UNITED STATES FLEET 
UNITED STATES NAVAL FORCES, GERMANY 
SENIOR U. S. NAVAL LIAISON OFFICER 
ATTN.: TECHNICAL SECTION (MEDICAL) 
Room 111, Headquarters 
Fourth Medical Laboratory 
Heidelberg / Germany 
APO 403, U.S. Army 
File: p 3-5 
Serial: 252-Med. 
20 October 1948 
From: Senior U, So Naval Liaison Officer, EUCOM HQ., 
Attn: Technical Section (Medical), APO 403, U.S.Army 
To: Chief, Bureau of Medicine and Surgery, 
Attn; Chief, publications Division. 
Via: (1) Technical Officer, U.S. Naval Forces, Germany, 
(2) Chief of Naval Operations (0p~32-F2). 
Subject: Marknagelung (Medullary Nailing) - Additional Trans- 
lation - Forwarding of. 
Reference: (a) Letter P 3-5, Serial 243-Med, dated 22 April 1948 
from Assistant Technical Officer (Medical) U.S©Naval 
Forces, Germany0 
Enclosure: (A) Copy of Subject Translation (Project II, Folio V) 
Discussion of other uses of the medullary nail, by 
Professor Dr. D. HAEBLERo 
1. Because of its bulk Enclosure (A) will be forwarded under 
separate cover to each of the below listed recipients of a copy of this 
letter. 
) 
2. Folio IV of the same project was forwarded with Reference 
(a) and contained a review of the treatment of fresh fractures of the up- 
per and lower limbs with the medullary nail. Folio V represents the con- 
tinuation of the same publication by Prof. Dr. C. HAEBLER and contains a 
discussion of other uses of the meoullary nail. 
3» The editing of this folio was completed by Commander Harry 
J. ALVIS,(MC), USN., as Head of the Medical Section before his return to 
the United states. The mechanical completion of the folio was continued 
by a portion of the Medical Section which is presently operating under the 
administrative supervision of the Senior U.S. Naval Iiason Officer, EUCOM 
HQ., APO 403. 
4. Attention is invited to the fact that this folio is from an 
unpublished manuscript prepared for the U.S. Navy and publishing rights are 
therefore a property of the Bureau of Medicine and Surgery, Navy Department. 
5» The reserve supply of this folio is limited, It will be 
forwarded to the Bureau of Medicine and Surgery, Publications Division, 
on a Government Bill of Lading. Requests for additional copies or fur- 
ther distribution should be directed to that office. 
/ A' // , 
Captain, U.S.N© 
Senior U. S. Naval Liaison Officer. 
cc: 
p.t.o. Page 2 of letter dated 20 October 1948, Serial 252-Med,, to Chief, 
Bureau of Medicine and Surgery, Attn: Chief, Publications Division* 
cc: 
ONA, OMGUS, 
CNO (0P-32-F2) 
BUMED (Publications Division) 
BUMED (Research Division) 
BUMED (Professional Division) 
National Naval Medical Center, 
Navy Medical school 
National Naval Medical Center, 
Naval Medical Research Institute 
Army Medical Library, 
Department of the Army, 
Office of the surgeon General 
Department of the Air Force, 
Office of the Surgeon General 
U. S* Public Health Service, 
Office of the Surgeon General 
U*S* Veterans Administration 
Office of the Chief Medical Director. EXPERIENCES WITH THE MARROW NAIL OPERATION ACCORDING TO THE 
PRINCIPLES OF KUENTSCHER 
PART II a 
by 
Prof, Dr. C. HAEBLER 
Translation prepared by: 
U*3, Naval Technical Unit, Europe, (Medical Section) 
Office of Naval Advisor 
Office of Military Government (US) 90 
aJ_Frac tur gs_o f _t he_Femur_due_1: o 
guja s ho t_ in juries • 
5 fatal cases occurred all in femur fractures, so 
that this type of fracture has the relatively high mor- 
tality rate of 10$. 
3 fatal cases which were treated outside our clinic 
have been dealt with in detail in another place (HAEBLER, 
a.a.O, page 29 and Arch.Klin.Chir. 207, (1944) page 517). 
The cause of death in one cases was sepsis due to an in- 
sufficient treatment of the wound infection, in one case 
death due to fat embolism and in the third case by operat- 
ing shock. 
Patient Nr.4 who was also treated outside our clinic 
also died from operation shock. 
This patient suffered from a 4 months old fracture 
due to gunshot injury which was still fistulating 
and the X-ray picture revealed several sequestra. On the 
third day on the occasion of an inspection of the wound, 
a collapse and stagnation of the respiration occurred after 
the administration of 3cc, of Evipan, so that the operation 
was postponed. 14 days later a blood transfusion (0 donor) 
had to be interrupted because of nausea and labored breathe 
and in the following days the treatment was always jeopar- 
dized by a pronounced vasolability. Although an intensive 
treatment of the general circulation had been carried throug 
duriftg three weeks prior to the operation and although 
the patient endured the removal of 6 large sequestra with- 
out special difficulty, the pulse rate rose to 140 when the 
connective tissue scars of the fragments were mobilized. 
The nailing was performed in spite of this situation and 
offered no difficulties. The general circulation did not 
recover although infusions and heat stimulants had been 
administered during the operation. The patient died 9 
hours after the operation. The post mortem findings re- 
vealed a fatty degeneration of myocardium and liver and 
a generalized anemia, but no fat embolism. 
There is no doubt tha.t the nailing caused the death 
in this case. The nailing of a femur fracture is a major 
operation no matter how smooth its performance may be. 
This fact must be borne in mind especially in fractures 
due to gunshot injuries which not infrequently have only 
a "vita minima". 
The case Nr. 5 was a late casualty having no direct 
connection .with the marrow nailing operation. 
The patient in question suffered 
from a one year old compound fracture of 
the femur which still drained pus with offen- 
sive odor and in which a 3 centimeter long 
tubular seauestrun had developed. Knee-and 
hip joints wore stiffened to a considerable 
extent. Repeated attacks of colic and large 
numbers of leukocytes in the urine suggested 
the formation of calculi in the left kidney 
although stones could not be demonstrated. Considering the atrophic bone we did 
not proceed to the nailing without hesi- 
tancy as a last attempt to save the limb, 
Tho patient, an active officer, insisted 
upon having the operation performed. The 
osteosynthesis was stabile in the beginning. 
The nail loosened very soon, however, so 
that rotary movements of the distal fragment 
became possible. Four weeks after tho oper- 
ation, we observed in addition to a large 
decubitus, on the os sacrum, an empyema of 
the knee joint. The decubitus -did not heal 
in spite of a permanent bath and other mea- 
sures and the general condition of tho patient 
became worse, so that the limb had to be 
amputated in the thigh eight weeks after the 
narrow nailing operation. Tho patient re- 
covered at first. Later wo observed gravity 
abscesses, septic hemorrhages and infection 
of tho hip joint. After the resection of the 
hip joint, tho general condition of the patient 
improved and tho decubitus finally healed. 
Eight months after the nailing a nephrectomy 
had to bo performed because of a purulent 
kidney with calculi. Still four weeks later 
an erysipelas spread from the stump of the thigh 
and finally caused the death of the patient. 
Although the marrow nailing did not directly cause the 
dcatn, it is proba.ble that at least the metastatic infection 
of the knee and hip joint could have been avoided without 
the nailing. There is no doubt that the irritation which 
was necessarily caused by the nailing must have favored 
the infection of the stiffened joints. 
of or c_be_cqnc ludcd. that the nailing .pper- 
alion_q£_a_still_purulent_fracturc_should_not~boIierfornod 
i£-thc_joint s_are_s£iff oncd_to_a_considerablc_e2tcr2t 9 A s 
a matter of fact it can hardly be avoided that these joints 
are (oven unintentionally)mobilized in the course of the 
operation and this creates the hazard of a spread of the 
infection. 
BOEHLER (technique of the treatment of bone fractures, 
Vol* III* 1931, Vienna 1944) has challenged me to prove 
that the treatment of infected fractures (of the upper 
arm) is shortened by the use of the nail. This is 
difficult to prove, since we do not know in the conserva- 
tive treatment how long the fractures will continue to 
fistulate. It is also difficult to prove that the re- 
sults arc good, because in the majority of the cases the 
patient came already with considerable stiffenings and 
shortenings. Table IV 
ld_Fr ac t ur e s_due 
of 
Number 
cases 
Bony 
healing 
Accompanied by 
formation Osteo- 
of sequestr, myelit 
. o tcotomies, wounds healed 
for more than 9 months 
8 
8 
3 
1 
Osteotomies, healed for 
2-3 months 
5 
5 
1 (41) 
1 
Osteotomies healed for 
6 weeks 
4 
4 
(D . 
Pseudarthroses 8-18 months 
old, with wounds healed 
for 6-7 months 
4 
4 
2 
2 
Pseudarthroses 8-18 months 
old ,with wounds healed 
for 3 to 5 months. 
3 
3 
(1) 
Old fractures 6-14 weeks 
old, wounds healed for 
6 weeks 
3 
3 
_ 
Old fractures, 1-2-12 months 
fistulating 
19 
19 
10 
i—i 
H 
t v 
Old fractures, 4 to 12 
weeks, purulent 
7 
7 
7 
- 
Total of fractures, the wounds 
of which Y/ere healed after 
less than 6 months or were 
still purulent* 
45 
45 
19 
(~ 3) 
3 
(4 1) 
( ) formation 
nail * 
of 
sequestra after 
removal of 
t he v 
j perforati 
u articula 
on 
abs 
of the point of the 
cess after removal 
nail, para-c 
of the nail. 93 
In table VI, we give a survey of the cases of nailed 
thigh fractures due to gunshot injuries which we observed 
until the removal of the nail. In the first column, we 
have included fractures, the wounds of which had been 
healed for more than 9 months and which would have been 
also suitable for other methods of osteosynthesis using 
foreign bodies. 
We sec first of all that all fractures came to a 
bony healing and this can certainly be called a good re- 
sult , 
That a formation of fistulac and sequestrae will 
take place in purulent fractures is a matter of course 
and will occur in much the same way in the conservative 
methods. An infection of the marrow can, however, be 
definitely avoided by the conservative methods, and if 
the nail would constitute a hazard in this respect, its 
use should be refused. 
In the cases of the seriously purulent fractures we 
had no osteomyelitis at all. In the fistulating fractures 
we observed once a case of a gravity abscess in the path 
of the nail which perforated the bone. Throe cases of 
osteomyelitis were, however, observed in fractures the 
wounds of which had already healed. Two of these cases 
have already been described in detail. 
In the thigh fracture of 111, 86, 
4 months old, which had healed in a faulty 
position, (the v/ounds had healed after 2 
months) we observed a completely stabile 
osteosynthesis. The wounds had, however, 
been primarily sutured without drainage 
and when fever, swelling and pulsating 
pains set in, the surgeon waited 5 days 
before opening the wounds widely. It 
is logical that the infectious secre- 
tion followed the path of the nail that 
has the effect of a drain and finally 
extended into the marrow cavity. 
Also in the 8 months old pscu- 
darthrosis in the distal third (HAEB- 
LER, a.a.O, 111. ll), the wounds of 
which had been healed for more than 5 
months, a primary suture was applied. 
The osteosynthesis was only relatively stabile 
in this case. In the distal fragment 
the nail found only a grip in the spong- 
iosa (ill. 87), The patient was allowed 
to use the limb 9 days after the oper- 
ation, One week later one observed 
the collection of scrum with an in - 
fectious infiltration of the adjacent 
area. The 'scrum was drained by open- 
ing the bleb with a tweezer and the 
infiltration was treated by diathermy. 
Eight days later the secretion became 
purulent and fever set in. When the a 
b 
Illustration 86 
a) Four month old gunshot fracture of the thigh which 
is in poor position. The wounds have been healed for 
2 months. Open nailing with primary wound suture without 
drainage. Application of a VOLKMANN1s splint. The day 
after the operation the temperature rose to 39° C. The 
patient complained about throbbing pains and a tight 
swelling of the thigh was observed. The wound was opened 
on the 6th day after the operation. After that the temper- 
ature decreased. 
b) The same fracture 4 months after the nailing: 
Osteomyelitis in the fracture cleft and in the proximal 
fragment. a 
b 
Illustration 87 
a) Eight month old gunshot fracture in the thigh which 
had been operated 5 months ago because the fragments were 
in bad position. At that time a primary wound healing was 
obtained. The fragments are not yet stabil. Open nailing 
with primary wound suture without drainage. No additional 
plaster cast or bandages. Four days after the operation 
the first attempt was made to subject the limb to weight 
bearing. One week later the patient suffered from swellings 
in the fracture cleft. Wound infection. 
b) The same fracture 3g months after the nailing. The 
osteosynthesis is not stabil. Osteomyelitis in the fracture 
cleft and in the proximal fragment. wound was finally inspected (29 
days after the operation) the X-ray 
picture reveals already a clear cut 
osteomyelitis with its periosteal depo- 
sits. An abscess developed at the wound 
of the trochanter and finally a gravity 
abscess and an osteomyelitis which spread 
as far as the subtrochanteric areas (ill, 
87b) and necessitated even after the re- 
moval of the nail (3*g_ months post-oper- 
ative) several sequestrotomies. The final 
result is a difficult treatment which lasted 
for more than two years and resulted in a 
considerable stiffening of the knee joint. 
The nail can, however, not be blamed for 
this poor result. It is rather due to the 
unsuitable treatment. 
The fixation of the fracture would 
certainly have been possible by conserva- 
tive treatment, for we read in the operation 
report: "with a view of reducing the fragments 
and of driving the marrow nail in the distal 
direction, it became necessary to separate the 
fracture cleft widely which was not easy to 
perform. Although the fracture is not solid 
we observed considerable masses of callus at the 
posterior part of the cleft". Impatience of the 
surgeon (and of the patient) as BOEHLER says 
influenced the indication in this case. This 
impatience is confirmed by other facts: osteo- 
tomy because of faulty position , justified and 
correctly performed, then plaster cast, addi- 
tional fruit diet, Vitamin C and diathermy "be- 
cause the callus formation was only slight 
after five weeks". After 8 weeks removal of 
the plaster cast, VOLKMANN1s splint, diathermy, 
calcium, C-Bion and massage" because "more 
properly, although the fracture was still 
movable". As could not be expected otherwise, 
it came to a posterior angulation of the 
distal fragment. The limb was left on the 
VOLKMANN splint and the fracture was loaded 
with a sand bag, a measure which is never of 
any use. Two weeks later, that is 3 months 
after the osteotomy, BECK1s drilling was per- 
formed and a walking cast was applied after 
another 4 weeks. When after 4 weeks the X-ray 
picture did not reveal enough callus it is 
"considered whether a marrow nail might bring 
the necessary fixation and stimulate the forma- 
tion of callus. The nail could at the same time 
compensate the antecurvation," If one had 
applied a walking cast after the osteotomy or 
at least corrected the antccurvation under 
anaesthesia and then left the ’walking cast 
in position long enough, the fracture would 
have healed quicker and with a better result. That the delayed opehing of the wound is re- 
sponsible for the spreading of the infection into 
the marrow is confirmed by the localization of the 
osteomyelitis which developed in both cases in the 
proximal fragment, where the lowest amount of mechanical 
counterpressure prevails that is in the path of the 
nail due to the drainage of the nail towards the soft 
parts above the trochanter. It docs not spread into 
the distal fragment because the spongiosa and the 
bone mantle do not offer any "outlet". 
The reaction is different if the nail does not 
have a firm hold in the bone. The nail will then 
permit tilting movements when the limb is used and 
will force or suck the secretion into the empty spaces. 
This result was observed in an osteotomy nailing 
of an 11 months old fracture duo to gunshot injury, the 
wounds of which had healed 10 months prior to the oper- 
ation, A drain and a plaster cast was applied when 
an osteomyelitis developed. In this cast it came to 
a decubitues of the heel which was incised and two weeks 
later to the infection of the fracture. 
Also the osteomyelitis of the 8 months old comminuted 
fracture (ill, 88) is due to the fact that the nail did 
not obtain a firm hold. 
The patient whoso wounds had already 
healed six months before was admitted to the 
special ward because of a faulty position and 
"absence of callus formation and imminent 
pseudarthrosis", We were influenced by this 
statement when we decided to nail the fracture 
by the open method, although clinically the 
fracture had solidified to a considerable 
extent, I overlooked that it would be neces- 
sary to remove most of the transversely lo- 
cated bone splinters which would imply a 
considerable shortening. When checking 
the medium sized nail in position (111.88a) 
by means of an X-ray picture it was overlooked 
that the distal marrow cavity was too wide for 
this nail. The nail was driven in as far as 
the spongiosa of the epiphysis, so that at 
first the fracture was fixed (ill.88b), The 
wound which was drained and closed by approx- 
imation suture had to be opened shortly after 
the operation because of a venous hemorrhage. 
