Benefits of early stabilization of femoral shaft fractures, in mitigation of pulmonary and other complications, have been recognized over the past decades. Investigation into the appropriate level of resuscitation, and other measures of readiness for definitive fixation, versus a damage control strategy have been ongoing. These principles are now being applied to fractures of the thoracolumbar spine, pelvis, and acetabulum. Systems of trauma care are evolving to encompass attention to expeditious and safe management of not only multiply injured patients with these major fractures, but also definitive care for hip and periprosthetic fractures, which pose a similar burden of patient recumbency until stabilized. Future directions regarding refinement of patient resuscitation, assessment, and treatment are anticipated, as is the potential for data sharing and registries in enhancing trauma system functionality.

Cite this article: Bone Joint J 2023;105-B(4):361–364.

Abstract

Hip fractures frequently occur in elderly patients with osteoporosis and are rapidly increasing in prevalence owing to an increase in the elderly population and social activities. We experienced several recent presentations of TFNA nails failed through proximal locking aperture which requires significant revision surgery in often highly co-morbid patient population.

The study was done by retrospective data collection from 2013 to 2023 of all the hip fractures which had been fixed with Cephalomedullary nails to review and compare Gamma (2013–2017) and TFNA (2017–2023) failure rates and the timing of the failures. Infected and Elective revision to Arthroplasty cases were excluded.

The results are 1034 cases had been included, 784 fixed with TFNA and 250 cases fixed Gamma nails. Out of the 784 patients fixed with TFNA, 19 fixation failed (2.45%). Out of the 250 cases fixed with Gamma nails, 15 fixation failed (6%). Mean days for fixation failure were 323 and 244 days in TFNA and Gamma nails respectively.

We conclude that TFNA showed remarkable less failure rates if compared to Gamma nails. At point of launch, testing was limited and no proof of superiority of TFNA over Gamma nail. Several failures identified with proximal locking aperture in TFNA which can be related to the new design which had Substantial reduction in lateral thickness at compression screw aperture.

Introduction and Objective

Trochanteric fractures are associated with increasing incidence and represent serious adverse effect of osteoporosis. Their cephalomedullary nailing in poor bone stock can be challenging and associated with insufficient implant fixation in the femoral head. Despite ongoing implant improvements, the rate of mechanical complications in the treatment of unstable trochanteric fractures is high. Recently, two novel concepts for nailing with use of a helical blade – with or without bone cement augmentation – or an interlocking screw have demonstrated advantages as compared with single screw systems regarding rotational stability and cut-out resistance. However, these two concepts have not been subjected to direct biomechanical comparison so far. The aims of this study were to investigate in a human cadaveric model with low bone density (1) the biomechanical competence of cephalomedullary nailing with use of a helical blade versus an interlocking screw, and (2) the effect of cement augmentation on the fixation strength of the helical blade.

Aims: There are concerns over the physiological effects of intramedullary femoral fracture stabilisation in patients with pulmonary injury. This large animal study used invasive monitoring to obtain sensitive cardiopulmonary measurements and compared the responses of ‘Early Total Care’ (intramedullary fracture fixation) and ‘Damage Control’ (external fixation), after the induction of lung injury. Methods: Acute lung injury (PaO2/FiO2 < 200 mmHg) was induced in 12 invasively monitored and terminally anaesthetised sheep via oleic acid infusion into the right atrium. Each animal underwent surgical femoral osteotomy and fixation with either reamed intramedullary (n=6) or external fixation (n=6). Haemodynamic and arterial blood-gas measurements were recorded at baseline, 5, 30 and 60 minutes after fracture stabilisation. Results: The mean (+/− S.E.) PaO2/FiO2 fell significantly (p< 0.05) from 401 (+/− 39) to 103 (+/− 35) and 425 (+/− 27) to 122 (+/− 21) in the externally fixated and intramedullary nailed groups respectively after acute lung injury. The further combined effect of surgical osteotomy and fracture fixation produced a mean (+/− S.E.) PaO2/FiO2 of 98 (+/− 21) and 114 (+/− 18), in the externally fixated and intramedullary nailed groups immediately after surgery. This was not significantly different within or between groups. Similarly the pulmonary vascular resistance (PVR) measured at 5.8 (+/− 0.8) and 4.8 (+/− 0.7) after lung injury in the externally fixated and intramedullary nailed groups changed to 5.7 (+/− 0.5) and 4.0 (+/− 0.7) after surgical osteotomy and fracture fixation (no significant difference within or between groups). The PaO2/FiO2 or PVR was not significantly different at the monitored 5, 30 and 60 minute intervals after fracture stabilisation. Conclusion: Against a background of standardised acute lung injury, there was no further deterioration produced by the method of isolated femoral fracture fixation in sensitive physiological parameters commonly used during intensive care monitoring

