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.

Objectives

The use of two implants to manage concomitant ipsilateral femoral shaft and proximal femoral fractures has been indicated, but no studies address the relationship of dynamic hip screw (DHS) side plate screws and the intramedullary nail where failure might occur after union. This study compares different implant configurations in order to investigate bridging the gap between the distal DHS and tip of the intramedullary nail.

Aims. Osteopetrosis (OP) is a rare hereditary disease that causes reduced bone resorption and increased bone density as a result of osteoclastic function defect. Our aim is to review the difficulties, mid-term follow-up results, and literature encountered during the treatment of OP. Methods. This is a retrospective and observational study containing data from nine patients with a mean age of 14.1 years (9 to 25; three female, six male) with OP who were treated in our hospital between April 2008 and October 2018 with 20 surgical procedures due to 17 different fractures. Patient data included age, sex, operating time, length of stay, genetic type of the disease, previous surgery, fractures, complications, and comorbidity. Results. The mean follow-up period was 92.5 months (25 to 140). Bony union was observed in all of our patients. Osteomyelitis developed in two patients with femoral shaft fractures, and two patients had peri-implant stress fractures. Conclusion. Treatment of fractures in OP patients is difficult, healing is protracted, and the risk of postoperative infection is high. In children and young adults with OP who have open medullary canal and the epiphyses are not closed, fractures can be treated with surgical techniques such as intramedullary titanium elastic nail (TENS) technique or fixation with Kirschner (K)-wire. Cite this article: Bone Joint J 2020;102-B(8):1082–1087

The October 2014 Children’s orthopaedics Roundup. 360 . looks at: spondylolisthesis management strategies; not all cervical collars are even; quality of life with Legg-Calve-Perthe’s disease; femoral shaft fractures in children; percutaneous trigger thumb release – avoid at all costs in children; predicting repeat surgical intervention in acute osteomyelitis; and C-Arm position inconsequential in radiation exposure

1. The combination of femoral shaft fracture with dislocation of the hip in the same limb has been recorded in eighty-one patients since 1823. 2. A further fourteen cases are reported. 3. In over half the cases the hip dislocation was diagnosed late or not at all, and this error has occurred more often in modern times. The reasons for this are outlined. 4. The diagnostic physical signs of hip dislocation in the presence of a femoral shaft fracture are described. 5. The mechanism, sequels and treatment of this combined injury are discussed

We performed a retrospective review of all patients admitted to two large University Hospitals in the United Kingdom over a 24-month period from January 2008 to January 2010 to identify the incidence of atypical subtrochanteric and femoral shaft fractures and their relationship to bisphosphonate treatment. Of the 3515 patients with a fracture of the proximal femur, 156 fractures were in the subtrochanteric region. There were 251 femoral shaft fractures. The atypical fracture pattern was seen in 27 patients (7%) with 29 femoral shaft or subtrochanteric fractures. A total of 22 patients with 24 atypical fractures were receiving bisphosphonate treatment at the time of fracture. Prodromal pain was present in nine patients (11 fractures); 11 (50%) of the patients on bisphosphonates suffered 12 spontaneous fractures, and healing of these fractures was delayed in a number of patients. This large dual-centre review has established the incidence of atypical femoral fractures at 7% of the study population, 81% of whom had been on bisphosphonate treatment for a mean of 4.6 years (0.04 to 12.1). This study does not advocate any change in the use of bisphosphonates to prevent fragility fractures but attempts to raise awareness of this possible problem so symptomatic patients will be appropriately investigated. However, more work is required to identify the true extent of this new and possibly increasing problem

