Fractures of the Femoral Diaphysis

One hundred and sixty femoral shaft fractures (in 154 patients) all treated in the same hospital, seventy-seven by early Kuntscher nailing and eighty three by traction and a spica cast, were studied retrospectively and the costs of treatment were analyzed and projected for the future. Twenty-nine per cent of the patients treated by traction and a cast had complications all requiring surgical treat. ment, mostly by secondary nailing. Including primary and secondary nailings, there were nineteen complications after 100 nailings. Of these complications, three were major infections and four were fracture healing problems. The healing time was less in the closed group, but the time in the hospital and time to return to work were less in the nailed group. The cost of care both now and projected was 20 to 30 per cent less for open reduction and nailing. It was concluded that open treatment has decided advantages despite the risks of infection. Since KÃ1⁄4ntscher's original report, intramedullary fixation of fractures of the fenioral diaphysis has vied with skeletal traction followed by immobilization in a hip Spica cast as the preferred method of treatment. In a study of military personnel, Stryker, Fussell, and West found that over 20 per cent of fractures treated by traction and immobilization in a Spica did not unite without additional treatment. In the retrospective study to be reported here, the results of treatment by the two aforementioned methods in a non-selected group of adults admitted to one hos pital are compared. as well as the incidence of coniplications and the cost of care for the two methods. Materials and Methods In the decade 1959 through 1968, 160 consecutive fractures of the femoral diaphysis in 154 adults were primarily treated in the Charlotte Memorial Hospital. This study is based on these patients. All available data were obtained from the hospital charts and roentgenograms, physician's office records, and verbal and written communications with the patients themselves. The length of time for follow up ranged from one year to twelve years. At the time of writing an attempt was made to contact all patients so that as long a follow-up as possible was obtained for each. For the purpose of this study, the femoral diaphysis was defined as the fifty to fifty-three centimeters of tubular bone extending from five centimeters below the lesser trochanter to five centimeters above the adductor tubercle. An adult was de fined as any patient sixteen years of age or older. No pathological fractures and no fractures not primarily treated at Charlotte Memorial Hospital were included. Most * Read at the Annual Meeting of The American Academy of Orthopaedic Surgeons, Wash ington, D.C., February 2, 1972. t 1822 Brunswick Avenue, Charlotte, North Carolina 28207. t McConnell Air Force Base Hospital. Kansas 67221. 690 THE JOURNAL OF BONE AND JOINTSURGERY FRACTURES OF THE FEMORAL DIAPHYSIS 691 of the injuries were the result of automobile crashes. Not included were several patients who had femoral fractures and other injuries treated during the time covered by this study but who died within the first week of hospitalization. There were no deaths associated with a femoral diaphyseal fracture after the first week. The age range of the patients studied was from sixteen to eighty-two, and men outnumbered women by I I I to forty-three. Eighty-nine right and seventy-one left femora were fractured. To compare the results of open and closed treatment, the fractures were divided into three types: Type I, or simple fractures, were transverse or oblique; Type II, or comminuted fractures, had a single butterfly fragment or several smaller frag ments, making up at least one third of the circumference of the shaft; and Type III, the coniminuted-segmental fractures. had either seven centimeters of the shaft com pletely coniminuted or the shaft was broken into three distinct segments. The method of treatment used was the one chosen by each individual surgeon. Twenty-one attending surgeons and numerous house officers were involved. The initial treatnient was traction followed by spica-cast immobilization for eighty-three fractures and intramedullary nailing within three weeks of the time of injury for seventy-seven. Preliminary traction was usually employed prior to nailing. Ninety-five fractures were transverse or oblique Type-I fractures; forty-nine, comminuted Type-I I fractures ; and sixteen, commi nuted-segmental Type-I II fractures. For each of the three fracture types, the two methods of treatment were com pared with respect to the following: ( I ) the incidence and types of complications, (2) the total time the patient spent in the hospital, (3) the time required for the fracture defect to be obliterated as seen on roentgenograms, and (4) the time required for the patient to return to his previous occupation or profession. However, as can be seen in Table I, all of the required data were not available for each patient and each fracture; hence, the number of patients and fractures varied in the different analyses. No attempt was made to correlate the results with the level of fracture or to assess other factors such as the rate of return of knee niot ion. For the study of the incidence and types of complications, data were available for all patients which included seventy-five with seventy-seven fractures in the nailed group and seventy-nine with eighty-three fractures in the closed group (Table I). In the analysis of the time spent in the hospital, patients with bilateral fracture were either excluded or counted as two patients with two fractures. Thus a patient with the same type of fracture in each femur treated identically was counted as two patients with two fractures, whereas a patient with a different type of fracture in each femur was excluded (Table I, footnote). In the determination of the time to union, the necessary data were not avail able in soiiie cases because roentgenograms showing the fracture gap obliterated had not been obtained. In addition, the fractures which were initially treated closed but required secondary nailings for defects in healing were excluded from this analysis. In the study of the time required to return to work, two patients each with associated injuries that prolonged their disability were excluded, as were the pa tients who required secondary procedures for defective healing after closed treatment. Finally, inforniation as to sonie patients' return to work was not available so that they were likewise excluded. The distribution of the patients with the necessary data according to fracture type and treatment is shown in Table I. Knee mot ion could be evaluated at one year or niore after fracture in all I60 knees. If motion was from 5 degrees of fixed flexion to 110 degrees of free flexion or of greater range and the patient did not complain of any limitation, the motion was considered functional and adequate. If the range of motion was less, however, the fracture was classified as having the complication of knee stiffness (Table I). Ty Nailedpel ClosedTy NailedpeIl ClosedTy NailedpeIII ClosedPatients*53391633610Fractures55401633610Complications13162903Non-union100000Delayed union180803Refracture140000Malunion01000. 0Superficial wound infection200000Deep wound infection100000Osteomyelitis200000Footdrop100000Nail migration301000Knee stiffness131100Average hospital stay in days468241674080(Patients available)(53)(36)(16)(32)(6)(8)Average time to union in10.46. 18.56. 08.66. 5months(Fractures available) t(22)(21)(14)(19)(3)(4 Average time back to work in8.711.010.710.89.617.1months(Patients available) @(42)(30)(15)(18)(5)(6) 692 C. R. CARRANDC. H. WINGO