From a series of 190 consecutive fractures of the shaft of the femur treated by closed Kuntscher nailing, 32 of the more severely comminuted have been studied to determine whether treatment by closed nailing was justified. Radiological criteria were used to divide them into 19 who were moderately comminuted and 13 grossly so. Twenty-four patients were less than 21 years of age and 19 patients had 40 significant associated injuries. Fifteen fractures were nailed on the day of injury, and complications were few. Nineteen patients had a supplementary cast-brace and all those who had been employed returned to work. Twelve patients had shortening of up to two centimetres and two had three centimetres; four had mild rotational deformities; seven had mild restriction of knee flexion; and two had delayed union. There were no infections. The advantages of this technique include a negligible risk of infection and rapid stabilisation of even grossly comminuted fractures, thus facilitating management of other injuries. The 44 per cent incidence of shortening is counterbalanced by early mobilisation and rapid return of knee function. It is concluded that when proper equipment and expertise are available then closed nailing is the treatment of choice for severely comminuted fractures of the femoral shaft

In two hospitals, 115 consecutive open femoral shaft fractures were treated by meticulous wound excision and early locked (97) or unlocked (18) intramedullary nailing. All the fractures united; union was delayed in four, three of which required bone grafting. The average range of knee flexion at follow-up was 134 degrees (60 to 148). Five patients had a final range of less than 120 degrees, but three of these improved after manipulation under general anaesthesia. Three patients developed staphylococcal infections and required further surgical treatment. All eventually healed

We studied 47 patients with closed, displaced, diaphyseal fractures of the femur caused by blunt trauma, to determine the incidence of associated knee injuries, particularly of the meniscus. After femoral nailing, all patients had an examination under anaesthesia and an arthroscopy. There were 12 medial meniscal injuries (5 tears) and 13 injuries of the lateral meniscus (8 tears). Ten of the 13 tears were in the posterior third of the meniscus, and two patients had tears of both menisci. Synovitis was common at the meniscal attachments. Complex and radial tears were more common than peripheral or bucket-handle tears. Examination under anaesthesia revealed ligamentous laxity in 23 patients (49%), but meniscal injuries had a similar incidence in knees with and without ligament injury. Femoral shaft fractures are often associated with injuries to the ipsilateral knee, and a high index of suspicion is necessary to identify these lesions

We have treated 42 consecutive complex ununited fractures of the femoral shaft by wave-plate osteosynthesis at five different medical centres. There were 13 with previous infection, 12 with segmental cortical defects, and 3 were pathological fractures. In 39 cases there had been previous internal fixation and 21 patients had had more than one earlier operation. Union was achieved in 41 patients at an average of six months, although three had required a second bone graft. Two patients had recurrence of infection and in one this resulted in the persistence of nonunion. There were no failures of the implant. All 41 patients with union are now fully weight-bearing, but four have a leg-length discrepancy, one has axial malalignment, and nine have residual stiffness of the knee. These results are surprisingly good, despite the complexity of the initial problem, and appear to confirm the biological and mechanical advantages of the wave plate over the conventional plate for such cases

We describe the use of intramedullary reconstruction nails in the treatment of 14 patients with pathological subtrochanteric fractures and coexisting metastases in the femoral shaft. After nailing, all patients were free from pain and regained mobility. They were followed up clinically and radiologically until death from the primary disease. There were no mechanical failures even when a less than ideal reduction had been achieved

We describe the use of Ender nails for the internal fixation of femoral shaft fractures by a closed technique via the greater trochanter and report the treatment of 100 patients with 106 fractures, of which 88 were reviewed 12 months or more after operation. There was primary union in 85 fractures (96.6%) and significant angulation, rotation or leg length discrepancy in eight (9%). We discuss the principles of management which we have evolved