Purpose. There are concerns with regard to the physiological effects of reamed intramedullary femoral fracture stabilisation in patients who have received a pulmonary injury. This large animal study used invasive monitoring techniques to obtain sensitive cardiopulmonary measurements and compared the responses to Early Total Care (reamed intramedullary femoral fracture fixation) to Damage Control Orthopaedics (external fixation), after the induction of acute lung injury. We hypothesised a greater cardiopulmonary response to intramedullary fracture fixation. Method. Acute lung injury (PaO2/FiO2 < 200 mmHg) was induced in 12 invasively monitored and terminally anaesthetised male sheep via the infusion of oleic acid into the right atrium. Each animal underwent surgical femoral osteotomy and fixation with either reamed intramedullary (n=6) or external fixation (n=6). Simultaneous haemodynamic and arterial blood-gas measurements were recorded at baseline and at 5, 30 and 60 minutes after fracture stabilisation. Results. The mean (S.E.) PaO2/FiO2 fell significantly (p<0.05) from 359(37) to 107 (23) and 382 (33) to 128 (18) in the externally fixated and intramedullary nailed groups respectively as a result of the acute lung injury. The further combined effect of surgical osteotomy and subsequent fracture fixation produced a mean (+/− S.E.) PaO2/FiO2 of 114 (21) and 113 (12), in the externally fixated and intramedullary nailed groups respectively, immediately after surgery. This was not significantly different either within or between groups. Similarly the pulmonary vascular resistance (PVR) measured at 4.7 (0.9) and 4.2 (0.5) in the externally fixated and intramedullary nailed groups respectively after lung injury changed to 4.9 (0.7) and 4.3 (0.6) after surgical osteotomy and subsequent fracture fixation which, again was not significantly different either within or between groups. No significant difference in either PaO2/FiO2 or PVR was detected at the monitored 5, 30 and 60 minute intervals that followed fracture stabilisation. Conclusion. Against a background of standardised acute lung injury, there appeared to be no further deterioration produced by the method of isolated femoral fracture fixation in two sensitive physiological parameters commonly used by intensive care physicians

Most hip fractures treated with modern internal fixation techniques will heal. However, failures occasionally occur and require revision procedures. Salvage strategies employed during revision are based on whether the fixation failure occurs in the femoral neck, or in the intertrochanteric region. Patient age and remaining bone stock also influence decision making. For fractures in young patients, efforts are generally focused on preserving the native femoral head via osteotomies and repeat internal fixation. For failures in older patients, some kind of hip replacement is usually selected. Disuse osteopenia, deformity, bone loss, and stress-risers from previous internal fixation devices all pose technical challenges to successful reconstruction. Attention to detail is important in order to minimise complications. In the majority of cases, good outcomes have been reported for the various salvage strategies.

Cite this article: Bone Joint J 2013;95-B, Supple A:7–10.

Proximal femur fractures are increasing in prevalence, with femoral neck (FN) and intertrochanteric (IT) fractures representing the majority of these injuries. The salvage procedure for failed open reduction internal fixation (ORIF) is often a conversion to total hip arthroplasty (THA). The use of THA for failed ORIF improves pain and function, however the procedure is more challenging. The aim of this study was to investigate the clinical and radiographic outcomes in patients who have undergone THA after ORIF.

This retrospective case-control study compared patients who underwent THA after failed ORIF to a matched cohort undergoing primary THA for non-traumatic osteoarthritis. From 2004 to 2014, 40 patients were identified. The matched cohort was matched for date of operation, age, gender, and type of implant. Preoperative, intraoperative, and postoperative data were collected and statistical analysis was performed.

The cohort of patients with a salvage THA included 18 male and 22 female patients with a mean age of 73 years and mean follow up of 3.1 years. Those with failed fixation included 12 IT fractures and 28 FN fractures. The mean time between ORIF and THA was 2.1 years for IT fractures and 8.5 years for FN fractures (p=0.03). The failed fixation group had longer procedures, greater drop in hemoglobin, and greater blood transfusion rate (p<0.05). There was one revision and one dislocation in the failed fixation group with no revisions or dislocations in the primary THA group. Length of admission, medical complications, and functional outcome as assessed with a standardised hip score and were found not to be statistically different between the groups.

