EXPERIENCES WITH THE MARROW NAIL OPERATION ACCORDING TO THE 
PRINCIPLES OF IOJENTSCHER 
PART II 
by 
Prof. Dr. C. HAD BLUR 
Translation prepared by: 
U.3. Naval Technical Unit, Europe, (Medical Section) 
Office of Naval Advisor 
Office of Military Government (US) 50 
III. 
F£acture£jeealed_witji_def e s_wit]i_def icient_calli2S 
£i2£i2Shioa».and_p t hr o se s 
l-^_Ii}.g-^hazards_of_inarrow_nail_ing .with exposure of the 
e_site 
Fractures_which^have_healed_in_a^bad_£osition and 
the greater part of old fractures and £seudarthroses must 
be nailed with exposure of the fracture site, This oper- 
ation is also referred to as "open marrow nailingn, The 
exposure facilitates the technique, since the nail can be 
visualized when it is driven into the distal marrow cavity 
as is the case in fresh compound fractures. As compared 
with other methods of bone surgery, the marrow nail offers 
the advantage that a wide separation of the periosteum is 
avoided. It is only removed in the immediate proximity 
of the fracture regardless of considerable masses of 
callus that might adhere to the ends of the fragments. 
In favor of the marrow nailing method it may also be 
said that extensive resections can be avoided in most of 
the cases. It is entirely sufficient to provide two 
new joining surfaces and to open the closed marrow 
cavity with gimlet or awl wide enough to allow the nail 
to enter. The callus adherent to the fragments is left 
in position, unless it is not obstructive, as it consti- 
tutes an important element in the regeneration and pro- 
tection of the periosteum* 
The exposure involves, hoYrevor, the hazard of infection 
and as has been demonstrated in fresh compound fractures, 
the marrow nail may prove more hazardous in case of an 
infection than a wire suture or a LANE * s plate, especially 
so if the osteosynthesis is not stabile. 
The hazard of infection appears to be rather import- 
ant as is set forth in Table IV* Today we have 35 infect- 
ions in 219 open nailings, that is 15*6$, a figure 
y/hich is alarmingly higher than that of our patient 
material in 1944* 
In my own clinic, including the special v/ard, the 
percentage of infections was considerably loYfer, (not 
ouite 5%) and severe consequences could be avoided in 
most of the cases. It must, therefore, be concluded that 
special circumstances are responsible for this high 
infection rate, n. 
The fact that the osteotomies of thigh fractures 
comprise almost 30% of the infected cases whereas there 
was only 1 infection in old fractures is particularly 
striking. 
This one case was caused by the negligence of the 
surgeon. As a matter of fact v.re found a swab in the 
cavity of the abscess of the patient who had been nailed 
in another hospital 2 months before. La-iJLa-JE 
Infections of the fracture cleft in the open nailing 
of aseptic fractures. 
Fresh Fractures 
1 Osteotomies 
j Old Fractures 
J & p seudarthr. 
Total 
Number 
of 
cases 
Number 
of 
infect, | 
Number 
of 
cases 
Number 
of 
infect, 
Number 
of 
cases 
Number 
of 
infect, 
Thigh 
3 
0 
32 
9 
44 
1 
Tibia 
0 
0 j 
5 
0 
46 
20 
Upper 
Arm 
2 
0 
3 
0 
58 
0 
Fore 
Arm 
1 
• 
6 
0 
23 
5 
r 15t/o 
Total 
6 
0 
46 
9 
171 
26 
Insufficient stability of the osteosynthesis cannot 
be considered as the only reason, although !:• Sections 
developed in both the osteotomy nailings ’in which the 
osteosynthesis was not stabile, because there were 3 
old thigh fractures with incomplete fixation which 
healed primarily, whereas infections developed in 7 
cases with a perfectly stabile osteotomy. 
In 7 of the nailings it was neglected to apply a 
drain. This is definitely hazardous, since an infection 
developed in 5 of the patients. An inflammation developed 
in four other cases in spite of proper drainage and 
stabile osteosynthesis. 
Apart from more or less extensive damage, the soft 
parts and vessels will be put under considerable tension, 
if, in case of an extraordinary shortening and deformity, 
a marrow nailing operation is performed immediately follow- 
ing osteotomy. This may have an unfavorable effect on 
the nourishment and resistance of the tissue and thus 
create a specific proneness to infections. And yet, it 
could be observed that it was by no means the areas of 
the most apparent damage which became infected first, 
but on the contrary the old long healed fractures, the 
operation of which was difficult and tedious, rate first 
in the infection statistics. 
We considered it the main objective of the marrow 
nailing osteotomy and so did many of our colleagues, to 
restore the anatomic conditions as accurately as possible ✓ 
and, above all, to compensate for shortenings. The 
marrow nail offs&re excellent possibilities in this 
respect, since it will not be necessary to resect the 52 
bone until the marrow cavity is freely exposed. It 
will rather be possible to provide a canal through the 
obstructing callus by means of a gimlet and chisel 
which affords a particularly good hold for the nail. 
A complete restoration can thus be achieved by severing 
the bone in the old fracture line. This is, however, 
difficult in the old long healed fractures. The old 
contours can well be distinguished on the X-ray picture 
when exposing the site, however, one will find a homogen- 
ous incredibly hard bone substance which does not offer 
any indication whatsoever as to what is old and new. 
If one has finally succeeded in severing the bone in 
approximately the old fracture line, new difficulties 
crop up in that it is not easy to determine the direction 
of the marrow • cavity in the abundant callus formation and 
to secure the path for the nail, which not infrequently 
will stick in such a manner that it will not move back- 
ward or forward. So, the operation often lasts for 
several hours and different X-ray pictures become necessmy, 
This all constitutes a serious hazard to asepsis. If iu 
addition to this, the soft parts are under tension, if 
a drain is omitted, or if split off callus is used 
to fill still remaining gaps and if no solid junction 
was attained after all, it is really not surprising if 
the infection sets in. 
All these difficulties do not come into consideration 
if the fracture is still movable or recently healed, 
A badly healed thigh fracture should, thcrefc e, be 
operated upon as early as possible. 
In case that the fracture has healed some time 
ago, and the exact location and severance at the fracture 
line offers considerable difficulties, the bone should 
be resected (as conservatively as possible of course) 
as to establish sufficiently large joining areas and the 
ends of the marrow cavity should be opened. Under 
those conditions one has to put up with a shortening, 
but this is the lesser evil to the patient as compared 
to an infection. The marrow nail is still advantageous 
in these cases over the other bone fracture methods, 
since the resection can definitely be performed under 
more favorable conditions and above all a long lasting 
immobilization can be avoided and the joints be moved 
early. 
After a thorough study on my patient material, I 
deem it advisable to accept even a shortening of 2 
centimeters and to shorten the other log accordingly using 
the marrow nail, rather than to force the compensation 
and expose the patient to the risk of an infection which 
might be synonymous with sacrificing the limb or even 
prove fatal. 
The infection rate in old fractures of the tibia is 
still higher(43%). In our own clinic and special ward, 
however, not one infection occurred in the nailing of old 
aseptic fractures of the tibia. ( I here include those fractures, the wounds of which 
are healed for more than 6 months). Thus we are entitled 
to say that the infection can be avoided. As a matter 
of fact, the indication for an open marrow nailing was 
alv/ays considered with special care. 
In the military hospital one was obviously too 
liberal in this respect and it could be observed that 
the greater part of the infection cases had been nailed 
by surgeons without or with little experience of the 
method, (Authors Note: To their excuse it must be said 
that a particularly high number of old and badly healed 
fractures was seen in military hospitals at home. 
Fascinated by the new method and desirous of giving it 
a tryout, many a surgeon overlooked a few words when 
reading KUENTSCHER who writes that the marrow nailing 
is the simplest surgical approach that can be thought 
of, namely the words "in typical cases". The nailing of 
an old fracture of the tibia is not such a typical case 
of marrow nailing.,) So it may be said that lack of ex- 
perience and of technique are responsible for a consider - 
able percentage of the infections* And still the hazard 
must be greater than for instance in old fractures of 
the upper arm of which a great many were nailed with 
exposure of the fracture site by surgeons with little 
experience. 
The position at rest v/ithout doubt plays an im- 
portant rele. In 19 of the 20 infected case-- the 
osteosynthesis (as is so often the case in tibia frac- 
tures) was only relatively stabile and it was considered 
sufficient to splint the leg. If an additional plaster 
cast is applied in such cases, as we do and always have 
recommended, there is considerable prospect that no 
infection will occur, 12 fractures with only a relatively 
stabile fixation healed primarily with a plaster cast. 
These cases included 7 originally infected fractures, 
the wounds of which had been closed for more than 
6 months. 
The door wings incision seems to be particularly 
hazardous and lead in 4 cases to a skin necrosis from 
which the infection spread to the fracture cleft. We 
have abandoned it completely* A longitudinal incision 
along the lateral edge of the tibia suits the purpose 
and has a better chance in the final healing because 
it is padded by soft parts. 
The absence of a sufficient padding of the skin 
increases the infection hazard because the suture easily 
becomes subject to considerable tension due to post- 
operative swelling. The suture then is likely to cut 
into the skin and to disturb the nourishment and resistance. 
These two factors: insufficient stability and lack 
of padding by soft parts do as a rule not come into con- 
sideration in the upper arm which consequently docs not 
present the same infection hazard. 54 
On the forearm the hazard is again greater that the 
suture will be under tension, especially if tho suture 
is applied next to the bone. In this case and if both 
bones are broken considerable technical difficulties 
may arise which may ouite easily break sepsis. 
If the temperature rises after the operation it is 
imperative to open the wounds widely (including the 
entrance opening of the nail) to alio?/ the secretion 
to drain off. The limb must (if not performed in the 
very beginning) be immobilized by a plaster cast. If 
this is done, an infection is generally avoided. These 
points were neglected in the majority of the cases referred 
to above and valuable time was lost instead with the 
administration of sulfonamides and wet compresses during 
which the swelling constantly increased and the infectious 
secretion is forced in to the fracture cleft and marrow 
cavity. 
A descriptive example: 
In an osteotomy of a 10 weeks old 
fracture, healed with a shortening of 6 centi- 
meters (in an axially correct position. (Ill,, 
54a)) the periosteum was widely severed. The 
surplus callus was cut back and shifted into 
the wound cavity at the end of the operation. 
Since the shortening could not be compensated 
by extension, the fracture ends were brought 
in proper position when the nail appeared at 
the fracture cleft and was driven a little bit 
into the distal marrow canal. After that the 
nail was hammered in further and a piece of bone 
at the posterior part of the distal fragment 
broke off, so that the nail did not find a 
proper hold. (ill. 54b). The wounds were sutured 
without previous drainage, A BRAUN*s splint was 
applied. Although the temperature rised to 
39° the day following the operation and did not 
return to normal the following days, the wound 
was opened only on the eighth day and an abundant 
amount of pus came out. Inasmuch as the frac- 
ture was freely movable, a wire extension was 
applied through the tibia which caused dis- 
traction. A long tubular sequestrum developed 
on the proximal fragment, apparently to the extent 
to which the periosteum was previously severed, 
(111. 54c), The joining of the fracture ends was 
finally achieved by plaster cast thanks to the 
formation of a strong capsule about the dead bone 
and after 9 months, the nail and the sequestrum 
could be removed. A few abscesses had to be 
opened and sequestra had to be removed later on, 
but after 20 months the fracture had healed with 
a shortening of 2* centimeters, a stiffening of 
the knee joint in 175 degrees and a stiffening 
of the ankle joint. a 
b 
c 
Illustration 54 
a) 10 weeks old fracture of the femur which had healed 
with a shortening of 6 centimeters. Osteotomy - marrow 
nailing, during which a large area of the periosteum was 
separated. After the insertion of the marrow nail into 
the proximal marrow cavity the fragments were put together 
at an angle and at the same moment when the nail slipped 
into the distal marrow cavity the fragments were straight- 
ened. Compensation for the shortening by traction forces 
alone was not possible. Surplus callus chips were placed 
in the open wound at the end of the operation. Wound 
suture without drainage. Application of a BRAUN’S splint. 
b) The same fracture two days after the operation. The 
nail is too short. At the rear part of the distal fragment 
a large part of the bone has broken off. Consequently the 
nail did not find sufficient hold and a displacement of the 
fragments has occurred. Temperature around 39° C. In spite 
of this the wound was opened only on the eighth day after 
the operation and a marked extravasation of pus was observed. 
Wire extension of the tibia. 
c) Same fracture 8 weeks p.op. The fracture is distracted. 
In the proximal fragment a long (total) sequestrum is ob- 
served which extends up to the end of the area of periosteum 
which had been separated. Nine months after the operation 
an involucrum was observed around the sequestrum which 
strongly united both fragments. Consequently the nail as 
well as the sequestrum were removed. During the following 
period several more abscesses had to be drained and some 
more sequestra were removed. The total period of treatment 
amounted to 21 months. The final result was a shortening 
of 2 ciEi and a completely stiff knee joint which was in a 
straight position. The impediment of the foot joint 
amounted to 66 % (the X-rays were destroyed). As a matter of fact the operation on this patient 
was fully justified because a shortening of 6 centi- 
meters especially in young persons, is likely to imply 
severe damage to the hip joint. The fracture was suit- 
able for nailing as far as the location was concerned, 
and a stabile osteosynthesis could definitely be ex- 
pected, When it was seen, however, that a proper re- 
duction met with difficulties due to an excessive 
shrinkage of the soft parts, it was indicated to apply 
a wire extension and to wait until the damage to the 
soft parts had subsided. That would have been the case 
in 1 to 2 weeks and there was considerable chance that 
the rnarroY/ nailing could have been performed then un- 
eventfully, After the nailing had been performed pre- 
maturely it would have been absolutely necessary to secure 
o. position at rest for the leg by a plaster cast, bo- 
anus c the nail had no grip due to the breaking off of 
a piece of bone. Furthermore drainage was imperative. 
When temperature was observed, the wound should have been 
opened widely without delay. This would have prevented 
the pus from bei ng forced into the proximal marrow cavity 
along the nail. The large sequestrum could have been 
avoided in all probability and the abscess of the 
entrance wound with certainty. The excessive severance 
of periosteum is very likely to have favored the bone 
necrosis. As a matter of fact the sequestrum extends 
almost exactly as far as the fragments had been shifted. 
The reintroduction of the callus at the end of the oper- 
ation was superfluous and was liable to increase the in- 
fection hazard, The same is true for the wire extension, 
all it did, was to cause a distraction, A plaster cast 
would have fitted the case far better. 
It was repeatedly asserted that an exposure of the 
fracture will delay the formation_of_callus, Fritz 
KOENIG refuted this concept as early as in 1931 and we 
could never observe a delayed callus formation in the great 
many patients who were operated upon with exposure of the 
fracture site. Where such a delay was observed, the reason 
could always be traced back to a faulty technique, such 
as insufficient position at rest, obstructing bone, faulty 
position of the fracture etc. Neither have we observed 
a delayed healing due to an open marrow nailing operation. 
But it must be emphasized that the nail per se does not 
stimulate the callus formation, it only assures favorable 
conditions to this end. Whore these favorable conditions 
do not prevail (lack of stability, defects etc.) the nail 
will not only be of no use, but it may even prove hazard- 
ous , 
may occur in both, the open and 
closed nailing operations. While I was originally of 
the opinion that the overpressure developing in the marrow 
cavity was the main reason for fat embolisms,I have now 
to revise this opinion after a careful study of my patient 
material. It is rather surprising that the case histories 
pertaining to fat embolisms always speak of a sticking of 
the nail and of force that was necessary to drive the 
nail in. It is reported a wain and again that the pulse 
rate is affected and that collapses occur after vigorous 
hammering, so that the operation must be interrupted. The maltreatment of the bone thus seems to be the 
main cause. As a matter of fact an obstruction of the 
marrow cavity by connective tissue or callus may favor 
the development of an overpressure in old th:gh 
fractures, since the incidence of fat embolisms is 
particularly frequent in this type of fracture. It is, 
therefore, recommended to perform an open marrow 
nailing operation in case of old fractures. 
high_Fr ric tur e s 
a) ..Osteotomies of obliquely .healed fractures 
As mentioned before, the osteotomy nailings of 
obliauely healed thigh fractures lead to infections in 
more than 30% of our patient material and had rather 
severe consequences for the patients. 
We have seen that the difficulties and the long 
duration of the intervention are mainly responsible for 
the incr eased infection hazard. The operation should 
therefore, take place as early as possible before the bone 
solidifies in the faulty position. This is, hov/ever, 
in most cases beyond our control and depends on when the 
patients turn up for treatment. 
The forcible compensation of shortenings and angu- 
lations usually accompanied by considerable damage to the 
soft parts and vessels constitutes another important in- 
fection hazard. It is recommended to perform the oper- 
ation in such cases in two sessions. In the first session 
only the osteotomy will be performed and a wire extension 
be applied. Only if the shortening is compensated by these 
measures and after complete healing of the operation wound 
(that is after 2-3 weeks) the marrow nailing v/ill follow. 
The osteotomy should be performed as conservatively 
as possible. The periosteum will be removed only very 
sparingly at the line where the bone is going to be cut, 
which should be if at all possible identical with the old 
fracture line. The bone should be cut in such a manner, 
as to provide a smooth abutment of the ends. In the 
second session the marrow cavities v/ill be opened and 
the canal for the nail will be drilled, obstructing bone 
parts will be resected. 
