other possibility for covering the tibia. -ilso in 
this case we use only adhesive tape* 
On principle the wound should be uept wide open and an 
efficient drainage should be applied if symptoms of a 
spreading infection are observed. In sue' a case we 
content ourselves with the "wound toilet" with the economic 
removal of all torn out and contused parts arid with the 
opening of all pockets. In case of an acute infection 
i.e. if suppur tion and fever arc observed, we had better 
renounce the nailing. It is decisive for the success of 
the nailing of open fractures - and in this connection 
I agree with BOEHLER to obtain a stabile osteosynthesis by 
the nail. In all cases in which this objective cannot be 
achieved it will be bett r to abstain from nailing. 
BOEHLER (l) recommends: "If the union of the frag- 
ments is not absolutely stabile just like in spiral 
fractures at the upper or lower end of the bone it is 
indicated to apply one or two wire sutures". I cannot 
agree with that despite the fact that in many cases I 
have treated compound fractures with wire and plate just 
like my very 4»Sj>eemed teacher Fritz KOENIG. Also in tbsao 
fractures it is possible to achieve a stabile osteosynthesis, 
(at least during the first weeks) if the technioue applied 
is correct (length of the nail). Therefore the ouestion 
arises: Why should we use an additional wire which causes 
further injuries because of the separation of the periosteum? 
If a stabile osteosynthesis cannot be obtained b*r the nail 
an additional wire loop will not be of any creat help. 
This at least is my own wipinion.If an infection occurs the 
n il which does not forge a stabile union with the bone 
will be especially endangered (2). It will bo better to 
renounce the nail therefore-in such a case and to use a 
wire loop or Lane’s plate if necessary. If in such a 
case an infection occurs it will at* least not spread to the 
marrow cavity. 
In the following let me refer once more to the 
"additional immobilization" of the limb; one of the basic 
principles of the treatment of accidental wounds is to 
immobilize the injured limb as long as a danger of infection 
exists. The nail immobilizes the fragments and not the soft 
(2) In BOEHLER*s cases there is no compound fracture that 
came tro an aseptic healing with an additional wire loop. 
There are, however, some cases in which an infection occur- 
red . 37 
parts. Therefore the limb must be kept immobilized even 
after the nailing. Most suitable for this purpose is the 
un-uphoIstered cast with a window or the un-upho 1stered 
cast-splint which must be attached in such a way that it 
may bo kept in position during the change of dressing, 
i * 
The limb should be kept in such a position that tho 
drain in the wound is at the most dependent point. If, 
however, Braun's splints are used the insertion site 
must be at the most dependent point. Blood or wound 
secretion extravasating from the wound will easily drain 
off in the direction to the the insertion site along the 
nail which acts as an ideal drain* Event iully an infection 
may be transmitted to that site. 
a) Frekh compound thigh fractures. 
Nineteen fresh compound fractures of the femur were 
nailed but the course of only one of those could be ob- 
served until a final healing was obtained. This was the 
only fracture with an inf ction of the wound; 
Open fractures of the left thigh and leg after a 
motorcycle ac ident in a 20 year old sergeant* 
left thighs, Double green-stick fracture in the 
middle of the thigh, The central fragment is 4 centimeters 
long (ill, 44a). The 6 centimeter Iona open somewhat 
torn up wound reaches to the bone. 
Left leg: Green-stick fracture of the tibia, eomewhat 
below the middle, fracture of the fibula in the upper third 
(see 111, 48). Torn up and dirty wound which is larger 
in size than a hand and from which the bones project. 
Immediate operation under anaesthesia: Widening and 
trimming of the thigh wound. All torn up and dirty parts 
of the musculature arc removed and the blood is staunched. 
Exposure of the fracture site. The proxima.l fragment is 
elevated somewhat by means of a bone hook. After that the 
guide rod is inserted into the marrow cavity and driven 
through the skin at the trochanter. Insertion of a 
38 centimeterg long marrow nail by using the guide rod until 
it appears at the fracture cleft. ((An X-ray to determine 
the correct length of the nail was not taken). Then the 
guide rod is extracted and inserted into the nail from 
above. The middle piece is slipped over the nail re*- 
spectively over the guide rod and then nail and guide rod 
arc driven into the distal fragment until finally only about 
2 centimeters are projecting out of the trochanter, 
(ill, 44b) MARFANIL-PRONTALBIN-powder is distributed in all 
wound pockets and the depth of the wound. Three drains 
were applied. A row of sutures of the wound is made. The 
wound is closed at the trochanter after the application of 
Marfanil-Frontalbin-powder for all wound pockets and 
a rubber drain is inserted. After that, trimming of the 
wound and nailing of the leg fracture with only one nail a 
b 
c 
Illustration 44 
a t b h c 
a) Comminuted compound fracture of the left th: gh (with accompany 
ing compound fracture of the left leg) due to a motorcycle acci- 
dent. The wound is slightly mutilated and six centimeters long. 