Salvage THA for failed initial fixation of proximal femur fractures yields comparable clinical results to primary THA with an increased operative time, blood loss, and blood transfusion rate.

Although the vast majority of fractures of the proximal femur will heal with well-done internal fixation, occasionally failure of fixation will occur. Having effective salvage options is important to restore function and minimize complications. In general, it is logical to separate salvage options into those for fractures of the femoral neck, and those for fractures of the intertrochanteric region. Additionally, patient age and remaining bone stock should be considered.

Femoral neck fracture fixation failure salvage, young patients: All efforts are focused on preserving the native femoral neck. Valgus producing osteotomy is typically indicated, and can be successful even with small patches of AVN.

Femoral neck fracture fixation failure salvage, older patients: Total hip arthroplasty is generally most predictable. Be prepared for very poor bone quality. Supplement uncemented acetabular component with multiple screws. Be prepared to cement femoral component if necessary.

Intertrochanteric fracture fixation failure salvage, young patients: Repeat internal fixation attempts with fixed angle devices (such as a 95 degree blade plate) and bone grafting generally preferred. Avoid varus of proximal fragment and target inferior femoral head bone.

Intertrochanteric fracture fixation failure salvage, older patients: Total hip arthroplasty preferred. Long stems to bypass femoral shaft stress risers and “calcar replacement” stems may be necessary due to proximal bone defects. Trochanteric fixation must be stable. Results are generally good but trochanteric complaints are common.

Introduction

Failed operated intertrochanteric fractures (with screw cutout, joint penetration, varus collapse, nonunion, or femoral head avascular necrosis) pose treatment dilemmas. The ideal approach is re-osteosynthesis with autologous bone grafting. When the femoral head is unsalvageable, conversion to a prosthetic hip replacement is necessary.

Introduction: The proximal femoral nail antirotation (PFNA) system is a cephalomedullary device originally designed to contend with the challenge of unstable tro-chanteric femoral fractures with the novel helical blade component aimed at limiting femoral head limiting cutout. We demonstrate its use in a variety of cases.

Methods: This is a prospective study of 370 consecutive patients treated with short and long PFNA systems at a single center with 1-year follow-up. The device was used for unstable trochanteric femoral fractures (AO-classification 31. A.2 and A.3), prophylactic and definitive fixation of pathological fractures and high energy femoral fractures for a wide age range (19–101 years). Clinical outcome involved assessment of general mobility & function, operative and post-operative parameters & complications. Radiological outcome involved assessment of blade tip-apex distance, nail tip-femoral scar distance and distal locking configurations.

Results: 17% died within the follow-up period. 72% achieved their pre-trauma mobility status and nearly all fractures healed within 6 months including those in over 85 years. Of 18 problematic cases, serious complications included deep infection, loss of proximal reduction, ipsilateral femoral shaft fracture and periprosthetic supra-condylar fracture. There were no cases of acetabular penetration or blade cut-out. Short PFNA was associated with the majority of femoral shaft fractures and the only significant finding regarding instrumentation.

Discussion: This study supports long PFNA design theory demonstrating adequate purchase in the femoral head-neck zone, shown by lack of cut-out. Positive results have been demonstrated in a variety of cases making it a useful option in fractures in all ages and indications alongside unstable trochanteric configurations.

Four matched pairs of fresh frozen human femora were used to compare the biomechanical properties in axial and torsional loading of a Locking Condylar Plate and a retrograde intramedullary nail. One-centimeter gap osteotomy was created in the supracondylar region to simulate an AO/OTA 33-A3 fracture. The instrumented specimens were then mechanically tested under physiologic conditions in axial and torsional loading to determine the stability of the constructs. This laboratory study enhances the biomechanical advantages of the Locking Condylar Plate when fixation stiffness is essential. Devices with head locking screws provide angular rigidity and maximize fixation stability in osteopenic bone.

To compare the biomechanical properties in axial and torsional loading of a Locking Condylar Plate and a retrograde intramedullary nail. To determine the modes of failure of these two devices under axial loading.

Four matched pairs of fresh frozen human femora were used. Plain film radiographs and Dexa scanning were performed to evaluate bone quality and to screen for pathologic lesions. For each pair, one femur was stabilized with the Locking Condylar Plate and the other with a retrograde nail.