As a rule, drainage must be provided in this oper- 
ation which has to be applied at the physically correct 
spot (that is posteriorly in the septum intramuscularo 
fibulare) and led off by a special skin incision. We 
use a long drainage tube which is led outside the bandage 
into a small sterile flask. This arrangement has in some 
way the effect of a syphon and allaws the elimination of 
the wet space in the bandage, V7h:ch often forms an 
ideal stratum for germs. The tube must sutured on to the skin to prevent its withdrawal or shifting from the 
wound cavity due to the movements of the patient, 
BOEHLER emphasizes the necessity of operating in 
two sessions for all cases in wh?ch the shortening 
exceeds 4 centimeters. We were guided in the first place 
by the force necessary to correct the position after 
osteotomy. If no unusual maneuvers were necessary we 
did not refrain from nailing shortenings up to 6 
contimeters primarily, including old fractures due to 
gunshot injuries, and no infections have ever occurred. 
On the other hand we performed the operation in two 
sessions in cases where the shortening was less than 
4 centimeters if the compensation was difficult. In 
all 4 cases in which the operation was performed in 
two sessions we observed primary healing and this pro- 
cedure is certainly more agreeable to the patient than 
a one session operation. 
If the fracture has not healed long before the oper- 
ation and if a cloudy callus is seen on the X-ray 
picture, it can in most cases be easily chiseled off 
and the operation will not present any difficulty. If, 
however, we deal with a fracture that has healed for • 
more than 8 weeks and which has even been put under stress, 
we do not waste our time trying to locate the old fracture 
line. This will in most cases not be successful and 
presents too many hazards of breaking asepsis. We make 
a tracing of the X-ray picture showing also the limitation 
of the marrow cavities and mark the proposed cut. 
The tr acing will then be cut accordingly and superposed 
in such a manner that the shifting is compensated. It 
can then be seen how much must be removed of the bone 
ends to provide proper abutments and to open the marrow 
cavities at least partly. The cut will be performed so 
as to cause no or little shortening (ill, 55) 
It is perfectly possible to use the newly formed 
bone as part of the elongation, as is illustrated in 
111, 56 concerning an 0bliquely'healed fracture due to 
gunshot injury with a shortening of 6 centimeters. This 
possibility constitutes an important advantage of the 
marrow nailing osteosynthesis over other methods,' And 
yet, we have abandoned the use of the newly formed bone 
because it is often diffcult and especially so in old 
fractures, to find the marrow cavity and to provide the 
canal for the nail through the hard callus and the hazard 
to piercing the corticalis in the wrong direction is ever 
present. The result is seen in 111, 57. The osteosynthesis 
will nevertheless be stabile, since the nail is firmly 
engaged for a long time in the hard bone, but the 
difficult and tedious manipulations are a serious hazard 
to asepsis, 
In some instances it is the best solution to 
accept a shortening. If it is important, there is al- 
ways the possiblity of shortening the other leg as was 
proposed by BAUER, That is incomparably less hazardous 
to the patient than an infection and recovory is faster too. a 
Illustration 55 
b 
0 
a) 1U months old closed fracture of the thigh which has 
been stabil for 10 months. The patient was released from 
the hospital 8 months previously. The shortening amounted 
to 3 centimeters. The patient limps and tires quickly. 
The movements of the knee joint are limited by about 50 
b) Sketch of the X-ray showing the separation line and 
indication of the old ends of the fragments. 
c) The two parts of the cut sketch are superposed in such 
a way that the lines indicating the ends of the fragments 
are lying upon one another and the angulation is corrected. 
In this way the original shape of tho bone would be restored 
in an exact manner. 
If the bones are cut across at point (a) the ends of the 
fragments touch each other on tho medial side for only V3 
of the circumference. In this way they are not protected 
against rotation and consequently the osteosynthesis will 
not be stabil. 
If the bones are cut across at point (b) a broad plane 
of contact is obtained but the callus of the distal fragment 
must be drilled through and there will be considerable 
difficulty in finding the marrow cavity and in inserting 
the nail. d 
Illustration 55 
e 
f 
d) Therefore the sketches were superimposed in such a way 
that a slight shortening existed. If after that the bone 
is cut across along line (c) both marrow cavities are open. 
In this way it will be easy to enlarge them enough so that 
a nail can be driven in. Furthermore, we have the advantage 
of a broad plane of contact of the bone and with this 
better stability. 
e) The same fracture after the nailing. The nail could 
have been somewhat longer but it finds sufficient hold in 
the marrow cavity which has become narrower because of the 
callus. The osteosynthesis was stabil, the shortening 
amounted to J centimeter. Drainage in the dorsal direction. 
f) Same fracture five months after the operation. The 
nail was removed and the fragments had healed in good posi- 
tion. No measurable shortening. The flexibility of the 
knee joint amounts to 80 - 180°. b 
a 
Illustration 56 
a) 11 month old gunshot fracture of the right thigh which 
has been treated with a traction bandage for 11 weeks and 
with a plaster cast for 4 weeks. The wounds have been 
healed for 9 months. The shortening amounts to 6 centi- 
meters. We had to deal with a typical genu recurvatum 
with a 50 fo limitation of the ■ movements. The patient tires 
quickly. 
b) Osteotomy along the old fracture line. In order to 
obtain a prolongation the tip of the distal fragment was 
not resected. Because of this it was very difficult to 
find the marrow cavity and the nail does not lie in the 
proper axial direction, but it is firmly seated in the 
callus canal. The osteotomy planes on the flexor side 
stand one upon the other over a broad area. Satisfactory 
position of the axis. The shortening amounts to 1 centi- 
meter. Drainage was applied in the dorsal direction for 
two days with the plaster cast kept in place for 3 weeks. 
Primary healing. 
With the opening of the marrow cavity in the sound 
part, as required by the old methods of osteosynthesis, 
the shortening would have amounted to at least 5 centi- 
meters . G 
a 
Illustration 56 
o) Sane fracture eight months after the operation. The 
nail had been removed 4 weeks previously. The patient had 
been sent to his unit for garrison duty 2 months p.op. 
d) The patient the day of his release from the hospital. 
He is fit for service. The shortening amounts to 1 centi- 
meter. From the clinical point of view a recurvation of 
the knee does not exist, the motion amounts to 180 - 60 
degrees. 57g 
a 
b 
0 
Illustration 57 
a) Six month old closed thigh fracture which for a period 
of 4 weeks has been treated with a wire extension and 
plaster cast despite the fact that distraction existed. 
Three months after the injury another surgeon tried to 
nail the fracture. He did not however succeed in fixing 
the fragments. The shortening amounted to 2 centimeters, 
motion of the hip joint was considerably limited, the 
flexibility of the knee amounted to 180 - 160 degrees. 
b) Osteotomy: It is relatively easy to open the fracture 
with a broad chisel. The distal marrow cavity was located 
under X-ray control by using KIRSOHHER wires. After that 
the canal was enlarged and the guide rod inserted which is 
fairly well seated in the distal marrow cavity. It was not 
observed that the guide rod was somewhat angulated. During 
the insertion of the nail it left the guide rod and entered 
the corticalis. In this case it would have been indicated 
to turn the nail 180 degrees with the opening pointing 
forwards and then insert it. Due to the fact that the 
nail could not be removed it was cut at the trochanter. 
c) The same fracture after the nailing. The fragments 
are in good position, shortening does not exist and the 
fracture is absolutely stabil. Primary healing. The drain 
was removed two days later and the plaster splint was 
removed two weeks p.op. After that the patient started 
subjecting his limb to active exercises and to exercises 
after the manner of walking. Eight weeks after the oper- 
ation the patient started subjecting his limb to weight 
bearing. d 
e 
Illustration 57 
d) The same fracture 10 weeks p.o'p. Good formation of 
callus. Ball callus as well as rarefactions round the nail 
are not observed which proves that the nail is firmly 
seated. 
e) The same fracture 5 months after the operation, k weeks 
after the extraction of the nail. The fracture is healed. 
The impediment of the hip joint is only slight, the knee 
joint impediment amounts to 180 - 80 degrees. The patient’s 
gait is unhampered. Any callus which docs not interfere with the 
proper reduction of the fracture is left untouched and 
constitutes an important factor in the initiation of 
bone regenerations. We do not think it advisable, 
however, to reintroduce once removed pieces of callus 
into the wound, as is done according to VOELKER-LIFFLER 
in the operation of pscudarthroses, since the healing 
tendency is not disturbed. The detached pieces of callus 
are likely to decay and may form dangerous infection foci. 
Two cases treated in a military hospital in this manner 
resulted in severe infections, 
Wc consider it an important point to conserve the 
periosteum as much as possible. The fact that it is 
admissible in marrow nailing to deviate from LANGENBECKWs 
time honored principle of the subperiosteal osteotomy 
counts definitely to the credit of the method. In the 
nailing osteotomy the periosteum is in the first phase of 
the operation only incised at the site of the osteotomy; 
After the bone is cut with a chisel or GIGLI saw, the 
periosteum will be loosened only so far as will be 
necessary for the resection of certain parts of the bone. 
The wide loosening of the periosteum was often held 
responsible for the delayed healing in old ostcosynthesesc 
Whether th:s is true or not is difficult to say, The 
operation report relating to the fracture as illustrated 
under number 58 points out that: Hthe fracture ends were 
exposed with ample loosening of the periosteum" although 
the soft callus could be easily rended with a chisel. 
One year after the operation the fracture is only bridged 
over at the medial side, where the old remnants of callus 
were left untouched. The fracture cleft was still clearly 
visible in its total length. It must be admitted that 
the nail is rather short, the clarification next to its 
point indicates that it moved in the bone, but this does 
not, according to our experience, materially delay the 
healing of fresh thigh fractures. This is by the way 
the only osteotomy of the femur that healed so slow. In 
other cases where the osteosynthesis was also only 
"relatively stabile" the healing process took quite a 
normal course. It may, therefore, be safely said, that 
the wide loosening of the periosteum actually caused the 
delayed healing. Hoy/ far this goes is demonstrated by 
the formation of the tiny callus spicules* 
The wide loosening of the periosteum is especially 
hazardous if an infection sets in. The denuded bone is 
seriously jeopardized as to nourishment and extensive 
necroses may ensue, as in 111, 54* The severity of the 
infection is certainly due to the fact that the osteo- 
synthesis was very instabile and that the v/ound was not 
opened widely in due time. 
Even if the nail is solidly engaged in the callus, 
as seen in 111, 57, and the osteosynthesis is sure to 
become stabile, it is still better to drill the nail 
path from the very beginning in such a manner that a 
nail of sufficient size may be driven in. We had to 
make this experience lately/in an obliquely healed 
fracture due to gunshot injury. a 
Illustration 58 
b 
c 
a) Six months old closed thigh fracture treated with a 
6 kilogram traction splint* Osteotomy because of a shorten- 
ing amounting to 6 centimeters and marked angulation. 
Application of a traction bandage 8 weeks previously. 
Infection of the operation wound which is successfully 
overcome. Four weeks later the traction weights are 
diminished despite the fact that a shortening of 2 centi- 
meters still exists. 14 days later the extension apparatus 
is removed and treatment with hot air, massage and electric 
stimulation started, iAfter a lapse of 8 days another 
shortening of 4 centimeters and angulation is observed. 
The fracture seems to be stabil. Marrow nailing. 
b) The same fracture after nailing. The nail is rather 
short. During the operation the ends of the fragments 
were "widely exposed subperiosteally in all directions". 
The fragments were resected until the marrow cavity was 
open. In this way a shortening of 2 centimeters occurred. 
Primary wound healing. The patient was able to get up 
4 weeks later. 
c) The same fracture 11 months after the nailing. The 
fracture cleft is still noticeable to its full extent. It 
is bridged over by callus only medially at the spot where 
the old callus is located. Around the nail tip we observe 
rarefactions with an accompanying irritation of the margins. 
The existing bridges of callus demonstrate how far the peri- 
osteum was separated. The nail was extracted 4 weeks later. 59 
In the fracture due to gunshot injury represented 
in 111, 59, 3 years old, healed with a shortening of 
6 centimeters, wounds healed year ago, we started 
cutting the bone along the line 1-1, Then the proximal 
marrow cavity was opened along the line 2 - 2* The 
point of the distal fragment was cut off (line 3) and 
the marrow cavity was located by means of a drill. The 
correct position of the drilling canal was checked by 
X-ray and inserted tube. This canal was enlarged with 
ball trepan and chisel Y/ide enough to make the intro- 
duction of a middle sized nail possible. With a view 
to determine the length of the nail required, we intro- 
duced a thin nail into the distal fragment. It was ob- 
served. that the nail was lying at an angle and hit the 
corticalis if introduced by 9 centimeters* We did not 
attach too much attention to it and refrained from 
drilling a new canal* The bone ends were then brought 
into position and held with a LAMBOTTE*s bone forceps 
and after checking by X-ray and securing the position 
clinically, a groove was chiseled into the bone to avoid 
axia 1 B-t.; Nov/, a guide rod, was introduced 
into the distal marrow cavity to measure the distance 
(a) up to the trochanter* When the guide rod had pierced 
bone and skin at the trochanter, a medium size nail was 
driven in, the length of which had been determined as 
follows - a ( = length of the proximal marrow cavity) 
plus 4 centimeters (« length that the nail may jut out 
at the trochanter) plus 9 centimeters (z length of the canal 
in the distal fragment)., The nailing was uneventful 
and the fracture was absolutely stabile. The ends of 
the fragments joined only half of the periphery, (ill. 59b)r 
A drain was applied posteriorly, BRAUN*s splint and 
plaster splint were used. Residual shortening 1.5 centi- 
meters. The musculature did not reveal abnormal tension, 
the reduction was carried through v/ithout using undue 
f orce, 
The operation was followed by two days of slightly 
raised temperature, on the third day the patient was 
free from fever. The drain was therefore removed on 
the fourth day. Then followed a sudden risec of temperature. 
The drain was reintroduced and a plaster cast was applied. 
The temperature returned promptly to normal. The 
drain is definitely removed on the 11th day and the plaster 
cast on the 12th day. The operation wounds had healed 
by that time. On the 21st day, after the operation a 
new rise of temperature up to 3B° was observed. A 
collection of serum is palpable in the area of the fracture 
which is punctured. The temperature then returned to 
normal. (Cultures of straphylococcus were ascertained 
in the serum). The temperature remained normal and the 
patient began to move the limb on the 26th day after the 
operation. After two more days the patient was allowed 
to be ambulatory. After 35 days, the treatment could 
be continued on an outpatient ba.sis. The patient could 
use the leg without any trouble and walk considerable 
distance if using a cane for support, 4 weeks later the 
patient could walk without a cane and the mobility of the 
knee which had previously been almost stiff had improved 
considerably. 32" months after release from the hospital 
*) aistoition a 
Illustration 59 
b 
c 
a) Three year old gunshot fracture. The wounds have been 
closed for lj years. The shortening amounts to 6 centimeters 
and the knee joint flexion to 45°. The lines in the picture 
show the separation of the bone, the hatched drawings indi- 
cate that part which had to be removed. The distal marrow 
cavity must not be opened. Attempts must be made to locate 
it by drilling in KIRSCKNER wires under X-ray control. After 
the insertion of a nail into the hole made with a chisel the 
nail touches the lateral corticalis 9 centimeters from the 
insertion spot because the canal did not run precisely in 
the axial direction. 
b) The fracture after the nailing. Slight varus position. 
At the frontal aspect the nail projects 3 centimeters. The 
fracture is absolutely stabil. Long drainage tract to the 
rear. The^shortening amounts to 1.5 centimeters. After 
the operation a rise of temperature was observed but the 
wounds came to a primary healing. After a lapse of 21 days 
another rise of temperature and the formation of serum at 
the fracture cleft were observed. After aspiration the 
temperature slowly decreased to normal. The patient was 
released for ambulatory treatment 35 days after the oper- 
ation. Painless weight bearing. When walking the patient 
had to use a cane. 
c) 3j months later. For 14 days the patient has complained 
about increasing pains at the fracture site. Abscess at the 
operation wound. Rarefactions of the bone particularly of 
the distal callus. Rarefactions round the nail tip which 
penetrates the corticalis. Periosteal layer. The fracture 
is completely stabil. Wide incision of the abscess, drainage, 
and application of a cast with a window. d 
e 
Illustration 59 
d) 4 weeks later. The nail tip has pierced through the 
corticalis. An increase of the periosteal layer is observed. 
Beginning formation of a ring sequestrum of the proximal 
fragment. Despite the fact that the nail holds the frag- 
ment firmly together and bony healing cannot be expected, 
it was removed in order to prevent a farther piercing through 
of the nail. After the extraction of the nail a marked 
springiness of the fragments was observed. After that 
traction bandages and plaster casts were applied. Several 
sequestra had to be removed. 
e) The same fracture 7 months after the operation, which 
is in satisfactory position and stabil. The shortening 
amounts to 2| cms. and the motion of the knee amounts 
to ISO - 90 degrees. The wounds are closed. 
It would have been better to resect the bone enough 
so that the distal marrow cavity would also have been 
opened and to perform a two-phase operation. In such a 
case the shortening "would probably have also amounted to 
only 2g centimeters and it would have been possible to 
shorten the sound leg later by means of a marrow nail. 