Wound excision and marrow nailing from the fracture site imme- 
diately after the patient was brought to the hospital, vfound 
suture and insertion of three drains. A rubber drain is used in 
the trochanter wound. VOLKMANN splint. Next day the tc: per.atu.ro 
rose to 39° C, Change of dressing and irrigation of the wound 
only four days later. Only three weeks later was the wound wide- 
ly opened, 
b) Same fracture after the nailing. The nail is too short, it 
does not find sufficient hold in the distal marrow cavity, 
c) Same fracture seven weeks p.op. Distinct rarefaction of the 
corticalis at the distal fragment and around the nail. Again 
and again the drainage was dammed up and incisions were 
necessary, d 
e 
Illustration 44, 
a e 
d) Same fracture five months p.op. The central fragment is 
seouestrated. At the proximal fragment a typical ring sequestrum 
was cast off. At the distal fragment the nail has worked its way 
into the corticalis because the osteosynthesis was not stabile 
enough. The fracture came to a valgus position, at the inner side 
a beginning formation of callus is observed. 
c) 8 months after the injury the fracture is bridged over by 
callus on the inner side. Above the nail point a thin formation of 
newly grown periosteal bone is observed. There arc fistulae in 
the wound. The patient subjects the limb to weight be .ring. 38 
after which the fracture cleft was still gaping, A 
defect of the skin of the size of a 5 mark coin cannot 
be closed. M.P.-powder-drain. The thigh and the leg 
are immobilized in a Volkmann-splint, 
In spite of the fact that one day after the 
operation the patient shows temperatures higher than 
39 degrees which are increasing, the dressing is changed 
only four days later and a considerable secretion of 
pus coming from the wound is observed. "Therefore to 
begin with some (l) of the sutures are removed." After 
that11 the wounds are thoroughly cleaned every second day 
with a solution of RIVANOt and RIVANOL-i/icks are inserted 
into the wound". Fourteen days aft r the operation a 
pelvic cast with a window is applied and finally (three 
weeks after the operation) the wounds are widely opened 
because the temperature of the patient had not yet de- 
clined. In the X-ray wh‘eh was taken 4 weeks liter 
(in. 44=) wo observe a distinct rarefaction of the cor- 
ticalis of the distal fragment. Again and again retentions 
of pus occur which require ifurthei* incisions. The third 
fragment becomes necrotic and from the proximal fragment 
a (typical) ring seouestrum id cast off. The nail which 
is too short penetrates the- corticalis (ill 44d), Thus 
a slight bending of the fracture occurs but at the inner 
side of this curvature an abundant formation of callus 
is growing which causes a bridging over of the fracture 
(7 months after the operation) so that tto limb may bo 
subjected to weight bearing (111. 44©)• Vhe leg wounds 
which had cast off some Jeouestra are cloied. now but a 
fistulization of the thigh still exists. months after 
the operation (December 3944) the ability to walk is 
restored to such an extent that the patient can get a 
Christmas furlough from which he did not return because of 
the events of the war, A short time ago he Reported that 
the nail was removed one year after the accident, 14 
days later a refracturc had occurred which came to a 
healing in a varus position of 160°. Half a year later 
another formation of abscess is observed at the thigh 
and 7 seouestra had to be removed. Since then tho 
wounds came to a healing and other sequestrations did not' 
take place. His hip is not afflicted but his knee and 
foot joint became ouit© stiff. Total shortening : 6 centi- 
meters. 
It 13 very difficult to decide whether or not the 
trimming of the wound was really sufficient. It is 
a matter of fact, however, that it is wrong to direct 
the drains through the wound, It is clearly proved • 
by the course of tho disease how dangerous the wound sutufo. 
©ty bar first of all in those cases in which the wound is 
not inticdiatcly widely opened(l) after an infection of the 
(l) Again and Again I have noticed that particularly young 
surgeons dislike open wounds and therefor- want to retain the 
skin sutures. Conseouently they hesitate to open the wound 
widely. Maybe they think of previous exporienceswith ab- 
dominal operations (abdomen eviiaraftionf abdominal hernia). 
In order to'n*©t nnidoi I %0a9h .m3r fro© the 
vary beginning to renounce the suture of the skin entirely 39 
wound occurred. First of all, however, a stabile osteon- 
synthesis had not bee achieved because the nail was too 
short. Therefore the infection of the fracture cleft, 
the necrosis of the middle fragment, the ring seoucstrum 
at the proximal fragment and the oenetrating of the nail 
into the corticalis must be ascribed to that instable 
osteosynthesis. 
Also in the case of the open fracture demonstrated by 
111, 45 the osteosynthesis is only relatively stabile. 
Nevertheless a primary healing was achieved but in t-is 
case the nail was applied only 14 days after the injury 
i.e. at a time when the wounds had already come to a 
he aling. 
The grcc-stick fracture in the central third was 
complicated because of a bleeding wound 3x1 centimeters 
on the inner side. The wound was trimmed and a suture ap- 
plied* 2 days later a splint was a 'plied after that wire 
extension. 14 days after the accident when the wound had 
already come to a healing the fracture was nailed after 
its exposure from the outer side. 2 days after the 
operation a large size hematoma was opened at the fracture 
site and irrigated with salt solution. With an exception 
of two days during which the patient suffered fro: an 
increase of fever (12 days after the operation) the course 
of the healing process was uncomplicated and four months 
after the accident the patient was released as being fit 
for service after the nail was removed. 
The diameter of the marrow cavity below the fracture 
site is so wide that a true jamming effect of the nail 
cannot be obtained. therefore the nail should have been 
much longer. The osteosynthesis was only relatively 
stabile which may distinctly be proved by the rarefaction 
seen in the X(-ray in the area of the nail point in the 
picture taken 9 months after the operation (ill. 45)* 
It is certainly less dangerous to wait for an aseptic 
healing after the trimming of the wound and to begin 
with the nailing operation after that. In such a case 
however, we must take into consideration that we have to 
deal with a simple fracture and therefore we should nail 
without exposing the fracture cleft. This result was 
achieved in 6 cases, four of which must, however, be con- 
sidered to be only relatively stabile regarding the 
peculiarities of the fractures in ouestion. 
