Intramedullary nailing was performed on 520 femoral fractures
in 500 patients. The series included eighty-six open fractures and
261 comminuted fractures. Closed intramedullary nailing was used
in 497 femora and open intramedullary nailing with cerclage wiring,
in twenty-three. The union rate was 99.1 per cent. The range of
motion of the knee at follow-up averaged 130 degrees. Complications included
four infections (0.9 per cent). Shortening of more than two centimeters
occurred in ten patients (2.0 per cent) and malrotation of more
than 20 degrees was observed in twelve patients (2.3 per cent). After
prompt emergency measures had been taken, routine treatment included
strong preoperative traction followed by accurate positioning of
the patient on the operating table; selection of the correct insertion
point for a properly sized, pre-bent, flexible, bullet-tipped nail; and
accurate reduction of the fracture. Careful rehabilitation of the patient
also contributed to the excellence of the results.
Why was this article selected as a classic
orthopaedic reference?
Despite the revolutionary work by Küntscher in the 1930s,
closed intramedullary nailing techniques were only slowly introduced
in the United States. The clinical study by Winquist et al. documented
the excellent results of nailing at an American trauma center and
also offered multiple insights, based on careful observations, on
how to improve the technique. Currently accepted concepts such as
early fixation of long-bone fractures in multiply injured patients,
immediate fixation of open fractures, use of the piriformis fossa
as an entry portal, limited reaming, and the value of interlocking
screws were all identified in this seminal article.
How has the information in the article withstood
the "test of time"?
The striking results of this study, which surpassed those provided
by any other treatment technique, had a profound effect on the management
of femoral shaft fractures in North America. In a preliminary 1971
report1, the authors had noted a promising technique, but this large
series was compelling evidence of its superiority over traction,
cast-bracing, and open fixation. The article ushered in the era
of intramedullary nailing and spawned numerous clinical and biomechanical
investigations in American trauma centers. The basic principles
of closed nailing delineated in this study are valid today.
How has our thinking changed with regard to
this subject since the publication of this landmark work?
The relatively high rates of shortening and malrotation reported
by the authors have been addressed over the last fifteen years by
a remarkable growth in interlocking nailing systems. Improvements
in reamer and nail designs, reduction maneuvers, and retrograde
nailing techniques have also been advocated. Closed intramedullary
nailing of femoral fractures has remained one of the most predictable
and rewarding procedures in orthopaedic trauma care.R.W.B.Reference
Many classic, landmark articles have been published in The
Journal in the past. Monthly, we will be publishing summaries of
selected articles, along with a contemporary commentary by a knowledgeable member
of the editorial board identifying the article’s significance
in orthopaedics and its continuing relevance to our practices. Please
let us know of a classic Journal article that you believe should
be summarized and commented upon in the future. J.D.H.