The vessel could not be located so the wound 
was tamponated. The primarily closed wound of 
the trochanter was not opened. A dorsal 
plaster splint extending up to the pelvis was 
applied. One week later the tampon was 
removed, there was little secretion from the 
wound and the patient was free from tempera- 
ture, Six weeks after the operation a rise 
of temperature and an abscess at the wound 
of the trochanter were observed, which was 
opened xwidely. Sonn after-wards an abscess 
occurred at the fracture cleft, from which metal 
splinters and sequestra had to be romoved. b 
a 
Illustration 88 
a) Eight month old gunshot fracture of the thigh. The 
wounds had healed more than six months ago. poor formation 
of callus. The nail is too short for the broad marrow 
cavity of the distal fragment. (The lines of the shadow 
of the nail were drawn on the illustration). 
b) The sane fracture after the nailing. The splinters 
which are lying obliquely must be removed in order to be 
. able to insert the nail and to press the fragments together. 
In this way we obtained a shortening of 9 centimeters. The 
nail had been driven into the spongiosa and thus granted a 
good hold for the fracture. Infection of the wound and 
formation of abscesses in the fracture. c 
d 
e 
Illustration 88 
c) Six months after the operation. Increase of temperature 
and circumscribed painfulness above the knee joint. Marked 
rarefactions around the nail tip. After that the wounds 
were opened and the leg was kept in an elevated position. 
Decrease of temperature. 
d) Eight months after the operation. After the patient 
had subjected the limb to exercises after the manner of 
walking during his confinement to bed another increase of 
temperature and the formation of an abscess above the knee 
joint was observed. Marked periosteal layer in the distal 
fragment. The fracture healed and therefore the nail was 
removed. 
e) 17 months after the operation. The fracture is healed 
and the wounds are closed. The shortening amounts to 9 cm. 
The knee is stiff and the impediment of the hip joint 
amounts to 50 %. Fractures of this kind are better treated 
conservatively. Plaster cast, decrease of temperature, 
but strong pus secretion especially from 
the wound of the trochanter which subsided 
only very slowly. Six months after the 
operation there was again an increase of 
temperature and pains above the knee joint* 
An effusion into the joint did not exist. 
The X-ray picture (ill. 88c) showed in addi- 
tion to a loosening of the structure next to 
the point of the nail, a distinct rarefaction. 
Therefore elevation of the limb and wider 
opening of the wounds was proscribed. The 
result was a decrease of the temperature. 
When the secretion of pus subsided, treading 
exercises in the bed were instituted, which 
had to be stopped immediately, however, be- 
cause of pains at the site of the fracture 
and increase of the temperature. Three weeks 
later an abscess above the knee joint had to 
be opened. The joint was not involved, rough 
bone was not palpable. The rarefactions at 
the point of the nail did not increase, but 
distinct periosteal deposits could be ascer- 
tained along the medial side of the whole 
distal fragment. (ill. 88d). As the bone 
is obviously solid, the nail is removed 8 
days later. Sequestra had to bo removed re- 
peatedly from the fracture cleft and the 
healed wounds broke open several times*, The 
patient could be discharged from the hospital 
only 17 months after the operation. The 
final result (ill. 88e) was a shortening of 
the limb by 9 cm,, stiffening of the knee 
joint and impediment of the mobility of the 
hip joint by 50%9 
This fracture should not have been nailed. Mobiliza- 
tion under anaesthesia with subsequent wire extension and 
plaster -would have secured a quicker healing and the con~ 
siderable shortening could have been avoided. 
It must always be borne in mind when dealing with 
comminuted fractures that the shortening will become 
greater by the use of the nail than would be the case in 
the conservative treatment, so that the nail will not 
bring substantial advantages and is better not used. 
If infactions occur, it is imperative to open the 
v/ounds of the trochanter widely and to elevate the leg, 
so that no accumulation can take place in the distal 
fragment. The knee must be in a h__p°s±-t±°n than 
the operative wound and the wound at the trochanter. 
We have suggested before that the leg be kept in 
a horizontal position after the operation, so that the 
drain becomes the deepest point and declined to use 
BRAUN*s splint because with its use, the wound at the 
trochanter will be the lowest point and the secretion of 
the wound which is still suspected of carrying infectious 
natters could follow the nail in an upward direction. This is not quite correct since the knee is generally in 
a lower position than the trochanter if the linb is 
in a horizontal position, especially so if a dorsal 
plaster splint or a plaster cast in the extended po- 
sition is applied. The knee must in every case bo 
kept at a sonewhat higher position* 
The osteosynthesis of the fracture (ill, 89a) 
was only relatively stabile* 
When the patient was admitted to our 
hospital 10 months after the injury, the 
fracture was still fully movable and the 
wounds had healed 3 months before. As 
the other leg was amputated we did not need 
to take a shortening into consideration and 
we resected the proximal fragment to the 
extent that the fracture could be easily re- 
duced. The nail had to be driven into the 
spongiosa to obtain a firm hold. The 
wounds at the fracture and at the trochanter 
were drained and a pelvic plaster cast was 
applied. Four weeks after the operation 
when the wounds had healed, the plaster 
cast was removed and treading exercises in 
the sick bed were instituted as the frac- 
ture was clinically solid. (ill, 89b), 
Two weeks later an increase of temperature 
occurred, the ?;ound at the fracture site 
broke open and inspection revealed an abs- 
cess cavity at the fracture the size of a 
fist, which was due to the fact that the 
nail had loosened. The X-ray picture re- 
vealed already (111. 89c) the rarefactions 
next to the point of the nail which were 
lined by a distinct margin. When, after 
a position at rest the secretion subsided, 
movement exercises were again instituted 
and the result was a prompt increase of 
temperature and increased excretion of pus. 
Only 5 months after the operation when the 
X-ray picture (89d) revealed a distinct 
formation of callus, could the nbvements be 
performed without pain and without causing 
an inflammation of the wounds which had 
healed in the meantime, Soon afterwards 
the patient could use his limb and 6 weeks 
later the fracture was healed to an ex- 
tent that allowed the removal of the nail. 
(6-g- months after the operation, (lll0 89e}), 
This illustration reveals an irritation 
space next to the relatively large rare- 
faction at the point of the nail. This 
rarefaction is, however, merely due to 
mechanical influence (in contrast to the 
rarefaction of 111, 88d) because the limb 
was always put at rest and elevated in 
due time, so that no accumulation could ) 
occur in the distal fragment. a 
b 
Illustration 89 
a) Ten month old gunshot fracture of the left thigh. 
The wounds had been healed for throe months. No formation 
of callus to be observed. The right log was amputated. 
b) The same fracture 1+ weeks after the open nailing. 
During this operation so much of the proximal fragment 
had been resected, that it was possible to obtain a good 
reduction. The wounds are healed and from the clinical 
point of view the fracture is stabil. The osteosynthesis 
is only relatively stabil. The patient begins subjecting 
his limb to exercises after the manner of walking while 
still in bed. c 
a 
e 
Illustration 89 
c) The sane fracture 14 days later. The temperature 
had increased and an abscess in the fracture cleft was 
observed. The rarefactions round the nail tip prove that 
the nail became loose. Once again the fracture was immo- 
bilized by a plaster cast. After that a decrease of temper- 
ature and suppuration occurred. 
d) The same fracture 5 months after the operation. Marked 
formation of callus. No osteomyelitis. The wounds are 
healed. From now on exercises and weight bearing do not 
show any reactions. 
e) 6J months later. The fracture is healed and the nail 
has been removed. An irritated margin around the nail tip 
is clearly noticeable. It must thus be concluded that all wounds must be 
opened widely if an infection occurs, this is especially 
true if the osteosynthesis is not fully stabile. It is 
furthormore necessary to prevent,by appropriate position 
of the limb, that no sagging towards the distal fragment 
can take place. This sagging and penetration is a hazard 
which is still present after the removal of the nail, 
especially if the wounds arc still excreting pus. 
In the 3 months old fistulating 
fracture due to gunshot injury (ill. 
90a) which was in a bad position and 
showed little formation of callus, it 
was decided to perform the removal of 
the sequestrum and the nailing in one 
session. Because of the wide distal ca- 
vity, the nail had to be driven into the 
spongiosa (ill. 90b) in order to obtain at 
least a relatively stabile osteosynthesis. 
A drain was applied at the trochanter and 
at the fracture.a plaster cast.was used. 
Temperature returned to normal and the se- 
cretion of pus subsided soon afterwards. 
The plaster cast was therefore, replaced by 
a plaster solint 4 weeks after the operation. 
The X-ray picture revealed a distinct dye- 
trophy of the condyles of the femur and a 
very subtle rarefaction next to. the point of the 
nail which we overlooked (111. 90c). Four 
weeks later the pus secretion increased and 
several abscesses due to gravity developed 
which subsided only after the renewed use 
of a pelvic plaster cast. A sequestrum had 
to be removed from the fracture site 6 months 
after the nailing. The fracture was bridged 
over by good callus (111. 90d) and the plaster 
cast was removed. The purulent secretion did 
not subside and the nail was finally removed 
7 months after the operation. The limb was 
put at rest in a plaster splint in a horizont- 
al position. Two weeks later a diffuse swelling 
in the area of the knee joint without effusion 
was observed which subsided by the use of wet 
cataplasmae. Two months after the withdrawal 
of 'the nail a paraarticular abscess had to be 
opened. Rough bone was palpable above the 
lateral condyle and a perforation on the ex- 
tension side was noted (ill. 90o). This per- 
foration was std 11 visible in the X-ray picture 
four months later when the fistulae were closed 
and when the path of the nail was hardly re- 
cognizable (ill. 90f). The patient was dis- 
charged from the hospital 13 months after tho 
operation. The fracture had healed without 
shortening but the knee joint was stiffened 
to a considerable extent. The bones were at 
that time still dystrophic the site of the perfora- 
tion was hardly recognizable (ill* 90g), a 
Illustration 90 
b 
c 
a) Three month old fistulating gunshot fracture which 
is in bad position (not treated in our hospital). Slight 
formation of callus. The fracture is not yet stabil. 
Formation of sequestra in the fracture cleft. 
b) The same fracture after the open nailing. The distal 
marrow cavity is too broad for the nail and consequently 
it must be driven into the spongiosa. The osteosynthesis 
is only relatively stabil. Application of a plaster cast. 
4 
c) The same fracture four weeks later. Slight suppuration. 
The temperature is normal. Slight rarefactions around the 
nail tip, which proves that the nail does not find suffi- 
cient hold. This, however, was not observed and the plaster 
cast was replaced by a splint. Marked suppuration four 
weeks later which subsided only after the application of 
a pelvic plaster cast. a 
e 
Illustration 90 
d) Six months after the operation. A sequestrum which 
developed at the fracture has been removed. The fracture 
cleft is bridged over by good callus. Four weeks later 
the nail was removed. After that we applied a plaster 
splint with the limb in the extended position. 
e) Two months after the extraction of the nail, 9 months 
after the operation. Para-articular abscess in the knee. 
A perforation of the bone on the extensor side is observed. f 
s 
Illustration 90 
f) The fistulae were closed 1+ weeks later. The fracture 
is healed. The place of perforation however is still 
distinctly visible. 
g) 13 months after the operation. The fracture is healed 
in good position without shortening. The knee is stiff to 
a considerable extent. The bones about the knee joint are 
still atrophic. 99 
The above case illustrates a serious mistake. The 
attention was always focussed on the fracture cleft and 
no attention was paid to the point of the nail. The 
point of the nail is only to be seen in one of the X-ray 
pictures (ill* 90c) (and that is probably due to a 
coincidence). When comparing illustrations 90d and 
90b it becomes evident that the nail has moved lateral- 
ly and its point has presumably pierced through the 
bone similar to the case shov/n in 111* 38. It was 
also a mistake that the limb was not elevated after the 
removal of the nail. If this had been done the 
infectious secretion could have flowed off through 
the bed of the nail which is encapsulated by smooth con- 
nective tissue and there is a likelihood that the spread- 
ing could have been avoided. 
An osteomyelitis could be avoided in the above 
and in the proceeding case because the limb was duly 
put at rest. Osteomyelitis is not to bo feared if the 
nail has a firm hold and if the v;ounds are immediately 
opened widely at the onset of the infection. 
In the 6 months old fracture of 111* 91a, 
the wounds had healed per granulationem, 
after the first wound treatment. When the 
attempt was made 3 weeks after the accident 
to correct the position under anaesthesia, 
it came to the formation of an abscess with 
a tedious secondary healing. Eight days 
after the healing of the wounds, a nail- 
ing osteotomy was performed at anothor 
clinic because_thc f racturo had already 
solidified to a considerable extent. The 
wounds were sutured primarily, but had to 
be opened 4 days after the operation be- 
cause of intense swellings. No pus was 
found. The fracture was in an axially 
correct position, but there was a gap of 
almost 1 centimeter at the fracture cleft 
(ill. 91b), Two weeks later the wound 
had healed without irritation and the pa- 
tient began to use the limb so that the 
fragments were pushed together. Eight 
days later the old fistula broke open 
again. It was enlarged and the secretion 
lasted for a long time without any ejec- 
tion of sequestra. In spite of this, the 
limb was used without pains but the frac- 
ture was not pushed together. The X-ray 
picture (ill* 91c) taken 3 months after 
the operation reveals a slight loosening 
of the structure at the fracture cleft, 
but not an osteomyelitis and a distinct 
still cloudy formation of callus. The 
nail was removed 6 months after the oper- 
ation and the fistula still had a slight 
secretion. After the removal of the nail, 
the fistula subsided. An attempt to mo- 
bilize the knee joint which was already stiff 
before the operation had little success* b 
a 
Illustration 91 
a) Six month old gunshot fracture of the femur which had 
healed in a bad position. The wounds have been closed for 
a week. The knee is stiff and the impediment of the hip 
joint amounts to 50 %. 
b) The same fracture after the osteotomy nailing. The 
osteosynthesis is stabil but the fracture cleft is still 
gaping. The primarily sutured wound was widely opened 
on the fourth day p.op. because of an increase of temper- 
ature. Secondary healing within 14 days. The patient 
began subjecting the limb to weight bearing in order to 
press the fragments together. Eight days later another 
reactivation of the fistula was observed which, however, 
did not cause an impediment of the weight bearing. c 
a 
Illustration 91 
c) Three months after the operation. The fragments were 
not pressed together. Slight structural rarefactions at 
the fracture cleft, an osteomyelitis however did not develop. 
The fracture cleft is bridged over by spongy callus. 
d) Eight months after the operation. The fracture is 
bridged over by bone. The nail was removed 2 months ago. 
Shortly after that the fistula healed. The hip joint is 
freely movable, the motion of the knee joint amounts to 
10 degrees. A shortening does not exist. 100 
The patient was discharged from the 
hospital 8 months after the operation. 
The fracture showed a bony healing' with- 
out any shortening (ill, 91d), The de- 
fect was completely bridged over (BOEHLER 
denies such a'possibility), hip and ankle 
joint are freely movable, the knee is mov- 
able by 10O , 
This example shows that the nail does not constitu- 
te a case of an infection of the wounds and 
that the nail does not favor the spreading of the in- 
fection into the marrow and also the infection of the 
fracture cleft can be avoided if the wounds are widely 
opened in due time. 
The ouestion whether or not the postponement'• of 
the operation assures a greater safety against wound in- 
fections is of special importance with regard to the 
fractures healed with angulation because the chances for 
the restoration of normal conditions is the less and the 
operation is the more difficult - and this implies an 
increased infection hazard - the more solid the callus 
is. Unfortunately, the" reports do not, as a rule, contain 
any statements as to the blood picture or sedimentation 
rate which could give valuable hints with regard to the 
infection hazard. But we still see - if the restricted 
number of our patient material allows for such conclusions 
- that the incidence of infections is just as high in 
the osteotomies which were performed more than 9 months ' 
after the healing of the wounds as in the earlier operated 
ones and that the incidence is even lower in the latter 
category. This is especially striking in the pseudarthroses 
of old fractures. The explanation probably lies in the 
fact that we have done without a suture of the wound's in 
the operations which were performed shortly after the 
healing. 
The bad results of the nailing operations have in- 
tentionally been given so much space because it is only 
by the mistakes that we can learn and come to a perfection 
of the indications. Sincerity serves the cause and our 
patients more than a list of successful operations, the 
more so, because this might induce the beginner to under* 
estimate the difficulties. 
The results of the -marrow nailing operations are 
superior to any other method on the condition that the 
osteosynthesis is stabile. 
All fractures came to a' bony healing, including the 
pseudarthroses which wero one year and more old. 
Only one instructive example will be given in this 
connection. Femur fracture, left, due to gunshot 
injury on December 27, 1941» First treat- 
ment included removal of numerous splinters. 