In all cases in which a true stabile osteosynthesis 
can be obtained such an attitude sec s not to be indi- 
cated because one will forego the advantage of the elimina- 
tion of the danger of infection which is due to the 
imimobilization of the fracture. In al1 cas's, however, In 
*(even in abdominal surgery) as soon as a danger of infection 
exists, I even reject the so-called approximation sutures 
because they may easily lead to a true suture of the skin. Illustration 45 
Compound fracture of the femur 3 months after 
the open nailing, w ch was made 7 days 
following the injury and when the primarily 
trimmed wound located on the inner side had 
healed. Primary healing. The osteosynthesis 
was only relatively stabile because the nail 
did not find sufficient hold in the broad 
distal cavity. In this way the rarefactions 
round the nail tip occurred. The nail should 
have been driven into the epiphysis. An 
infection did not occur. 40 
which only a relatively stabile osteosynthesis can be 
obtained this procedure will be better than tho primary 
nailing. 
In those * 12 cases of primarily nailed fresh compound 
fractures the osteosynthesis was stabile and all cases 
healed without any disturbances of the wound* 
In those 13 fractures which could bo observed until 
a final healing was achieved the treatment in the 
hospital lasted from 21 to 90 days or 69 days on an aver- 
age. However, the duration of unemployability of those cascr 
amounted to 30 to 138 days c>r 115 days on an average* 
A distinct difference betv/een tho primary Inailing and the 
nailing after the healing of the trimmed wound could not 
be observed. All 13 cases healed v/ithout an impediment cf 
the leg. 
In EHALTS 1 s cases which had healed ”Y/ithout any 
complications” tho average treatment lasted 200 days. 
Nine of h:s cases of compound thigh fractures would have 
been suitable for the nailing operation. In two cases 
in which the traction was too strong, pscudarthrosis 
occurred v/hich had to bo eliminated - operatively but in 
one case an impairment of the knee joint remained* 
Therefore there is no doubt that the nailing of 
fresh compound th:gh fractures shows great advantages 
in comparison to the conservative treatment* 
b) Leg Fractures. 
At my clinic all compound, leg fractures were former- 
ly fixed b means of the twisted wire method or by Lane*s 
Pla tes, If, however, a primary wound excj sion was pos- 
sible (l) we frcouently have used the marrow nail method. 
Wo did not treat only those cases which were !,very suit- 
able” (cases of that kind are rare) but also those in 
which tho osteosynthesis was only relatively stabile 
(oblicue and spiral fractures below the middle of the 
bone etc,). It must be admitted that many a technical mis- 
take has been made (by using nails win ch 7/ere too short or 
b~ subjecting the limb to weight bearing too early). The 
same conditions prevailed in the field hospitals, 
A total of 39 fresh compound leg fractures were 
nailed, the course of 29 of which could. be observed until 
a final healing was achieved. 
In those 39 cases of nailed fractures an infection of 
the wound was observed in 12 cases. In four cases the in- 
fection had extended to the bone and caused a cartin'" off 
of sequestra. 
(l) In general small smooth wounds out of which bone rplint- 
ers woro projecting were not trim ed by us. Cases 
t hat kind were treated cons ervatively, The comminuted fracture demonstrated by 111. 46a 
was complicated because of a wound which was larger in 
size than the palm of a hand in which there were several 
bone splinters and torn up musculature, The skin 
which surrounded the wound was badly damaged and contused 
and on the skin of the leg there were several abscesses of 
the size of 2-3 mark coins. Consequently it was not 
possible to cover the entire bone by soft parts after 
the excision of the wound and the nailing. The exposed 
splinters were removed. The nail stabilized the fracture 
satisfactorily (ill. and consequently a serious in- 
fection did not occur. At that spot where the bone was 
exposed corticalis sequestra were cast off so that the 
fracture cleft became wider but the broken out splinter 
was well attached to the bone (ill 46c), Eight months after 
the operation the wounds were closed except for a small 
fistula and the nail was removed because the fracture cleft 
was bridged over by bone. A l; the fracture cleft a se- 
questrum of the size of a grain of barley was observed which 
was removed 14 days later. After that the wounds healed 
auickly and the patient could be released from the hospi- 
tal. A late examination took place 11 months after the 
accident which showed that the wounds as well as the 
leg abscesses were healed and that the fracture was com- 
pletely stabile and suitable for weight bearing, A 
shortening was not observed, the impediment of the ankle 
joint amounted to 25$. The X-rays (ill 4&d) showed t at the 
structure of the callus was not yet suffici ~.nt it the 
medial side but symptoms of an osteomyelitis were not 
observed. 
in the fracture, demonstrated bjr 111. 47a, however, 
a considerably smaller, relatively smooth oblique wound 
existed at the level of the fracture site which was 
trimmed and primarily sutured. ihis operation and the 
one described above were made by my chief-physician. 