In doing so the operation would have been more simple 
and therefore an infection probably would have been 
prevented. The healing process would have been shorter. 60 
the patient returned to the clinic with an abscess 
on the outer side of the thigh which had to be in- 
cised* The X-ray picture (ill, 59c) reveals, apart 
from a loosening of the a distinct neoformation 
of periosteum at the proximal fragment in the area of 
the point of the nail and below it a gradually increasing 
rarefaction of the corticalis was to be seen (ill* 59d), 
so that we decided to withdraw the nail, although a solid 
bony fixation of the fracture could not yet be expected* 
A couple of abscesses had still ot be opened and a few 
sequestra to be removed when finally after 7 months 
following the operation the wounds had healed and a 
satisfactory fixation was achieved by the use of ex- 
tension, bandages and plaster casts. Shortening 
2 centimeters, Satisfactory axial position, knee joint 
movable between 180 and 90°, 
• If we havo to deal with a torsion of the fracture 
site, as we could observe in four cases of thigh nailings, 
performed in other clinics, the osteotomy will be performed 
in the ideal portion of the bone, that is the middle 
third. The extent of the torsion is ascertained by deter- 
mining the angle between the median line of the sole of 
the foot and the surface of the table at tho utmost inward 
rotation of the hip joint. The difference between the 
sound and the affected sides constitutes the necessary 
correction. After exposure of the bone and loosening of 
the strict minimum of periosteum a longitudinal groove 
is chiseled into the bone which is then cut es far as 
possible with the nail lying in position. The nail is 
then drawn back as far as the fracture cleft and the re- 
maining bridge of bone will be cut through. Then a guide 
rod is introduced into the nail and distal marrow cavity 
and the distal fragment is rotated to the extent of the 
necessary correction, so that tnc longitudinal groove is 
displaced by 3.5 millimeters per 10°. *By comparison with 
the sound leg at the utmost inward rotation of the hip 
joint, one makes sure that the position is correct and 
the nail is then driven in. It is not necessary to take 
a thicker nail. It is recommended, however, to drive 
the nail in 2-3 centimeters deeper which will always be 
practicable, (ill, 60), 
The results obtained: 
In 23 nailing osteotomies which were uneventful 
the atlxjsiasi&iu&XLt could be completely compensated for, 
except in one case (ill. 61), 
In 11 cases of shortenings up to 3 centimeters the 
compensation was a 100$ successful. In 1 case a shorten- 
ing of 12* centimeter was left because the ends of the 
* The circumference of a circle over an angle of 10° is 
10 arc l0r • • With p.n average die.meter of the thigh 
no tiso-w _ 
of 20 mm this will amount to —■ g— z 3,4bmm, 
& distortion 60a 
a 
Illustration 60 
b 
a) Closed transverse fracture of the thigh 8 weeks after 
the nailing which was performed in another hospital. X-ray 
report: "Ideal position, very good formation of callus”. 
The rotation of the nail to the exterior which amounted to 
20 degrees could probably have been compensated inoperatively 
because the nail was too short, but it was not observed. 
The patient was brought to various hospitals and treated 
medico-mechanically, and with gymnastics. The impediment 
of his gait however did not subside. 4 months later, after 
he had been transferred to the special department of the 
hospital the fracture came to a bony healing. 
Due to the fact that the nail was relatively short a 
rotation osteotomy was made at the junction of the upper 
and central thirds. In this way it was possible to use 
the old nail. 
b) The same fracture 8 weeks after the osteotomy nailing. 
The patient is able to subject the limb to painless weight 
bearing. The osteotomy cleft is bridged over. The patient 
was released to his unit for garrison duty. The nail was 
removed two months later. Complete restoration. Illustration 61 
Osteotomy nailing of the thigh performed in another 
hospital, 11 months old. The fracture is healed. Marked 
valgus position. The shortening amounts to 2 cms. The 
wounds have been closed for 10 months. 4 months after 
the operation the shortening amounted to 1 centimeter, 
the valgus position amounts to 15 degrees. 
The nail was not inserted in the proper axial direction 
into the distal fragment. Fractures of this kind are not 
suitable for the nailing osteotomy. It is better to treat 
them according to the traction method after the osteotomy. 
Even a wire suture would not have been indicated in a 
fracture of this kind because it would not protect the 
fragments from slipping. A LANETs plate could at the best 
be applied but it would not give any advantage as compared 
to simple wire extension. Due to the fact that we have 
to deal with an old gunshot fracture the danger of infec- 
tion might even increase. fragments were resected, in another case the shortening 
left was 1 centimeter (see 111, 61), 
In 5 shortenings of 4 centimeters the leg remained 
1 centimeter too short in one case. A shortening of 
5 centimeters was successfully compensated. In 3 shorten- 
ings of 6 centimeters the leg remained 1 centimeter too 
short in two of the cases; 
Of special importance are the advantages with re- 
gard to the mobility of the joints. In all of the 23 
cases under consideration the mobility of the knee joint 
and in 8 cases the mobility of the hip joint was limited, 
in some instances even to a considerable extent. In all 
fractures which were not older than 9 months the full 
mobility was restored. A considerable improvement was 
achieved in the older fractures. All the hip joints were 
movable and the flexion of the knees at least up to 
90° was achieved in all operations. 
It must be admitted that the limited mobility of 
the joints may also be successfully treated by osteotomy 
and wire extension. The fact that a stiff knee joint 
resulted in 4 cases where infections occurred weighs heavily 
on the method and the final compensation of the shortening 
means little if this price is to be paid. 
and not yet fully healed_thigh 
fr ac turc s_in„bad_jco sit ion 
and 
£seudarthroses 
Under the impression of the relatively high inci- 
dence of infections in the open marrow nailing we were 
inclined to adopt the closed nailing in all cases of old 
fractures. In that case the patient enjoys al'l the ad- 
vantages which were attributed to the marrow nailing of 
fresh fractures and all indications and contraindications 
apoly to these cases* 
The closed nailing will only be successful,* however, 
if the fracture is thoroughly mobilized, even in case it 
appears to still be entirely free. When more than 3 weeks 
have elapsed there will always be certain fixations of 
the connective tissue of the fragments which make a correct 
reduction impossible. These fixations must be broken up 
forcibly. 
In 20 thigh fractures which were from 4 to 10 
weeks old we were always able to perform the closed nail- 
ing after a thorough mobilization, whereas In the military 
hospitals one was not suecessful in fractures which were 
only 4 weeks old because the mobilization was omitted and 
the exposure of the fracture site became necessary. As a matter of fact, the surgeon who undertakes 
to nail old fractures must have experience with the nail- 
ing of fresh fractures, since the old fractures offer a 
considerable amount of additional difficulties. Although 
we have nailed 16 of the 20 fractures v/ithout the re- 
duction apparatus, we have found that the use of this 
apparatus facilitates matters greatly and we recommend 
its use warmly. 
If the shortening exceeds 5 centimeters it is re- 
commended that a wire extension be used after the mobi- 
lization and to wait until the shortening is compensated 
for or even overcorrected. This is generally the case 
after 8 to 10 days and the operation is greatly facili- 
tated by this measure. 
Before the beginning of the nailing properly speak- 
ing, one must make sure that the fracture ends abut pro- 
perly, If this is not the case one should not waste any 
time with renewed mobilizations and attempts of reduction 
but rather choose the open marrow nailing. The infection 
hazard, as we have seen is not so high in not yet healed 
thigh fractures. 
Above all we warn against the closed nailing of 
fractures which arc older than 5 weeks, especially so 
since we have experienced a fatal outcome due to fat 
embolism. The hazard that the marrow cavity be closed 
by more or less solid callus thus causing an overpressure 
when the nail is driven in is definitely higher in thigh 
fractures than the infection hazard in the open marrow 
nailing, 
In 36 of our 44 cases of open nailed thigh fractures 
which were 4 to 40 weeks old we could observe the entire 
course of healing. The stay in the hospital lasted from 
47 to 215 days, thus an average of 131 days. The un- 
employability lasted 86 to 240 days, with an average of 
179 days. 
We observed approximately the same values in 19 
fractures which were treated by a closed nailing and which 
were 4 to lo weeks old. 
It is still more important to note that a shorten- 
ing of 1 centimeter was observed only in one fracture which 
had been resected although it was only 4 weeks old. All 
the other fractures, including those which were more than 
6 months old, healed without any shortening. 
In one thigh fracture, 32 weeks old, in which the 
knee joint was already stiffened the nailing restored a 
90° mobility. In all other cases the full mobility was 
restored although the knee joints were considerably hampered 
before the nailing. 
There is no doubt that the greater part of old thigh 
fractures can be healed by bringing the fragments into con- 
tact by a bloodless mobilization and a sufficiently long 
period at rest. The old methods of osteosynthesis hardly meant any progress over this conservative treatment. 
The advantage of the marrow nail, however, is that an 
additional bandage to secure the position at rest is no 
longer required and that the mobility of the joints is re- 
stored early. This advantage is go important that we 
give preference even to the open narrow nailing in case 
of old thigh fractures, under the condition, however, 
that at least a relatively stabile osteosynthesis can be 
achieved by the nail. 
In deciding whether this is possible or not, one has 
to consider, apart from the location and form of the 
fracture, the condition of the bone, especially in subtro- 
chanteric fractures. We have seen in the fresh fractures 
that a wandering of the nail may occur in the massive 
part of the trochanter which may lead to new angulations 
and loosenings of the osteosynthesis. The hazard of such 
wanderings is particularly high if the bone in case of an 
old fracture is atrophic and in such cases it may even 
happen that the nail is completely breaking out of the 
proximal fragment. In case of fractures below the middle, 
in which the nail must be driven in as far as the line of 
the epiphysis into the spongiosa, the nail may enter the 
knee joint in case of an atrophy of the bone, 
I'foe presence of a bone qtrophy, therefore. epcc ludeq 
tfoe .marrow nailing in, thigh frqctures,» 
The hazard that these fractures will heal in a bad 
position is small. The atrophy is generally associated 
with a deficient callus formation and a bloodless reduction 
of the position will always be possible, at least to an 
extent that the usability of the leg will not be seriously 
hampered. If the fracture does not solidify in spite 
of satisfactory position, the nailing can be performed at 
a later date after the improvement of the calcareous con- 
tents of the bone. If the calcareous condition, is normal, 
one should not hesitate to perform the nailing operation 
if the position of the fracture is not satisfactory. The 
more callus has developed and the more solid the fracture 
becomes in the faulty position, the more dangerous will 
the operation be and the greater will be the infection 
hazard. It is recommended again to perform a bloodless 
mobilization followed by the application of a wire ex- 
tension in case that the shortening exceeds 4 centimeters. 
The nailing will be performed 8 to 10 days later when the 
shortening is compensated and the effects of the injury 
to the soft parts are overcome. We also v/ish to repeat 
that we introduce on principle a long drain posteriorly 
for 24 to 48 hours. Both measures reduce the infection 
hazard. 
The old fractures in which the osteosynthesis becomes 
instable are not suitable for open nailing, that is all 
fractures which are less than 6 centimeters away from the 
tip of the trochanter and from the knee joint. If in these 
cases the faulty position cannot be compensated for with the 
conservative methods or if we have to deal with a pseudar' . 
throsis,recourse must be made to the osteosynthesis with 
Y/ire or LANE1 s plate, respectively to the bone graft or 
MATTI*s operation. The use of the nail would not mean any 64 
advantage, since an additional plaster cast or wire ex- 
tension will be needed anyhow. If, however, an infection 
sets in, the nail would still increase the multiple hazards. 
3. Fractures of the Lower Leg, 
a) Nailing osteotomy of obliquely healed fractures 
A really stabile osteosynthesis in obliquely healed 
fractures of the tibia is still more rarely obtained by 
osteotomy than in the fresh fracture, because the nail will 
only be firmly engaged in the hour-glass shaped marrow 
cavity if the fracture is located in the middle of the bone. 
The smooth resection areas will not afford any hold if 
pressed together and one will only very rarely succeed in 
obtaining a firm hold for the nail in the callus which 
closes the fracture ends. If the cuts are applied trans- 
versely to avoid a slipping off, it will always be necessary 
to resect a large piece of bone. This will make a shorten- 
ing unavoidable. The smooth transverse fractures of the 
tibia have a tendency to a delayed callus formation. If 
no resection was performed to avoid the shortening and if 
a gap is left between the abutments of the fracture, as 
seen in 111. 62, there will be a still greater hazard of 
a delayed healing in spite of the osteosynthesis being 
stabile in the beginning. The nail will gradually loosen 
in the bone, the fibula will heal early and a shearing 
of the smooth cuts is likely to develop which 
seriously interferes with the healing process. It is of 
little use to fill the gap with pieces of the resected bone 
(111. 63) not to mention the increase of the infection 
hazard. 
If the cut is applied at a slant it will become 
necessary to use a wire suture and a plaster cast to 
avoid slipping and shortenings. Thus the nail does not 
bring any advantages. 
Only by cutting the bone in the shape of a staircase 
will one obtain a wide contact of the fracture ends and 
avoid all longitudinal displacement. This procedure may 
appear relatively simple in the copies of the X-ray picture. 
In reality, however, it is a complicated and tedious 
procedure and if a satisfactory result is striven for, the 
operation will imply many hazards of breaking asepsis. 
It is by far easier to perform an oblique osteotomy 
and to unite the fracture ends by wire suture after the 
removal of a corresponding wedge. This method will serve 
to compensate the angulation and the shortening at the 
same time (111. 64). (Authors Note: It is not quite easy 
for the inexperienced surgeon to establish the proper form 
of the wedge after the X-ray copies in two planes. To 
facilitate the determination of the bone wedge it is re- 
commended to prepare a Plastilin model according to the 
(possibly stereoscopic) X-ray pictures and to perform the 
resection on this model). The plaster cast required in this 
method will not constitute an important inconvenience. It a 
b 
Illustration 62 
a) One year old open leg fracture. Yalgus-position and 
recurvation; the shortening amounts to 1 centimeter. 
b) The same fracture U weeks after osteotomy and nailing. 
The nail is too short and the osteotomy planes are in 
contact less than 50 %. It would have been better to 
resect the fibula at some distance from the osteotomy site. 
Four months later no formation of callus to be observed. 
Therefore the fibula was resected. 
Six months after the operation the fracture cleft 
was still gaping, some symptoms indicating a formation 
of console callus were observed. Marked rarefactions 
around the nail tip (pictures were lost). Removal of 
the nail, BECK'S drilling, application of a plaster cast. 
Eight weeks later the fracture was stabil. a 
b 
Illustration 63 
a) Fracture of the leg which was nailed. 2 months before 
in another hospital. Due to bhe fact that the simple nail 
was too short an angulation of the fracture occurred which 
was in good position in the beginning. The limb was 
subjected to weight bearing too early, and was not well 
enough observed. 
b) The same fracture 7 months after the nailing after the 
patient had been brought to the special department of the 
hospital. The nails have been removed. After resection 
of the fibula an attempt was made to correct the angulation 
by use of the osteoclast but this failed. Therefore, eight 
days later osteotomy with marrow nails was performed. c 
d 
Illustration 63 
c) The same fracture after the osteotomy. The fracture 
cleft which is gaping in front and medially was filled 
with resected parts of the bone (I). The fragments are 
in good position. It would have been better to use 
longer nails. 
d) The same fracture 4 months after the operation. The 
fracture cleft is not yet healed but only filled with 
cloudy callus. It is stabil from the clinical point 
of view and the patient does not complain about pains 
during weight bearing. Four weeks later the nail was 
removed. Pains and swellings were observed which.sub- 
sided 5 weeks later. will also be required in most of the cases where a marrow 
nail is being used and besides this, the hazard of a 
stiffening of the joint is less imminent in fractures of 
the tibia* The hazard of damage due to infection appears to 
be increased by the use of the marrow nail* 
Guided by these considerations I did not use the 
marrow nail for the correction of obliquely healed fractures 
of the tibia* 
In the Military Hospitals the marrow nail was used 
5 times for this purpose. Infections did not occur* 
Two patients could not be observed until final heal- 
ing. The fracture of 111* 62 did not reveal any formation 
of callus in spite of a completely healed fibula for this 
reason a resection was performed. Eight weeks later the 
fracture was still springy and it could be seen in the 
X-ray picture (unfortunately now lost) that the fracture 
cleft was still open. There was a slight indication of 
spicules of callus and rarefactions next to the point of 
the nail could be observed. The nail was, therefore, 
withdrawn, BECK* s drilling and a plaster cast were used. 
After eight more weeks the fracture finally solidified. 
In case of the fracture of 111. 63, the additional 
plaster cast could also be removed only after 3 months* 
Four months after the operation the fracture cleft is 
still clearly visible (63b) and when the nail was removed 
5 months after the operation, the fracture was clinically 
solid but swellings occurred and pain was felt when putting 
stress on the fracture and the patient could be discharged 
only 6-2 months after the operation. 
The fifth patient also required 6 months for the 
healing. The fracture treated with nailingtosteotony-was 
located at the limit between the median and distal third, 
A plaster cast was necessary for 4 months. A shortening 
of 1 centimeter occurred. 