We have reviewed 402 traumatic fractures of the femoral shaft, 320 of which had been treated by operation and had a long follow-up. Of these, 228 closed fractures and 37 open fractures had been stabilised by plating. There was no significant difference in healing between those stabilised early and those having delayed internal fixation. Re-fracture after removal of the implant occurred more often after early operation. All 55 fractures treated by intramedullary nailing healed and there were no re-fractures after nail removal. We found no correlation between delay before operation and the incidence of postoperative infection

We reviewed and radiographed 30 skeletally-mature patients after isolated closed femoral shaft fractures in childhood which had been treated conservatively. When the fracture had occurred between the ages of 7 and 13 years, the limb overgrew about 1 cm regardless of sex, upper limb dominance, age, fracture site or configuration. Excessive fracture overlap at the time of injury, but not at union, increased limb overgrowth. Angulation of the fracture remodelled in children injured under 10 years of age, but in older patients this sometimes added to limb shortening. Rotational deformities were minor and gave no symptoms. Treatment of the 7- to 13-year-old patient should aim at 1 cm overlap at union, with correction of angular deformity being more important in children over 10 years of age. This management of fractures will give a maximum leg length discrepancy of 1 cm at skeletal maturity

One hundred and two fractures of the femoral shaft, including eighteen pathological fractures, in 100 patients were internally fixed by closed Kuntscher nailing. Sixty-eight fractures resulted from motor vehicle accidents; ten were compound. Seventy-five patients were under the age of thirty years and thirty-four had multiple injuries. Sixty-nine fractures were nailed on the day of the accident and the operative technique is described. Complications during and after operations were few. Fifty-eight patients left hospital within four weeks and 77% of those working returned to work in less than four months. There were no wound or bone infections. The results are discussed and it is concluded that, with the correct equipment and careful attention to detail, closed nailing is a straightforward procedure with few complications. Advantages include the wide range of fractures that can be nailed, the short hospitalisation, the rapid return of function to the knee, the early return to work and the absence of infection

Over 15 years (1967 to 1982) 140 uncomplicated femoral shaft fractures in children under four years of age were successfully treated using Bryant's traction. Forty of these children were treated after the introduction of the domiciliary management policy in 1976; 13 children were managed at hospital and 27 were managed at home. No significant complications occurred. The advantages to the family, and the safety and economy of domiciliary management lead us to recommend its adoption in favourable cases. Treatment at home relies on an efficient and experienced home nursing service. Possible complications of the injury and treatment with recommendations to prevent them are discussed

Ninety-eight fractures of the shaft of the femur were seen in one unit over the two years 1974 and 1975, and the results have been assessed in sixty-nine. Of these, thirty-eight were treated by skeletal traction in a Thomas's splint followed by skin traction, and thirty-one by skeletal traction followed by a cast-brace. The technique of application is described in some detail. The average time for application of the cast-brace was six weeks after the injury, the time in hospital eight weeks and the time till removal fifteen weeks. The patients selected for a cast-brace were in hospital for just over half the time of the others and their fractures on average united more quickly, though with some trouble from angulation of fractures of the uppermost third of the shaft. It is concluded that when used with all the judgment and skill it demands, the cast-brace method is a great advance in conservative treatment.

1. The results of treatment of fractures of the shaft of the femur in fifty patients aged sixty-five years and over seen over a twelve-year period are presented.

2. Half of the patients were treated by internal fixation and half by conservative methods. The mortality in the former group was three times that of the latter.

3. The length of hospital stay was only slightiy less after internal fixation because many patients in both groups had to remain in hospital because of social problems.

4. The indications for internal fixation of fractures of the shaft of the femur in elderly patients are discussed.

A protocol for the treatment of fractures of the middle third of the femur by the early application of a hip spica has been evaluated in 191 children aged 10 years or less. Children without other injuries spent only a few days in hospital for the application and later removal of the spica. At all ages, anterior angulation of less than 20 degrees and valgus angulation of less than 15 degrees were accepted at the one-week review. Acceptance of shortening varied with the age of the child and the stage of treatment, but was 10% or less of the femoral length at the time of spica removal. At late review leg-length discrepancy was rare and clinically insignificant. This method of treatment was simple and effective. It dramatically reduced the cost of care and freed a number of children's hospital beds.