After the nailing the fracture was clinically stabile 
but the osteosynthesis was only relatively stabile be- 
cause the fracture was rather deeply seated. The 
nail could have been somewhat longer* Therefore a 
plaster U-splint was applied (111* 47b). Two days 
after the operation the fever rose up to 39° and con- 
sequently the wound was widely opened and discharged a puru- 
lent bloody substance. Despite the fact that a 
cast with windov/ was applied an osteitis occurred at the 
fracture cleft mainly o-f the proximal fragment and at the 
broken out splinter. An infection of the marrow cavity, 
ho?/ever, was avoided, (ill. 47c), A part of the splinter 
was cast off as a sequestrum but a good periosteal form- 
ation of callus bridged over the fracture cleft. Four 
months after the operation r-arefactionsof the spongiosa were 
observed in the vicinity of the nail (ill 47d). After the 
removal of the sequestrum the wound closed pretty soon, 
5-2 months after the accident the healing of the fracture 
had progressed so much that the nail could be removed, A 
late examination six weeks later proved thet the nail 
channel could be recognized only at the insertion site. 
A coarse defect with two small sequestra was observed at 
the fr cture cleft which, however, was not surrounded by 
sclerotic bone (ill. 47e). Fistulae and swellings end 
an impediment of the limb were not observed. The two *■> 
b 
Illustration 1+6 
a +■ b 
a) Comminuted fracture of the right leg which was com- 
plicated because of a wound the size of the palm of a 
hand with the bone and several splinters being completely 
loose. Serious damage of the musculature. The skin near 
the wound was seriously contused. On the outside of the 
leg several ulcer a cruris were observed. The wound ex- 
cision was made immediately and the loose bone splinters 
were removed. Nailing operation , Due to the existence of 
the ulcers, the wound was kept widely open because a graft- 
ing of skin was not possible. The fracture site was part- 
ly uncovered. Application of a splint and of a ■"’’rain in 
the posterior direction, 
b) Same fracture after nailing. The double nail which 
was driven into the spongiosa found a good hold in the 
distal marrow cavity. The fragments were well pressed 
together. The osteosynthesis was stabile. c 
d 
Illustration 46 
c+- d 
c) 42 months later. In front the exposed bone was partly- 
cast off from the inside so that the fracture cleft gaped at 
that point. The greenstick splinter* however, reaches from 
one fragment to the other. Symptoms of an ostitis were not 
observed. The nails forge a stabile union with the bone and 
reactions were not observed. The splinter had been removed 
4 weeks after the operation and the patient had started sub- 
jecting the limb to some active exercise and exercises after 
the manner of walking. The wounds healed with exception of 
two spots the size of a 5 mark coin. A small fistula ex- 
tended to the bone. All joints freely movable. 
d) Same fracture 11 months after the injury. Bony haling. 
Medially the callus appears poor in calcium. The wounds were 
completely closed. No shortenings'-Were observed and all 
joints were freely movable. 41c 
a 
b 
Illustration 47 
a 4- b 
a) Compound fracture of the log with a relatively smooth 
wound which is 4 centimeters long and extended oblieucly. 
Wound trimming, open nailing, drainage in the posterior 
direction, primary suture of the wound. U-shaped plaster splint. 
b) Same fracture after the nailing. The nail should, hwe been 
driven to the epiphyseal line because it could not find suffi- 
cient hold in the broad marrow cavity. The osteosynthesis is 
only relatively stabile. An infection of the wound occurred 
which was immediately opened widely. Cast with a window* 41d 
4 
d 
Illustration 47 
c+d+c 
c) Same fracture two months later. 
Loosening of tho bone structure at the 
fracture cleft. Beginning necrosis 
of tho cast off greenstick splinter 
but, at the same time beginning 
formation of callus, 
d) Same fracture 4 months p.op. 
Seauestra at tho greenstick splint- 
er. Medially and. behind a good 
formation of periosteal callus was 
observed which extended far below. 
This was not due to the presence 
Df the nail, for, at the side at 
vhich it is lying a new formation of 
periosteal callus was not noticable, 
distinct rarefactions round the nail 
sip which are an indication that the 
lail was not firmly so&tod. The se- 
mes t rum was removed and after that 
/he fistula healed. The nails 
rcre extracted 4"2 months p.op. 
) Same fracture 7 months after the e 
njury. It is bridged over by bone. Two small sequestra wore ob- 
icrved at the fracture cleft which were spontaneously cast off later, 
he nail bed is noticable only at the insertion site. 42 
seouestra were cast off spontaneously and medical assis- 
tance for that was not necessary, The late examination 
which took place 1-g- years after the accident did not prove 
any limitation of the movements and the fr-.ctu.rc cleft was 
barely recognizable. 
The fracture had come to an ideal healing (picture 
was lost). 
In this case the broad opening of the wound and the 
sufficiently long period of immobilization of the limb have 
obviously prevented the infection of the marrow cavity. 
In the leg fracture demonstrated by 111, 48 (and 
in the thigh fracture of 111. 44), however, a serious 
infection of the marrow cavity with extended periosteal 
abscesses and abscesses of the soft parts, the formation 
of seouestra which reruired several incisions were due to 
the negligence of the above described procedure. Even 
later, several seouestra were cast off until one year 
after the operati n the nail was extracted. Due to a 
sudden fall ■§• year after that a refracture with an 
accompanying infection occurred in the course of which 
several other seouestra were cast off, A defect pseu- 
darthrosis had to be expected and conseeuently the fibula 
had to be removed. final result is a shortening of 
3 centimeters with a stiffening of the knee joint and of 
the foot joint and scar tumors occurring again and again. 