Five months extension bandage. In March 1942 
osteosynthesis with LANE*s plate which had to 
be removed after 3 weeks because of an in- * 
foction. Extension bandage until June 1942, 
then pelvic plaster cast. In October 1942 
fixation by means of ivory pins and again 
Allegedly slight)wound infection. Wounds 
closed since February 1942. Bony healing 
fails to develop. In June 1943 admission to 
the special ward. Wounds firmly healed, ab- 
normal mobility at the site of the fracture, 
shortening 6 centimeters, knee stiffened 
in the extended position, patient could 
only walk with a hinged splint (ill, 92a), 
On July 8, 1943, marrow nailing with exposure 
of the fracture site, removal of the ivory 
pins and the remnants of tho wire, resection 
of the callus as sparingly as possible. 
Drain of the approximation suture, splint. 
Osteosynthesis stabile (111. 92b), good 
healing of wounds, July 15, (one week after 
operation ) start of movement exercises of 
the knee joint. September 8, discharge from 
the hospital. Patient walks perfectly well 
with a high heel, without limping. X-ray 
picture: distinct formation of callus, no 
rarefactions at the point of the nail, (ill. 
92c). The fracture pushed together and the 
nail pushed out at tho trochanter. March 7, 
fracture healed, tho nail which had wandered 
further in an upward direction was removed 
(ill, 92d). The patient was discharged from 
the hospital 10 days later. Same findings as 
on September 8, Stay at the hospital after 
the nailing operation a 73 days. Unemploy- 
ability a 125 days. 
The course, the duration of the stay at the hospital 
and of the unenployability after the narrow nailing cor- 
respond in every respect to what is known in the nailing 
of fresh fractures, the sane is true for all other ascptical- 
ly healed cases. There are no particulars to be reported 
in this respect. With regard to the space and to cases 
described in other places no further descriptions or 
X-ray pictures will be given in this connection. (HAEBLER 
a.a.0,,Page 30 and following). 
In case of smooth transverse fractures shortenings 
could be avoided in all cases, the sane is true with 
regard to impediments of the joint in fractures which were 
not older than 3 months* If the joints are already 
stiff before the operation a considerable improvement 
was achieved in all cases with an aseptic course* The 
shortenings in osteotomies were in all cases consider** 
ably improved. These are results which cannot b6 6t>tained 
by any other method. a 
b 
Illustration 92 
a) 20 month old gunshot fracture of the femur. An ivory , 
bolt was inserted 10 months ago in another hospital. The 
wounds are healed but the fracture is freely movable. The 
shortening amounts to 6 eras . The knee is stiff in the ex- 
tended position. The patient uses a hinged splint. 
b) The same fracture after the open nailing and extraction 
of the ivory bolt. Conservative freshening of the bone. 
The osteosynthesis is stabil. Primary healing. The patient 
starts subjecting the limb to exercises 8 days after the 
operation. c 
Illustration 92 
d 
o) Three months after the operation. The fragments 
were somewhat pressed together by the weight bearing but 
the nail has partially slipped out of the trochanter. 
The shortening amounts to 4§ cms. The patient’s gait 
is not hampered when using an elevated heel. He was 
released from thfc hospital to his unit for garrison duty. 
d) Eight months p.cp. The fracture is healed. The nail 
will be removed. The motion of the knee amounts to 160 - 
180 degrees, the hip and ankle joints are freely movable. Unfortunately we had no possibility to gain 
experience with Penicillin* It can be expected that 
the infection hazard can be reduced to a consider- 
able extent* 
As a .natter of fact it is not always possible 
to foresee if an osteosynthesis will become stabile 
and it is dangerous to wait and see, especially if 
the bone threatens to solidify in a bad position. 
If it becomes evident during or after the operation, 
that only c relatively stabile osteosynthesis will 
be achieved by driving the nail in as far as the 
spongiosa of the epiphysis, it will become necessary 
to provide an additional plaster cast from the very 
beginning* In case of an infection the fixation must 
be maintained until the fracture has reached an ad- 
vanced degree of solidification* An important advan - 
tage of the nail is then lost and marrow nailing does 
not excel any other type of osteosynthesis in this 
case. This cannot be changed, however, and does 
not outweigh the risks described above* If no in- 
fection occurs it will be necessary to check very 
closely on the patient about 6 to 8 weeks after the 
operation, as we have seen before, this is the time 
when the nail begins to loosen in the spongiosa. 
This condition is indicated by rarefactions next 
to the point of the nail* As soon as the patient 
complains about the slightest pain or if swellings 
occur, it is imperative to insist on bed rest, which 
must be observed more strictly than in simple frac- 
tures because of the possible revival of the in- 
fection with all its complications. 
The indication for nailing while the wounds 
arc still fistulating or even secreting pus, depends 
on whether or not the nail constitutes a hazard as 
regards the spreading of the infection* That this is 
generally not the case is demonstrated by the fact 
that an osteomyelitis did not occur, in any of our 
fistulating femur fractures and also by our experience 
with the described fistulating femur fracture (HAEB- 
LER a.a.O*, page 4-3, 111* 15) in which the nail 
was driven in by mistake up to the knee "joint* Al- 
though wo observed an (irritation) in tho 
knoe j’oint, asepsis was not broken and the condi- 
tion subsided after 3 days* As improbable as it may appear, the germs are ob- 
viously brushed off the smooth surface of the nail upon 
entering the scar tissue which closes the marrow cavity. 
If any germs are spread at all,they are so few that the 
marrow with its great amount of blood cells can ea sily 
cope with them. This mechanical cleansing seems to be 
almost perfect if the nail enters through solid bono 
(marginal lamella of the joint). The center of the 
infection is entirely hold up by a dam of granulations 
as soon os the acute stage is overcome. If this granu- 
lation is pierced by the marrow nail it will close again 
in a very short time and full protection is afforded 
under the conditions, however, that the nail has a firm 
hold. 
In consideration of these facts, we try to avoid any 
resection of the fracture ends and severance of the 
poriosteum and adopt the same procedure as in the closed 
nailing: The nail is driven in by approach from the 
trochanter (and not as is customary in the open nailing 
in the reverse direction, that is by approach from the 
fracture cleft). If the nail has reached the fracture 
cleft, the fracture is properly reduced (as a rule traction 
by the assistant will suffice) and the nail or guide rod 
is directed into the distal marrow cavity with the finger 
wliich is introduced into the wound. This manipulation does 
not offer any difficulties in fractures of the tibia and 
upper arm. The conditions are far more difficult in femur 
fractures but this painstaking is worth the while. Only 
in the nailing carried through in this manner were we 
able to avoid the formation of sequestra. This may be a 
mere coincidence. It is rather surprising, however, that 
an increase of temperature always occurred and that the 
purulent stage was always very tedious and included the 
formation of sequestra, if the nailing had been performed 
by approach from the fracture cleft and especially so, 
if the fracture site had been widely exposed. 
We had no opportunity to nail fistulating fractures 
which had healed in a faulty position. If after all 
one decides to nail this type of fracture, the operation 
should - on the basis of the above consideration - be 
performed in two sessions: Osteotomy (or rather re- 
fracture) of the fracture and extension fixation until 
the acute soquelao are overcome. If these measureedo 
not prove satisfactory as to reduction and fixation, 
and only then, the nailing may be performed (after 3 
weeks at the earliest, after the fever has subsided), 
As set forth in the table wo have nailed 7 fomur 
fractures in a stage of most severe purulence. The 
marrow nail was indicated in those cases, because of 
purulent formation of sequestra, tubular abscesses or 
pneumonias and the impossibility of a proper fixation 
(regardless of position). Only in such emergency cases 
do we advocate the stabile osteosynthosis with the 
marrow nail. The perfect fixation which can bo achieved 
with the nail has shown surprisingly good results in 
fighting infections and improving the general condition of the patient, as is demonstrated - besides the 
other cases described above - in the fracture shown 
in 111* 93, on which we could check up recently. 
Several gravity abscesses had been 
opened in this 43 days old fracture of 
the thigh and the patient still had fever 
of about 40°# The wire extension did not 
fit the purpose because the patient was 
very nervous and since we had been able to 
separate a few loose splinters from the 
wound, we decided to nail the fracture* 
The palpable splinters and sequestra were 
removed without opening the wound veiy 
widely. The guide rod was then introduced 
into the proximal marrow cavity with 
X-ray control after placing several needles 
for guides (as is done in the closed marrow 
nailing) and after that the nail was driven 
in. When it was about 6 centimeters deep in 
the marrow cavity the guide rod was removed 
and the nail driven in until it could be 
felt at the fracture cleft. The nail was 
then directed with the finger and could be 
easily introduced into the distal fragment 
after appropriate reduction performed by 
the assistant. It was driven in as far 
as into the spongiosa of the epiphysis 
and gave the fracture a firm hold (ill* 
93b), The operation- and trochanter 
wounds were then drained, the former 
posteriorly. The limb was kept on a 
splint in a slightly elevated position* 
The patient still had 40° fever on 
the day following the operation. After 5 
days the temperature returned to normal by 
lysis* The patient was entirely free from 
pain and recovered well* The wound was 
still seriously purulent after 4 weeks, but 
after that it quickly decreased in size and 
8 weeks after the operation the patient could 
start motion. After 3 months, the patient 
was allowed to be ambulatory. Several gra- 
vity abscesses had to be opened later on 
and when 6-g- months after the operation a 
sequestrum of about the size of a cherry 
pit was removed, the secretion soon came 
to a standstill. The fracture revealed 
after 5 months a good callus formation 
(111, 93c.)#and the limb could be used, Nino 
months post-operative the nail was with- 
drawn with the still fistulating wound. 
The leg was again put db rest for two 
weeks, several small sequestra were ejected 
and finally the fistula closed and the 
patient could be discharged from the hospi- 
tal, The hip and ankle joint were free iy 
movable, the flexion of the knne was possible up 
to 60°, Six months later the samo patient 
suffered from a fracture of the patella of 
the samo leg and this was fixed with a 
wire suture* a 
b 
Illustration 93 
a) 43 day old gunshot fracture of the femur with foul 
smelling secretion. A formation of sequestra was observed. 
High temperature. The immobilization of the limb by means 
of a wire extension was not sufficient. The patient was 
very restless. 
« 
b) The same fracture after the nailing and after the 
removal of the exposed grafts. The osteosynthesis is stabil. 
Immobilization by means of a BRAUN*s splint, open wound 
treatment. Within five days the fever slowly decreased 
by lysis. 8 weeks after the operation the patient began 
subjecting the limb to exercises and he was able to get 
up 3 months p.op. c 
d 
Illustration 93 
c) Five months after the operation. Good formation of 
callus. The fracture is healed from the clinical point of 
view and it can be subjected to weight bearing. The wound 
is still fistulating. Some time later another sequestrum 
must be removed. 
The nail was removed 9 months after the operation with 
the wound still fistulating. After that several more small 
sequastra were cast off. Release from the hospital 11 months 
p.op. The wounds were healed, the hip and ankle joints 
freely, movable, the flexibility of the knee amounted to 
60 - 180 degrees and the shortening amounted to 9 cm. The 
gait of the patient is not impeded when wearing orthopedic 
shoes. J year later a fracture of the patella occurred 
in the same leg. Application of a wire suture, primary 
healing, 
d) Three years p. op. Good healing of the fracture without 
formation of cavities. The shortening was 9 centimeters and was 
compensated about 50% by special foot wear, Hip 
and ankle joint were free, flexion of the knee 
80° to 180 , The patient walks all right with* 
out a cane. The fracture came to a perfect bony 
healing and revealed no formation of cavities or 
sequestra (ill, 93d). The sound leg is to be 
shortened in the near future using a nail. 
The advocates of the conservative treatment will 
perhaps maintain that the fracture would have solidified 
without using the nail. But the marrow nail means at 
least an alleviation of pain to the patient and it 
appears doubtful whether such a good mobility of the 
joints would have been obtained. Even BOEHLER could 
not help it that more than one third of his femur frac- 
tures due to gunshot injuries had a mobility of the 
knee joint of loss than 60°, 
Only 8 of the fistulating and seriously purulent 
fractures came in for treatment earlier than 2jr months, tha* 
is at a time when the existing impediments of the joints 
still scorn to bo repairable. Six healed without any im- 
pediment whatsoever. In three cases the knee was mov- 
able by 90° and more. Throe fractures healed without 
shortening, in two cases we observed a shortening of 1 
centimeter and three comminuted fractures healed with 
shortenings of 3 to 6 centimeters. 
In the remaining 18 cases of fistulating and purulent 
femur fractures, the injuries dated 5 to 12 months back. 
After such a long time it is impossible to restore the 
full mobility of the joint. A definite improvement was, 
however, achieved.in all of these cases. 
The time of hospitalization can hardly servo as a 
basis for any comparative evaluation, because this de- 
pends in the conservative methods as well, solely on 
the type of fracture. It varied in our cases between 
180 and 450 days. It was rather surprising that the 
stay in the hospital was particularly long in those frac- 
tures which had been opened widely and in which the guide 
rod or nail was introduced from the fracture cleft. These 
cases were characterized by gravity and tubular abscesses 
and formation of sequestra. 
Today we would abstain from nailing 
a comminuted fistulating fracture in so 
good a position as shown in 111. 94. The 
fixation of this fracture would have been 
just as quick by conservative treatment, 
111. 94a shows the same fracture 72* months 
later with a distinct formation of callus. 
The nailing resulted in a shortening by 
2 centimeters (ill. 94b). Although the 
nail had a firm hold in the distal frag- 
ment it could under those circumstances 
not assure an osteosynthesis stabile 
enough to allow for an early use of the 
limb, the less so, since the ejection of a 
Illustration 94 
b 
c 
a) 7i month old fistulating comminuted fracture of the 
femur with formation of callus. The fragments are in good 
position. Beginning formation of aallus is clearly notice- 
able . 
b) The same fracture after the nailing. Due to the 
pressing together of the fragments a shortening of 2 cm. 
occurred. The nail finds sufficient hold in the distal 
fragment. Weight bearing is not yet possible because of 
the comminuted fracture. Several sequestra have been 
cast off. 
c) 10 months p.op. A bony healing of the fracture has 
been obtained. The wounds are still fistulating. The nails 
were removed and the patient began subjecting the limb to 
weight bearing. Three months later the fistula was healed. 
Final result: The shortening amounted to 2 eras., 
abduction impediment of the hip joint, motion of the knee 
from 110 - 180 degrees. In this case a conservative treat- 
ment would probably have shown better results. sequestra continued for quite a long time. 
Only 10 months after the operation had 
the fracture healed to such an extent that 
the nail could be removed, (ill, 59c) and 
only after 3 more months were the fistulae 
closed. The final result was a shortening 
by 2 centimeters, impeded abduction move- 
ment in the hip joint and a mobility of the 
knee of 190 to 170°. If an ordinary UNNAls 
extension bandage had been used instead, a 
better result would possibly have been obtained 
with a shorter delay. There is some prob- 
ability that the shortening would have been 
avoided. 
It is, therefore, deemed advisable to exclude 
fistulating comminuted fractures in good position with 
beginning formation of callus from nailing. The con- 
ditions are favorable for nailing if the position is 
bad and if a faulty healing is to be feared, as was 
the case in the 5 months old still intensely purulent 
fracture of 111, 95a , 
In this case sequestra and shell 
splinters were obviously the reason for 
an infection with an offensive odor which 
finally made the exposure of the fracture 
site necessary. After the removal of the 
sequestra the fracture was completely 
movable and 111. 95b reveals distinctly 
(and as could be presumed in 111. 95a) 
a threatening pseudarthrosis. The puru- 
lence subsided soon after the operation 
and the general condition of the patient 
improved rapidly. Temperatures were nor- 
mal 4 weeks post-operative and tho patient 
could begin with motion. A small sequestrum 
was later ejected and 5 months after the 
operation the fracture had solidified to 
such an extent that the patient could be- 
gin to use the limb (ill. 95c). The nail 
was removed 8 months post operative 
(ill, 95d), the fistula then soon closed* 
Two small sequestra were still ejected. 
The final result was a shortening by 4 
centimeters (8 centimeters before nail- 
ing), the abduction of the hip joint was 
impeded by Vs? mobility of the knee joint 
liO to 18t°. 
These cases illustrate all aspects and we conclude 
as follows; a 
Illustration 95 
b 
a) Five month old comminuted gunshot fracture of the 
femur which had healed in bad position. Formation of 
sequestra. The suppuration has not yet subsided and the 
fracture is still freely movable. 
b) The same fracture after the removal of the sequestra 
and after the nailing. The beginning pseudarthrosis 
below the trochanter minor is clearly visible. The 
osteosynthesis is stabil. After the operation the 
suppuration decreased and the-general condition of the 
patient improved. Four weeks after the operation the 
temperatures were normal and the patient was able to 
subject the limb to exercises. Some time later several 
more sequestra were cast off. c 
Illustration 95 
a 
c) Five months p.op. The fracture cleft is bridged 
over by callus. The patient now begins subjecting the 
limb to weight bearing. 
d) Eight months p.op. The fracture is healed and the 
nail will be removed. Two more small sequestra were cast 
off, after that the fistulae healed. 