One-centimeter gap osteotomy was created in the supracondylar region to simulate an AO/OTA 33-A3 fracture. Radiographs were obtained to exclude iatro-genic fractures before mechanical testing. The instrumented specimens were then mechanically tested under physiologic conditions in axial and torsional loading to determine the stability of the constructs. Three-dimensional displacement across the fracture site was recorded. Finally, all femurs were loaded to fracture under axial loading. The modes of failure were determined by assessing final radiographs.

The Locking Condylar Plate provided statistically significant greater rigidity both in axial (p = 0.048) and torsional loading (p = 0.031) compared to the retrograde nail. The axial mode of failure occurred proximally for the plate and mainly at the distal fixation for the nail.

This laboratory study enhances the biomechanical advantages of the Locking Condylar Plate when fixation stiffness is essential. Devices with head locking screws provide angular rigidity and maximize fixation stability in osteopenic bone.

There is conjecture on the optimal timing to administer bisphosphonate therapy following operative fixation of low- trauma hip fractures. Factors include recommendations for early opportunistic commencement of osteoporosis treatment, and clinician concern regarding the effect of bisphosphonates on fracture healing. We performed a systematic review and meta-analysis to determine if early administration of bisphosphonate therapy within the first month post-operatively following proximal femur fracture fixation is associated with delay in fracture healing or rates of delayed or non-union. We included randomised controlled trials examining fracture healing and union rates in adults with proximal femoral fractures undergoing osteosynthesis fixation methods and administered bisphosphonates within one month of operation with a control group. Data was pooled in meta-analyses where possible. The Cochrane Risk of Bias Tool and the GRADE approach were used to assess validity. For the outcome of time to fracture union, meta-analysis of three studies (n= 233) found evidence for earlier average time to union for patients receiving early bisphosphonate intervention (MD = −1.06 weeks, 95% CI −2.01 – −0.12, I. 2. = 8%). There was no evidence from two included studies comprising 718 patients of any difference in rates of delayed union (RR 0.61, 95% CI 0.25–1.46). Meta-analyses did not demonstrate a difference in outcomes of mortality, function, or pain. We provide low-level evidence that there is no reduction in time to healing or delay in bony union for patients receiving bisphosphonates within one month of proximal femur fixation

Using the Mayo Clinic definition (>62mm in women and >66mm in men), the “jumbo acetabular component” is the most successful method for acetabular revisions now, even in hips with severe bone loss. There are numerous advantages: surface contact is maximised; weight-bearing is distributed over a large area of the pelvis; the need for bone grafting is reduced; and usually, hip center of rotation is restored. The possible disadvantages of jumbo cups include: may not restore bone stock; may ream away posterior column or wall; screw fixation required; the possibility of limited bone ingrowth and late failure; and a high rate of dislocation due to acetabular size:femoral head ratio. The techniques for a successful jumbo revision acetabular component involve: sizing-“reaming” of the acetabulum, careful impaction to achieve a “press-fit”, and multiple screw fixation. We recommend placement of an ischial screw in addition to dome and posterior column screw fixation. Cancellous allograft is used for any cavitary defects. The contra-indications for a jumbo acetabular cup are: pelvic dissociation; inability to get a rim fit; and inability to get screw fixation. If stability cannot be achieved with the jumbo cup alone, then use of augment(s), bulk allograft, or cup-cage construct should be considered. Using titanium fiber-metal mesh components, we reported the 15-year survival of 129 revisions. There was 3% revision for deep infection and only 3% revision for aseptic loosening. There were 13 reoperations for other reasons: wear, lysis, dislocation, femoral loosening, and femoral fracture fixation. The survival was 97.3% at 10 years, but it dropped to 82.8% at 15 years. Late loosening of this fiber metal mesh component is likely related to polyethylene wear and loss of fixation. Dislocation is the most common complication of jumbo acetabular revisions, approximately 10%, and these are multifactorial in etiology and often require revision. Based on our experience, we now recommend use of an acetabular component with an enhanced porous coating (tantalum), highly crosslinked polyethylene, and large femoral heads or dual mobility for all jumbo revisions