In leg freotnreo .the primary suture «f tho wound seems 
to bfr particularly dangerous. In 12 out of 15 cases ( 80. >) 
a wound infection occurred which in one case extended 
to the marrow cavity and in three cases caused the 
casting off of seouestra. All 17 wounds how-ver, wbach 
had been drawn together by adhesive tape came to a good 
healing, 
Only in one case of a relatively stabile osteosynthesis 
and early healed fibula a late abscess with formation of 
seouestra occurred after the patient had worked two weeks 
(i). 
Even in those four cases in which the wounds had to 
be kept widely open because they were too extended and 
very dirty in only one case was an infection of the bone 
observed. 
It stands to reason that the suture of the wound 
is particularly dangerous as soon as the osteosynthesis is 
not absolutely stabile. The immobilization of the limb 
is a precious means in fighting infection. In six out 
of 1 sutured wounds the osteosynthesis was stabile, three 
cases came to a ptinary healing and an infection of the bone 
never occurred. See table V, 
Table_V. Healing of the wound in fresh open leg fractures: 
S- stabile osteosynthesis 
rss relatively stabile osteosynthesis 42a 
Illustration 48 
Compound fracture of the leg(with 
simultaneous compound femur frac- 
ture (111,44)) 8 months after the 
nailing. The sutured wound was 
not immediately opened when the 
infection was observed and con- 
sequently an infection of the 
marrow cavity and periosteal ab. - 
soeu*<s developed. Now, the wounds 
are healed but there is no doubt 
that a chronic osteomyelitis 
exists, tater on several se- 
questra are observed. One year 
p.op. extraction of the nail, 
1t=t year p.op. refracture with an- 
other casting off of sequestra with 
an imminent formation of pseudar 
throsis which was counteracted by 
the resection of the fibula. 
Final result: Shortening of tho 
leg of 3 centimeters, stiffen- 
ing of the knee joint and ankle 
joint* 
Illustration 49 
(ref. Text see P. 45) 
Nailed compound fracture of the 
arm above the elbow 2 .years 
after the injury. The wound 
excision w-s insufficient and 
consequently a serious infec- 
tion occurred which extended 
to the elbow joint and caused 
there a bony ankylosis. Se- 
questra were cast off several 
times, 43 
Total 
s1 1 rs 
Go 
heal 
tan 
Di. 
. of 
a und 
. r.a„ 
u o u 
inf 
s 
nd 
ect i 
r s 
fc 
o: 
Si 
_ s. 
?r m. 
*q. 
,rs 
inf 
mar 
cav 
s 
.of 
row 
ity 
r s 
Lat 
abs 
ces 
s 
e 
s 
r s 
Prim.sut.of the wound 
6 : 9 
*T ~ 
111 6 
3 
0 
3 
9 
• 
3 
0 
1 
0 
0 
•ound adapt.b. means 
of adhes. tape. 
11 
6 
0 
0 
0 
0 
0 
0 
0 
l 
.ound kept open 
2 ; 2 
1 
2 
„ 
: 0 
0 
1 
0 
0 
0 
0 
0 
after the 
heal, of the trim, 
wound . .. 
! 
3 1 0 
3 
0 
0 
TOTAL 
22 ! 17 
22L__ 
17 
26. 
9 
-66 fo 
lz 
Jims? 
0 
_1= 
0 
_1 
BOEHLER rejects the nailing of compound leg frac- 
tures because serious infections occurred in 21,7% of the 47 
cases treated by him, whereas in the conservative treat- 
ment (EHALT (2) only in 6,2% of the lases were infections 
observed. In our own material in only one case (2,6%) 
a serious infection occurred and it certainly could have 
been avoided. If we do not consider EHALT*s cases of 
shaft fractures which were suitable for the nailing wo have 
to deal with 80 fractures, 18 or 25% of which showed 
disturbances of the wound healing including 2 gas 
phlegmons and 9 cases (11%) formation of seouestra. In 
comparison to tnis the results obtained by the nailing- 
method are much bettor. Wound infections occur more 
freouently but only in those cases in which the wound 
were primarily sutured. Therefore there is no reason to 
reject a marrow nailing of fresh compound leg fractures 
because of an increased danger of infection, iVe do warn, 
however, against suturing the wound. 
Unfortunately only 29 cases could be observed until 
a final healing was achieved. The results obtained and 
the length of the stay in the hospital and the length 
of time necessary to restore the employability are noted 
in table VI and compared with the 80 cases of EHALT. 
Table VI., Duration of treatment and results ob- 
tained in fresh compound leg fractures. 
i 
1 
.Nr. 
Duration of 
stay in tM unemploy- 
hospital J ability 
I 
Final 
IX 
resul 
Lt s 
U.I3L 
Harrow nailing 
29 
8?33-180) 
127 
(53-406) 
26»90% 
2= 1% 
1 
Conservative treat, 
*OEHLER-FHALT 
SO 
- 
183 
(68-399) 
50 = 
62% 
23 a 
21% 
—— 
6, 
17% 
l 44 
I. Healing without shortening, angulation or impairment 
of the joint. 
II, Slight angulation, shortening or impairment of the 
joint. Pensions less than 20% 
III, Marked angulation, shortening or impairment of the 
joint. Pensions 20% or more 
IV. Pseudarthrosis, 
The results obtained are distinctly better and 
therefor we believe that the nailing of suitable fresh 
compound leg fractures should be preferred to the con- 
servative treatment. 