The fracture of 111, 64, however, with osteotomy and 
wire suture was healed after 8 weeks to an extent that the 
patient could be discharged with an UNNA's bandage. The 
shortening was completely compensated for and the joints 
were perfectly movable* In 6 other osteotomies of the 
tibia treated in the same way the stay in the hospital 
varied between 36 to 98 days, an average of 56 days. The 
unemployability lasted for 81 days on the average. A 
permanent involvement of the joints was not observed in 
these cases, A shortening of 1 centimeter occured in one 
case, 
It may, therefore, be concluded that the marrow 
nailing after the osteotomy of obliquely healed fractures 
of the tibia doss not promise any advantage whatsoever. In 
consideration of the hazards due to the marrow nail in case 
of an infection, preference should be given to the old 
osteosynthesis methods. a 
b 
0 
Illustration 64 
a) 15 months old closed leg fracture. Recurvation, 
Varus-position, the shortening amounts to 2 ciie. Plotting 
of the osteotomy line and removal of the hatched part of 
the bone. 
b) The same fracture after an oblique osteotomy of the 
fibula and resection of a wedge out of the tibia. The 
fragments are held in place by means of wire sutures. 
Shortening was compensated. The varus position as well 
as the recurvation were eliminated. 
c) The same fracture 8 weeks after the operation. 
Healing was obtained and all joints are freely movable. 
Shortening was not observed. Very slight recurvation 
which is negligible from the clinical point of view. b) Old but „not yet .healed Fractures, and Pseudarthroseq 
Apart from the old fractures with faulty position, 
those tibia fractures with deficient callus formation and 
pseudarthroscs are the ones which necessitate surgical 
intervention. The poor healing tendency is in the majo- 
rity of cases with the exception of infections due to 
disturbed mechanical conditions, including inadequate fix- 
ation. If these mechanical disturbances are eliminated, 
one will as a rule be successful in obtaining bony heal- 
ing in old fractures of the tibia. 
In case of genuine pseudarthroses in which the ends 
of the bones are covered with a newly formed fibrous 
cartilage, and in defect pseudarthroses it will always 
be necessary to expose the fracture site. In case of the 
fracture without healing, that is the connective tissue 
pscudarthrosis, it is sufficient to resect the obstructing 
fibula and to assure a perfect abutment of the fragments 
(with or without BECK’s drilling)and adequate position at 
rest. The healing will take place without exposure of the 
fracture site. 
According to our experience it will not always be 
possible to distinguish with certainty between a genuine 
pscudarthrosis and a fracture without healing. The time 
that has elapsed since the accident does not furnish any 
clues. The X-ray picture is not conclusive either in most 
of the cases. 
I would like to mention an example from my experience 
as assistant. 
An osteosynthesis with LANE t s plate had been per- 
formed on tibia fractures as per illustration 65a two 
years previously. As no bony healing occurred, the 
patient was given a brace. When the patient was admitted to 
our hospital, the fracture was distinctly springy. The 
brace was too wide and I requested in my ■'report the modi- 
fication of the apparatus. One year later the patient came 
back for a final check up. The apparatus had not been 
changed. The fracture had healed clinically and rcontgen- 
ologically (ill, 65b) without resection of the fibula, 
without BECK*s drilling and without a bone graft solely 
through the brace which prevented lateral movements and 
since the brace was too short, allowed for a pushing to- 
gether in an axial direction. The healing was possible 
only because we had to deal with a connective tissue 
pscudarthrosis and consequently the bone ends were not 
covered with fibrous cartilage. a 
Illustration 65 
b 
a) Pseudarthrosis of the tibia, two years after osteo- 
synthesis by means of a LANETs plate. Probably the 
fibula was not severed and therefore the osteotomy is 
gaping. The plate is loose, because the screws were 
fixed in only one side of the corticalis. The marrow 
cavities seem to be entirely covered. We have to deal 
with a typical pseudarthrosis. The patient uses a brace 
which is too loose. 
b) The same fracture one year later. Bony healing, 
without any additional operation. Consequently there 
was not a true pseudarthrosis in question but only a 
"fractura non sanata". According to our experience a bony healing may still 
be expected in tibia fractures which are up to 5 months 
old if the fracture ends are well adapted (with or without 
BECKls drilling) and if a sufficient position at rest 
by a walking-cast is assured. It is, however, necessary 
and this is often omitted - to resect the obstructing 
fibula. (Authors Note: The resection of a piece of bone 
about 1 centimeter long is preferable to a simple ob- 
lique osteotomy. The latter heals so early that the bone 
will obstruct again. 
If the closed nailing can be used in such fractures 
in the place of the plaster cast and if at least a re- 
latively stabile osteosynthesis can be achieved, the 
patient enjoys all the advantages which are indisputably 
established in the marrow nailing of fresh tibia fractures. 
In this case it is not important, whether the bony heal- 
ing will take 6 or 16 weeks, inasmuch as the patient has 
the full use of the limb with the nail in position and the 
employability is only slightly reduced. The main hazard, 
namely the infection is completely eliminated in the closely 
marrow nailing. 
In 16 fractures of the tibia which were 4 to 23 
weeks old, we have carried through the closed marrow nail- 
ing and all have healed without shortening and with 
free mobility of the joints, although there were already 
considerable restrictions in the mobility of the ankle 
joint in nearly all fractures more than 14 weeks old. The 
stay in the hospital varied between 18 and 80 days, the 
average was 43 days? The unemployability lasted from 
85 to 170 days, that is 125 days on the average. Similar 
results cannot be obtained without using the marrow nail. 
We are, therefore, of the opinion that the attempt 
is indicated to nail all old tibia fractures, as far as 
they arc suitable for nailing, without exposure of the 
fracture site. And this should be done the earlier, the 
better. All the contraindications which exist in case 
offresh fractures must be considered very carefully. 
The resection of the (alroo.dy healed or intact) fibula 
will become necessary in all cases. The fracture must be 
throughly mobilized. If there is no considerable shorten- 
ing or lateral displacement, tic nailing will be performed 
in one session together with the resection of the fibula. 
In case of a considerable laterc.1 displacement or shorten- 
ing, however, and in case of very old fractures, a wire 
extension will be applied after the resection of the fibula 
and the nailing will be postponed until the faulty position 
and particularly the shortening are compensated for and 
until the injury to the soft parts due to the mobilization 
of the fracture has subsided. 
In case of old compound or infected fractures, the 
extension bandage must be left in position until one can 
be sure that the infection will not suddenly flare-up. In deciding the question whether it is advisable 
to perform the nailing of an old compound fracture of 
the tibia in case that the closed nailing is not possible, 
it must be considered if the nailing offers important 
advantages over other methods. This decision will 
always be possible in case of pseudarthroscs and fractures 
wh?ch are older than 20 weeks* 
An abnormal variation in tho time of necessary 
treatment could not be observed in our patient material. 
Even in those 26 primarily healed cases, the average stay 
in the hospital after the operation was 123 days and the 
period of unemployability lasted 178 on the average. These 
results can also be obtained with other methods. 
The average will still be worse if the infections are 
taken into account. Only 10 of the infected cases could 
be observed until their final healing. The average 
stay in the hospital of the 36 patients then is raised to 
245 days, the unemployability to 273 days, 
' 17 of the asejptically healed fractures (49p) did 
not show any shortening or impediment of the joints. 2 
cases resulted in a slight impediment of the ankle joint. 
4 patients had a permanent impediment in the mobility of 
the ankle or knee joint and 3 pscudarthroses did not 
come to bony healing, All the fractures complicated 
by infections healed with stiffened ankle joints and a 
more or less pronounced impediment of the knee joint. 
It must, therefore, be admitted that the results of 
the open nailing of the old tibia fractures, even in 
case of aseptic healing, did not show a result which 
could be called appreciably superior to other methods. 
The hazard of infection is ever present in this method 
and the nail means additional hazard in that case. 
Two of these infected cases turned out fatally. 
In a transverse fracture in the middle of the tibia, 
the site had been exposed after several unsuccessful 
attempts to perform a closed nailing (the mobilization 
had been omitted). The osteosynthesis was stabile, 
An elevation of temperature was already observed one day 
after the operation. On the fifth day an abscess at the 
entrance wound of the nail had to be opened. The wound 
at the fracture healed primarily. 
As the fever did not subside and in consideration of 
the poor general condition of the patient, a blood trans- 
fusion of 5©0cc, was carried through on the 12th day after 
the operation, 4 hours later the patient was seized by 
a chill with high temperatures, apparently the onset of 
an acute sepsis, which caused the death of the patient 
the next day. The postmortem findings revealedsa 
streptococcic sepsis with chronic tumors of the spleen, 
liver and myocardium were damaged; fresh septic infarcts 
of the lungs as mctastascs from foci in the tonsils. The 
patient had suffered from an acute angina in the previous 
hospital, a fact which he had not mentioned. He alr^dy had a slight fever before the nailing and this had been 
overlooked afterwards as the attention was concentrated 
on the fracture. Although the blood transfusion can be 
considered as the directly releasing factor of the fatal 
septic action, there is no doubt that the nailing also 
contributed to mobilize the latent sepsis. This outcome 
is the more regrettable since the position of the fracture 
was not too bad and could have been healed conservatively. 
It results from the foregoing that the surgeon must 
ascertain the general condition of the patient very care- 
fully before a nailing operation is performed. 
In the second fatal case, the nailing is also only 
indirectly responsible for the outcome. 
In the ten months old tibia fracture of 111, 66a 
an open marrow nailing was performed, because the fracture 
was still movable two months after the severance of 
the fibula, A necrosis of the skin developed (lobular 
incision) which turned into an erysipelas and the 
fracture became infected. The osteosynthesis was not 
stabile because only one nail, the thin one, had been used 
(ill, 66b), so a slight valgus position developed (in 
spite of a splint), When the fracture was clinically 
fixed 12 weeks after the operation (ill, 66c) and the 
fistula showed only a very little secretion, the nail was 
removed. With the view of obtaining a better hold on the 
nail, the intensely stiffened knee joint was mobilized 
(!) and now an empyema of the knee joint developed wh:ch 
was drained by resection of the condyles, A new abscess 
developed at the fracture site which lead to sepsis with 
fatal outcome, because it was omitted to amputate in due 
time. In the autopsy still another empyema was found in 
the ankle joint, which had spread by way of the nail 
path. This wandering took place after the removal of the 
nail and was due to the fact that the nail had been driven 
in too far beyond the lino of growth, almost to the car- 
tilage of the ankle. 
In this case too the position of the fracture was not 
bad at all and a healing would certainly have been ob- 
tained without the use of the nail with adequate immobili- 
zation, Once again the ru’es of general surgery were 
disregarded, since it is strictly prohibited to forcibly 
mobilize a stiffened joint if it is in a purulent state 
as this means a serious hazard of infection to the joint. 
As has been mentioned before, there was no stabile 
osteosynthesis in almost all the infected cases and the 
results are different if viewed from this angle (Table V). a 
Illustration 66 
b 
o 
a) 10 months old leg fracture, 2 months after the resection 
of the fibula. Open narrow nailing indicated because the 
fracture is not yet stabil from the clinical point of view. 
b) The sane fracture after the nailing. According to 
the records the fragments were properly separated and 
the marrow cavities were opened by drilling. Only too 
thin a nail was used. An erysipelas and infection of 
the fracture occurred which were developed from a skin 
necrosis in the lobe shaped incision. 
c) The same fracture 3 months later. Slight structural 
loosening at the fracture cleft. Laterally the fracture 
is somewhat angulated. A small fistula was observed at 
the level of the fracture with only slight secretion. 
The nail was removed because the fracture was stabil 
from the clinical point of view, and bridged over by 
callus at least in the rear. It was hoped that in this 
way the suppuration would subside. During this operation 
the knee was mobilized with the patient under anesthesia. 
Subsequently a knee joint empyema was observed and 
shortly after that a lethal sepsis occurred. 70 
T a b 1 e 7 
Qpcn .marrow nailing in ol<4 ,tibia fractures 
cudar t]ir o so s 
Number 
of 
cases 
A v e 
rage 
In- 
fee - 
tion 
R 
e s 
u 
L t 
stay in the 
hospital 
unempfoyability 
in days 
I 
II 
III 
iv* 
Osteosynthe- 
si s 
stabile 
14 
(+ 1) 
53 
(31-96) 
108 
(85-193) 
1 
(+1 
see 
text) 
13 
1 
- 
- 
Qsteo synthc- 
sis 
21 
221 
248 
10 
prim, 
hea. 
.ed 
relatively 
(* 10 
(136-368) 
(136-380) 
(+9) 
4 
1 
4 
2 
stabile or 
not 
-61% 
instabile 
observ, 
infected 
until 
final 
2 
1 
7 
- 
6 
2 
11 
2 
It becomes evident that the Infection hazard is 
very low in case of a really stabile ostoosyntnesis and 
that the results .in that case are better than could possibly 
be achieved by other methods of osteosynthesis. The stay 
in the hospital is generally shorter and impediments of the 
joints are avoided and existing ones ameliorated or com- 
pensated, because the patients may begin quite soon after 
the operation with adequate movement exercises. 
In case of an insufficient stability, however, the 
infection rate is very high (61%!), the treatment as very 
long and the results must be called very poor, 
To a large extent the infection can be held respons- 
ible for the poor results. The fracture must remain for 
a rather long time in the plaster cast because of the 
pus secretion and considerable stiffenings of the foot 
and sometimes of the knee joint are the consequence. In- 
tense angulations or shortenings could be avoided in the 
infected cases because the fractures were not put under 
stress too early. 
* I. Healing without shortening, angulation or im-pediment 
of the joints 
II. Slight angulation, shortening or impediment of the 
joints EM 20% 
III, Marked shortening, angulation or impediment of the 
joints EM 25% 
IV, Pseudarthrosos 
* The open, previously infected fractures, the wounds of 
which had healed more than $ weeks before are included 
in the "aseptic” fractures, Old fractures due to gun- 
shot injuries are not included. The cases grouped under III of the table of the 
aseptically healed fractures refer to narked angulations, 
which were either present after the nailing and were not 
noticed (ill, 67) or were due to the fact that the patient 
was allowed to use the fractured limb too early without 
paying attention to the gradually increasing angulation. 
The stability gains special importance in pseudar. - 
throscs, which according to our usage will include all 
fractures which are older than 6 months, regardless if 
we have to deal with a genuine connective tissue psou- 
darthrosis or with a fracture without healing. 
We would like to give a few examples in this 
connection: 
A 24 weeks old tibia fracture located at the limit 
of the distal third was treated with closed nailing and 
simultaneous resection of the fibula. The osteosynthesis 
is stabile and a bony healing is achieved so that the 
nail can be withdrawn after 5 months. 
In the 26 weeks old fracture of 111, 68a, however, 
the resection of the fibula was omitted and only one nail, 
the thin one was introduced from the distal side without 
opening the fracture (ill, 68b), No healing was observed 
after 11 months (ill, 68c), because the thin nail had no 
grip and could not prevent the undesirable lateral and 
tilting movements and because the fibula had not been 
resected. The nail was then removed, an osteotomy of the 
fibula was performed and a shifting of the bone graft 
at the pseudarthrosis was carried through (ill, 68d). 
It is very likely that healing would have occurred 
in this case without the nail if the obstructing fibula had 
been resected. 
In the 10 weeks old pseudarthrosis of.Ill, 69, in 
which the marrow cavities were closed by hard eburnised 
bone and the fracture cleft was filled with connective 
tissue, the marrow cavities wore only opened wide enough 
to allow the nail to enter. The osteosynthesis was stabile 
(ill, 69b) and the patient could walk freely without 
a cane 4 weeks after the operation* Five months after the 
operation the fracture was completely healed and the patient was 
discharged from the hospital. 
In the 7 years old pseudarthrosis of 111, 70, however, 
the scar tissue that filled the fracture cleft was re- 
moved only at the anterior part and the marrow cavities were 
opened wide enough to introduce the nail. The gap thus 
left at the anterior side was filled with previously de- 
tached bone chips. The patient could use the leg 4 weeks 
after the operation and was drafted for the Labor Service 
8 weeks after the operation. Three months after the oper- 
ation the patient could not walk any longer and the 
fracture site was painful to palpation or use. After 4 
weeks confinement to bed the troubles were apparently over- 
come, but a callus formation could not be observed 4 months 
after the operation (ill, 70b), The lateral X-ray picture 
revealed slight rarefactions which indicated that the Illustration 67 a 
Four month old oblique fracture of the leg in the lower 
third. The fibula is healed. 
b 
Illustration 67 
c 
b) The same fracture after open nailing had been performed 
in another hospital. The nail does not find sufficient hold 
in the distal fragment. The fibulawas only severed. Appli- 
cation of a plaster cast. Four weeks later the patient 
started subjecting the limb to weight bearing with the cast 
in place. Two months after the operation the plaster cast 
was removed, because the fracture was thought to be stabil 
(X-ray missing). 
c) The same fracture months after the nailing. It was 
healed in a recurvation and typical varus position. 
If one had decided to only resect the fibula and to apply 
a walking cast the fracture would have healed in better 
position and more quickly. Old fractures of this kind are 
not suitable for nailing. If an osteosynthesis is really 
necessary, the only suitable method is the use of a wire 
suture. a 
b 
Illustration 68 
a) Six month old leg fracture without any formation of 
callus. The fibula is healed. 
b) The same fracture after the closed nailing. Due to 
the fact that it was impossible to insert the nail into 
the distal marrow cavity from above it was inserted from 
the distal side. Only a thin nail was used which did 
not find sufficient hold in the proximal marrow cavity. 
The osteosynthesis was instabil. The healing was hindered 
by constant waddling movements which were due to the 
fact that the fibula had not been resected. c 
d 
Illustration 68 
c) The same fracture 11 months after the operation. 