Background. Femur fracture fixation systems depend on the stability of the supporting cortical screws, inside the host bone. Only a few works have studied the stability of cortical screws in femur shafts and compared their results with previous studies. Methods. In present study, five different cortical screw types are assessed using artificial femurs, under equated testing conditions. The maximum force needed to cause screw-bone inter face failure was measured, for each screw type by pullout tests. The obtained results were normalised according to traditional methods and cross-compared. The best performer was searched for and the effect of screw dimensions on the screw performance was investigated. To make the pullout tests solely dependent on screw dimensions, the effect of the bicortical bone thickness was eliminated by equating the conditions of screw insertion. Results. Evaluation of the test results proved that the non-locking screws with larger diameter and pitch depth required larger pullout forces to be extracted, thus showed statistically superior performance compared to locking screws with smaller dimensions. However, the observed statistical differences between the absolute pullout forces were diminished, after the traditional normalisation of the results. But, traditional normalisation was challenged due to its known short comings. A new normalisation method was proposed based on a solid geometric reasoning, which is supported by true observations. Conclusion. This novel approach showed that a screw type that appeared to show average performance; in fact, did not have significantly different results than the top performers. The outcome of the comparisons pointed out that surgeons are not obliged to prefer larger dimension screws, in small dimension host bones. Level of Evidence. Level 5. Disclosure. The authors declare that no conflict of interests were associated with the present study

Aims

Patient decision aids have previously demonstrated an improvement in the quality of the informed consent process. This study assessed the effectiveness of detailed written patient information, compared to standard verbal consent, in improving postoperative recall in adult orthopaedic trauma patients.

Using the Mayo Clinic definition (>62mm in women and >66mm in men), the “jumbo acetabular component” is the most commonly used method for acetabular revisions now. There are numerous advantages: surface contact is maximised; weight-bearing is distributed over a large area of the pelvis; the need for bone grafting is reduced; and usually, hip center of rotation is restored. The possible disadvantages, or caveats, of jumbo cups include: may not restore bone stock; may ream away posterior column or wall; screw fixation required; the possibility of limited bone ingrowth and late failure; and a high rate of dislocation due to acetabular size:femoral head ratio. The techniques for a successful jumbo revision acetabular component involve: sizing-“reaming” of the acetabulum, careful impaction to achieve a “press-fit”, and multiple screw fixation. We recommend placement of an ischial screw in addition to dome and posterior column screw fixation. Cancellous allograft is used for any cavitary defects. The contraindications for a jumbo acetabular cup are: pelvic dissociation; inability to get a rim fit; inability to get screw fixation; and the presence of <50% living host bone. If stability cannot be achieved with the jumbo cup alone, then use of augment(s), bulk allograft, or cup-cage construct should be considered. Our results with the jumbo acetabular cups in revision arthroplasty have been reported. Using predominantly titanium fiber-metal mesh components, we reported the 15-year survival of 129 revisions. There was 3% revision for deep infection and only 3% revision for aseptic loosening. There were 13 reoperations for other reasons: wear, lysis, dislocation, femoral loosening, and femoral fracture fixation. The survival was 97.3% at 10 years, but it dropped to 82.8% at 15 years. Late loosening of this fiber metal mesh component is likely related to polyethylene wear and loss of fixation. Dislocation is the most common complication of jumbo acetabular revisions, approximately 10%, and these are multifactorial in etiology and often require revision. Based on our experience, we now recommend use of an acetabular component with an enhanced porous coating (tantalum), highly cross-linked polyethylene, and large femoral heads for all jumbo revisions