Open oblioue fractures and spiral fractures in the 
distal third and fractures near the joint are not con 
sidered to be suitable for the nailing operation, be- 
cause in these cases it cannot be ascertained whether 
the nail will forge a stabile union or not. If th s 
auestion must be answered in the negative (and it is not 
possible to say in advance with certainty) an infect! n 
of the marrow cavity may be expected. An additional 
wire loop cannot prevent that, which is proved by the 
experiences made by BOE-HLER (l). In those cases 
the osteosynthesis is obtained by a wire loop(in oblirue 
fractures)or a lane’s plate(in transverse fractures) just 
as my teacher Fritz KOENIG did it and BOEHLER recommends 
it. In such a case, however, a plaster cast is required 
which must be kept in place until a final healing is 
achieved. 
c) Fractures of the Forearm, 
The course of sixteen out of 17 cases of nailed 
compound fractures of the arm above the elbow could 
be observed until a final healing was obtained. In one 
case a serious wound infection occurred which had extended 
to the elbow jopnt and conseouently had caused a stiffening 
of the joint. Thore is no doubt that this infection was 
due to the insufficient trimming and the late opening of 
the wound. 
The transverse fracture of the arm above the elbow 
near the limit of the middle and lower thurd was com- 
plicated because of a five centimeters long tr .nsverse 
wound and the complete separation of the flexor musculature, 
During the wound excision it was observed that the 
brachioradialis was torn off at its insertion (the wound 
was not extended to the elbow). Despite the fact that a 
paralysis of the radial and of the median nerve existed 
only the radial was exposed. It was not separated (cut 
through) but at the height of the fracture cleft an 
endoneural hematoma was observed. After the nailing v/hich 
was made from the distal side and which resulted in an 
absolutely stabile osteosynthesis (the X-ray pictures 45 
were destroyed) the wound was drained in the direction 
of the extension and a suture applied after administering 
of Marfanil-Prontalbin-powder, After that a plaster 
splint was applied. The temperature was not higher than 
38 and conseeuently the drain was removed on the second 
day. In the evening the temperature rose to 39,2°. No 
symptoms of reaction appeared and so the wound was not 
opened. The temperature stayed between 38 and 39 and the 
wound seemed to come to a primary healing. An edematous 
swel ing of the area of the elbow Joint and of the fore- 
rm was observed. Eight days after the operation the 
temperature climbed up to 40° and after the opening of the 
wound plenty of pus was drained off. After that we ob- 
served abscesses at the elbow joint and on the forearm 
and a casting off of large necrotic muscle and fascia 
parts. The elbow joint became stiff. The paralysis of 
the radial and of the median nerves was not getting 
better and the final result was: a stiffening of the el- 
bow joint which stands at an angle of 110°, a consider- 
able stiffening of the wrist and contractures of the 
fingers with a paralysis of the radial and of the median 
nerves. Desoite the bony healing of the fracture several 
seouestra were cast off at the fracture cleft. The nails 
were removed four months after the accident. But also 
after the extraction of the nails several seouestra were 
cast off at the fracture site and at the nail insertion 
site and fistula© were observed a' a ? r. anr’ again it the 
olecranon. Therefore one year a "ter the oper ation the 
bone was opened at the nail insertion ,c: t - and some 
small seouestra were removed. After th t the wounds 
come to a healin'?' and a late examination two years after 
the accident (ill* 49) proved that the wounds ,,rere healed 
without any reaction and inflammation did not occur.any- 
more . 
There is no doubt that the infection was due to an 
insufficient excision of the wound. It would have bean 
absolutely necessary to expose also the spot of the se- 
paration of the brae hioradialls and to open this pocket 
too and to apply a drain to that spot. Sulfonamides ar* 
in no case substitutes of a thorough excision of the 
wound. It may be that the delayed appearance of the in- 
fection must be ascribed to those sulfonamides5 but it is 
just because of this dealy that we Tfere mistaken (low 
temperature) and conseeuently the wound was not immediately 
opened. An immediate broad opening of the wound would 
certainly have avoided the infection of the elbow joint 
and maybe also of the bone. Under consideration of all 
these mistakes we had made even a conservative treatment 
or the applic tion of a wire suture would not have prevented 
an infection, of tlie fracture cleft. The extension of 
the infection to the marrow cavity, however, and the 
formation of seouestra would certainlv have been avoided 
without using a marrow nail. Therefore -vVe agree with 
BOEHLFR that the marrow nail method facilitates the 
treatment of fractures but at the same time it renderes 
it more dangerous. 
In spate of these facts there is ro reason to abandon 
the nailing method ®f fresh compound fractures of the 
arm above the elbow and to apply the old methods once 
again, if it is possible to obtain a stabile osteosynthesis. 46 
It was proved in the chapter "Fresh fractures" under which 
conditions this objective can be achieved* 
It is our opinion that an additional wire suture 
or wire loop , as recommended by BOEHLER - is not re- 
quired. Contrary to the findings in old fractures, the 
musculature is intact. Therefore the afflicted arm which 
must be kept in the elevated position during the confine- 
ment to bed after the application of a plaster U-splint, 
'Then getting up the arm must be held in this direction 
by means of an cr an, cfcduction splint.must ba qppljl'pd* 14 
days later when the finds are healed the elbow must be 
given some passive motion with the sling in place which 
may be removed three weeks later at the earliest. In all 
cases treated in this way we never observed a distraction 
of the fragments. On the contrary we even observed a 
pressing together of the fragments which was due to these 
exercises. 