Final result: The shortening amounts to 4 cm. 
(before the operation: 8 cms), the impediment of the 
hip joint abduction amounts to 2/3} the knee: 100-180 
degrees. 107 
If an old fracture due. £.ogunsh.ot_injury 
h.as healed in a position, nailing osteotomy is 
indicated which should be performed as soon as possible 
under the condition, however, stabile osteosyn- 
thesis can be obtained.. 
The nailing is contraindicated in cases of commi- 
nuted fractures where splinters have to be removed and 
where the fracture must be pushed together. The nail- 
ing does not bring any advantages in these cases and 
might even imply a considerable hazard* 
If a stabile osteosynthesis cannot be expected, 
the operation should be performed in two sessions. 
First the osteotomy with wire extension. If no in- 
fection occurs, the open marrow nailing can be performed 
after the correction of displacements and after the 
damage of the tissues has been overcome, generally this 
will be the case after 2 to 3 weeks. 
In case of old_t high_f tur e s_,due_to_gunsho t_witj} 
defi£ient_callus_formation_and_pseudarthroses.* the 
wounds of which have just healed, the marrow nailing is 
indicated under the condition that a stabile osteosynthesis 
can be expected. 
If only a relative stability can be achieved in 
that the nail is driven in as far as into the spongiosa, 
it is advisable to first mobilize the fracture under 
anaesthesia and to apply a wire extension and then to 
wait until the shortening is compensated for and until 
the injury to the soft parts has subsided. 
If the infection flares up again it will become 
necessary to treat the fracture conservatively. 
An additional plaster cast will become necessary 
if only a relatively stabile osteosynthesis has been 
achieved and it should be left in place until the in- 
fection hazard has definitely been overcome. Special 
attention is necessary when the limb is first used about 
6 to 10 weeks after the operation. At this time the 
nail begins to become loose in the spongiosa. Rare- 
factions next to the point of the nail point to this 
hazard. Strictest bed rest must be instituted if the 
patient complains about the slightest pain or if a 
rise of temperature occurs and bed rest should be main- 
tained until the fracture is bridged over by callus. 
If this is neglected there will be a considerable hazard 
that the infection will flare up with all its compli- 
cations. 
As a rule the wounds at the fracture cleft and 
trochanter are to be drained. If the wounds have healed 
only shortly before, greatest care with regard to the 
suture is indicated. If an infection occurs the wounds 
have to be opened widely without delay and the limb must 
be put at rest, to avoid a sag in the distal fragment. The fistulating_femur_fracture_due_to_gunsj3ot 
injury may he nailed and a spreading of the infection 
into the marrow need not to he feared. It is, however, 
an important condition that the osteosynthesis he ab- 
solutely stabile. 
Special care must he taken not to break the pro- 
tective granulation dam of t(ie infection center. The 
nail should he introduced in£b the proximal marrow 
cavity as is done in simple fractures by approach from 
the trochanter and not retrogradely from the fracture 
cleft, 
The wounds must he drained and left open. An 
additional plaster cast is necessary. 
Comminuted fractures and fractures in which a 
stabile osteosynthesis cannot be achieved are unsuitable 
for nailing. 
Though the nailing of fistulating fractures offers 
many advantages, it is very important to be extremely 
careful about the indication. The first condition is 
a stabile osteosynthesis. If this condition can be ful- 
filled the nailing is indicated if a satisfactory 
fixation of the fracture cannot be achieved by conservative 
means or if a pseudarthrosis actually exists or threatens 
to develop or if the formation of sequestra makes the 
exposure of the fracture site necessary,anyhow there is 
no objection to perform the nailing on the same occasion 
if the fracture lends itself to nailing and if the gene- 
ral condition of the patient is good. 
In case of intensely purulent fractures, the nail- 
ing should only be performed if regardless of the 
position, it will not be possible to obtain a satis- 
factory fixation of the fracture as is necessary to 
fight the infection and especial].y so if the formation 
of sequestra or tubular abscesses makes an operation 
necessary anyhow. 
Nailing of femur fractures due to gunshot injuries 
should not be performed in the state of the acute fresh 
suppuration, that is as long as the marrow and tissue 
clefts arc not yet closed by protective granulations, nor 
in a bad general condition of the patient. It must al- 
ways be borne in mind that the nailing of a fractured 
femur is a major operation. 
The stabile osteosynthesis with the marrow nail 
is advantageous over all other methods hitherto known, 
even in fistulating and intensely suppurating fractures 
due to gunshot injuries if its indication is carefully 
considered. 
bfi Tibia Fractures 
In case of old tibia fractures due to gunshot in- 
juries, the wounds of which have already healed, we were very reserved with regard to the nailing on account of Our 
experience gained in old simple fractures. In those 
fractures, the sites of which were not located in the 
median third, that is in which a stabile osteosynthesis 
cannot positively be expected, we confined ourselves 
to a resection of the fibula, mobilisation of the 
fracture, reduction of the fracturo (direct or by means 
Of wire extension) and subsequent walking cast, A 
fixation after 8-12 weeks was obtained this way in 
five fractures which were 9-14 months old. In one 
case (12-i- months old) we had to perform a bone graft 
after 6 weeks which lead to healing* 
In only 2 cases with the fracture site in the middle 
of the bone, we have performed the nailing and the re- 
section of the fibula in one session* The fractures 
were 10 and llig- months old, the wounds had healed 4 and 
3-g- months before the operation. Both cases healed with- 
out infection. As a matter of fact we only sutured the 
periosteum and the soft parts. The skin was left open and 
a drain was applied as usual. 
One of the patients could use the limb after 3 
weeks and 6 weeks later was drafted for the Labor Service, 
The nail was removed 4 months after the operation. The 
joints were freely movable, but a shortening of 1 centi- 
meter occurred. 
In the case of the second patient, the healing was 
delayed, because we had only performed an osteotomy and 
not a resection of the fibula (ill, 96). It healed 
quickly and finally became obstructive and although the 
osteosynthesis was apparently stabile, the patient repeatedly 
complained about pains when using the limb and the 
X-ray picture revealed (ill, 96c) distinct rarefactions 
next to the point of the nail. After the resection of 
the fibula, the fracture quickly solidified (ill, 96d), 
The surgeons in the military hospitals were more 
liberal as to the indication of the nailing ihethod. 
Among seven nailed fractures, there’were only 3 which 
lent themselves for this type of treatment, only a rela- 
tively stabile osteosynthesis could be expected in all the 
other cases. 
The operation wounds had in all cases been prima- 
rily sutured (in some of them even without drainage), 
although the wounds had healed only for 2 to 4 months. 
All cases with the exception of one with a stabile 
osteosynthesis resulted in long lasting suppurations, 
formation of sequestra and in one case in which the 
wounds had not been opened in osteomyelitis with abscess 
at the entrance spot of the nail and suppuration of the 
prepatellar bursa. 
So a 10 to 16 months long stay in the hospital became 
necessary - except in that primarily healed case- and the 
results were decidedly bad, inferior to those which would 
have been obtained with the conservative methods. b 
a 
Illustration 96 
a) Eleven month old gunshot fracture in the leg. The 
wounds have been healed for 4 months. A healing of the 
fracture was not obtained because of the early healing 
and jamming of the fibula. 
b) The same fracture after the osteotomy of the fibula 
and open nailing of the tibia. The connective tissue 
callosity between the fragments was removed, but the 
bone ends were not freshened. The fracture cleft is 
still slightly gaping. Primary wound healing. c 
Illustration 96 
d 
c) Four months p.op. During weight bearing the patient 
constantly complained about pains at the fracture site. 
The fibula is healed but the fragments are not pressed 
together. Marked rarefactions around the nail tip. No 
formation of callus. 
Resection of the fibula and application of a U-shaped 
plaster splint with which the patient starts subjecting 
the limb to weight bearing. 
d) Eight weeks later the fracture is bridged over by bone. 
The nail was extracted four weeks after that. 
If in this case the fibula had been resected immediately 
the fracture would have cone to a quicker healing even 
without a nailing operation. 110 
The polypragmatism and impatience of the surgeon 
is again typical in these cases. 
In the 15 months old fracture due to 
gunshot injury of 111, 97, the wounds of 
which were closed for two months, the 
fibula had been resected. It was omitted 
however, to reduce and fix the fracture. 
Diathermy had been instituted 3 times 
weekly instead. When no callus formation 
was observed after 4 weeks (which is not' 
an abnormal fact in these circumstances), 
the fracture site was exposed, the fracture 
ends which were closed by connective 
tissue were freshened and united by on- 
ly one nail which was much too short 
fcll. 97b). Drainage of the fracture cleft 
towards the calf, suture and plaster cast 
followed. The wound had to be opened 8 
days later. Several small sequestra wore 
ejected. The nail was removed 4 months 
after the operation, although an advanced 
formation of callus could not be observed 
because the wounds were still fistulating. 
The fracture cleft was still recognizable 
to its full extent (ill* 97c), the frac- 
ture was still movable. The fistula closed 
only three months later and after a walking 
cast had been applied the fracture finally 
solidified after two more months. The 
final result was a shortening of 3 centi- 
meters, ankle and knee joint stiffened 
by 50Sf. 
In this case, the same as in 111, 98 the nailing was 
useless , 
111. 98 refers to a 13 months old 
fracture due to gunshot, the wounds of 
which had been healed for two months. 
The same surgeon had p-erformed a fibula 
resection without reducing the still 
movable fracture and without applying a 
plaster cast. An open marrow nailing 
was performed 4 weeks later. On this 
occasion "part of the wall of the dis- 
rupted fragment had to be removed as 
being an obstacle to proper adaption." 
By the fact that the nail lay laterally 
in the proximal fragment and that the 
fracture ends were pushed together, a 
lateral shortening of 4 centimeters 
(ill. 98b) occurred. The sutured wounds 
became infected and had to be opened. 
Several sequestra were ejected. The 
limb was left in the plaster cast, so 
that a severe infection of the marrow 
was fortunately avoided. The distal 
fragment revealed a distinct loosening 110a 
a 
Illustration 97 
b 
c 
a) 15 month old gunshot fracture in the leg. For two 
months the wounds have been closed. The fibula was resected 
4 weeks ago but the fracture was not mobilized and reduced. 
A plaster cast was not applied. Open nailing because no 
formation of callus was observed. 
b) The same fracture after the nailing. Only one nail 
was used which however is too short. Consequently the 
osteosynthesis is not stabil. 8 days p.op. the sutured 
wounds must be opened. Application of a plaster cast. 
Several sequestra were cast off at the fracture site. 
c) Four months p.op. after the removal of the nail 
because the wound still fistulated. The fragments are 
movable and the entire fracture cleft is visible. Further 
plaster casts were applied. Three months later the fistulae 
had healed and consequently a walking cast was applied. 
Finally, two months later, i.e. 11 months after the nailing 
the fracture is healed. The shortening amounts to 3 cns. 
The impediment of the foot and ankle joint amounts to 50 
A quicker healing would have been obtained if after the 
resection of the fibula the fracture had been reduced and 
walking casts applied. 110b 
b 
a 
Illustration 98 
c 
a) 13 nonth old gunshot fracture. The wounds have been 
healed for 2 months. Four weeks ago the fibula was resected 
but the fragnents were not reduced and a plaster cast was 
not applied. 
b) The sane fracture after the open nailing. In the 
proximal fragment the nail is seated very far distally. The 
fragnents were so much pressed together that the shortening 
amounted to 4 cns. The two ends of the resected fibula 
are standing one upon the other. Infection of the sutured 
wounds. Several sequestra were cast off. plaster casts 
had to be applied for a long period of tine. The nail 
was removed 4 months after the operation because the wound 
was still fistulating. Application of a VOLKMANN’s splint 
despite the fact that the fragments were still movable. 
c) Eight months after the operation the fracture healed 
in slight anteeurvation and valgus position. After the 
extraction of the nail an angulation was observed. The 
shortening amounts to 4 cms. The ankle joint is stiff and 
motion of the knee amounts to 180 - 100 degrees. A healing 
would probably have been obtained more quickly without 
the nailing operation, if, after the resection of the 
fibula, the fragnents had been reduced and a plaster 
cast applied. of the structure. The nail was removed 
in this case too, 4 months after the 
operation, because the wounds were still 
fistulating at that time. The leg was 
only put on a VOLKMANN splint, although 
the fracture was still springy. So a 
slight antecurvation and valgus 
developed in which position the fracture 
finally healed. When the wounds were 
closed, the patient could bo discharged 
from the hospital S mbhths after the 
operation* Shortenihg 4 centimeters, 
ankle joint stiffened, knee movable 
between ISO and 100°. These impediments 
could have been avoided if the fracture 
had been properly reduced after the re- 
section of the fibula and if walking casts 
had been applied in due tine. 
Table VII gives a survey over those 15 tibia frac- 
tures due to gunshot injuries the wounds of which wore 
still purulent. Most of these fractures were not nailed 
in our clinic. 
I have written before (See HAEBLER a. a. 0. 111. 
S page 3B) under the general procedures that in such 
fractures the nailing should be performed only in 
those cases, where the formation of sequestra makes it 
necessary to expose the site of the fracture which 
has healed in a bad position, A bad position did not 
prevail in any of the less than 3 months old fractures, 
the surgeon was rather guided in all of the cases by the 
desire to achieve a better fixation with the nail and 
thereby a quicker elimination of the infection. 
With this idea in mind one has also nailed isolated 
tibia fractures, tho site of which was not exposed but 
the sequestrum was removed by enlarging the fistula 
and a "closed” nailing was performed. 
In these fractures one has achieved a quick employ- 
ability of the patient (case 8 and 10) but it must be 
admitted that similar results would have been obtained 
without tho nail. In another case (Nr, 7) we have a 
rather long stay in the hospital with a "closed" nail- 
ing, It must furthermore be admitted that the nailing 
did not constitute a material advantage in all the less 
than 3 months old fractures. If the conservative methods 
would have been applied the time of treatment would have 
been shorter and the final result just as good. We have 
in only 3 of the 11 fractures a full mobility of the 
joints. Tedious suppurations occurred especially in those 
cases in which approximation sutures had been applied. 
We have pointed out already on another occassion the 
special hazard of "approximation" sutures which become 
so easily a complete closure of the wound. It'may be 
objected that all these difficulties could have cropped 
up in the conservative treatment as well and that they 
constitute an ever present hazard in fractures due to gunshot injuries. But it still holds true that a 
clear cut advantage did not become evident, although 
all fractures were well suitable for nailing and the 
osteosynthesis was perfectly stabile. 
These facts may be illustrated by the following 
cases* 
In the 10 days old fracture due to 
gunshot injury of 111. 99 (Table Nr* l), 
the wounds of which wore intensely purulent, 
it was attempted to secure a better fixa- 
tion and control of the suppuration by the 
use of the marrow nail. In the operation one 
not only removed the transversely located' 
splinters but also those bridging over the 
medial side of the fracture, although they 
were connected with the poriostoum. The 
fracture had to be pushed together after the 
nailing and thus resulted in a shortening 
of 3 centimeters. The hope that the nail 
would have a favorable influence on the 
suppuration was, however, not justified. 
On the contrary, gravity abscesses deve- 
loped again and again which started from 
the entrance site of the nail and from the 
fracture. Several sequestra developed at 
the fracture site and the nail had to be 
removed for these reasons although the 
fracture had not yet solidified. Only 
after 11 months in a plaster cast the 
fistula began to subside and the patient 
was finally discharged from the hospital 
with a stiffened anklo joint and an impedi- 
ment of the knee joint by 50^. 
If the slight antecurvation had been corrected and 
the' fracture put at rest from the very beginning in a 
fenestrated unpadded plaster cast, the shortening would 
presumably have been less pronounced, because the medial 
splinters would have presented a good matrix for the 
callus. The healing would have been quicker and there is 
a strong probability that the mobility of the joints would 
have been better. 
In the 4 weeks old fracture of 111. 100 
we performed the nailing because the lateral 
displacement could not be compensated for by- 
extension fixation and because the proximal 
fragment lay free in the granulating wound. 
We expected a stabile osteosynthesis and 
thought that an early use of the limb 
would stimulate the apparently deficient 
callus formation. The fragments could be 
reduced without special difficulty and 
without wide exposure with the finger in- 
troduced into the wound and the nailing was 
uneventful (ill, 100b). The fracture was 
clinically solid after the nailing, but the 
nails wore too short. The suppuration sub- 112a 
a 
Illustration 99 
b 
a) 10 day old gunshot fracture of the leg. We decided 
to perform a nailing operation because of the foul odor 
of the wound and it was hoped to fight the infection 
effectively in this way. During this operation those 
chips which were still covered by periosteum were removed 
(mistake!). Due to the pressing together of the fragments 
the shortening amounted to 4 cms. The wounds were kept 
open. Long lasting suppuration with a gravity abscess 
from the insertion site and from the site of the fracture. 