A medical and engineering study was made of 1074 car accidents involving 2520 vehicle occupants. The injuries they sustained were correlated with details of the crash and with contact points inside the cars. Where possible the forces which were generated in the crash were estimated and related to the injuries. In all, 39 car occupants suffered femoral shaft fracture, with an incidence of 1.7% and 0.8% for front and rear seat occupants respectively. Of these, 31 had associated injuries to other regions of the body; these were the cause of 13 of the 14 deaths in this group. Associated injuries were more severe in car occupants who were not wearing seat belts but the incidence of femoral fracture was not significantly different. The mean velocity change (delta-V) causing femoral fracture was 26 mph (42 km/h) and there was a higher incidence of femoral shaft fracture when delta-V was over 30 mph. Estimates of forces needed to cause fracture were higher than those found in cadaver studies. The time to union of femoral fractures did not correlate with the severity of the crash but was longer (mean 19 weeks) than the average for other femoral fractures

1. A series of 154 patients with 156 femoral shaft fractures treated during a three and a half year period is reviewed. Fifty-four fractures were treated by closed intramedullary nailing, sixty-four by open intramedullary nailing and thirty-eight by conservative methods. 2. All the patients had fresh fractures of a similar degree of severity. Seventy-eight per cent of the fractures were sustained in traffic accidents, and 21 per cent were compound. 3. The technique of closed intramedullary nailing is described in detail. The importance of a complete and faultless armamentarium and a high-quality image intensifier is emphasised. 4. All fractures united within twelve months after the accident. 5. The functional results were assessed upon the basis of walking ability and return to work. Nailed fractures did better than conservatively treated ones, and closed nailing was slightly superior to open nailing. At twelve months after the injury all patients treated by closed nailing walked without a stick, compared with 96 per cent of the cases treated by open nailing and 81 per cent of the conservatively treated patients. The same trend was noted regarding return to work. 6. The benefit of intramedullary nailing was partly dependent on the severity of the fracture and the age of the patient. The most gratifying results of nailing were obtained in patients over thirty-five years of age with severe fractures. 7. Osteitis occurred in one case treated by closed nailing, and low grade wound infections in five cases, representing an overall infection rate of 3·8 per cent. 8. Seventy-four per cent of the patients were examined one to four years after the fracture. There was less angular deformity and more rotational deformity in the nailed than in the conservatively treated fractures. The tip of the nail gave slight discomfort in the trochanteric area in one patient in three. Residual joint stiffness was infrequent in the nailed cases as compared to the conservatively treated ones. 9. The indications for closed intramedullary nailing of femoral shaft fractures are outlined

The April 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: CT scan of the ipsilateral femoral neck in paediatric shaft fractures; Meniscal injuries in skeletally immature children with tibial eminence fractures: a systematic literature review; Post-maturity progression in adolescent idiopathic scoliosis curves of 40° to 50°; Prospective, randomized Ponseti treatment for clubfoot: orthopaedic surgeons versus physical therapists; FIFA 11+ Kids: challenges in implementing a prevention programme; The management of developmental dysplasia of the hip in children aged under three months: a consensus study from the British Society for Children's Orthopaedic Surgery; Early investigation and bracing in developmental dysplasia of the hip impacts maternal wellbeing and breastfeeding; Hip arthrodesis in children: a review of 26 cases with a mean of 20 years’ follow-up

The October 2023 Trauma Roundup³⁶⁰ looks at: Intramedullary nailing versus sliding hip screw in trochanteric fracture management: the INSITE randomized clinical trial; Five-year outcomes for patients with a displaced fracture of the distal tibia; Direct anterior versus anterolateral approach in hip joint hemiarthroplasty; Proximal humerus fractures: treat them all nonoperatively?; Tranexamic acid administration by prehospital personnel; Locked plating versus nailing for proximal tibia fractures: a multicentre randomized controlled trial; A retrospective review of the rate of septic knee arthritis after retrograde femoral nailing for traumatic femoral fractures at a single academic institution.