If the nail does not find sufficient hold in the 
bone it is not only superfluous but disadvantageous. 
The additional wire suture cannot pi-vent the nail from 
getting loose in the bone because of the movements of 
the limb. As soon as an infection exists this infection 
will be transferred to the marrow cavity by the nail* 
The period of hospitalization, the time of unemploy- 
ability and the results achieved in our 16 cases are 
summarized in table VII. Seven out of 24 compound frac- 
tures mentioned by EHALT would have been suitable for the 
nailing method and the results obtained in these cases are 
compared with our cases. 
Time of treatment and results obtained in 
fresh compound fractures in the arm above the elbow: 
Duration of 
Final results 
stay in hos- 
pital,. _ . . 
unemploy- 
ability 
I 
ii 
III 
IV 
Marrow nailing 
16 
58 
(21-186) 
131 
(42-325) 
15 
0 
1 
0 
cons. Treatment 
(BOEHLER-EHALT) 
7 
168 
(47-309) 
5 
2 
- 
- 
lisregarding the avoidable result III some advantages in 
comparison to the conservative treatment are clearly 
noticeable, but the differences are not very great. In 
case of an infection, however, considerable complications 
may arise which are due to the nail. Therefore the strictest 
indication possible is recuired. All surgeons who are not 
well acquainted with the treatment of si'ple fractures and 
with the technioue of the nailing and first of all with the 
excision of the wound, should not nail compound fractures 
of the arm above the elbow. b 
a 
Illustration 5C 
) Compound transverse fracture of the 
rm above the elbow with a torn-out 
ound of the soft parts the size of a 
mark coin. Hound excision, marrow 
ailing from the proximal side. A- 
aption of the wound by means of ad- 
osive tape, use of drainage. The 
~m was put to rest by means of a 
cAMFR splint and an arm sling. 
) Same fracture 2 days p.op.,the 
emperaturesarc normal. The drain- 
ge was removed and the nail grants 
ufficient hold to the fracture, 
ound healing per primum. The splint 
as removed 14 days later. The limb 
s subjected to active exercise with 
he arm sling. The patient was re- 
eased from the hospital on the 21st 
ay, the wound being without any 
andage. 
) Same fracture 4 we ks p.op. The 
nds of the fragments were pressed 
ogether by the exercise movements, 
eginning formation of callus, no 
mpairment of the arm. 
) Same fracture 4'2 months p.op., 
hich can© to a bony healing. The 
ails will be removed. 
c 
d 46b 
a 
b 
Illustration 51 
a) Open fracture of the arm above the elbow with a torn out 
wound which is 5 centimeters long - after the nailing. Primary 
wound excision, adaption of the wound by means of adhesive 
tape, drainage, which was removed 24 hours later. Primary heal- 
ing of the wound. 8 days later the patient began subjecting 
the limb to active exercise. 
b) Same fracture 14 days later. It is distinctly visible that 
the fragments have been pressed together by the exercise movements. In one case a closed nailing was made aft r the primary 
healing of the wound excision. In one case a na.il was 
applied (on the third day) despite the fact that the 
wound was not yet closed. The wound did not show any 
symptoms of reaction. Though an infection did not occur 
this kind «f treatment is not suitable according to our 
own experience. From the technical point of view the 
open nailing is much more simple and the fracture is 
immediately immobilized. This helps to fight infection. 
First of all, however, rather complicated reductions are 
necessary in clos d nailines so that damages of the 
soft parts cannot be avoided, which are another source of 
infection. 
At the same time we think it is wrong to perform 
the closed nailing first and then to excise the wound. 
This procedure had been applied in one case of a wound 
from, which bones projected but an infection 1id not occur. 
One never knov/s (and this is particularly true for small 
wounds) to what extent the soft parts are damaged and 
whether or not any dirt or parts of the clothing were 
brought into the wound the bone. On the other hand, 
these foreign bodies may be dislocated by the reduction. 
First of all, however, the bone ends cannot be carefully 
examined anymore after the nailing and even the wound 
cannot be checked as well as in case of a movable frac- 
ture. 
d) Fractures of the Forearm, 
In my clinic compound fractures of the forearm were 
not nailed because according to the experiences made with 
simple fractures it is not possible to obtain a firm 
pressing together of the fragments with the nail which is 
particularly true for all cases in which only one bone is 
broken. In those cases the wire suture is applied with 
best result. 
Two observations made by other surgeons seem to 
confirm our own opinion: 
In an open ulna fracture with a cast off radius 
head the fragments were firmly standing one upon the other 
in a slight valgus position after the nailing (111, 52a). 
The wounds came to a primary healin and the patient 
was able to begin some exercises, two weeks later and 
he was released from the hospital three weeks later. 
Fxaminations which were made in intervals of four weeks 
did not reveal any formation of cal1 us and 3w months after 
the operation the fracture was distracted (ill. 52b), 
The nail was removed four months later and the final re- 
sult was a "tight” pseudarthrosis (ill, 52c). 
In the fracture demonstrated by 111. 53a, which was 
complicated because of a serious damage of the soft parts 
in the distal third, a nail inserted into the radius burst 
the bone because the marrow cavity was very narrow. a 
b 
Illustration 52 
a -hb 
a) Compound fracture of the ulna 4 weeks after the 
nailing. Healing of the wound after the operation. 