The off-loading characteristics of the cast-braces of 30 patients with fractures of the shaft of the femur have been investigated, during axial loading, using strain-gauge transducers. These were applied at the level of the fracture, where the cast was circumferentially split, and to the hinges of the brace at the knee. They measured the load transferred between the two portions of the thigh cast, and between the thigh cast as a whole and the below-knee cast; by subtraction from the total load on the limb, the skeletal force at the fracture level and at the knee could be calculated. In all patients there was an increase in the fracture load as union progressed which was thought to be due to physiological feedback mechanism from the fracture site. The load carried by the two portions of the thigh cast and by the thigh cast as a whole was proportionately high at first and stabilised at an average of 35 per cent of body weight.

We have reviewed our experience of four iatrogenic femoral neck fractures in 315 consecutive closed intramedullary nailings with the AO/ASIF universal femoral nail. The average neck-shaft angle in the bones that fractured was 139.3 degrees +/- 1.2 degrees SD (136 to 141); in the whole series the average neck-shaft angle was 125.3 degrees +/- 8.6 degrees and only 11 had angles of more than 135 degrees. The upper ends of the nails in the four which fractured were 17 mm, 5 mm, 3 mm, and 1 mm below the tip of the greater trochanter. In the seven patients with neck-shaft angles greater than 135 degrees but with no fracture, none of the nails had been inserted beyond the tip of the greater trochanter. We nailed six cadaver femora to simulate the forces produced by intramedullary nailing. Despite deep insertion, only one of the six sustained a neck fracture. This specimen had a radiographic neck-shaft angle of 140 degrees against an average of 127.3 degrees +/- 4.0 degrees for the other five. We believe that the medial prong of the AO insertion jig, with its medial overhang of 2 to 3 mm, may impinge on the superior aspect of a valgus femoral neck during final impaction, causing a neck fracture. This may be avoided by leaving the end of the nail above the tip of the trochanter in such cases.

It is accepted that resurfacing hip replacement preserves the bone mineral density (BMD) of the femur better than total hip replacement (THR). However, no studies have investigated any possible difference on the acetabular side.

Between April 2007 and March 2009, 39 patients were randomised into two groups to receive either a resurfacing or a THR and were followed for two years. One patient’s resurfacing subsequently failed, leaving 19 patients in each group.

Resurfaced replacements maintained proximal femoral BMD and, compared with THR, had an increased bone mineral density in Gruen zones 2, 3, 6, and particularly zone 7, with a gain of 7.5% (95% confidence interval (CI) 2.6 to 12.5) compared with a loss of 14.6% (95% CI 7.6 to 21.6). Resurfacing replacements maintained the BMD of the medial femoral neck and increased that in the lateral zones between 12.8% (95% CI 4.3 to 21.4) and 25.9% (95% CI 7.1 to 44.6).

On the acetabular side, BMD was similar in every zone at each point in time. The mean BMD of all acetabular regions in the resurfaced group was reduced to 96.2% (95% CI 93.7 to 98.6) and for the total hip replacement group to 97.6% (95% CI 93.7 to 101.5) (p = 0.4863). A mean total loss of 3.7% (95% CI 1.0 to 6.5) and 4.9% (95% CI 0.8 to 9.0) of BMD was found above the acetabular component in W1 and 10.2% (95% CI 0.9 to 19.4) and 9.1% (95% CI 3.8 to 14.4) medial to the implant in W2 for resurfaced replacements and THRs respectively. Resurfacing resulted in a mean loss of BMD of 6.7% (95% CI 0.7 to 12.7) in W3 but the BMD inferior to the acetabular component was maintained in both groups.

These results suggest that the ability of a resurfacing hip replacement to preserve BMD only applies to the femoral side.