Introduction. Cementless acetabular fixation in total hip replacement (THA) is reliable and has been the fixation method of choice in the United States for decades. While revision for failure of osseointegration or early loosening is relatively rare, recurrent dislocation remains a leading cause of early revision. Novel acetabular implants and those offered by smaller companies often lack constrained or dual mobility liners, which may result in revision of well-fixed, well-positioned cups in cases of recurrent dislocation. The purpose of this study was to compare outcomes of THA with three different acetabular cups with differing fixation surfaces. One hydroxyapatite (HA)-coated cup (Trident, Stryker, Kalamazoo, MI, USA) offered dual mobility or constrained liner options. The other cups were a novel highly porous cup (Restoris PST, Stryker, Kalamazoo, MI, USA), and a Calcium Phosphate (CaP)-coated cup (Trinity, Corin, Cirincester, UK), neither of which offered dual mobility or constrained options at the time of investigation. Endpoints of interest were: clinical and radiographic outcomes including evidence of osseointegration, overall reoperations, reoperations for acetabular fixation failure, and reoperations to address dislocation in which a well-positioned shell was revised due to the lack of dual mobility or constrained options. Methods. A retrospective review of 370 acetabular cups implanted in 328 patients for THA by a single surgeon between February 2013 and June 2016 was performed. There were 100 Trident cups (Stryker, Kalamazoo, MI, USA), 105 Restoris PST Acetabular Cups (Stryker, Kalamazoo, MI, USA), and 165 Trinity Acetabular Cups (Corin, Cirincester, UK). Patient records were reviewed for post-operative complications, clinical outcomes scores and radiographic signs of acetabular osseointegration at minimum 1-year follow-up. Results. Despite differences in fixation surface, there was no difference in Harris Hip Scores at minimum 1-year follow-up and all three cohorts had 100% 1-year survivorship free of revision for failure of acetabular fixation. No cup showed signs of acetabular migration or loosening. Overall reoperation rates were low, ranging from 2.4%-3.8% (p=0.81). Femoral fractures and fixation problems were the most common cause of reoperation, occurring in nearly 2% of cases (n=7), but did not differ between groups. Reoperation for infection occurred in less than 1% of cases (n=3) and did not differ between groups. Revision for recurrent dislocation occurred in 1% of cases (n=4). All occurred with cups lacking dual mobility or constrained options. In all 4 cases the acetabular component was within the Lewinnek “safe zone” and deemed well positioned. In one revision, a lipped liner and longer head were used given concerns about the risk of acetabular component revision due to poor bone stock. In the remaining revisions, the well-positioned cup was revised to allow for the use of constrained or dual mobility implants. Conclusion. All acetabular revisions in our cohort were related to instability or infection, while none were related to acetabular fixation. Subsequent to this experience and analysis, we are wary to select any “new and improved” acetabular cup that does not have an option for a constrained or dual mobility liner, even when enabling technology makes us confident of safe-zone placement. For any figures or tables, please contact authors directly

Introduction. To compare the union rates and post-operative mobility of antegrade intramedullary nailing of osteoporotic traumatic supracondylar femoral fractures (AO classification A to C2) with those of plating. Materials/Methods. We studied any traumatic intra or extra-articular supracondylar femoral fracture from 2005–2010. Patients were either admitted directly to our level 1 trauma centre or were referred from another hospital. Nineteen patients were identified, consisting of primarily fixation with five antegrade nails and fourteen plates. We defined osteoporotic bone as being present in anyone over sixty years old or who had a clinical diagnosis. One nail and six plates were excluded due to young age or fracture severity. This left four nails, six less invasive stabilisation system plates and two dynamic condylar screw plates. Both groups were comparable with respect to age, sex and AO fracture classification. Results. There was a significant difference in achieving union between the two groups (p=0.040). Union occurred within three months in all four fractures in the nail group but only three fractures (38%) united after primary fixation in the plate group. There were two failures due to screw pullout, one failure due to screw breakage, one broken plate after delayed-union and one screw breakage after non-union. The patients in the nail group had better mobility and less pain than the plate group but the difference was not statistically significant. Conclusion. We have shown that for patients with osteoporotic, supracondylar femoral fractures, fixation with an antegrade IM nail provides significantly better healing compared to plate fixation

Damage Control techniques involve primary external fracture fixation to reduce the ‘second hit’ of surgery. This study used a large animal (ovine) trauma model to compare pathophysiological responses of primary external femoral fixation and intramedullary stabilisation. Under terminal anaesthesia bilateral femoral fractures and hypovolaemia were produced using a pneumatic ram. 24 sheep were randomised into 4 groups and monitored for 24 hours. Group 1 – Control; Group 2 – Trauma only; Group 3 – Trauma and external fixation; Group 4 – Trauma and reamed intramedullary stabilisation. Outcome measures: pulmonary embolic load (transoesophageal echocardiography); plasma coagulation markers; bronchoalveolar lavage differential cell counts (neutrophils, lymphocytes and macrophages). Total embolic load was significantly higher (p<0.001) in the intramedullary fixation group (median score 42 versus 20). All trauma groups had a significant increase (p < 0.05) in prothrombin time with a fall in antithrombin III and fibrinogen levels. No significant differences occurred between trauma groups with any coagulation or alveolar lavage marker. Intramedullary femoral fracture fixation produced a relatively higher pulmonary embolic load. However, the initial fracture fixation method did not affect any of the changes seen in the measured coagulation or inflammatory markers during the first 24 hours of injury