Pseudarthrosis of the proximal fracture cleft. 
d) Removal of the nail, supramalleolar osteotomy of 
the fibula. Displacement of the graft in the pseudar- 
throsis site. Healing obtained 8 weeks later. 
Also in this case a simple resection of the fibula 
without nailing would probably have been more simple 
and healing would have been obtained more quickly. 7ia 
a 
b 
Illustration 69 
a) 10 week old leg fracture without formation of callus. 
The fibula is healed. 
b) The sane fracture after the resection of the fibula and 
open marrow nailing. The nail finds a good hold in the 
distal narrow cavity and the osteosynthesis is stabil. The 
patient was able to walk freely and therefore he could be 
released to his unit after a period of eight weeks. 
Illustration 69c 
The sane fracture 5 months after the nailing. Bony- 
healing. All joints are freely movable. a 
b 
Illustration 70 
a) Seven year old pseudarthrosis of the leg after the 
resection of the fibula and open nailing. The connective 
tissue which filled the cleft of the pseudarthrosis was 
removed only in front. After that the marrow cavity was 
opened enough so that the nail could be inserted. Bone 
splinters were inserted into the cleft, where the connective 
tissue had been removed. The nail found sufficient hold 
in the spongiosa so that 4 weeks later the patient was 
able to subject the limb to weight bearing and 8 weeks 
later he was drafted to the Labor Service. 
b) The same fracture 4 months later. No noteworthy 
formation of callus to be observed. The fracture cleft 
has not yet healed at any place. Slight rarefactions 
round the nail tip indicate that the nail is "working”. 
Four weeks before the patient had suffered such terrible 
pains that he was not able to walk any longer. He felt 
better after confinement to bed. The nail was removed in 
the hope that in the vicinity of the nail canal a new 
stimulation of callus would develop. After three months 
treatment with the walking cast the fracture was healed 
(X-rays destroyed). nail could woik. The hail was withdrawn with the 
expectation that the callus formation would be stimulated 
at the path of the nail. The fracture was still springy 
(Result IV), After 3 months with a walking cast it 
finally solidified. 
The withdrawal of the nail would not have been 
necessary. The fracture would have solidified in the 
same way if only an additional plaster cast had been used. 
The insufficient stability is probably responsible to 
a certain extent for the delayed callus formation. Be- 
sides it would have been indicated in such an old pseudar' 
throsisto remove all the scar tissue or the gap should 
have been filled with the spongiosa in the sense of MATTIls 
operation. It cannot be expected that the removal of the 
nail might have a stimulating effect on the callus form- 
ation comparable to BECK*s drilling since no new bone 
wounds are thus created, 
111, 71 shows that a several years old pseudarthrosis 
with absolutely stabile osteosynthesis will heal without 
any grafting of spongiosa if the faulty tissue is care- 
fully removed. 
In the following we describe a 3 year old pseudar 
tbrosis following a complicated fracture of the tibia with 
a shortening of 3 centimeters. The ends of the fractured 
bone which were connected by a sturdy connective tissue 
callus were exposed. Part of the fragments were covered 
with fibrous cartilage. In order to prevent a further 
shortening, the faulty tissue was Qarefully removed from 
the ends of the fractured bones until fresh bone was 
exposed throughout. The marrow cavities were not opened. 
They were difficult to trace by means of KIRSCHWER wires 
and X-ray control and a canal for the nail was then 
pierced through the hard callus. The driving in of the 
nail presented considerable difficulties. The fracture 
had at first to be fixed in a strong recurvation and then 
bent into position. The nail became S-shaped by these • 
manipulations Gad soon touched the posterior corticalis> 
to which it finally became so firmly engaged that the 
nail could not be driven in any farther and had to be 
cut. The fracture was absolutely fixed after the oper- 
ation (ill* 71b), As only the thin nail had been used, 
we applied a. light plaster cast for the following 8 weeks 
and although the X-ray picture (ill, 71c) revealed a 
distinct callus formation, the patient had to wear a 
hinged brace apparatus for another 3 months. After this 
he could walk long distances without any trouble, (ill# 71d), 
He was then drafted for military service and came back 
only 6 months ago, that is 4 years after the nailing oper- 
ation to have the nail withdrawn. The fracture showed a good 
bony healing (ill, 71e). The removal of the nail was 
not possible, because of its S-shape it could not pass 
through the small canal in the callus. The blood picture 
did not reveal any changes whatsoever and the patient had 
no trouble. The shortening was still 3 centimeters. 
Rotation of the ankle joint was reduced to of the normal. 
Flexion and extension were normal. Since the patient was 
only 28 years old we proposed to shorten the sound leg 
in the femur by 3 centimeters by use of the marrow nail. 
This operation is going to take place in the near future. 72a 
a 
Illustration 71 
b 
a) Three year old pseudarthrosis of the tibia after 
a compound leg fracture. Two years before the fibula had 
been resected and an unsuccessful BEGKfs drilling had been 
made. The shortening amounted to 3 cms. and the patient 
used a splint (Stuetzapparat). 
b) The same fracture after the nailing and resection of 
the fibula. Tho bones were partly covered with cartilagi- 
nous fibres. They were united by thick sclecrotic 
connective tissue. Diseased tissue was carefully removed 
until finally fresh bone was exposed everywhere. Through 
the hard callus which covers the bones a canal was drilled 
for the insertion of the nail. This operation proved to 
be very difficult. The inner nail jammed in the distal 
fragment so much that it was impossible to drive it in 
any farther. Therefore it had to be cut. The outer nail 
could not be inserted at all. After the operation the 
fracture was stabil. A walking cast was applied because 
the thin nail did not guarantee a stabil osteosynthesis. 72b 
o 
Illustration 71 
d 
c) The sane fracture 8 weeks later. The fragments were 
pressed together because of the weight bearing. Beginning 
formation of callus. The patient was able to subject the 
limb to painless weight bearing. He must however use a 
splint in order to prevent angulation. 
d) The same fracture 5 months after the nailing. It is 
widely bridged over by callus. The patient was able to walk 
without a splint even for long distances and does not suffer 
from pains any more. Rarefactions round the nail tip cannot 
be observed which proves that the nail has wandered somewhat 
higher. The patient was drafted two months later. Illustration 71e 
The sane fracture 4 years after the operation. Bony 
healing. The extraction of the nail was unsuccessful, it 
is held in the callus by the curvature. In the proximal 
fragment reactive formation of bone can be seen around 
the nail. In order to compensate the shortening of 3 cns. 
it was intended to shorten the sound thigh by using a marrow 
nail. The operation of the 3 year old pseudarthrosis as 
per 111, 72 presented similar difficulties. The frac- 
ture cleft was filled with connective tissue but a trans- 
formation into fibrous cartilage could not be observed. 
Although double nails had been used, the fracture was 
still readily movable. The nails were too short, they 
should have been driven into the spongiosa as far as the 
line of growth. A U-shaped splint was at first applied 
for two weeks. The fracture could then be stressed and 
the patient was discharged. He continued wearing his 
hinged brace apparatus for some time. After 6 months 
when the nail was removed, the fixation of the fracture 
was complete. In the X-ray picture, however, the frac- 
ture cleft was still clearly visible (lll„ 72c), 3 months 
after the removal of the nail the patient came back 
and complained about pain and swelling at the fracture 
site. Clinically we observed a slight springiness of 
the fracture and we proposed the resection of the fibula 
to which the patient did not consent, When the patient 
came back again 4 years after the operation, we observed 
a persistent slight elasticity of the fracture and the 
X-ray picture, (ill 72d) still shows the entire fracture 
cleft. There is again a tight, apparently connective 
tissue pseudarthrosis„ The reason for this faulty healing 
is the obstructing fibula, which we had ( this was a fault) 
only osteomized and not resected as is necessary. Judging 
from the X-ray picture it can be expected with certainty 
that the resection of the fibula will bring final healing. 
The patient refused again because his pseudarthrosis which 
saved him at the time from military service will now save 
him from undesired work. 
These faulty healings wore due to technical errors 
(premature removal of the nail, omission of the fibula 
resection) and could have been avoided. If the surgeon 
tries to avoid an extensive resection of the bone and thus 
a shortening, then the location of the marrow canal and 
the provision of the path for the nail in the hard callus 
will present considerable difficulties and makes tedious 
manipulations necessary. This means an increased in- 
fection hazard. One is never sure whether or not an 
absolutely stabile osteosynthesis will bo achieved by the 
use of a simple marrow nail. The use of a spread nail, 
will, however, render the operation still more complicated 
We, therefore, no longer naiA routinely when the conditions 
arc adverse. 7fo rather perform the bone graft operation in 
addition to a resection of the fibula. The disadvantage of a 
long plaster cast is certainly more than compensated for 
by the greater security of healing and if a light 
plaster walking cast is used, the hazard of a stiffening 
of the joints will be small. a 
Illustration 72 
b 
a) Three year old pseudarthrosis of the tibia after a 
compound fracture. Resection of the fibula. A nailing 
operation after the removal of the connective tissue 
callosities between the ends of the fragments was tech- 
nically very difficult without resecting the bone. 
b) The same fracture after the nailing. The nails should 
have been longer. The fracture was still somewhat movable 
and therefore a U-splint was applied for 2 weeks. The 
patient was able to subject the limb to painless weight 
bearing. Later on the patient wore a hinged brace. c 
Illustration 72 
a 
c) The same fracture 6 xuonths after the operation, which, 
after removal of the nail is absolutely stab.il from the 
clinical point of view. The greater part of the fracture 
cleft is still visible. Three months later the patient 
complained about pains and swellings after excessive 
walking. The fracture is slightly springy. The X-ray 
(unfortunately lost) revealed that the fibula was healed 
and in the tibia the same findings were observed as in 
Illustration 72 d. The patient refused a proposed resection 
of the fibula. 
d) The same fracture 4 years after the operation. The 
fibula is healed and the entire fracture cleft in the tibia 
is readily noticeable. The fracture is slightly springy. 
We have to deal with a connective tissue pseudarthrosis. 
The patient uses a splint and refuses a resection of the 
fibula once again, which probably would have brought a 
bony healing. 4-i_UpBor Arnij 
q.l Osteotomy Jlailing of oblinucly healed Fractures, 
Fractures of the upper arm very infrequently heal 
in such a bad position that the function of the arm is 
seriously hampered. In most of the cases the patients 
come for expert treatment before a bony fixation has 
developed, 
So we count only three osteotomy nailings in our 
case material which became necessary because of a marked 
angulation of the axis. Our records of former times in- 
clude 4 osteotomies which were provided twice with LANE *s 
plates and twice with wire suture. 
As far as these few cases allow a comparison, it can 
be said that the marrow nail docs not essentially further 
the bony healing. 
The marrow nailing should still be given preference 
in all cases where it secures a stabile osteosynthesis, 
that is in all fractures located at a distance of more 
than 7 centimetcrs.f-om the joints, The nail facilitates 
the treatment greatly because the plaster cast, if re- 
quired at all, wA«.l r.aw be necessary for more than 2 to 3 weeks 
and the patinnts can move the joints early, The sane 
as in fresh fractures, the stay in the hospital and the 
unemployability are considerably shortened. 
Since a shortening of the upper arm is of no con- 
sequence with regard to the function of the arm, it is 
indicated to resect the fracture e.nds far enough to 
open the narrow cavity and to freshen the fragments in 
the shape of a staircase to secure large abutments. 
An additional wire suture is, in our opinion, not 
necessary. As a rule there is already a shortening and 
the muscles have shrunk accordingly so that there is still 
enough tension after the freshening of the bone ends to 
hold the fragments together. We did not observe in any 
of the three cases that this tension was insufficient. 
b) Old Fractures and Pseudarthroses 
Whereas in peacetime surgery we rarely had to deal 
with fractures of the upper arm which were in such a bad 
position that a bony healing was not secured, the same as 
with pseudarthroses, we have seen even in civilian practice 
during wartime a surprisingly great number of such frac- 
tures, The reason for these conditions was in most of the 
cases a faulty treatment due to the circumstances ( in- 
exact reduction, inadequate fixation). A closed marrow nailing of old fractur s of the 
upper arm in faulty position may be performed up to 
6 weeks after the accident if the fracture is previously 
well mobilized and if a wire extension is used for 8 days 
in case of a considerable shortening. If this is done 
the marrow nailing will have all the advantages v/hich 
it has in the case offresh fractures, 
14 fractures so treated healed uneventfully and 
without any impediment of the joints and with an average 
stay in the hospital of 32 days and an average unemploy- 
ability of 73 dayso 
In fractures more than 6 weeks old we did not 
attempt to perform a closed nailing, inasmuch as the in- 
faction hazard is very small in the upper arm and the 
operation is greatly facilitated by the exposure. 
Among the 55 cases of old fractures of the upper arm 
which we nailed with exposure, there was only one case 
of a (5 years old) genuine pseudarthrosis which is 
shown in 111, 1* In all other cases the fracture ends 
were covered by callus connective tissue. The reason 
for the disturbed healing was the same in all cases, 
naneJyan inexact reduction, that is a distraction of the 
fragments. 
Five patients with 8 to 12 weeks old fractures could 
only be observed about 3 to 4 weeks after the operation, 
so that nothing can be said about the final healing 
result, N 
Eight more patients whose fractures were 2i to 
4 months old, were treated on an outpatient basis after 
their discharge, A distinct callus formation could 
be distinguished after 6 to 10 weeks, A bony healing can 
be expected in these cases, although the final healing 
result could not be checked, 
37 of the remaining 42 cases showed a bony healing 
with full mobility of the joints. The stay in the 
hospital lasted 21 to 89 days, that is an average of 
47 days. The unemployability lasted 74 to 168 days, 
that is an average of 108' daysc 
Five of the cases, including the above mentioned 
pseudarthrosis did not show a bony healing and it is 
desirable to discover the reasons, 
In case of the genuine pseudarthrosis, that is the 
formation of a new cartilage surface of the joint, the 
removal of this cartilage together with fixation is 
apparently not sufficient to achieve the healing. This 
seems rather surprising at first if we think of an 
arthrodesis of a joint in which we also remove the carti- 
lage and furthermore we have seen in many connective 
tissue pseudarthroscs that a stabile osteosynthesis with- 
out resection of the bone assures a full success, I had 
this fact in my mind when I abstained from performing 
a resection in the genuine pseudarthrosis of the upper arm shown in 1. The nervus radialis was imbedded 
in the ne ; joint capsule and passed proximally through 
the callus in which remnants of the former wire suture 
still lay. I intended to perform the operation as simply 
as possible so as to create the smallest possible hazard 
to the nerve. 
And still there is a distinct difference between 
the genuine joint and the pseudarthrosis on the one hand, 
and between a genuine and connective tissue pseudarthrosis 
on the other hand. Below the thin intermediate lamella 
of the genuine joint (which will always be removed), lies 
sound spongious bone with blood and cell containing 
marrow which is just able to initiate the regeneration 
of bone as the marrow of the flat bone in case of a frac- 
ture. Below the cartilage of the pseudarthrosis, however, 
we find a rather thick layer of eburnised bone which is 
poor in vessels and free of marrow and which cannot give 
rise, therefore, to a noteworthy regeneration which could 
take place only in case of a decomposition of this bone. 
Such a decomposition is observed in almost any bone 
fracture healing and this is the only souroc for the 
minerals required for the calcification of the bone. 
It can take place in. the presence of a local acidity 
(increase of the H-ions), It develops in the first phase 
of a reparative inflammation of the wound and fracture 
healing but will subside in a relatively short period of 
tine in an aseptic course. This will be sufficient if 
we have to deal with a thin bone which is easily diffused 
by the tissue juice to dissolve the precipitated salts. 
It will, however, not be enough in case of the almost im- 
permeable eburnised bone. 
In case of a fracture without healing, a connective 
tissue pseudarthrosis, the fragments are also not infre- 
quently covered by such eburnised bone. In this case, 
however, the periosteum is separated from the bone and 
will initiate the callus formation. The decomposition 
necessary for the calcification takes place at the sub- 
periosteal parts of the bone which are easily diffused 
and rich in blood cells, and not at the eburnised ends 
of the bone. It appears on the X-ray picture (see 111, 
71e) that the marrow cavities are still closed after two 
years. It must also be borne in mind that the scar tissue 
is readily dissolved and thus prepared for a deposit of 
minerals. The histologic picture of this tissue changes 
into a fresh connective tissue, which is liable to a 
metaplastic bone formation. If, in case of a genuine 
pseudarthrosis, the cartilage will be resected within 
the capsule without separating the periosteum, a peri- 
osteal neoformation of bone cannot take place. 
In the genuine pseudarthrosis too it is, therefore, 
necessary to resect the fracture ends far enough so that 
sound bone tissue is exposed and that the sound periosteum 
can assume the formation of callus. 
In the other four fractures the faulty healing was 
due to a lack of stability of the osteosynthesis, similar 
to what was observed in tibia fractures. Whereas in the 
latter type of fractures it was the healed fibula which 
favored lateral movements, in the fractures of the upper 
arm we observe a distraction caused by the weight of the 77 
arm, a hazard which we already observed in compound 
fractures. This hazard is particularly great if the 
muscles have become atrophic due an extensive immobiliza- 
tion. 