We analysed retrospectively the risk factors leading to femoral overgrowth after flexible intramedullary nailing in 43 children (mean age 7.1 years (3.6 to 12.0)) with fractures of the shaft of the femur. We reviewed their demographic data, mechanism of injury, associated injuries, the type and location of the fractures, the nail–canal diameter (NCD) ratios and femoral overgrowth at a mean follow-up of 40.7 months (25.2 to 92.7). At that time, the children were divided into two groups, those with femoral overgrowth of < 1 cm (Group 1), and those with overgrowth of ≥ 1 cm (Group 2). The mean femoral overgrowth of all patients was 0.6 cm at final follow-up. Overgrowth of ≥ 1 cm was noted in 11 children (25.6%). The NCD ratio was significantly lower in Group 2 than in Group 1, with an odds ratio of 30.0 (p = 0.003). We believe that a low NCD ratio is an indicator of an unstable configuration with flexible intramedullary nailing, and have identified an association between a low NCD ratio and femoral overgrowth resulting in leg-length discrepancy after flexible intramedullary nailing in paediatric femoral shaft fractures. Cite this article: Bone Joint J 2013;95-B:254–8

Aims

The aim of this systematic review and meta-analysis was to gather epidemiological information on selected musculoskeletal injuries and to provide pooled injury-specific incidence rates.

We made a randomised prospective comparison of the Dynamic Hip Screw and the Gamma locking nail for the internal fixation of 200 petrochanteric femoral fractures in elderly patients. There was less intraoperative blood loss and a lower rate of wound complications in the patients treated by the Gamma nail. They had, however, a high incidence of femoral shaft fracture which we relate in part to implant design. We do not recommend the use of the Gamma nail for these fractures

We have reviewed 107 patients of 80 years or over who underwent primary total hip replacement. They had many more complications than younger patients. Thus, acute dislocation occurred in 15%, and became chronic in 9%; there were femoral shaft fractures in 4.6% and these, with shaft perforation gave universally poor results. Nevertheless, 75% of patients had a satisfactory outcome, with worthwhile relief of pain. It would seem sensible to warn elderly patients and their relatives of the increased risks in this age group

1. The results in 211 fractures of the shaft of the femur in adults treated by internal fixation have been reviewed. 2. A comparison has been made between the effects of early internal fixation within the first six days of injury and delayed fixation. 3. Eighty-five fractures treated by early fixation gave a rate of non-union of 23 per cent; in 126 fractures treated by delayed fixation the rate was 0·8 per cent. 4. Delayed operation is therefore advocated for the majority of femoral shaft fractures for which internal fixation is indicated

Aims

Prior to the availability of vaccines, mortality for hip fracture patients with concomitant COVID-19 infection was three times higher than pre-pandemic rates. The primary aim of this study was to determine the 30-day mortality rate of hip fracture patients in the post-vaccine era.

We investigated the spines of 15 patients who had significant leg-length inequality as a result of femoral shaft fractures sustained after skeletal maturity but below the age of 21 years. The patients were examined at least 10 years after fracture. The spines were studied clinically and radiographically before and after correction of leg-length inequality with a shoe-raise. Lateral spinal flexion was measured from radiographs. The lumbar scoliosis associated with the leg-length inequality was compensatory: after equalisation of leg-length the overall curve and the axial rotation were corrected completely. There was also an equal range of lateral flexion to either side after correction. Minor malalignments of the whole spine remained despite correction of the compensatory scoliosis, and within the lumbar spine correction of the scoliosis had not occurred equally at all levels. No patients complained of significant discomfort and neither structural abnormalities nor degenerative changes were seen on the radiographs

It seems right to draw the following conclusions from this study of the relative merits of early and delayed fixation for fractures of the femoral and tibial shafts. 1. In patients under the age of sixty years with femoral shaft fractures there seems to be a significant improvement in the speed and quality of union when internal fixation is delayed. In patients over the age of sixty years the results of delayed fixation are worse than those of early fixation, and in any case the dangers of prolonged recumbency make the latter method preferable. 2. Delaying fixation for tibial shaft fractures does not affect speed of union or functional result. However, the incidence of non-union in these fractures is reduced by over 50 per cent by delaying fixation. This is a good reason for delaying fixation of this fracture too. Some possible reasons for the improved results after delayed fixation have been discussed