Several sequestra were cast off. The nail was removed 
four months later despite the fact that the fracture was 
not yet stabil. (The X-rays were destroyed). 
b) The same fracture 5i months after the nailing, 
6 weeks after the removal of the nail. The fracture 
cleft is bridged over by callus which is not yet strong. 
Formation of sequestra at the fracture cleft. 11 months 
after the nailing the wounds were healed. The shortening 
amounted to 3 cms. The ankle joint was stiff and the 
impediment of the knee amounted to 50 %, The use of the 
nail had no advantageous effect. a 
Illustration 100 
b 
a) Four week old gunshot fracture of the leg. The tip 
of the proximal fragment is exposed in the granulated 
exit wound. 
b) Six weeks after the nailing. The loose bone chips 
were removed. In this way a small defect developed at 
the front edge. From the clinical point of view the 
fracture is absolutely stabil. The nail however is 
rather short. 112c 
c 
Illustration 100 
a 
e 
o) Three and | months after the nailing. The patient 
started subjecting the limb to weight bearing 8 weeks p.op. 
Marked structural loosening and beginning formation of 
sequestra at the fracture cleft. Marked rarefaction round 
the nail tip - the osteosynthesis is only relatively stabil. 
A blackish colored secretum extravasating from the fistula 
indicated the existence of rust damages. Therefore the 
nail was removed despite the fact that the fracture was 
not yet stabil. Application of a plaster cast. After a 
sequestrum had been cast off, the fistula closed. 
d) Five J months after the nailing. The fibula is 
healed but the formation of callus is only slight. 
Therefore the fibula was resected and a plaster cast was 
applied. 
e) Six weeks after the resection of the fibula. The 
callus had increased and was more compact. From the clinical 
point of view the fracture is healed. Application of ULNA'S 
bandages. Ten weeks later, i.e. 9i months after the 
operation the patient was released from the hospital. 
The shortening amounted to g cm. The impediment of 
the ankle joint was only slight, the motion of the knee 
amounted to 180 - 90 degrees. sided gradually and 8 weeks after the 
operation the patient could start with 
motion exercises which wefe free from 
pain. The wound then began to excret 
a dark secretion which bedame almost 
black and the fracture cleft revealed 
a distinct loosening of tho structure 
with a beginning formation of sequestra, 
which point to a rust damage (ill. 
100c)« The nail was, therefore, removed 
34" months after the operation, although 
hardly any callus had formed. The rare- 
factions next to the point of the nail 
confirm that the nail had no firm hold. 
The nail revealed a thin black coating 
and sigiis of corrosion. After the re- 
moval of the nail, a small sequestrum \ias 
ejected, then the wound closed quickly. 
As-the fibula had already healed, the 
callus formation was still insufficient 
after 8 weeks of treatment with a plaster 
cast (ill. lOOd). The fibula was there- 
fore resected. Four weeks later the 
fracture was pushed somewhat together and 
clinically was solidified (ill.100c). The 
patient was transferred with a 
cast to the hospital near his home from 
which he was discharged 94' months after 
the operation. Shortening 4" centimeter, 
ankle joint slightly impeded, mobility 
of the knee between ISO and 90°, 
In this case it must qgain be admitted that the 
nailing did not bring any substantial advantage. On 
the contrary, the necrosis at the fracture cleft 
would have been avoided without the nai}.. The delayed 
healing due to the obstructive fibula could not bo 
avoided by the use of the nail. 
The same is true for the other fistula ting tibia 
fractures. The fact that the fracture Nr, 7 has healed 
with full function 7 months after the operation is no 
special success in a 6 weeks old oblique fracture, from 
which a sequestrum v;as removed. On the other hand, 
there is considerable hazard that the nailmay penetrate 
unnoticed into the soft parts if a large fragment has 
disrupted from the proximal fragment, the more so, be- 
cause the fracture ends are not exposed if at all possible, 
In this case the nail may be the cause of a spreading of the 
infection, phlegmons, gravity abscesses and tedious sup- 
purations. 
In our opinion it is conplctoly out of place to nail 
an isolated tibia fracture due to gunshot as in 111* 101 
(Table Nr. 7) for the only reason that "the fracture is 
still movable 4lir weeks after the accident”; this is also 
true a closed nailing is performed as is done in simple 
fractures. It must be borne in mind that the conditions 
arc not aseptic and it is not surprising that a formation 
of abscesses and tedious suppurations will ensue if the 
entran cc wound of the nail is primarily closed. It will a 
Illustration 101 
b 
c 
a) Isolated fistulating gunshot fracture in the tibia, 
kh weeks old. ’’Closed nailing because the fracture is 
still movable”. 
b) The same fracture after the nailing. Formation of 
abscesses and long lasting suppuration which require 
additional plaster casts. The nail was extracted 5 months 
later. 
c) Six months after the operation. 5 months after the 
removal of the nail. The fracture is healed but the wounds 
are still fistulating. A marked dystrophy of the bones 
of the foot is observed. The patient was released from 
the hospital only 10 months after the nailing operation. 
The impediment of the ankle joint amounted to £ and the 
motion of the knee amounted to 80-180 degrees. A better 
result would certainly have been obtained without a nailing. then become necessary to apply plaster casts (as is 
the case without the nail)* 
This unsuccessful case would in itself be sufficient 
to outweigh the cases 8 and 10 in which favorable con- 
ditions prevailed (We can dispense here with a more de- 
tailed description which is given by HAEBLER a.a.0,,page 
38, 111* 8). In case Nr. 11, the healing was agaih com- 
plicated by long suppuration with formation of sequestra 
and delayed formation of callus due to the obstructive 
fibula. 
It is rather surprising that in the fractures 
which are less than 12 weeks old a faulty position did 
nj»t support in a single one of the cases the indication 
for the nailing. Tibia fractures due to gunshot injuries 
which are still movable may practically always be satis- 
factorily reduced with the conservative methods* If a 
healed or not injured fibula hinders the reduction it will 
be sufficient to perform a resection* This is a minor 
operation and presents no hazards and which we have successful- 
ly performed also in case of an insufficient callus 
formation. 
It must therefore be concluded that the marrow 
nail does not bring advantages in fistulating or purulent 
tibia fracture duo to gunshot injuries and one should 
abstain from nailing with regard to the considerable hazards 
even though the exposure becomes necessary because of a 
formation of sequestra. 
If an early healed fibula hinders the proper re- 
duction of the fragments or if it is the reason for an in- 
sufficient callus formation the resection with subsequent 
application of plaster casts will fit the purpose better 
and docs not constitute any hazard. 
Fistulating fractures of the tibia 5 to 18 months 
old, were nailed in four instances. The fibula had 
healed in all of them and if we consider the X-ray pictures 
critically, it appears probable that the final healing 
could have been obtained by resection and proper reduction. 
This obvious solution - as is so often the case - not 
attempted. In case Nr. 15, wo were ourselves not impressed 
by the fact that the pseudarthrosis existed already for 
18 months but wore simply overonthusiastic about the 
marrow nailing method. 
In this case the nail was the cause of late com- 
plications which would very likely have been avoided with- 
out the nail. 
The patient wore a hinged splint, the 
knee joint was freely movable, the ankle 
joint was stiffened by about After the 
patient had been discharged from the Army, 
several ejections of sequestra occurred, 
the last time 14 days prior to his admission 
to the hospital (ill. 102a), After osteotomy 
of the fibula and mobilization of tho fracture a 
b 
c 
Illustration 102 
a) 1| year old pseudarthrosis after gunshot fracture 
which fistulated. 14 days ago a sequestrum, was cast off. 
b) After an oblique osteotomy of the fibula and closed 
nailing. The fracture cleft is still somewhat gaping. 
The patient started subjecting the limb to weight bearing 
3 weeks after the operation. The fistula had healed 
three weeks after the nailing. 
c) 35 months p.op. Due to the weight bearing the fragments 
were pressed together. Marked formation of callus. d 
e 
Illustration 102 
d) 5 months after the operation. 2 weeks 
after the extraction of the nail. The fracture is healed 
and the fistulae are closed. 
e) 11 months p.op. The wounds are closed and the 
fracture is stabil. Release from the hospital. t 
Illustration 102 
g 
h 
f) l3/4 years after the nailing. The patient constantly 
complains about pains and swellings which subside only after 
the wounds have opened up, therefore the patient was taken 
into the hospital again. The filling of the fistula shows 
the remnants of the nail canal which extends to the middle 
of the tibia. The clearly visible nail canal obviously 
ends below the central part of the contrast shadow and the 
marrow cavity seems to be closed. 
g) Between the two sounds inserted into both fistulae 
the marrow cavity is closed. Therefore the marrow cavity 
is widely opened at the end of the upper canal of the 
fistula. 
h) Four weeks later the wounds are healed and the patient 
can be released from the hospital. After that other 
fistulae did not develop. In this case complications would 
have been prevented if only the fibula had been resected 
and walking casts applied. With such a treatment the 
pseudarthrosis would have healed more quickly. 115 
we wero successful though with diffi- 
culties in nailing the fracture with- 
out exposure of the site. The frac- 
ture was clinically solid. There 
was, however, a slight gap at the frac- 
ture cleft (ill, 102b), A small gravity 
abscess developed 10 da ys after the 
operation at the entrance site of the 
nail which was loft open. Apart from 
this the healing process was uneventful 
and the patient could begin to use the 
limb 3 weeks after the operation. The 
fistula at the fracture had closed. 
Weight bearing caused the fracture to 
push together (ill, 102c), a small se- 
questrum was ejected at the fracture-cleft 
and then the wounds closed and the patient 
could be trated 2i months after the oper- 
ation on an outpationt basis. The fistula 
broke open some time later and secreted'a 
dark colored liquid. After 5 months the 
fracture was clinically healed far enough to 
allow the withdrawal of the nails. The 
outer nail was attacked by rust at both 
edges so that there remained only a 3 milli- 
meters strong bridge at the fracture cleft. 
The inner nail revealed similar defects. 
The nail would have broken in the near fu- 
ture. The nail had obviously obtained a 
firm hold in the callus which closed the 
marrow cavities in spite of the unfavorable 
location of the fracture, since there • were 
no rarefactions to be noticed at the point 
of the nail. A sequestrum had formed though 
at the fracture cleft (ill. 102d), This se- 
questrum was removed after the entrance wound 
of the nail had healed by flattening of the 
bone. The wounds had healed after 6 months 
when the patient was discharged from the 
hospital (lll,102o). 
The patient suffered later on again and 
again from pains and swellings at the fracture 
site which subsided only if one of the wounds 
had broken open. Sequestra were not ejected 
on these occasions. The patient was therefore 
readmitted to our hospital 1 yearn after the 
nailing operation. Sequestra could not be de- 
tected, a contrast medium introduced by approach 
from the tuberositas tibiae revealed that a 
fistula canal in the marrow cavity reached to 
the middle of the tibia (111, 102f). The fistula 
could even at the operation not be traced as 
far as the fracture cleft. There remained an 
area about 4 centimeters wide between the sounds 
which were introduced from above and from bo- 
low in which the marrow cavity appeared to be 
closed. A blue solution which was injectod by 
means of an urether-cathcter did not appear at 
the fracture cleft (ill, 102g). We there* fore chiseled the bone at the upper section 
of the canal to expose the fistula (111.102 h). 
In a distal direction the marrow cavity was 
completely closed by hard bone. The patient 
could be discharged from the hospital 6 weeks 
after this operation with the wounds healed 
and has had no complaints since. 
There is no doubt that this long stay in the hospital 
would have been avoided if the nail had not been used. 
And it is really a shame that nobody (including ourselves) 
ever thought of resecting the obstructing fibula. 
It cannot be maintained in the three other cases of 
connective tissue pseudarthrosis that the anil brought 
clear out advantages. 
The fracture due to gunshot injury, 
5 months old, which was described in de- 
tail in another place (HAEBLER, a.a.0,,page 
36, 111. 7) and which was nailed because the 
lateral displacement could not be compensated 
for otherwise, had not solidified when the 
nail was removed months later, but healed 
quickly after the resection of the fibula. 
In this case also one had omitted to resect 
the fibula. This was the reason why the in- 
troduction of the nail into the distal frag- 
ment was particularly difficult even after 
the exposure of the fracture site and there was 
a gap of several millimeters at the fracture 
cleft. The fracture was pushed together to 
a certain but insufficient extent when the 
limb was used. The nail penetrated closely 
to the talo-crural joint. If the obstructive 
fibula, which was responsible for the delayed 
healing had not made a further pushing to- 
gether impossible, the nail would probably have 
perforated the joint and caused additional 
complications. 
Even in the 7 months old fracture of 
111. 103 (Table Nr. 13) in which a beginning 
pseudarthrosis was suggested by the X-ray picture, 
we are inclined to think that a simple re- 
section would have fitted the purpose better and 
lead to a ouicker healing. In the operation 
there was found only connective scar tissue be- 
tween the fracture ends which also closed the 
marrow cavities. In this case it was like- 
wise omitted to resect the fibula and when the 
nails were removed 4 months after the operation 
because a dark colored discharge indicated rust 
defects, the fracture had not yet solidified 
(ill, 103b), (The nails had oxydized at the 
fracture site). The wounds closed soon after the 
nails had been removed bqt the fracture solidified 
only after 4 more months to such an extent that 
the walking cast could be replaced by an UNNA 
bandage (ill. 103c), b 
a 
Illustration 103 
c 
a) Seven month old fistulating gunshot fracture of the 
leg. The fibula is healed. Open nailing. Sclerotic 
connective tissue observed between the two fragments had 
to be removed during this operation. Non-operative re- 
fracture of the fibula. (Pictures were destroyed). 
b) Four months after the operation. Removal of the nail 
because blackish secretum indicated the existence of rust, 
which was true. The fracture is movable. Therefore 
further plaster casts were applied. 
c) Eight months after the nailing. Four months after 
the extraction of the nail the fracture was bridged over 
by bone and the wounds were closed. A quicker healing 
would probably have been obtained with a resection of 
the fibula and non-operative reduction. I maintain that those 4 fractures would have 
satisfactory solidified if one had resected the fibula 
and if a non-operative reduction had been performed with 
subsequent application of walking casts, because we had 
not to deal in these cases with genuine pseudarthroses 
but with an unhealed fracture. To prove this state- 
ment I wish to point to 111, 104 which resembles.Ill* 
103 very much and in which it seems fully justified 
to diagnose a pseudarthrosis, This "pseudarthrosis” 
solidified after the resection of the fibula and 6 wee' s 
in a pla ster cast, to such an extent that it could be 
placed in an UNNA bandage. The patient could perform 
his duties 8 weeks after the resection. This is one 
example out of a great number, because we have, in con- 
sideration of our bad experience in the case shown in 
111, 102, confined ourselves at first to resection of 
the fibula. Apart from cases having very serious 
defects we have always been successful. 
On the basis of our experience we therefore might 
say, in contrast to our previous statements that a nail- 
lng_l-S_Qnl.Y to be performed in old tibia fractures duo to 
Hlinshot t he_wounds_of _whi ch__]iaye_ just 
healed, if we have to deal with a transverse or short 
oblique fracture in the median third, in which a stabile 
osteosynthesis may be expected with certainty. Even 
if these conditions are fulfilled, the greatest reserve 
is indicated and it is recommended to perform the nail- 
ing only if one docs not succeed in obtaining a satisfactor 
position by non-operative measures after the resection of 
the fibula. 
The - wounds must bo drained. It is better to not 
suture the skin. An additional plaster cast is necessary 
until the infection hazard is definitely overcome. 
r ac tur es_duo_t o„gunshot_iQ- 
Jil£2-ijj^-.ii^iili£^should_N0T_bo_uerformed. They will b - 
come solid as a rule by a resection of the fibula with 
subsequent position at rest by walking cast, if one succeeds 
in bringing the fragments to a proper abutment. 
\ If healing fails to come, supporting apparatuses are 
indicated and one of the time honored pseudarthrosis oper- 
ation should be performed (bone graft or MATTIES 
if at least one year has elapsed after the definite closure 
of the wounds. 
The nailing of the old f5,stulatiflg , fracture ,due 
to, gunshot injury should not. be performed even though 
a pseudarthrosis exists or is imminent. The nailing does 
not bring any advantage but it does constitute an additional 
hazard of complications which can be avoided without the 
nail. 