In the fracture shown in 111, 73, 8 weeks old, only 
the thin nail had been used and it was much too short. It 
can be seen distinctly in 111* 73b that the nail has con- 
siderable play in the proximal marrow cavity. Four weeks 
after the operation the patient made his first movement 
exercises and he complained continually about pains, 3 
months after the operation, it was noticed that the fracture 
was somewhat movable and a plaster cast was applied for 
" o. short while”. It is overlooked that the fracture 
was distracted (the nail had slipped oat of the proximal 
marrow cavity (ill, 73c)), It was omitted to push the 
fracture together and a plaster cast up to the shoulder 
was applied instead of a thorax-arm-abduction cast. Eight 
weeks later the nail broke off at the fracture cleft due 
to the rcinstitution of exercises., The marrow cavities 
were gradually covered by bone caps and a pseudarthrosis 
developed due to the permanent lateral movements at the 
fracture cleft (ill., 73d) which fully developed within 
the following 3 months (111. 73e), It was bridged over 
by a tibia graft and now a thorax abduction cast was 
applied for 8 weeks which leads to final healing. 
According to our experiences' with a similar fracture 
(ill, 74) the pseudarthrosis could have been avoided, if 
double nails of sufficient length had been used. 
It could probably still have been avoided if the distraction 
had been noticed, that is to say if the arm had been 
pushed together and put at rest in an abduction plaster 
cast, (See: Infected fractures due to gunshot injuries,) 
Similar conditions prevailed in the two other 5 to 
6 month old fractures which had also been treated outside 
our clinic. In these cases too only one short nail was 
used, the distraction was not observed and the immobiliza- 
tion was omitted, although the patients complained about 
pains when the exercises were instituted. 
The nail in position seems to have a suggestive in- 
fluence, All the interest centers around the nail and the 
callus formation and distractions, changes of the position 
and distorsions are overlooked. Guided by the desire to 
take advantage of the possibility of an early movement of 
the joints due to a stabile osteosynthesis, the principles 
of bone surgery are completely disregarded, namely that 
the fracture must be absolutely put at rest and that such 
movements are permissible which do not cause pains. 
That we also fell prey to this suggestion is shown 
in the following case of our special ward, A short green- 
stick fracture of the upper arm slightly below the middle 
was treated for 10 months with a plaster cast and abduc- 
tion splint, A final healing could not be achieved because 
of continuous dislocation of the fragments. a 
b 
Illustration 73 
a) Eight week old "fractura non sanata" of the am above 
the elbow. Only an inner nail which was much too short 
was erroneously applied on each side. 
b) Despite the fact that according to Illustration 73 a 
the thicker nail would find sufficient space in the marrow 
cavity only the inner nail was used. It is much too short 
and everywhere in the proximal marrow cavity it is loose. 
It should be driven into the spongiosa of the head. 
Instabil osteosynthesis. In spite of this, 4 weeks after 
the operation the patient began subjecting his limb to 
exercises which were painful. c 
a 
G 
Illustration 73 
o) Three months after the operation. Finally it was 
observed that the fracture was somewhat loose and con- 
sequently it was decided to apply a simple cast to the 
arm "for a short period of time." The fracture is dis- 
tracted because of the weight of the arm and the nail had 
slipped out of the proximal marrow cavity. This however 
had not been observed and consequently the fragments were 
not pressed together in the cast. 
d) Five months after the operation. Due to the exercises 
to which the patient had again subjected his arm for 6 weeks 
the nail is angulated in the fracture cleft. The fracture 
is still distracted and the marrow cavities have begun to 
form covers. Beginning pscudarthrosis. In spite of this 
the patient continues subjecting the limb to exercises. 
e) Eight months after the operation, after the removal 
of the nail a psoudarthrosis was observed. A graft from 
the tibia was applied. Application of an abduction cast. 
The fracture was healed 8 weeks later. If from the very 
beginning the fracture had been immobilized by an abduction 
cast or, after the distraction had been observed, the 
fragments had been pressed together again, a faulty healing 
would have been prevented. a 
b 
Illustration 74 
a) Ten week old similar "fractura non sonata" of the arm 
above the elbow, after the nailing. Marked atrophy of the 
bone due to previous immobilization of the limb with a 
plaster cast. The displacement amounted to lg times the 
width of the shaft and the fracture was angulatod. This- 
immobilization had been made in another hospital. Also 
in this case only the inner nail could be used because the 
narrow cavity was very narrow. The nail was driven into 
the spongiosa of the head. In this way the osteosynthesis 
was stabil. 14 days later the patient started subjecting 
the limb to exercises which were not painful. Three weeks 
after the operation the patient was released from the 
hospital for ambulatory treatment. He was able to resume 
working 6 weeks after the operation. 
b) The sane fracture 6 months after the operation* A bony 
healing was obtained. All joints are freely movable. Ex- 
traction of the nail. The fracture was then nailed outside our clinic (ill* 
75a). The nail was too short and did not find sufficient 
hold in the proximal marrow cavity, A distraction of the 
fragments which were not pushed together could be ob- 
served. The plaster cast was removed S weeks after the 
operation and the limb was moved in the abduction splint. 
Three months later a distinct valgus position and crepitatior 
was observed at another military hospital (ill* 75b). 
In spite of these findings the movement exercises were 
continued. Again two months later (5 months after the 
operation) the patient felt. slipping at the fracture 
site and the X-ray picture revealed an increased angu- 
lation of the fracture and of the nail (ill 75c). The 
fracture was then reduced under anaesthesia and a thoracic 
plaster cast applied and left in position for four weeks, 
Then again the patient began with movement exercises in 
the abduction splint0 X-ray pictures were not made. The 
fracture was still movable 9 months after the operation 
when the patient was admitted to the special ward. The 
X-ray picture revealed a pseudarthrosis and breaking of 
the nail, I removed the pieces of the broken nail and 
freshened the ends of the fracture conservatively (a. 
dorsal callus spicule was intentionally left in position) 
and two longer nails wore introduced distally. I 
overlooked that the marrow cavity in the proximal frag- 
ment was very wide* The nail should have been driven still 
farther into the spongiosa of the head (ill, 75e), The 
fracture was apparently fixed after the nailing, therefore, 
only a U-shaped splint and sling were applied, The 
patient began two weeks after the second operation with 
exercises of the shoulder and elbow joints. The U-splint 
was removed six weeks after the operation and an X-ray 
picture was made. The deputy chief surgeon who was in 
charge was under the impression that a callus bridge 
had developed at the posterior and inner sides (ill, 75f) 
So the movements wore made without any bandage. 
It passed unnoticed that the fracture was distinctly 
distracted and that the alleged bridge did not represent 
a ne" callus formation but was the bone spicule which I 
had left in position. Within 8 days the patienbcomplaincd 
of pains and a thoracic abduction cast was applied, the 
pushing together of the fracture, was, however, omitted, 
I saw the patient only two months later when the plaster 
cast was removed and I proposed to bridge the pseudarthrosis 
by a graft with the nail left in position. The bone ends 
were freshened, the fragments were pushed together and the 
tibia graft was fastened with wire loops (ill, 75g). In 
spite of a thoracic abduction cast, distraction of the 
fragments developed again in that the distal wire loop 
slipped off the slightly tapering bone end. I overlooked 
this when the patient was presented to me 3 months after the 
operation (ill. 75h) and I instituted exercises. Five 
months after the operation the fracture though resistant 
to bending permitted distinct rotary movements and the 
X-ray picture revealed that the bone graft was connected 
only to the proximal fragment, that the fracture had 
again distracted and that again a pseudarthrosis existed. 
The patient had to be discharged from the hospital due to 
the course of the war. He has reported tho„t the nail 
broke again despite the hinged brace apparatus. The nail 
was removed and a new bone graft was performed which again 
proved unsuccessful* a 
Illustration 75 
u 
a) Ten month old pseudarthrosis of the arm above the 
elbow after an open nailing which was made in another 
hospital. Application of only one nail which however, 
was too short and which did not find sufficient hold in 
the proximal marrow cavity. The fragments are not pressed 
together. The fracture cleft is gaping. The osteosynthesis 
is not stabil. A nailing from the proximal side would have 
been better. Application of a plaster cast for eight weeks. 
After that: exercises with the limb in the abduction splint 
despite the fact that "the fracture is still somewhat movable." 
b) The same fracture three months later (after the patient 
had been brought to another hospital). 
Marked valgus position. Clinically marked crepitation 
is observed. In spite of this the patient continued sub- 
jecting, the limb to exercises. c 
d 
Illustration 75 
c) Five months after the operation. During his exercises 
the patient suddenly felt a crack in the limb. Probably 
a callus jag had broken. The bending of the fracture and 
of the nail is more narked. Straightening with the patient 
under anesthesia and application of an abduction cast for 
4 weeks. Once again the patient begins with exercises. 
No X-ray control!! 
d) 9 months after the operation, after the patient was 
brought to the special department of the hospital; 
pseudarthrosis and fracture of the nail. e 
f 
Illustration 75 
e) After the second operation: Conservative refreshening 
of the ends of the fragments. Removal of the broken nail, 
insertion of a longer double nail which however is also too 
short. Its tip just touches the spongiosa of the epiphysis. 
After the nailing the fracture is stabil. Therefore only 
a plaster cast U-splint was used with which the patient 
subjects the limb to exercises 3 weeks later. 
f) Six weeks after the second operation. "Narrow callus 
bridges" are thought to be observed in the dorsal direction 
and therefore it was decided to remove the splint. It was 
not observed however that it was not newly formed bone in 
question, but only the remnants of the old callus bridge. 
Moreover, the distraction of the fracture was not noted. 
The nail had slipped from the spongiosa of the head. The 
old nail bed may be recognized at its bone margins (!). 
Due to the fact that once again the patient suffers from 
pains 8 days later another abduction cast was applied. 
The fragments however were not pressed together. g 
h 
i 
Illustration 75 
g) 2 months later, after another operation: Pressing 
together of the fragments, graft plastic with the nail 
in place. The wires for the graft were only led around 
the bone and were not pierced through it. 
h) Thus, 3 months after the third operation the wires 
had slipped from the conically shaped end of the distal 
fragment and the fracture is somewhat distracted again. 
This, however, was not observed and because the fracture 
seemed to be clinically healed the patient was subjected 
to exercises again. 
i) Five months after the third operation; Further dis- 
traction of the fragments, further slipping of the wire 
loop at the distal end. Rotation pseudarthrosis between 
the distal fragment and the graft. According to his own 
report the patient has later used a hinged splint in which 
however another nail fracture occurred. Removal of the 
nail and another bone graft was without success. There is no doubt that several technical mistakes 
were made in the case of this patient. First of all 
it would have been necessary to use in the very begin- 
ning a double nail which should have been chosen long 
enough to have a good grip in the spongiosa of the head. 
Considering the wide proximal marrow canal it was in- 
dicated to nail the fracture from above; I had an 
opportunity to correct this mistake on the occasion of the 
second operation but this possibility was unfortunately 
not present in my mind and I saw on the spur of the 
moment only the possibility of introducing a now nail 
along the old one which was then still too short. And 
if I had finally fixed the fracture ends by a wire suture 
a new distraction would have bcr,n prevented,, During the 
bone graft the nail should have been replaced by a longer 
one and above all the nails should have been lead through 
the bone to prevent the slipping off, 
BOEHLER postulates for an additi oral longitudinal 
wire suture in all old fractures of I: re upper arm to 
prevent distraction, One objection was raised against 
this suggestion, namely the undesirable effect of the 
v/ire suture in case of an atrophy of the bone, which 
according to our experience is observed very frequently 
in fractures of the upper arm. In this case the wire 
suture may cut the bone and present a hazard. We con- 
sider the wire suture suitable only in exceptional cases, 
such as very old pseudarthroses. The bono atrophy in 
itself docs in our opinion not constitute a definite 
contraindication to marrow nailing unless it is not too 
advanced (in contrast to thigh fractures). The breaking out 
of the nail is hardly to be expected in the upper arm, 
because the lateral stress is not so strong as in the 
thigh. In case of an atrophic bono the fracture of the 
upper arm can be nailed from above and the nail can 
bo driven very deep into the distal epiphysis so as to 
firmly engage and to make a distraction impossible (ill. 76). 
Ill, 77 confirms that also very old connective tissue 
pseudarthroses of the upper arm with a positively stabile 
osteosynthesis will finally come to a fixation by solely 
using the nail without any additional wire suture. It is 
very important in these cases to leave the abduction 
cast on long enough in caso of such old fractures with 
atrophic bone and musculature and that the arm is carried 
above the horizontal in this plaster cast (this require- 
ment is often disregarded), After 3 to 4 weeks the part 
of the cast next to the forearm may be removed and the 
elbow may be moved freely. The rest of the cast is left 
in position for at least 8 weoks and will bo removed 
only If the movements arc free from pain and if the X-ray 
picture reveals a distinct callus formation. If one is 
not overonthusiastic about the nail and if the hazard of 
a distraction is always borne in mind, especially if the 
nail was introduced from below, there will hardly be any 
disappointment, 79a 
a 
b 
c 
Illustration 76 
a) month old fracture in the arn above the elbow 
(which had been treated in another hospital), a formation 
of callus had not been obtained. A marked proximal bone 
atrophy was observed after the open nailing operation. 
The nails forge a stabil union with the distal spongiosa. 
The patient started subjecting the limb to exercises ten 
days later. He was released from the hospital after a 
lapse of 18 days. Ambulatory treatment. 
b) Six weeks after the operation. The patient uses 
his arm fully and no distraction can be observed. Beginning 
formation of callus. Due to the conditions of war the 
patient did not show up for a late examination. 
c) 2| years after the operation. The fracture is com- 
pletely healed and the joint is freely movable. The nail 
was then removed. 79b 
a 
b 
c 
Illustration 77 
a) 1& year old (connective tissue) pseudarthrosis of the 
arm above the elbow after a compound fracture which had 
been treated primarily with a wire suture and which became 
infected. The wounds have been healed for 8 weeks. Marked 
atrophy, particularly of the proximal fragment. During the 
nailing operation only the connective tissue callosities 
were removed. The bone was so soft that it could be cut 
and the marrow cavities are easily located. 
b) The same fracture after the nailing. Abduction cast 
with which the patient subjects the elbow to exercises. 
After a lapse of 8 weeks he starts subjecting the arm above 
the elbow to exercises with the abuuction plaster cast in 
place. The cast was removed after a lapse of 12 weeks. 
c) After the removal of the nail four months after the 
operation. Healing was obtained. 80 
Finally we want to show by one more example that the 
stabile fixation of the fracture constitutes the most 
important factor for the final healing. This case is 
particularly interesting because the healing was achieved 
with too small a nail. The fracture complicated by a 
small skin wound in the distal third was provided with 
too thin and much too short a nail (ulna nail). The 
vjounds healed primarily, but a healing was not achieved 
after 8 months of treatment with a plaster cast (ill. 78a)* 
I suggested therefore, exposing the fracture, freshening 
the fracture ends and using a properly dimensioned nail. 
I did not foresee, however, that the nailing was again 
performed with an ulna nail. Nevetheless, the nail got 
a good hold because it bent right in the beginning of 
its introduction and came at a slant into the proximal 
narrow cavity, where it finally stuck. The patient was 
able to move the arm freely 5 weeks after the operation 
and when he was admitted to our special ward 6 months 
after the second nailing, the fracture was healed well 
enough so that wo could withdraw the nail, (ill. 78b). 
On the strength of these results (and despite the 
accidents which were due to technical faults), we feel 
that we cannot share the negative attitude of BOEHLER 
and are of the opinion that the treatment of old fractures 
and pseudarthroscs of the upper arm are best treated with 
the marrow nail under the condition , however, that a 
positively stabile osteosynthesis is achieved. 
IT, 
Fracture s^of^tiiG^ForG^rn^. 
Aa_0 steot ornYrUaiilu£_of _f r ac t ure 
Hlth^A^ulatioi] 
If a fracture of the two bones of the forearn heals 
in a faulty position, the rotary movement will be im- 
peded and thus reduce the use of the hand to a consider- 
able extent. The old osteotomy methods did not prove 
quite satisfactory in this type of fracture. The bones are 
not thick enough for the proper use of LANE’s plate which 
may, in case of an inadequate technique, have an obstruc- 
tive effect and delay the healing. The cut must be per- 
formed at a very acute angle to allow the use of several 
wire sutures. If only one suture is applied in case of 
short cuts (which as a matter of course must be drilled 
through the bone) there will be a considerable hazard, 
that new displacements will occur. It could thus be ex- 
pected that the marrov; nail would bring special advantages. a 
Illustration 78 
b 
a) Compound fracture of the arm above the elbow (treated 
in another hospital) with a small pierced wound. An ulna 
nail was used which was too short and too thin. In spite 
of the application of several plaster casts the entire 
fracture cleft is gaping. No formation of callus to be 
observed. 
b) The same fracture 6 months after the second nailing. 
The ends of the fragments indicate that only the scar 
tissue has been removed and the bone was not resected. 
Onoe.again an ulna nail was used. This nail jammed in the 
proximal marrow cavity because it angulated at the fracture 
cleft. In this way the osteosynthesis became stabil 
despite the fact that the nail was too short and too thin. 
Plaster cast for 10 weeks. The fracture healed. We have used the narrow nail in 6 osteotomies of 
the two bones of the forearm in which,as a matter of 
principle, both bones were nailed. 
It is again necessary that the fractures are lo- 
cated far enough away from the ends of the joints, 
so that a stabile osteosynthesis can be achieved. Special 
attention must be paid to the fact that an atrophic 
bone should not be nailed because of the hazard of a 
perforation by the nail. The marrow cavities must be wide 
enough to offer at least enough space for the thin nail 
(1). 