The patient started subjecting the limb to active 
exercise movements 2 weeks p**p. He was released from 
the hospital three weeks p.op. Now he is able to use 
the arm. The fragments stand firmly one upon the 
other. The nail was too short. 
b) Same fracture 3l!t months p.op. The fracture was di- 
tract e d by the jamming effect of the radius and the 
nail slipped out of the distal .fragment for 3 milli- 
meters. No formation of callus is observed. Illustration 52c 
Same fracture 4l!r months p.op., after the re- 
moval of the nail. Tight pseudarthrosis. 
The impediment of the arm is negligible. The ulna fragments were united by means of a wire suture, 
(ill. 53b). After that the radius fracture cleft was 
still somewhat gaping. The wounds which were kept open 
he led per granulationem, 'three weeks later the cast 
was removed and the afflicted limb subjected to some 
exercises. In conseouence of this a displacement of the 
ulna fragments occurred which caused a pressing together of 
the radius fragments. In spite of this condition not 
even the slightest formation of callus was observed ten 
we ks later (ill, 53c). (The treatment has not yet come 
to an end). It is our opinion that according to the above 
mentioned experiences made with fractures of the forearm 
and which show fistulae, compound forearm fractures are not 
suitable for the marrow nail operation. 
e) Summarization: 
Any success of the nailing of fresh compound fractures 
depends largely on the technical correct wound excision 
(just as in any other compound fracture treatment). 
The suture of the skin is always dangerous and its 
applic cion should by no means be enforced. The wound 
margins should be adapted by means of 3 broad bands of 
adhesive tape. This procedure is much better than suture 
of the wound. 
If it is not possible to obtain a tensionless union 
of the skin margins it will be much better to not attempt 
their union. If possible the bone should always be covered 
by soft parts. In case of the leg, transplants of skin 
may be reruired, 
If the 3-hour limit is passed or if the wound is 
covered by some greasy dirt, the wound must by all means be 
kept wide open. 
The marrow nailing is not indicated in case of an 
acute infection. 
Open fractures should be nailed only if (at least 
temporarily) a stabile osteosynthesis can be obtained. In 
this connection we should desist from any attempt to 
stabilize the fracture by applying an additional wire 
suture. If a stabile union with the bone cannot be ob- 
tained by the nail it will be better to not apply it 
because in case of an infection the nail will facilitate 
the spreading of that infection. 
If an infection occurs the wound must immediately 
be opened otherwise most serious complications may occur. 
An additional immobilizing cast should be applied in 
all cases of nailing operations which must be kept in 
position until a danger of infection no longer exists, 
In this case the drain should be inserted at the most 
dependent point. 
The nailing of fresh compound thigh fractures, how- 
ever, is so advantageous in comparison to all the other 
methods if a stabile osteosynthesis can be tbtained 
that it must be considered to be the method of choice. a 
b 
Illustration 53 . , 
a +- b 
a) Complicated fracture of both forearm bones with serious 
damage of the soft parts. Excision of the wound, nailing of the 
radius and wire loop round the ulna. The wounds are kept open, 
only the soft parts above the bones are sutured. Plaster cast, 
b) Same fracture after the operation. The marrow cavity of the 
radius is very narrow and conseeuently the ulna nail cracked 
the proximal fragment. The fracture cleft of the radius is still 
gaping. Healing of the wound per granulationem without infection 
of the bone. The wire loop round the ulna is insufficient, it 
is located in the fracture slot proximally. Healing of the 
wound per granulationem, the cast was re-roved 3 weeks later. Illustration 53c 
Same fracture 6 weeks p.op. The ulna is 
angulated in valgus position. The frag- 
ments of the radius arc now pressed to- 
gether (The treatment has not yet come to 
an end), 49 
If under consideration of the location of the 
fracture site only a relatively stabile osteosynthesis 
can be expected it will be suitable to excise the wound 
first and then ,to wait for a primary healing with the 
limb in wire extension. 2-3 weeks later the closed nail- 
ing may be performed. 
The suture of the wound is especially dangerous 
in 'fresh compound leg fractures -particularly in those cases 
in which the osteosynthesis is only relatively stabile. 
In those cases the results obtained with the nailing 
method are better in comparison to those obtained by tho 
conservative treatment under t,he condition that the nails 
are applied in the technically correct way and the osteo- 
synthesis is at least relatively stabile. 
In cases in which the osteosynthesis is only relatively 
stabile special attention must be attached to the removal of 
the additional protecting cast and to weight bopring, 
otherwise late abscesses may occur. 
Open oblieue and spiral fractures and proximally 
located fractures are unsuitable for the nailing method. 
In these cases it will be better to treat the fractures 
either conservatively or by means of tho old methods of 
osteosynthesis, 
In fresh compound fractures of the arm above the 
elbow the results obtained by the nailing method are not 
considerably better than those by a conservative treatment. 
It is a matter of fact that the marrow nail method is 
much more simple but in cases of infection the dangers 
arising from the nail are much more serious. These dangers 
are not obse ved in oth-r methods. Therefore the most 
strict indication possible is required and the marrow nail 
operation should bo made only by those surgeons who dis- 
pose of sufficient experience in treating closed fractures. 
If a nailing is indicated the operation should be prima- 
rily and open. 
In fresh compound fractures of the forearm the marrow 
nail method does not show any advantages. Thorefore it 
will be bettor to treat fractures of that vind by means 
of the old methods of osteosynthesis in consideration of 
the dangers arising from infection.