The double nail is particularly susceptible to corro- 
sion by the suppuration and this type of nail therefore 
further sustains the suppuration (foreign body) and it 
obviously favors the formation of sequestra. Illustration 104c 
could not be re- 
produced as the 
negatives were 
not available. 
a 
Illustration 104 
b 
c 
a) l| year old gunshot fracture of the tibia. Diagnosis 
according to the X-ray: "Pseudarthrosis". The fibula is 
healed and the wounds have been closed for more than one 
year. 
b) Six weeks after the resection of the fibula with 
subsequent treatment in a walking cast. Marked formation 
of callus. The fracture is clinically healed. The patient 
was released from the hospital with an UDNA’s bandage. 
c) Ten weeks after the operation. Bony healing of the 
fracture. The shortening amounts to j cn. All joints 
are freely movable. - 118 - 
Since we have to deal in the tibia mostly with 
connective tissue pseud-arthroses, the resection of the 
fibula with subsequent application of walking cast will 
as a rule bring quick healing (apart from defect pseudar- 
throses), The fibula resection constitutes a minor and 
simple operation and should therefore be tried before 
any more serious operation is performed. If the re- 
section does not show the desirable result, one should 
wait until the wounds have healed for about one yeor 
and then perform a bone graft without nail. 
cl Fractures of tfro humerus due to gunshot._i,nj^r3,0s^, 
BOEHLER (in Technioue of the treatment of bone 
fractures, Ed, 9-11, Vol, 3, Vienna 1944, page 1986) 
advises against the marrow nailing of pseudarihroses 
of the humerus because it does not bring any advantages 
(epsecially v/ith respect to callus formation) over oth.r 
methods and because it failed in case of atrophic bone, 
just as the bone graft, and because of the greater hazard 
in case of an infection (which might spread over the 
whole marrow cavity due to the nail). 
In our 47 cases of marrow nailing operation of 
old fractures of the upper arm due to gunshot injuries 
an osteomyelitis occurred in three cases, namely in a 
three months old fistulating fracture, in a 19 months 
old pseudarthrosis, the wounds of which had been closed 
for 5 months and in a Zi year old pseudarthrosis which 
was operated upon 13 months after the healing of the 
wounds. All these patients were not treated in our 
clinic and the spreading of the infection was without 
any doubt due to deficiencies of the technique, above all 
to the delayed opening of the wound. 
In the already described (HAEBLER a.a.O, Page 175, 
111, 75) still fistulating fracture the neurolysis of 
the radialis had been performed together with the nail- 
ing, The wound of the neurolysis and the wound of the 
olecranon were sutured. The wound at the fracture"was 
closed by approximation suture and tamponaded.n Although 
the temperature rose and marked swellings took place, 
the neurolysis wound was only opened 4 days after the 
operation and the entrance wound at the olecranon only 
after 7 days, when an abscess already threatened to 
break through. The nail was much too short and had 
no hold in the proximal fragment. 
In the 19 months old pseudarthrosis in 
the median part (see HAEBLER a.a.O, page 43, 
111. 12) in which a severe infection and 
erysipelas had developed 10 months before on 
the occasion of the splintering, the osteo- 
synthesis was apparently stabile, but the 
wound had been sutured and only a small drain was placed into the wound for 24 hours, 
"because of the persisting soft part ca- 
vity in the extended arm11! In this case 
it was again omitted to open the wounds 
in proper time in spite of a marked swell- 
ing of the arm and although an ’’abundant11 
amount of serous liquid came out of the 
suture stitches after the removal of the 
suture. Even active movement exercises were 
instituted and an attempt was made to keep 
the inflammation down by alcohol cataplasma, 
(swellings and redness of the skin)* Finally 
16 days post-operative an abscess broke 
through. That the infection spread under 
these averse conditions into the distal frag- 
ment is quite natural (nailing had been 
performed by approach from the distal side). 
Fortunately, the nail had a firm hold, so 
that a severe inflammation was avoided, se- 
questra did not develop and the loosened 
structure of the bone soon subsided and the 
fracture became solid* 
Also in the case of a two year old defect pseudarthros51. 
the osteosynthesis proved to be instabile. Confident 
in the fact that the wounds had healed one year before, 
the site was primarily sutured and the drain was removed 
after 24 hours in spite of still existing fever. Here 
again valuable time was lost by the administration of 
sulfonamides and the application of cataplasma and although 
the fever was steadily* on the increase, the wounds were 
widely opened only 10 days post operative, when the pre- 
sence of the abscefes was quite obvious. 
The spreading of the infection into the marrow can 
be avoided with certainty if the wounds are immediately 
widely opened in case an infection occurs, even if the 
osteosynthesis is not completely stabile. (See 111. 106). 
A primary closure of wounds is always hazardous 
in old fractures due to gunshot injuries, because one is 
never on the safe side with regard to infections even if 
the fistulae are closed for more than 1 year* AmongS 
of that type of pseudarthroses only 4 healed primarily. 
On the other hand 3 out of 5 fractures healed with- 
out infection, which had been nailed 3 to 5 monthd after 
the closure of the fistulae and sutured primarily with 
adequate drainage. The postponement of the operation 
apparently does not bring any advantages* 
The suppuration was,If no osteomyelitis occurred, in 
all cases very tedious in which the wounds had not been 
opened widely and if one was satisfied instead with a 
simple drain. In contrast to this, 6 pseudarthroses which 
had been operated upon 4 to 6 weeks after the healing 
of the wounds, healed per secundam and much quicker, be- 
cause we renounced the skin suture (the wounds were tho- 
roughly drained), only the musculature over the bone was 
held in the proper place by a few stitches. A formation of sequestra was observed in none of 
the 11 cases in which the healing of the wounds took 
place less than five months prior to the operation, 
although there were a few comminuted fractures among 
these cases, 
We have nailed 14 psoudarthroses which were 5 to . 
22 months old regardless of the still existing fistula. 
As a matter of fact, the wounds wore thoroughly 
drained and left open. Not a single case of osteomyelitis 
occurred and sequestrum formation was observed in only 
two cases although the osteosynthesis was not absolutely 
stabile in all of the cases and in spite of the fact 
that existing sequestra (which were removed at the same 
session) were the reason for the fistula suppuration. 
We therefore feel justified in denying the possibility 
of a spreading of the infection into the marrow cavity 
due to the presence of the nail. We doom this hazard to 
be completely avoidable and it therefore cannot possibly 
constitute a factor of contraindication to the marrow 
nailing of pseudarthroses of the upper arm. 
All our cases (33) of pseudarthroses duo to gunshot 
fractures came to a bony healing. 
In an 8 months old psoudarthrosis in the distal 
third, however, a bone graft was performed 5 months 
after the operation with the nail in position (by one 
of my very "operation happy" colleagues) (See HAEBLER 
a,a.O, page 47, 111, 14) • 1 am not sure whether this 
was necessary or not. 
It must be admitted, however, that the treatment 
in the hospital was rather tedious and lasted in many 
cases more than 1 year and the nails were only removed 
after 6 to 7 months. 
The desire to create better conditions, that is 
better mobility of the joints by adequate movement, was in 
the first place responsible for this long hospitalization 
rather than the time required for bony healing (with the 
exception of suppurations and injuries of the nerves). 
The nail was left in position in these cases as an addi- 
tional fixation. The patients so treated were farmed out 
for work so that the time of the stay in the hospital is 
not an absolute measure of the unemployability. 
The fact, however, that all pseudarthroses came to 
a bony healing, including some cases with severe atrophy 
and cases in which a bone graft had previously been 
performed without much success is clearly in favor of 
the marrow nailing method and refutes the opinion of 
BOEHLER, 
As a matter of fact the osteosynthesis was stabile 
in the majority of the eases, at leist to such an extent, 
that the nail did not allow for any lateral movement. 
This is not always the case in the examples cited by 
BOEHLER, If the fracture after nailing was still movable in a longitudinal direction, which happened in several 
cases, we applied abduction plaster casts and pushed 
the fracture together at the same time. The arm 
was elevated above horizontal until the fracture be- 
came solid. Such loosenings of the nail occur 
especially if the nail was introduced by approach from 
the distal side they do not present any additional hazard 
if treated properly. It is not sure Y/hcther or not a 
longitudinal wire suture will prevent this distraction. 
In case of atrophic bone the wire suture is likely go 
cut through the bone and will then prove hazardous 
rather than helpful. 
This is illustrated by the following examples; 
Fractures in the middle third are the most suit- 
able because the nailing will secure a stabile osteo- 
synthesis. 
In the 6 months old fracture due to gun- 
shot injury in 111, 105, the wounds of 
which had been healed for six weeks, the 
broken out wedge had not found a junction 
to the distal fragment. First of all, we 
have mobilized the fracture under ana- 
esthesia, although it appeared freely 
movable, and we hoped to be able to per- 
form a closed nailing operation. Since no 
reaction was observed, we performed the 
operation 8 days later. 
We were not successful in performing 
a closed nailing. The KIRSCHIJER wire used 
as a guide rod repeatedly slipped off the 
proximal fragment. The exposure revealed 
that the marrow cavity was closed by strong 
callus and that a connective tissue psou- 
darthrosis existed between the broken out * 
wedge and the distal fragment. The connective 
tissue between the fracture ends was removed 
and the proximal marrow cavity was opened by 
means of an awl. We renounced, however, a 
resection of the bone. The wounds were pro- 
perly drained and the musculature at the 
fracture site, but not the skin,was brought 
in position by a few approximation stitches. 
Abduction plaster cast. The osteosynthesis 
was clinially stabile (111, 105), As no 
fever was observed,'the drains were removed 
after 10 clays and movement exercises were 
instituted 3 weeks post operative. The 
wounds had healed secondarily 6 weeks after 
the operation, the plaster cast was removed. 
The si'ght gap of the fracture is pushed In 
by the use of the limb with a slight angu- 
lation (ll*l, 105c) and has h ealed 6 months post 
operative to such an extent that the nail 
can be removed (ill. 105d), The patient is 
detailed to work during the period of move- 
ment exercises and on his discharge to the 
troop there was an extension defect of the a 
Illustration 105 
b * 
a) Six month old pseudarthrosis after gunshot fracture 
in the arm above the elbow. The wounds have been healed 
for 6 weeks. 
b) After the open nailing, during which operation only the 
connective tissue between the fragments was removed. The 
osteosynthesis is stabil. The fracture cleft is somewhat 
gaping. Drainage of the fracture cleft and of the nail 
insertion site. No skin suture. Abduction plaster cast. 
The patient started subjecting the limb to exercises 6 
weeks after the operation. The plaster cast was removed 
and the wounds healed per secundam. 121b 
c 
d 
Illustration 105 
c) Five months after the operation. The fragments were 
pressed together and they healed with slight angulation in 
the dorsal direction. Good formation of callus. The nail 
will be removed. 
d) • Six months after the operation. Bony healing. The 
defect of elbow extension amounts to 25 degrees. All other 
joints are freely movable. 122 
elbow joint of 25°, The elbow joint was 
almost stiff on his admittance. The 
shoulder was freely movable. 
The healing was less uneventful in the 
case of the 2 year old pseudarthrosis of 
111* 106a, where a bone graft had been per- 
formed 9 months after the injury but had 
not lead to healing. In consideration of 
the fact that the wound allegedly had healed 
for more than 1 year, the wounds at the fract- 
ure were sutured with application of a drain* 
The wounds had to be opened three days later 
because of a rise of temperature. Although 
an osteomyelitis or a formation of sequestra 
did not occur, the patient reacted to the 
movement exorcises with fever and pains, so 
that the plaster cast had to be left in po- 
sition. As the wound at the fracture con- 
tinued to fistulate we decided 7 months post 
operative to remove the nail, although the 
X-ray picture indicated that the callus 
formation was not too abundant. The 
fracture was clinically solid, but still 
was left in the plaster cast for 6 more weeks 
(ill* 106d) when the callus had finally 
solidified to such an extent that movement 
exercises could be instituted. The fistulae 
were completely closed only 11 months after 
the operation when the patient was discharged 
from the hospital* The condition of mobility 
of the joints had not notably improved. This 
could as a matter of fact hardly be expected in 
a 2 year old fracture. 
One cannot and must not rely upon the solidity 
of small callus bridges this is demonstrated by the des- 
cription of the fracture as seen in 111. 107. 
In the nailing of the 8 months old 
fistulating pscudarthrosis the outer nail had 
turned by 90°, so that one renounced intro- 
ducing the inner nail because the fracture 
appeared to be completely solid (ill* 107b), 
liight days later, the fracture could be moved 
longitudinally and was somewhat distracted 
(ill, 107c). In the abduction cast, the fracture 
became, after 9 months, so solid by the forma- 
tion of a sturdy callus bridge, that we removed 
the nail (ill. 107d). A refracture occurred 
2 months after the removal of the nail due to 
the physiotherapy. The wounds had healed in 
the meantime. Since the fracture had not 
healed after 10 months of treatment by plaster 
cast (ill. 107e), I decided to renail the fracture. 
For this purpose £ resected the tapering point 
of the distal fragment, the callus bridge was 
freshened and after the nailing which was this 
time performed by approach from the proximal 
side, the fracture ends were united by a b 
a 
Illustration 106 
a) 2 year old pseudarthrosis after gunshot fracture. 
Unsuccessful bone graft 3/g years after the wounding. The 
remnant of the graft in the distal fragment is still' visible. 
The wounds have been healed for one year. 
b) After the open nailing. The connective tissue 
callosities were removed, the tips of the fragments 
were conservatively resected and a blocking callus 
bridge was removed. Wound suture with drainage of the 
fracture site. Abduction cast. Three days after the 
operation the-wounds had to be opened. Subjecting 
the limb to exercises constantly caused an increase of 
temperature. Further immobilization by plaster casts. c 
a 
Illustration 106 
c) Six months after the operation. The wounds are still 
fistulating. Despite the fact that only a small bridge 
of callus was present the nail was removed. No osteomyelitis. 
From the clinical point of view the fracture is healed after 
the extraction of the nail. After that, the patient was kept 
in the cast for another period of six weeks after which the 
patient started subjecting the limb to exercises. 
d) Eleven months tifter the operation. Bony healing of the 
fracture. The fistulae are closed. The flexibility of the 
joints in comparison to the conditions before the operation 
is not much better. 
\ b 
a 
Illustration 107 
a) Eight month old fistulating defect pseu&arthrosis 
after gunshot fracture of the arm above the elbow. 
b) The sane fracture after the nailing. The nail had 
turned 90° so that the inner nail could not be inserted. 
The fracture is clinically healed. The wounds were kept 
open. An arm sling was used. c 
Illustration 107 
d 
e 
c) Eight days after the operation. Distraction of the 
fracture. The fragments can be moved up and down in the 
longitudinal direction. Abduction cast. 
d) Nine months after the operation, eight days after the 
removal of the nail. The fracture healed with a small 
bridge of callus. Soon after that the fistula at the 
fracture site healed. Two months after the extraction 
of the nail a refracture occurred during the medico- 
mechanical treatment. Application of an abduction cast. 
e) 21 months £.op., 10 months after the refracture: 
Pseudarthrosis between the callus bridge and the distal 
fragment. f 
Illustration 107 
6 
f) Once again open narrow nailing. The tips of the 
fragnents were resected and the callus bridge was freshened. 
After the fragnents had been pressed together they were 
held together by neans of a wire running in the longitu- 
dinal direction. Application of a plaster cast for a 
period of 10 weeks. Good healing of the wound. The nail 
was extracted after a period of 6 months. After that a 
fistula was observed at the fracture site extending to 
the wire which was removed. 
g) Nine months after the second and 2\ years after the 
first operation. Bony healing of the fracture. The 
fistulae are closed. longitudinal wire suturo (ill, 107 f). 
The nail appreared rather short, however, 
it was so firmly stuck in the distal marrow 
cavity that it separated the fracture when 
driven in farther. The drain wounds healed 
uneventfully. The plaster cast was removed 
only 12 weeks later; the nail was withdrawn 
six months post operative. Then a fistula 
occurred at the fracture which communicated 
with the wire suture which was then also 
removed ; 9 months after the second and 22- 
years after the first operation tho patient was 
finally released from the hospital (I11.107g), 
It is not sure whether or not a' better result would 
have been obtained in the first place if the fracture 
ends would have been resected. We refrained from pcr-~ 
forming the resection at tho first operation because wo 
had to deal with a fistulating pseudarthrosis in which 
as a matter of fact the protective granualtion tissue 
should be spared as much as possible with a view of avoid- 
ing a medullary infection. If the osteosynthesis is very 
stabile these pseudarthrosis will become solid even if 
the fracture ends do not widely abut but are only bridged 
over by callus splintors as is demonstrated in the follow- 
ing case. 