With regard to the appropriate technique, it may be 
said that the two bones should be severed, to begin with, 
and if possible at the old fracture line. Next, the 
bone ends of the ulna will be freshened (always at a slant 
or staircase-shaped) until they can be brought to a good 
abutment. Then follows a fixation with LAMBOTTlg bone 
forceps and the radius is put in the proper position. 
The result is checked by X-ray, (Attention to a possible 
luxation of the ulna in the distal radio-ulna joint,) The 
necessary corrections can now bo performed easily and no 
sooner than a perfect position is achieved, the bone ends 
will be brought together and the nailing will take place, 
preferably the ulna at first, because the nail may be driven 
in by approach from the fracture cleft, through the ole- 
cranon with its eye anteriorly. At the radius, however, 
one must proceed much as in simple fractures. If one pro- 
ceeds with the nailing without making sure that the cuts 
abut properly, conditions may arise similar to those 
shown in 111, 79aj 
After the performance of an osteotomy, wo nailed the 
ulna first and the position was satisfactory. When nail- 
ing the radius, however, it was discovered that there 
was again a gap in the ulna. So we had to withdraw the 
nail and resect the bone. After that, we still had a 
slight gap, the cuts not being fully congruent. This is 
not very important in itself. If, however, the nail is too 
short, as was the case in this instance ( a longer nail 
was not at hand) obstructing effects may develop and tilt- 
ing movements of the fracture cleft which might interfere 
with the healing process. The nail then works in the bone 
and may break through the corticalis (ill, 79b), A 
periosteal deposit of now bone will take place in case 
of an aseptic healing which will not cause any serious 
trouble, but the nail will have to be removed early, 
(111. 79c). 
Infections did not occur in these 6 osteotomies. a 
plaster splint was used in. all of the cases and the patient 
began to move the limb in this splint after 8 days. The 
splint was removed after 2 to 4 weeks. After 4 to 5 weeks 
the patients were able to make full use of their arms- '• 
and to perform their duties as usual. The advantage over 
the old osteosynthesis methods is quite obvious, 
(1) We are definitely against the '’inner splinting" using 
KIRSCHNER wires on the basis of our experiences gained in 
the treatment of fresh fractures. The simple wire is too 
elastic to prevent the undesirable lateral movements which 
cause a faulty healing. b 
a 
Illustration 79 
a) Fracture of both forearm bones which had healed in 
bad position. After the resection of both bones first 
the ulna and then the radius was nailed. The bones had 
not been put together before by means of LAMBOTTE's pincers. 
Due to the existence of a bone jag the fracture planes 
cannot come to a broad contact. Both bones should have 
been resected more thoroughly. The ulna nail is too short 
and the osteosynthesis is not absolutely stabil. Primary 
healing of the wound. The fracture is healed from the 
clinical point of view. The patient was released from 
the hospital for ambulatory treatment. 
b) The same fracture 7| months after the operation. For 
4 weeks after the operation the patient was able to use 
his arm without any impediment and to do all kinds of work 
with it. The radius bridged over by bone. At the ulna the 
greater part of the fracture is clearly noticeable. Round 
the tip of the ulna nail, which has penetrated the cortioalis, 
marked rarefactions and periosteal layer can be observed. 
The nail will be removed. c 
d 
Illustration 79 
c) The sane fracture after the removal of the nail. 
The nail canal and the cavity in the ulna are clearly 
noticeable. 
d) The same fracture three years after the operation. B, Old Fracturcg.gnd .PsGud.arthrog.eg 
It appears doubtful whether or not fractures of 
the forearm which are older than 1 week nay still be 
treated with the closed nailing method* We had no such 
cases in our clinic. 
15 of the 23 fractures nailed with exposure of the 
fracture site were up to 3 months old, that is in a con- 
dition in which a healing was still perfectly possible by 
using the old conservative methods. They all resulted 
in a bony healing with the nail. 
Isolated fractures of the shaft of the ulna were 
not among our cases. We had only one isolated fracture 
of the shaft, of the radius in which the nail could be re- 
moved after 2*2 months. 
An infection occurred in 4 of the 14 fractures of 
both bones- 
An infection of the entrance site of the ulna nail, 
which had been pinched off because it could not be driven 
in far enough, occurred in one of the cases. ,It was omit- 
ted to smooth the sharp edge with a file and an inflamma- 
tion developed. When a callus formation became clearly vi- 
sible at the fracture after 5 weeks, the nail was removed 
and an abscess developed at the fracture site 8 days later* 
It had been omitted to keep the arm in an elevated position 
after the removal of the nail. Eighteen days after drain- 
ing the abscess a small sequestrum was ejected, hereupon 
the wounds closed and the fracture healed with full function 
of the limb. 
In this fracture the osteosynthesis was stabile. In 
the following instance the fixation was only incomplete. 
In the fracture 'of 111, 80 only the ulna was nailed and 
the nail had been driven in hardly more than 2 centimeters. 
The point entered the corticalis (same as in 111. 79b) 
and when the nail was removed 3 months after the operation, 
a marginal sequestrum was ejected, whereupon the wound 
healed. Since the fracture was in good shape after the 
marrow nailing and thanks to the plaster cast T/hieh was 
left in position long enough, the full use of the limb 
was finally restored* 
The result was, however, bad in the two other frac- 
tures, because the nailing did not come up to the tech- 
nical requirements. 
In the 8 weeks old fracture of Ill„ 81, only the 
radius is nailed (incorrectly by approach from the head). 
The fracture ends were resected, it was omitted, however, 
to resect the ulna fracture at the same time, which apparent- 
ly had already solidified to a considerable extent. Thus 
a defect of about 5 millimeters developed in the radius. 
(111. 81a). The operation lasted for lg- hour, so it is 
no wonder that an infrction ensued. The wound being opened 
widely in proper time and the limb put at rest, an infection Illustration 80 
Six week old closed forearm fracture two months 
after nailing. Only the ulna was nailed. Infection 
of the wound. The nail, which is much too short, has 
perforated the corticalis of the distal fragment. a 
b 
Illustration 81 
a) Eight week old forearn fracture after the nailing 
which was made in another hospital. Only the radius was 
nailed (erroneously from near the head). The fracture planes 
had been resected. Due to the fact that the ulna was already 
stabil a distraction of 5 mm occurred. After the development 
of a wound infection it was immediately widely opened and 
a plaster cast was applied. In this way an infection of 
the bone was avoided. 
b) The same fracture 6 months after the operation. 
Luxation in the distal radio-ulnar joint. In this way 
the fragments of the radius were pressed together and 
healed. Pronation stiffening of the arm and impediment 
of the wrist extensors. 83 
of the bone was avoided. But a luxation of the 
distal radio-ulna joint developed and the final re- 
sult, (as shown in 111. 81b) is a pronation position of 
the arm with considerable impediment of the outward ro- 
tary movement and of the flexion of the wrist joint. But 
for the distal luxation which caused the radius fragments 
to come in contact, the radius would not have healed at all. 
In case of the fracture of 111, 82a, the first 
mistake was made in tho determination of the length of 
the nail according to the X-ray picture and secondly 
in that the nail was applied in the wrong way and that a 
radius nail was used for the ulna. The surgeon was 
apparently entirely indifferent about the X-ray picture, 
otherwise it could hardly have escaped his notice that 
the nail was too narrow for the proximal marrow cavity of th- 
radius. The marrow cavity was split when the nail was 
forced into it and it was not noticed that the nail 
no longer was in the bone. For fear that the same might 
happen at the ulna, the latter was "nailed" with KIRSCH- 
NER wires, (111, 82b) although a nailing would have been 
easily possible with a thin ulna nail. In this case, 
therefore practically nothing was achieved with the nailing, 
the fracture shifted repeatedly in the plaster cast and 
had to be corrected several times. Severe swelling and 
blebs developed in the plaster cast, due to tho insufficient 
reduction and fixation of the fracture. When the patient 
was admitted to the special ward, five months after the 
operation, the wounds as well as the fracture had healed. 
The fracture revealed a displacement of abcut the width of 
the shaft and a slight angulation (ill. 82c). The result 
was a complete impediment of the rotary movement, limita- 
tion of mobility of the hand joint by about 50% and of 
flexion in the elbow by 90°. 
One must admit that both fractures would have healed 
more quickly and presumably with a better result if 
they had been treated by the conservative methods. But in 
these cases the marrow nailing method cannot be blamed for t! 
failure but rather the faulty technique. If suitable 
nails were not available, the operation should not have been 
performed. 
If the fractures are less than 3 menths old, nothing 
should be resected off the bones, because the best abut- 
ment of the two bone ends is guaranteed if they are not 
resected. The marrow cavities are easily found. Neverthe* 
less it is recommended to proceed in the same manner as in 
the osteotomy, that is to reduce both bones with LAMB0TTE*s 
bone forceps before the nails are driven in. We have 
once seen a defect of several millimeters sustained at the 
radius, although nothing had been resected. In such cases 
it will be necessary to shorten the second bone accordingly 
in order to secure a wide abutment, A faulty healing is 
imminent if a wide abutment is not obtained. 83a 
a 
Illustration 82 
b 
c 
a) Nine week old fracture of the forearn. This picture 
was taken to determine the correct nails. Mistakes: A 
radius nail was placed along the ulna and the nail along 
the radius is not placed the right way. The marrow 
cavity of the proximal fragment is quite noticeable. 
It is much too narrow for the nail. 
b) The same fracture after the nailing which was made 
in another hospital. The nail of the radius is lying 
beside the proximal fragment. A KIRSCHNER wire had been 
used for the ulna, the marrow cavity of which would cer- 
tainly have been broad enough for the insertion of an ulna 
nail. Infection of the wound. 
c) Five months•later. The displacement of the fragments 
is equal to the width of the shaft. They are somewhat 
angulated and healed. Rotary movements are no longer 
possible and the function of the wrist amounts to only 
50 %. If the appropriate technique is applied the re- 
sult of the nailing of old double fractures of the fore- 
arm will be good. The 10 remaining fractures healed 
in a good position v/ithout any impediment whatsoever. 
The average stay in the hospital was 56 days and the 
unemployability was 115 days on the average. 
It may safely be said that the nailing of the old 
forearm fractures brings definite advantages. It is in- 
dispensable, however, that a really stabile osteosynthesis 
is achieved and this is possible only if both bones are 
nailed. In due consideration of the increased infection 
hazard, the operation will be performed only if one does 
not succeed in obtaining a satisfactory reduction by 
using conservative means or if no callus formation is ob- 
served after 3 months. 
Special attention must be attached to an accurate 
adaptation and fixation of the bone in those fractures 
which are older than 4 months, that is to say if we have 
to deal with a pseudarthrosis or if the development of a 
pseudarthrosis is imminent. In these cases it will re- 
gularly be necessary to freshen the fracture ends* 
The most favorable conditions prevail if there is 
no healing of the two bones* In this case the ends of 
the fracture can be brought together in such a way that a 
wide abutment is achieved and if sufficiently long nails 
arc used a stabile osteosynthesis is guaranteed. The 
technique in this case is the same as usually applied in 
osteotomies. In three cases of (connective tissue) 
pseudarthrosis, 7 to 12 months old, a complete recovery 
was achieved (ill, 83)* 
If a pseudarthrosis exists in only one bone a wide 
and positive abutment of the bonescan be achieved only 
in case of oblique fractures. 
If the fracture site is sparingly freshened obliauely, 
a positive abutment can be achieved under certain circum- 
stances, especially if the nail used is long enough. We 
'were successful in two radius operation of a 5 and 7 months 
old (connective tissue) pseudarthrosis. Both cases re- 
sulted in good bony healing, (ill, 84)* 
If the fracture ends do not firmly abut, as was the 
case in the above mentioned ulna pseudarthrosis (HAEBLER, 
a,a,0. 111. 88) and if in addition the nail is too short, 
or if even only a KIRSCHNER wire is used for the !,nailingn 
as was done in the I'year old ulna-pseudarthrosis, a faulty 
healing will be unavoidable. 
The hazard is erreat, that a defect develops as a re- 
sult of the necessary resection of one bone in case of a 
pseudarthrosis and that the second sound bone will have 
an obstructive effect and thus jeopardize the healing 
process. The solution imposes itself of resecting the 
other bone and using a marrow nail* a 
Illustration 83 
b 
a) Five month old fracture of the forearm. Three weeks 
after the accident radius and ulna were exposed and the 
ulna was fixed by means of a wire loop. After the removal 
of the plaster cast 4 weeks later, that loop had slipped 
and therefore the entire fracture was not stabil. 
b) The same fracture after the open nailing of both bones. 
Stabil osteosynthesis. The patient was released to his unit 
4 weeks after the operation. c 
d 
Illustration 83 
c) The same fracture 8 months after the operation. 
The fragments are healed and rarefactions around the 
nails cannot be observed. 
d) After the removal of the nails. a 
Illustration 
b 
a) Five month old oblique pseudarthrosis of the radius. 
Only the scar tissue located between the ends of the bones 
was removed. 
b) Ten weeks after the operation most of the fracture 
cleft is bridged over. The nail was removed 1+ weeks later. We proceed that way in all cases (except in old 
fractures due to gunshot) and we would like to describe 
the course of a lj year old pscudarthrosis of the radius 
(111. 85). 
In this case, a bone graft had been performed 9 
months previously, which due to infection lead to the 
ejection of the bone graft and resulted in a faulty 
healing. The marrow cavity was so narrow that 
an ulna nail could be used. This nail became so firmly 
engaged in the cavity that a shorter nail had to be chosen. 
A relatively short nail had also to be used for the ulna, 
because of the age of the fracture. As a consequence the 
fracture remained movable in an axial direction after the 
nailing and the osteosynthesis was instabile* (ill., 85b) 
An infection associated with a formation of sequestra 
which developed at the fracture cleft of the radius lead 
to a fresh luxation in the distal radio-ulna joint and to 
a wandering of the radius nail (ill, 85c), The final result 
was a defect pseudarthrosis with luxation at the distal 
radio-ulna joint, that is a condition which was worse than 
before the operation. 
It must be .admitted that we had to deal with an in- 
creased infection hazard and that the instabile osteosyn- 
thesis was responsible for the bad result. On the other 
hand, we have made similar experiences in isolated pseu- 
darthroses following fractures due to gunshot and wo re- 
frained from making further experiments. The hazard of an 
infection and the complications which ensue in such cases 
by the use of the marrow nail in the exposed nailing of 
old fractures of the forearm must be given serious con- 
sideration. 
For the same reason we do not see our way clear to 
adopt the recently renewed suggestion of resecting a corres- 
ponding piece of bone off the second bone for the pur- 
pose of inserting it into the defect with the marrow nail. 
On the strength of the results observed in patients nailed 
outside our clinic, we deem this method even more hazardous 
than a bone graft. 
In due consideration of these facts wo have refrained 
from nailing isolated pseudarthroses of a bone of the fore- 
arm if it could not be expected or if the operation re- 
vealed that a proper abutment of the fracture could not 
be achieved. In these cases we rather grafted a tibia 
strip and have always achieved (7 cases) a bony healing. 
Summary 
The hazard of an infection of the fracture cleft 
is considerably higher in the open than in the closed 
marrow nailing. The indication must therefore be checked 
very carefully. a 
Illustration 85 
b 
c 
a) lj year old pseudarthrosis of the radius. 9 months 
ago a bone graft was done and it became infected. (The 
nails had been laid alongside in the wrong way). The 
marrow cavity of the distal fragment of the radius is 
too narrow for a radius nail. 
b) After the nailing. In the radius only a thin ulna 
nail was used which however jammed so much in the proximal 
marrow cavity that it was impossible to insert it any farther. 
Also only a short nail was driven into the resected ulna 
because of the old fracture. Consequently the osteosynthesis 
was not stabil. Infection of the wound. Several sequestra 
were cast off from the radius. 
c 
c) Four months after the operation. The ulna is healed. 
Luxation of the distal radio-ulnar joint. Defect pseudarth- 
rosis in the radius out of which the nail has slipped distally* 86 
Long duration of tho operation, improper technique 
and especially an incompletely stabile osteosynthesis arc 
the main causes of infection. 
In those cases, where a stabile osteosynthesis cannot 
be expected from the very beginning it is better not to 
nail and to have recourse to the old methods of osteosyn- 
thesis, The nail constitutes in these cases a far greater 
hazard than the wire suture or plate. 
As a rule a (long) drain is to be inserted at the 
physically proper place in all cases of open marrow nail- 
ing and the limb will be put at rest in a plaster cast 
until tho infection hazard has definitely been overcome. 
In case of a relatively stabile osteosynthesis (tibia) 
there is a particular proneness to late abscesses if 
the limb is used too early* It is therefore recommended 
to use additional means of fixation such as a walking cast 
until the fracture has positively healed. At any rate, 
the fixation has to be instituted right away if the patient 
complains about swellings or pains. 
If an infection occurs (fever) it will be necessary 
to open tho wound widely to prevent the infection spreading 
into the marrow . 
The infection hazard is especially great in the osteo- 
tfiffiX-Of^fracturcs_of__the__thigh healed with angulation. 
Particularly so if the fracture has healed a long time be- 
fore the operation when it will be very difficult to re- 
store the accurate anatomic conditions. In these cases 
one should rather put up with a shortening and shorten the 
Bound leg with the nail. 