In the 6 months old fistulating pseu- 
darthrosis of 111. 108a, only two little 
sequestra were removed on the occasion of 
the nailing operation, whereas the splinters 
which were still in connection with the 
periosteum and partly connected with each 
other by callus were left in position 
although they made it impossible to push 
the fracture together. The nail which 
was driven in as far as the head gave the 
fracture a completely firm hold, although 
the nail lay free in the defect. The mus- 
culature over the exposed nail was held in 
position by an approximation suture. The 
wounds were properly drained and left open. 
Abduction splint. The wound at the olecranon 
healed uneventfully, A small sequestrum was 
ejected at tho fracture site whereupon the 
fistula closed, 10 weeks post operative 
motion could bo instituted and 1 year post 
operative the fracture was solid enough, 
so that the nail could be removed (ill, 
108c). Shoulder joint freely movable, mo- 
bility of tho elbow joint was 70 to 160°, 
The pseudarthroses in the median third are also very 
suitable for nailing, even if the distal fragment is 
rather short* 
In tho 22 months old fistulating 
pseudarthrosis of 111* 109, for instance, 
the fracture had so much solidified after 
5 months that the abduction cast could be 123a 
a 
b 
0 
Illustration 108 
a) Six month old fistulating defect fracture of the 
arm above the elbow after a shell splinter injury. 
The fracture is freely movable, 
b) The same fracture after the nailing, during which 
only two loose and sequestrated bone grafts were removed. 
Most of the splinters are covered by callus which prevents 
the pressing together of the fragments. The nail grants 
a good hold to the fracture. Abduction splint. The patient 
began subjecting the limb to exercises 10 weeks after the 
operation. The splint was removed 12 weeks after operation. 
4 months after the operation ambulatory treatment. The 
patient resumed working 6 months later. 
c) One year after the operation. Bony healing of the 
fracture and removal of the nail. The shoulder joint is 
freely movable, the motion of the elbow amounts to 70-160 
degrees. a 
Illustration 109 
b 
a) Pseudarthrosis after gunshot fracture of the upper aria, 
2 months after the nailing. (Pictures taken earlier were 
destroyed). The fracture cleft is still noticeable, 
suppuration of the wounds. The nail is exposed in the 
wound at the olecranon. No osteomyelitis. 
b) The same fracture 3 years aft'er the nailing- According 
to the statements of the patient the inner nail slipped out 
of the wound 2 years ago. The wounds are healed and the 
fracture is bridged over by callus. removed. During all the time the nail 
was visible in the open wound at the 
elbow and had here the effect of a very 
efficient drain so that the wound at the 
fracture closed relatively quickly. 'The 
wound at the elbow healed also but we did 
not yet remove the nail because the callus 
appeared to us to be too slight. The patient 
was then drafted for labor service and I saw 
him again only 2 years later because of 
an abscess at the elbow. The fracture had 
come to a good bony healing and the nail could 
be removed on the occasion of the incision 
of the abscess. The elbow joint was movable 
between 90 and 160°. This may certainly be 
called a good result. 
In this type of fracture special attention must be 
paid that the nail is introduced exactly at the upper 
edge of the fossa olecrani and that its end is bent 
a little bit, so as to avoid the distal fragment from 
slipping of the nail (See 111. 115), If these points 
are observed special measures as for instance the 
spiral spring proposed by MAATZ will not be necessary. 
If the nail is not introduced exactly in the middle in 
the hope that it will this way obtain a firmer hold in 
the spongiosa one risks splitting the bone and in that 
e the osteosynthesis will be the more instabile. 
It is recommended to nail fractures duo to gunshot 
injuries, especially if they arc still fistulating 
by approach from the distal side because of the ever 
present infection hazard in this type of fracture. By 
a distal approach the entrance spot of the nail will be 
the deepest point and the nail will guarantee a perfect 
drainage if the wound is left open. 
This will hardly be possible in case of fractures 
in the proximal third, because of the hazard that the 
nail will slip out of the head and cause a pseudarthrosis 
as actually happened in the fracture due to gunshot in- 
jury shown in 111. 110 which had been nailed (not in 
our clinic) immediately after the injury and which came 
to us for treatment one year lator. We obtained a heal- 
ing by means of a staircase shaped freshening and wire 
suture, 
We and many others have attempted to nail such 
pseudarthroses by approach from the proximal side and 
complications occurred in each of these cases. 
Two pseudarthroses, the wounds of which had healed 
for two months respectively one year, became infected 
and resulted in tedious suppurations with perforations 
towards the fossa olecrani respectively infection of the 
bursa subdeltoida, In two other fistulating pseudarthroses, 
the distal atrophic fragment was split once without se- 
quelae and in the other case it came to an infection of 
the elbow joint. Illustration 110 
1 year old gunshot fracture which had been nailed 
immediately after the injury. A splint was used for a 
period of 13 weeks. The old nail canal is clearly 
noticeable in the head, out of which the tip had slipped. 
In this way a pseudarthrosis developed. The marrow nailing 
operation is not indicated for gunshot fractures located 
so proximally. 125 
Although all these pseudarthroses cane to a bony 
hoaling, it must be said that the nail did not bring” 
any advantage whatsoever. There is a more simple means; 
which is more likely to be successful especially in , 
atrophic bone: The distal fragment is slightly pointed 
and pushed into the spongiosa of the head# Then an 
abduction cast is applied. This may also bo done if the 
fracture is still fistulating, In that case one must 
beware that no wire suture is used which will always 
cut the atrophic bone and cause the resorption of the 
fracture ends and the result will bo a faulty healing. 
The Illustrations 111 - 113 demonstrate the above 
fact®* 
The main advantage of the marrow nailing method 
with regard to old fractures due to gunshot injuries of 
the humerus in which an uneventful healing is not assured 
lies in the fact that it can be performed when the wounds 
are still suppurating. We have nailed 14 times under 
those circumstances, throe times with very severe suppura- 
tions and the results are set forth in table VIII, 
It is not surprising that a formation of sequestra 
occurs in this type of fracture which could not be avoided 
by any conservative method especially when dealing with 
severely comminuted fractures. It appears relevant to 
us that an osteomyelitis occurred only in one instance 
and this could have been avoided. 
It is important that only the sequestra are removed 
during the operation, the splinters, however, will as a 
rule be in position and freshening will be avoided. 
The splinters are useful and their removal would be 
synonymous with a destruction of the protective granulation 
dam. It is important also that the osteosynthesis be 
stabile, that the wounds be properly drained, that neither 
the entrance site of the nail nor the wounds be sutured to 
avoid a collection of the infectious secretion. 
The nailing is to be performed if possible by approach 
from the distal side to avoid collections of secretions 
in the marrow cavity. The nail will then constitute 
an ideal drain and its entrance site will bo the deepest 
point,• 
If the nailing is exceptionally performed by approach 
from the proximal side (ill, 114) it will be necessary 
to apply an abduction cast and to elevate the arm above 
the horizontal until the infection period is overcome. 
With reference to what has been said already to 
the point (HAEBLER a.a.0.,page 34, 111, 5 and 6) we abstain 
from giving more illustrations. Only one nailing will bo 
described because it typically demonstrates that conditions 
may arise in case of an atrophic bone which must be 
given special consideration. % 
/ 
j 
with 
Average stay 
in the hospi- 
tal 
Days 
— * ■ —- - 
Final Result 
Number 
Bony Heal 
ing 
a O hr) 
M Cl] p 
cto p 
P ! c+ 
Osteo- 
myeli- 
tis 
I 
II 
III 
Intensely purulent fractures, moderately 
splintered, 
6 days to 9 weeks old 
3 
3 
1 
- 
115 
2 
1 
- 
fistulating fractures 
. 
4-8 weeks old,without extens.splintering 
3 
3 
i 
- 
98 
3 
- 
, comminuted fractures 
2 
2 
1 
150 
2 
- 
mm 
10 - 16 creeks old,without ext. splintering 
4 
2 
3 
1 
210 
- 
1 
2 
, comminuted fractures 
2 
2 
156 
2 
*) I - entirely free mobility of the joints, no shortening 
II - Slight angulation or impediment of 
the joint 
EM< 20t per cent 
III - More important angulation or impediment of the joint EM >25 per cent 
Marrow nailing of intensely purulent and fistulating old Fractures of the upper arm due to gunshot 
" * injury* 
T A D L E VIII, a 
b 
c 
Illustration 111 
a) 15 month old pseudarthrosis after gunshot fracture. 
The wounds have been healed for 7 months. Serious bone 
atrophy. 
b) The same fracture after the nailing. Drainage of 
the wounds which werd closed by approximation sutures. 
The osteosynthesis is stabil. Application of an abduction 
cast. The drainage was removed 14 days later and the 
patient began with exercises with the abduction cast open. 
Fistulation of the wounds. 
c) The same fracture 4 months after the operation. It 
seems to be bridged over by good callus. The wounds are 
still fistulating. Removal of the cast. The patient 
complained about pains at the fracture site three weeks 
after that. Therefore another abduction cast was applied 
which was split. Continued fistulation of the wounds. d 
f 
Illustration 111 
e 
d) The sane fracture 5 nonths after the operation. 
Another distraction is observed. Further fistulation of 
the wounds. After that the fragments were pressed together 
and an abduction plaster cast was applied. Ambulatory 
treatment. 9 nonths p.op. the fistulation of the wounds 
had not yet subsided. The fracture is healed from the 
clinical point of view. The X-ray is similar to Illustra- 
tion 111 c. Additional plaster casts. 
e) 13 nonths after the operation an abscess at the elbow 
was observed. The callus which bridges over the fracture 
is thin but stabil. The nail had penetrated the fossa 
olecrani. It became visible during the incision of the 
abscess and therefore it was removed, additional plaster 
casts. 14 nonths after the operation the plaster cast 
was removed. 
f) 20 months after the operation. The wounds finally 
closed and the fracture is stabil. The shoulder can be 
raised up to the horizontal line. Motion in the elbow 
is 60-150 degrees. a 
b 
Illustration 112 
a) One year old fistulating pseudarthrosis after a gunshot 
fracture with formation of a sequestrum. The sequestrum was 
removed. The distal end of the fragment was conically 
sharpened. After that it was inserted into the spongiosa 
of the proximal fragment which had previously been refreshened 
with a curette. Drainage of the wound with the skin kept 
open. Abduction cast. The wounds are healed 8 weeks after 
the operation. Removal of the plaster cast 6 months after 
the operation. The fracture is stabil from the clinical 
point of view. 8 days later a fistula broke open in the 
operation wound out which a small sequestrum was cast off. 
After that the wound closed. 
b) 7| months p.op. The fracture is healed. In the elbow 
joint the impediment of extension amounted to 10 degrees, 
all the other joints are freely movable. a 
b 
c 
Illustration 113 
a) Three year old pseudarthrosis of the am above the 
elbow after gunshot fracture. A bone graft had been made 
one year before. The suppurating wounds have been healed 
for 8 months. The previously planned nailing operation 
was not made because the bone would become too short by 
the necessary freshening of its ends. Therefore only the 
distal fragment was freshened and inserted into the proximal 
marrow cavity. It was kept in place with two wire loops. 
Application of a plaster cast. 
b) The same fracture after the operation. Primary healing 
of the wound. 
c) Five months after the operation. Despite the fact that 
a primary healing had been obtained, and the limb was 
constantly immobilized, another pseudarthrosis had developed 
which was due to the resorption of the atrophic bone caused 
by the wires. 
The question whether or not a healing would have been 
obtained without the wire suture cannot be answered. It 
would have been better to take a possible shortening into 
account and to nail the fracture. It certainly would have 
been successful because a stabil osteosynthesis was possible.' 
Now the patient declines further operations. a 
b 
Illustration 114 
a) Five week old fistulating fracture of the arm above 
the elbow after nailing. The osteosynthesis is stabil. 
An abduction cast was applied. 
The wounds which had been kept open, healed without 
delay and per secundam, within four weeks. After that 
the patient started subjecting the limb to exercises. 
Removal of the plaster cast after a periou of 2 months. 
The patient was released to his unit for garrison duty 
three months after the operation. 
b) Six months after the operation. Bony healing of the 
fracture and extraction of the nail. All joints are 
freely movable. In the nailing of the 16 weeks old 
fistulating comminuted fracture of 111* 
115a, the nail stuck in the corticali's when 
driven into the proximal marrow cavity. It 
was withdrawn and the point was slightly 
angulated whereupon it could be easily driven 
in and came into a good position. After that 
the fracture was still movable in a longi- 
tudinal sense (ill* 115b). For this reason 
the inner nail was also driven in but the 
fracture could still be distracted. We pushed 
it together strongly and applied an abduction 
cast. The X-ray control which wo alwaysrper- 
form after the application of plaster casts 
revealed that the distraction was still exist- 
ing and that the nail had penetrated through 
the corticalis into the soft parts at the spot 
which is clearly visible in 111, 115b and c. 
When we removed the nail the point of which 
was palpable tbroughan incision, the outer 
nail slipped out of the distal fragment, 
Therefore we used another nail which was 2 
centimeters longer. The end of this nail was 
given the shape of the letter S to assure a 
firm hold in the proximal fragment. The nail 
now reached up to the spongiosa of the head, 
A piece of bone had broken out at the flexor 
side of the distal fragment which had to be 
removed because it was bare of periosteum. 
The fracture could now be easily adapted, but 
the nail did not have a proper hold and' was, 
therefore, fixed by wire loops. The position was 
now satisfactory but the fracture could still 
be distracted (ill, 115d), Considerable pres- 
sure was exercised from the side of the el- 
bow and an abduction cast was applied. The 
wounds which were left open came to an un- 
eventful secondary healing and the fracture 
had solidified, 4 months post operative to 
such an extent that movement exercises could 
be instituted (111, 115c), The patient was 
transferred 4 weeks later into a special 
hospital because of a paralysis of the radialis. 
The nail was then removed 0 months after the 
operation after a suture of the nerve had been 
done. X-ray pictures are missing. The shoulder 
joint was freely movable, elbow movable 90 to 
170°. 
It may be seen in the table that the result of the 
treatment is the better the earlier the operation id per- 
formed, Nevertheless we advise a careful consideration 
of the indication in every case, 
In summary we wish to say: 
The narrow nailing method is very successful in the 
treatment of ££eudar£jirosos_of_t 
injuries and has proved superior to all other methods_£.£_ 
a stabile osteosynthesis can be achieved. This is the case b 
a 
Illustration 115 
a) 16 week old fistulating comminuted gunshot fracture in the 
arm above the elbow. The nail was inserted in the wrong 
way. Fractures of this kind should be nailed only from 
the distal side. 
b) Even after the insertion of the outer nail the frag- 
ments could be moved in the longitudinal direction. The 
nail had jammed in the proximal marrow cavity and probably 
had pierced the bone at that spot (!). o 
a 
0 
Illustration 115 
c) At th e sane spot the inner nail hau. pierced the bone 
and penetrated the soft parts. During its extraction 
through an incision made at the spot where the nail tip 
was palpable, the outer nail slipped out of the distal 
fragment. 
d) After the second operation with a longer nail which 
is somewhat angulated at its end. It is held in place 
by means of a wire loop because a part of the.distal frag- 
ment had broken off. An abduction cast was applied because 
the fragments are still distractable. The wounds are kept 
open. Good healing. 
e) Four months after the operation. The fracture is 
bridged over by callus to a large extent and it is clini- 
cally healed. The nail was removed four months later. in nil fractures situated distal to the lino defining 
the boundary between the proximal and median third* 
It is not necessary to wait with the nailing 9 
months after the closure of the wounds, it can be 
performed when the wounds arc still fistulating, The 
nailing is to bo performed as a rule by approach from 
the distal side. In the further oourse of the treat- 
ment special attention must bo paid to a possible dis- 
traction of the fracture due to a loosening of the nail. 
If this occurs the fracture must bo fixed in an abductio: 
cast in an elevated position of the arm (above horizontal w 
An additional longitudinal wire suture may prevent the 
distraction its use, however, is not permissible in case 
of fistulating pscudarthroscs or atrophic bone. In these 
cases its use nay be hazardous because the wire night 
cut the bone and cause resorption. 
The nailing is not indicated in case of fractures 
due to gunhsot injuries located in the proximal third. 
In case of pseudarthroses in this area with atrophic 
bone it fits the purpose better if the distal fragment 
is sharpened and pushed into the spongiosa of the head. 
This can be done even if the wounds arc still fistulating. 
Wire suture must be avoided in this case under all cir- 
cumstances because it would lead to resorption of the 
bone. 
If tho wounds have healed in those pseudarthrosos for 
more than 9 months and if the calcarous contents of the 
bone are satisfactory, tho pseudarthrosis is freshened in 
the shape of-a staircase and a wire suture is applied. 
The nailing of the fistulating old fracture of the 
upper-arm is permissible only if a completely stabile 
osteosynthesis can be expected. 