The nailing osteotomy should as a rule be performed as 
early as possible in femur fractures, healed with angula- 
tion. 
Those fractures in which a stabile osteosynthesis can- 
not be achieved are not suitable for nailing. 
In case of a considerable shortening or displacement thr 
operation should be performed in two sessions. The first 
session includes osteotomy and wire extension and when tho 
shortening is compensated for by this treatment, thenopenH 
nailing will follow. 
If we have only to deal with a peripaeral dislocation, 
the nailing osteotomy will be performed remote from the 
fracture at the "site of choice". 
The results of the correctly performed nailing osteo- 
tomies of femur fractures healed with angulation, are su- 
perior to those of all other methods hitherto known, 
01d_thigh_.fractures which are not older than 5 weeks 
may be treated with the closed nailing method and will 
then benefit by all the advantages which the nailing offers 
in the treatment of fresh fractures. 87 
An important conditions is, that the fractures are 
thoroughly mobilized even though they may still appear 
quite movable, A reduction apparatus facilitates this 
operation greatly. 
In case of a considerable shortening one must wait 
after the mobilization of the fracture until this shorten- 
ing is compensated for or ovcrcorrected. 
Femur fractures which are older than 5 weeks should 
not be treated by the closed nailing method because of the 
increased hazard of fat embolism. 
The (connective tissue) thigh pseudarthrosis does 
not call for a resection of the bone. 
Atrophy of the bone excludes treatment by open 
marrow nailing of old femur fractures. All fractures 
which are located less than 6 centimeters away from the 
tip of the trochanter and from the knee joint are not 
suitable for nailing because the osteosynthesis has little 
chance to become stabile. 
If the osteosynthesis is good, the results of the 
marrow nailing method are definitely superior to all 
other methods and the infection hazard is low. 
In the osteotomy of tibia_fractures healed with angu- 
lation the marrow nail does not constitute any advantage 
over the old methods. In case of an infection the nail 
means an additional hazard. Therefore, the old methods of 
ostcosynthosis should bo given preference in this typo 
of fracture. 
01d_tibia_f racturc s_ wit h_a_dcQayed_fpr mat ior]_pf_ callus 
may be treated up to 20 weeks after the accident by closed 
marrow nailing if the fibula is resected and if the fracture 
is thoroughly mobilized. If these points are observed, the 
indications and advantages will be the same as in fresh 
fractures, 
In cases of a considerable shortening and in very 
old or previously compound or infected fractures, a wire 
extension is applied for a period of 8 to 15 days following 
the fibula resection and mobilization. 
In the opon_22aiiin£_£f_old_tibia_frac there is a 
serious infection hazard which threatens the limb and some- 
times the life of the patient., if the osteosynthesis is 
not absolutely stabile. Utmost care is therefore necessary. 
If a positively stabile osteosynthesis is achieved 
and if the appropriate technique is applied, good results 
may be expected and the nailing proves superior to all 
other methods. 
If the fracture is, however, older than 6 months, the 
marrow nail will not bring substantial advantages, regard- 
loss of whether wo are dealing with an unhealed fracture or 
a genuine pseudarthrosis. In these cases we can hardly 
expect a stabile osteosynthesis and a shortening cannot be 
avoided by the use of the marrow nail. If an infection occu this means complications which weigh more heavily than 
in other methods. 
The marrow nail is indicated in the ost 
fractures of the upper healed with angulation, 
if a stabile osteosynthesis can be achieved. It fits 
the purpose to resect the fracture ends (staircase shape) 
far enough, to open the marrow cavities. An additional 
wire suture is not considered necessary. 
03rd fractures of the humerus may be treated by a 
closed nailing up to 6 weeks after the accident, on the 
conditions that they are thoroughly mobilized prior to 
the operation. The results then will be comparable to 
those obtained in fresh fractures. 
The infection hazard is insignificant in the nailing 
of old fractures of the humerus with exposure of the site. 
The staircase shaped resection is imperative in the 
genuine pseudarthrosis which must be performed wide enough 
that sound bone is exposed. This resection is not neces- 
sary if we have to deal v/ith an unhealed fracture, 
A faulty healing is often caused by distraction due 
to the weight of the arm if the osteosynthesis is not 
stabile. A longitudinal suture will avoid this distraction, 
but it is of no use if the bone is atrophic. 
Atrophy of the bone is not a contraindication to 
the nailing of old fractures of the upper arm. The 
nails used in this case must be long enough so that they 
may be driven in as far as into the spongiosa of the epi- 
physis, An abduction cast in which the arm must be ele- 
vated above the horizontal will be necessary until the ' 
musculaturo is again strong enough, 
» 
The marrow nail is superior to all other methods for 
obtaining a stabile osteosynthesis in the fractures pf 
both bone.fi of the forearm headed v/ith angulatiop, 
As a rule both bones have to be nailed. The nails 
will only be driven in if the bones are properly resected ar. 
brought in position. 
The closed nailing will generally not bo possible in 
old fractures of the forearm. 
The infection hazard is rather great in the nailing 
with exposure of the site, so that the indication must 
be thoroughly checked and the operation should be restricted 
to those cases in which a satisfactory reduction cannot be 
achieved by the conservative methods. 
In case of pseudarthroses of the bone it will be 
possible only very rarely(in transverse fractures) to 
secure a wide abutment and accurate fixation of the fracture 
ends. The attempt to obtain bettor conditions by resection 
and nailing of the second bone, seems to be more hazardous 
than a bone graft1* 89 
The marrow nailing brings about excellent re- 
sults in case of a pseudarthrosis of the; two boneg 
if a stabile osteosynthesis is achieved. 
A KIRSCHNER wire will in no case be a substitute 
for a narrow nail, 
/ 
c t ed_f r ac tur es_due_ to_£uns ho t_injur i os 
Up to now the surgeons were guided by the rule that 
an osteosynthesis by use of a foreign body in infected 
fractures could take place no earlier than 9 months after 
an uneventful healing of the wounds, 
FRITZ KOENIG has, however, even before 1931, performed 
osteosyntheses using foreign bodies in infected fractures 
of the tibia. He considered this procedure as an emergency 
measure and the progressive development of the conserva- 
tive treatment (wire extension) reduced the number of these 
emergency cases to a minimum. The remembrance of these 
cases and the many osteosyntheses of fresh compound fractures 
which I saw during my time as his assistant at Wuerzburg 
and in my own practice convinced me that a stabile osteo- 
synthesis with the marrow nail should be possible before 
that period of time and oven in still fistulating wounds, 
since the complete fixation assists the struggle of the 
body to overcome the infection and the nail will not have 
the slightest ill effect if in proper position, as has beer 
shown by the course of the infection in case of open marre 
nailings. 
Already in 1941> I have successfully nailed a still 
purulent thigh fracture with concomitant performance of 
the necessary sequestrotomy. Also in the military hospital 
under my jurisdiction as a military consultant we nailed 
old fractures due to gunshot injuries with the wounds still 
in the fistulating stage. The majority of these operations 
were performed by younger colleagues who were enthusiastic 
about the method and liberal with regard to its indication. 
We, therefore, had very serious complications besides good 
results. The complications were particularly serious in 
cases without a stabile osteosynthesis. I finally had to 
assume the responsibility as to the indications and 
carried out most of the operations myself. For this purpose 
the patients were transferred to my special ward and with 
growing experience the results improved. The indica- 
tion was checked with an increasing accuracy. 
As is quite logical in military hospitals in the 
homeland, we had only very few cases of fresh fractures 
due to gunshot injuries. We dispose, however, of the 
history of 126 cases of old fractures due to gunshot injuries 
treated by the narrow nailing method, at a tine, when the 
wounds had just healed or in many instances were still 
fistulating or purulent. These cases included 51 femur 
fractures, 28 tibia fractures, 39 fractures of the humerus, 
8 fractures of the forearm. One femur fracture and three 
tibia fractures could not be observed’ until final healing. T lA B 1 e VII 
Marrow nailing of old fistula ting fractures of the tibia 
Nr"' 
| Time between injury 
and operation 
- 
Type and site of the 
fracture 
Condition of 
the wounds 
Nailing 
0 0 
k-g 
CO ts 
CO 
t 
Osteo- 
synthesis 
Addit 
fixat 
l 
§ 
•n 
\ « 
P 
c+ 
*i#n. 
/ion 
h 
0 H 
H P 
f S- 
P G 
jjj 1 
1 
CO 
'n 
e 
I—3 
Treatn 
•f 
Wounda 
nu 
53 ft 
C ►O H 
5 *1 b 
>< 0? 
. H • P 
O c-t 
Hj 03 ; 
ct- P 1 
c+ ;j 
§ 
O 
kt. COURSE OF HEALING 
Stay in hospital 
after the nailing 
operation 
Healing 
of the 
fracture 
FINAL RESULTS 
T 
Remarks 
m 
J3 CD C* 
M HW 
c+P cr 
P> & H* 
O' c H 
H- O 
1 h w 
Ci) c+ 
P. 
0 
H* 
H 
O 
1 .. 
tjj the wound 
,1? 1 Q -1 
/, /-I4 > CO 
1 : 1 t 
H-‘ Q O CO 
F ar so 4 hj p 
., co 03 < 3 ha 
OX) OH*Od 
B ro c+ cj hi 
J Ui id CD 
,:5 co d c+ 
CO 
0 
po 
£ 
0 
w 
ct- 
i 
0 
w 
ct* 
0 
0 
B 
vj 
0 
M 
H« 
c+ 
H* 
in 
Posi- 
tion 
Shor- 
ten- 
ing 
Joints 
HH 
K i 
V 1 
{0 PN 
H*0 
0 
C_!. 
C_l. 0 
0 H* 
H-P 
P c+ 
ct 
1 
5 
days 
Short comminuted fraci 
ture in the middle,po- 
sition satisfactory 
s torn up 
- strongly pu- 
rulent 
0 
R 
I 
Sd.'.ous sup- 
0/0 duration 
. GA 
i 
- 
11 
months 
bony 
good 
3 cm. 
A-stiffenc 
k-4 
3 See 
111.99 
1 
1 
2 
weeks 
Transverse Fracture 
just below the rrdddle, 
slightly splintered, 
Position satisfactory 
Granulating 
Fistulating 
Prox. fragment 
lies free in 
the wound 
0 
R 
R t 
5 
1 
,'per gran. 
D/O .'moderate 
' -.v.ppuration 
— 
after) 
r emo-! 
val of) 
the, 
nail 
- 
9j 
months 
delayed 
bony after 
resection 
of fibula 
good 
J cm. 
A- 1/5 
K- 180- 
90° 
See 
111.100 
3 
j 
6 
weeks 
Short oblique fract. 
in the middle, slight- 
ly splintered, slight 
valgus and recurva- 
tion sequestra 
Fistulating 
■ Removal of 
sequestra 
necessary 
0 
S 
BS 
! 
k 
v gran • 
D/q derate 
.uppuration 
. 
7 
months 
bony 
good 
— 
free 
1 
1 
. 
+ 
8 
weeks 
Short comminuted frac- 
ture in the middle, 
Sequestra, Recurvatioi 
■ Fistulating 
Removal of 
1 sequestra 
necessary 
0 
S 
r 
D/O supp.per 
' > ran. 
•if 
si 
months 
bony 
good 
2 cm. 
i 
A- 1/3 
K- 130- | 
90° ! 
5 
■»—— 
1® 
weeks 
Greenstick fracture 
just below the middle 
with broken out bend- 
ing wedge,sequestra, 
slight valgus and re- 
curvation 
Fistulating' 
Removal of 
sequestra 
necessary 
0 
R 
only one 
nail 
B2 
| 
f 
/ 1. and GA 
D/A ,edious supp. 
try sip el 
- 
- 
14 
months 
bony 
; good 
1 cm. 
Li f 
A- 2/3 
K- 180- 
100° 
Due to the 
defect of 
the bendg. 
wedge,the 
nail pene- 
trates re- 
peatedly 
into the 
soft parts 
at the 
distal fra, 
ment. 
i 
i 
6 
! 
| 
11 
weeks 
Oblique fracture 
slightly below middle 
sequestra, positions 
satisfactory 
Fistulating 
Removal of 
sequestra 
necessary 
0 
R 
P 
1) 
d/a 
long supp. 
- 
- 
9 
months 
bony 
after re- 
section of 
fibula 
good 
1 
2j cm. 
A« 1/3 
180- 1 
80° 
7 
4j 
weeks 
Isolated short com- 
minuted fracture of 
the tibia,middle,po- 
sition good 
Granulating- 
slight se- 
cretion 
c 
R 
BS and 
later 
P 
d/a 
•’edious supp. 
of the fract. 
;:nd entrance 
vound 
ifif 
repea 
tedlj 
10 
months 
bony 
good 
- 
A* J 
K* 180- 
80° 
See 
111.101 
8 
5 
weeks 
Isolated tibia frac- 
ture ,middle ,small 
bone splinter broke 
out which sequest- 
rates, slight re- 
curvation 
Fistulating 
Sequestrum 
can bo re- 
moved by en- 
larging 
opening of 
fistula 
c 
i 
S 
• 
i i 
I 
i » 
! 
n w ; losed after 
/u / weeks 
. i 
1 
! * 
, 1 . 1 
- 
- 
3 
months 
1 
bony 
good 
i 
l 
i 
j 
i 
f \ 
free 
! 
i 
J 
I 
iiwniiim.il pm 
£ ; isox. transverse fract* Fistulating \ i , -- c5’ 
g i weeks *of the tibia,slightly , Removal of | 0 R j p 
' i »below middle,sequestr.,; Sequestra 
slight recurvation. ; necessary 
—— i ■ L- L i i 
d/o 
» 
1 
j 
reaious su|>- 
puration 
if* 
4. 
11 
.months 
|delayed 
sopjLd_aft. 
resect.of 
fibula 
• " r 
godd 
■£ 
icm 
A -i- 
K- free 
r 
.. 
1 
Lo 
i 
i 
7 
weeks 
|Isol.oblique fracture 
iof the tibia,middle 
sequestrum, po- , 
sition good 
Fistulating 
Sequestrum re- 
moved by enlar- 
ging the wound 
— 
1 ° 1 
by appr.; 
from i 
the dist 
side . 
s 
1 
i 
BS 
Later w&2$ 
cast 
D/o 
S at en— 
1 trance 
wound 
closed after 
6 weeks 
- 
H 
months 
bony 
good 
1 
- 
j 
1 
ii 
7i 
weeks 
Isol. short oblique 
fracture of the tibia 
with sequestrum po- 
sition good 
Fistulating 
Sequestrotomy 
by enlarging 
the wound 
C 
s 
P 
d/o 
healed after 
14 weeks,aft. 
ejection of 
sequestra 
* 
- 
6 
months 
bony 
good 
1 
a - 
cm 
A-i 
K-free 
- 
12 
5 
months 
Isol. short oblique 
fracture.,middle,de- 
fect df 0.5cm.,lateral 
displacement by width 
of shaft, fibula solid 
Fistulating 
0 
not 
resect. 
s 
BS 
0 
Per 
granulationem 
- 
- 
Si 
months 
delayed, 
bony after 
resection 
of fibula 
good 
1 
CQL 
free 
* 
r.-j 
! 
1 
1 
t 
i 
i 
1 
! 
i 
1 
13 
7 
months 
Transverse fracture 
just above the middle 
line,lateral displ. 
more than width of 
shaft, fractured cleft, 
Covered, articulus 1 
talocruralis stiffened 
, . — , ■ = 
Fistulating 
Sequestrum pal- 
pal lo | 
L-—. ■ — , 
0 
<lb. not 
resect^ 
s 
• 1 
P 
d/a j 
Per 
granulationem 
- 
9 
months 
Nail re- 
moved aft. 
3 months, 
fract. sprgj 
becomes 
solid with 
walking 
cast 
. good 
1 
cm 
A-stj ff 
(alread. 
bef.oper. 
K—IOC— 
180° 
See.111. 
103 
14 
10 
months 
Transverse comminuted 
fracture,middle,Displ. 
by 3/4 of width of ' 
shaft, recurvation, 
hardly any formation of 
callus, gap at fracture 
cleft, fibula solid 
sequestrum, anklo joint 
stiffened, knee 180 - 
l60° movable 
Fistulating 
0 
Fib 
resect, 
s 
* 
P 
d/o 
Per 
granulationem 
- 
- 
7 
months 
* 
f 
1 
bony 
- 1 
good 
1 
cm 
A-stiff 
K-130 - 
100° 
—1 
1 
1 
i 
1 
1 
i 
i 
! 
5 
j 
15 
18 
months 
Defect fracture,loca- 
ted at the lino defin- 
ing the median and 
lower third, position 
good, sequestrum ejec- 
ted 14 days previous- 
ly, fibula sqlid 
Fistulating 
C 
Fibula 
Osteot. 
s 
Bsj 
weight- 
bearing 
after 14 
days 
Entr;u-.icd 
Wound o.ii 
the n.:L 
suturea 
Abscess at 
the entr.wound 
of the nail 
GA 
* 
ilso 
if ter 
heal, 
of 
the 
'ract,, 
- 
10 
months 
bony 
good 
2 
cm 
A-i 
K-free 
t 
Re-operat. 
because of 
Ver halt ling, 
in the nail 
canal. Nail 
corroded w. 
begin.fract 
of tho nail 
j 
i 
i 
i 
1 
• 
_J_ 
i 
Still a 102