The nailing should only take place if tho formation 
of callus is insufficient and if a psoudarthrosis 
is imminent or if the formation of soauostra necessitates 
the exposure of the fracture site anyhow. The nailing 
should be performed in those cases as a rule by approach 
from tho distal side, Fistulating fractures of the upper 
arm located above tho boundary of tho proximal and median 
third should always be excluded fron nailing because the 
nail will not find a proper hold in the proximal fragment. 
In case of a seyere_suppuration the stabile osteosynthos-, 
by means of the narrow nail should be performed only ex- 
ceptionally if one does not succeed with the usual con- 
servative methods to put the fracture at rest in such 
a way that tho infection can be efficiently fought. 128 
d<l-Psoudarthroses_of_thG_Forearm 
We did not see our way clear to nail old fractures 
of the forearm as long as they wore still fistulating. 
As 77e have seen the hazard that the nail will penetrate 
the thin corticalis of the bone is already great even 
if the course of the healing is aseptic. In case that 
a pseudarthrosis occurs or is already existing it must 
be foreseen that large areas of the bone become necrotic 
and that a defect pseudarthrosis will possibly ensue. 
In Table IX we give a survey on the nailed pseudarthros< s 
of the forearm, 
5 pseudarthroses of both bones of the forearm, the 
wounds of which had healed from 4 weeks to 9 months, came 
- with one exception - to a bony healing. 
This failure in case number 5 is duo 
to improper technique. 
We had to deal with a genuine pseu- 
darthrosis at the radius with fibrous car- 
tilage. (ill. 116a). Since the defect at 
the ulna was about 3 centimeters, the bone 
ends of the radius v/ere resected to the same 
extent in the sound bone. Hereafter the 
fracture ends of the ulna did not yet cone 
to a wide abutment, the freshened bone ends 
were still at a 'distance of about 1 centi- 
meter and we considered this result as good 
enough. When the nails were driven in there 
was still a gap in the ulna. We intended to 
avoid a further resection and v/ere of the opinion 
that it would be sufficient to bring the two 
bone ends together by means of a wire loop. 
In order to be on the safe side against longi- 
tudinal displacement a longitudinal wire suture 
was also applied (ill. 116b). A v/ound infection 
at the ulna occurred, the point of the distal 
fragment sequestrated and the result v/as a new 
defect pseudarthrosis of the ulna, whereas 
the radius came to a bony healing (ill. 116c). 
After sequestrum and wire had been removed, the 
fistula closed soon and the radius nail could 
be removed 5 months post operative. 6 months 
post operative the patient could be discharged 
from the hospital. Since the function of the 
limb 7/as not seriously hampered by the ulna 
pseudarthrosis v;e abstained from further in- 
tervention. 
The ulna nail was too short and did not find the necessar 
hold in the distal marrov/ cavity, this is clearly visible in 
111. 116b. So it finally cane to the penetration of the 
point into the corticalis, to an angulation (in spite of 
the plaster cast) and probably to a gradual fracture and 
sequestration of the point of the fra.gnent v/hich was held 
in place at the very end by a wire loop. I A 3 L - IX 
Marrow Nailine in Case of Psaudarthroses after fractures of the forearm due to gunshot injuries. 
Nr< 
» Type of Fracture 
Injury 
dating 
back 
Wounds 
healed 
since 
Type of Intervention 
Healing of Vfounde 
*■— — — * — —,J 
Total 
time of 
treatmt. 
Result 
j 
Remarks 
i 
Pseudarthrosis of ulna and 
radius after comminuted frac- 
ture in the middle of the 
shaft. 
i 
7 
nonths 
12 
weeks 
Marrow nailing of ulna and ra- 
dius osteosynthesis stabile 
Wound infection, formation 
of sequestra 
268 . 
days 
III 
as before nail. 
Radius nail introduced j 
by mistake into the el- 
bow joint, is withdrawn 1 
no infec.of joint$.3,111♦ 
2 
Contact pseudarthrosis of 
ulna and radius in the middle 
of the shaft, treated with- 
out success 6 months before 
with wire suture 
9 
months 
7 
months 
Exposed nailing of the ulna with 
removal of wire. Closed nailing 
of the radius 
Primarily 
68 
days 
V 
II 
117 
! 
! 
3 
Contact pseudarthrosis of 
the radius, ulna healed with 
angulation, middle of the 
shaft 
10 
months 
9 
months 
Resection of the ulna,freshening 
of the radius,nailing of the ra- 
dius. KIRSCHNER wire used for the 
ulna because of a very narrow 
marrow cavity 
Primarily 
150 
days 
II 
i 
! 
i 
1 
______ , 
4 
Defect pseudarthrosis of the 
adius, proximal third -Pseud. 
->f the ulna below the olecran. 
Wired unsatisfactorily 9 month 
before, wound infection 
12 
months 
4 
weeks 
Nailing of the ulna,stabile in 
spite of short nail. 3 months 
after nailing bone graft of the 
radius 
i 
Primarily 
slight wound infection 
280 
days 
II 
j 
See HAEBIER, a.a.0. 
Page 40, 111. 10 
Defect pseud, of the ulna, 
contact ps. of the radius, 
niddle of shaft.- 
14 
months 
7 
months 
Resection of the ulna, freshening 
of the ulna. Nailing of both 
bones, wire loop at the ulna, 
ulna nail* too short 
Infection,coronary se- 
questrum at ulna 
285 
days 
IV 
j 
i 
Poor technique, see 
111. 116 i 
-3 
z 
)efect ps. of the radius,dis- 
tal third,comminuted fract. 
dist. Luxation of the ulna 
(Madelune) 
5 
months 
3 
months 
Resection of the ulna, marrow 
nailing, with longitudinal wire 
suture 
Primarily 
180 
days 
III 
Ulna not far enough re- i 
sected, therefore, MA- 
DELUNG* s deformity ! 
? 
Distal luxation of the ulna 
with healed comminuted de- 
fect fract. of the radius 
8 
months 
4 
months 
Resection of the ulna, marrow 
nailing, p.op. good position 
Pcimarily 
140 
days 
IV 
function not im- 
proved. 
In spite of plaster cast . 
renewed sublux.of ulna 
wj.th distraction of the j 
site of resection.— ~i 
3 
Pseud,of the ulna, middle of 
shaft,luxation of the head of' 
the radius (Monteggia), Treat, 
unsuccessfully 8 months be- 
fore t*H t-h T.A'MR'.I * r>1 n+.o 
12 
months 
10 
months 
Thorough resection of head of the 
radius, marrow nailing of the 
ulna. 
Primarily 
90 
days 
I 
Cast removed 4 week® 
p.op. Movement. exer- j 
cises 
f-r.-Yr r VI.1 PXuvv 
Defect pseudarthrosis of the* 
ulna, middle of distal third, 
abt» 4 centimeter • 
4 
months 
3 
months 
Nailing and of tibia chip 
which it fixed by wire loop 
Wound infection with te- 
dious fistulation, no 
formation of sequestra. 
368 
days 
IV 
Pseudarthrosis between 
the graft and the dis- 
tal fragnent 
i 
3fl 
Defect Pseud* of the ulna 
in the middle of the shaft 
defect abt. 1 cm. 
16 
montha 
10 
months 
Haiww nailing and tibia graft 
which is only fixed by periosteum 
sutures. Nail too short. 
At first primarily, after 
5 weeks suppuration and 
ejection of graft, bone 
sequestrum 
more than 
1 year. 
IV 
Defect larger than be- 
fore the operation. a 
b 
c 
Illustration 116 
a) 11+ month old pseudarthrosis of the forearm after a 
gunshot fracture. The wounds have been closed for 7 months. 
b) The same fracture after the nailing. A piece 3 cms 
long has been resected from the radius. After that the 
freshened ends of the ulna can stand one upon the other 
for an area of 1 cm. Due to the fact that after the 
insertion of the nails the cleft is still gaping, the 
fragments are fixed by means of a wire loop. In order 
to prevent distraction of the radius a wire which runs 
in the longitudinal direction was used. The ulna nail 
is too short. The wounds were sutured but they had to 
be opened again because an infection developed. 
c) Three months after the operation. The radius is 
bridged over by good callus. The osteosynthesis of the 
ulna was not stabil. Consequently another angulation 
occurred and the fracture slowly increased with the 
sequestration of the tip of the distal fragment. Final 
result: Defect pseudarthrosis of the ulna. 129 
©n the basis of our experience we wish to warn 
emphatically against an additional v/ire loop. An angu- 
lation cannot be avoided by this wire loop if the osteosynth. - 
sis is not stabile, the bone will rather slip out of the 
loop and if an infection occurs resorption in the arra of 
the wire and formation of sequestra is imminent especially 
in case of atrophic bone. Only the longitudinal wire 
suture is justified as it avoids distraction. It should 
be applied as widely as possible (wider than is shown in 
the illustration). In case of atrophic bone, however, w' 
consider the longitudinal wire suture likewise as hazard- 
ous , 
If one wants to avoid an excessive resection it wil'J 
be preferable in these tases to nail the radius first (as 
has been described by HAEBLER a,a,0,,page 40, 111, 10) 
and to wait after the application of a plaster cast until 
the radius solidifies and only then to proceed to a bone 
graft of the ulna. 
In the other cases of pseudarthroses of both bones, 
the results are satisfactory. The osteosynthesis was stab?, 
in all these cases and this is an important factor to the 
final healing result. 
That the treatment is prolonged by an infection as 
in case Nr, 1 is quite natural. It is important to note 
that the pseudarthrosis healed satisfactorily in spite of 
the infection and in spite of the badly comminuted fracture 
(111. 117) 
At the operation the radius had by mistake been 
driven in as far as the elbow joint (ill, 117b), An in- 
fection could be avoided because the wounds were opened 
widely in proper time so that a collection of secretion 
could not occur and because the osteosynthesis was stabile. 
In case of a Monteggia-injury of the ulna fracture, 
with luxation of the head of the radius it will be useless 
to perform an osteosynthesis in case of an imminent faulty 
healing of the ulna and to reduce the head of the radius 
only by a non-operative procedure. 
Even if the marrow nail is used for this purpose, it 
cannot be avoided that the head of the radius slips out 
and the ulna nail will break or perforate the bone. The 
radius luxation must be reduced by operation and there- 
upon the ulna will be nailed, A healing can be achieved 
by these measures (See HAEBLER a,a,0,,page 2016, 111. 
4199 - 4212), 
A LANE 1 s plat e will never be sufficient for this 
purpose, especially not if it is fixed as is shown in 
111. 118a with only tuo screws. 
If the luxation existed already for a long timp, the 
reduction by means of an operation will not suit the 
posGj Fven in case of a bony healing there would be oon- 
siderable impediments in the elbow because the cartilage of the 
head of the radius is so severely affected that it will a 
b 
c 
Illustration 117 
a) Seven month old pseudarthrosis of the forearm after 
gunshot fracture. The wounds have been closed for 12 weeks 
b) The same fracture after the open nailing of the two 
bones. The radius nail has penetrated into the elbow 
joint. It was drawn back. The osteosynthesis was stabil. 
Three days after the operation the temperature increased 
and an infection of the sutured wounds developed at the 
radius. The wound was immediately widely opened. 
Several sequestra were cast off. 
c) The same fracture 7 months after the operation. Bony 
healing. The ulna nail was removed 4 weeks ago. The wound 
at the radius is still fistulating. Extraction of the nail 
Soon after that the fistula closed. 130 
become necrotic and a connective tissue deformation or 
calcification of the capsules will be the final re- 
sult. The only way out then is the resection of the 
head of the radius. If it is performed widely enough 
and if the pseudarthrosis of the ulna is united by the 
marrow nail after appropriate freshening, a good healing 
will be achieved ™-i.th an almost free mobility of the 
joints, even if the nail is somewhat too short as in 
111. 118. An additional wire is not required since the 
radius is no longer obstructing. 
If the head of the radius is resected too sparingly, 
the longitudinal wire will not be of any use and the re- 
sult will be either a distraction and faulty healing or 
a fracture of the nail (Sec HAEBLER a.a.0.,page 2019, 
111. 4213-4222). 
We suggest to neither resect the ulna in defoct_£soud- 
arthroses of the radius with luxation in the distal,, radios 
Ta3.na.r_nor to nail both bones after the resection. 
If one resects too sparingly as in 111. 119, a next luxation 
will be likely to occur and if an infection occurs especial- 
ly in case of a nailing of beth bones, the final state is 
possibly worse than before. Most of these fractures will 
solidify because the obstructive effect of the ulna is 
annulled by the distal luxation . 
If the fracture of the radius has solidified and if 
the function of the wrist is seriously hampered by a 
luxation of the ulna in the distal radio-ulna joint it 
will be useless to resect the ulna in the shaft and use 
the marrow nail. As we have seen in a case which was not 
treated in our clinic the scar shrinking at the wrist 
joint will cause a new distraction of the site of the re- 
section and a new pseudarthrosis will ensue in spite of 
a plaster cast. It is indicated in these cases to re- 
sect the styloid process of the ulna. 
In two cases of defect pseudarthrosis of the ulna 
a bone graft with additional marrow nailing has been 
performed. The idea that the nail might favor by the po- 
sition a so secured healing in of the graft is ouite ob- 
vious and this procedure has been recommended lately by 
several authors. BOEHLER, however, refutes it because he 
is of the opinion that the graft is impeded in its nu- 
trition by the destruction of the marrow. 
In our two cases of ulna pseudarthroses it also came 
to an infection and faulty healing, although the osteo- 
synthesis was stabile in both cases. 
In consideration of the fact that two other cases 
of tibia pseudarthroses which were not operated in our 
hospital also resulted in faulty healings we refrained from 
further experiments in that direction. Particularly with 
the forearm the plaster cast assures an adequate position 
at rest if it is left in position long enough (for at 
least 12 weeks) and the idea that the nail in position 
might interfere with the nutrition of the bone is by no 
fceans far fetched. As a matter of fact zones of resorption b 
a 
Illustration 118 
c 
a) 12 month old pseudarthrosis of the ulna with a central 
luxation of the radius (Monteggia). The wounds were healed 
2 months after the injury. Four months after the injury 
operative reduction of the radius and fixation of the ulna 
by means of a LANE’s plate. It does however not find suf- 
ficient hold because it was held by only one screw on each 
side. Another luxation of the ulna and a pseudarthrosis 
developed. 
b) After the operation. The cartilage of the radius head 
was entirely destroyed and because of a defect in the ulna 
which had occurred during a previous operation an extensive 
resection of the radius head was made. The connective tissue 
callosities of the ulna were removed and a marrow nail was 
inserted. The nail had jammed in the callus of the distal 
fragment so much that it was impossible to insert it any 
further. Consequently it had to be cut. In spite of the 
fact that the nail was too short the osteosynthesis was 
stabil. Primary healing*of the wound, application of a 
plaster splint for a period of 4 weeks, followed by exeroises. 
Release of theepatient to his unit 8 weeks after the operation. 
c) Six months after the operation*, Bony healing of the 
fracture. No rarefactions round the nail tip to be observed. 
Rotation is limited by J. All other joints are freely 
movable. 131 
afe usually to be seen at the wire loops when a graft 
is used. Our patient material is not large enough 
to draw definite conclusions but since we have had go *d 
results ■- the same as BOEHLER - with the bone graft with- 
out marrow nail we are inclined to avdise against the 
additional marrow nailing. It does not bring an appreciative 
advantage to compensate for the additional hazard* 
SUMMARY.: 
The marrow nailing brings important advantages in 
pseudarthroses due to gunshot fractures of both bones 
of the forearm if a stabile osteosynthesis can be achieved. 
It is necessary to resect wide enough to assure a wide 
abutment of the bones* 
The attempt to achieve this abutment by additional 
wire loop is hazardous. This might cause, in case of an 
infection, a gradual fracture and a formation of sequestra 
at the bone ends especially so if the osteosynthesis is 
not fully stabile and if the bone is atrophic. 
Only a longitudinal suture is of service if the cal- 
careous content of the bone is satisfactory. It must be 
applied widely enough# In case of a rea ny stabile osteo- 
synthesis it can usually be dispensed with. 
In defect pseudarthroses of one bone the bone graft is 
the treatment of choice. An additional marrow nailing is 
rather not performed because it might interfere with 
the nutrition of the graft, One must also advise against 
the resection of the second obstructing bone with subse- 
quent marrow nailing of both bones. This method is less 
certain than the bone graft. 
In case of an imminent p.scudarthrosis following a 
Monteggia injury it will be necessary besides the nail- 
ing of the ulna to reduce the luxation of the head of the 
radius by operation to avoid a faulty healing or a fracture 
of the nail, 
If the luxation existed for more than 6 months it 
will be necessary besides the nailing of the ulna pseud- 
arthrosis to resect the head of the radius. The resectic 
must be wide enough to prevent the radius from becoming 
obstructive again. 
In case of an old luxation in the distal radio-ulnar 
joint (MADELUNG) the resection of the styloid 
process will bring better results than the resection of 
the shaft of the ulna with subsequent nailing.