M.E.Müller: Atlas: Fracture 32-C1

Femur, Diaphysis,
complex fracture, spiral 0,34% of the total
0,56% of the femur
2,34% of the segment

88 fractures
47,6% group
68%M, 32%F

51 fractures
27,6% group
65%M, 35%F

46 fractures
24,8% group
89%M, 11%F

With two intermediate fragments +Q With three intermediate fragments +Q With more than three intermediate fragments +Q

These are complex diaphyseal fractures with two intermediate spiral fragments, and after reduction there is no contact between the main proximal and distal fragments. Ref. Manual of Internal Fixation:
535 - 547. 232 - 251.
Surgeon. RO.

In their proximal location, they form a small epiphyseal-metaphyseal fragment of quite peculiar anatomic characteristics that must be adequately utilized in order to obtain a perfect hold of this proximal fragment. In general, the 95º condylar plate is the implant of choice.

The illustrated case demonstrates an efficacious treatment alternative using a long straight plate, previously contoured to the greater trochanter. The plate is fixed to the proximal fragment by two cancellous screws that follow the neck axis up to the hard core of the femoral head, one long cortical screw from the tip of

the greater trochanter to the calcar and one small screw holding on to the lateral cortex. The distal and the intermediate fragments are then reduced to the plate. In this case, the two big intermediate fragments could be anatomically reduced without denuding them, making the bone participate in the stability of the assembly. Several screws, placed through the plate, perform interfragmentary compression. No bone graft was used.

Healing was obtained by direct callus between the cortices, not visible in the X-rays, demonstrating the perfect stability achieved with this technique.

preoperative postoperative + 1 month + 2 years

+ 9 years

preoperative preoperative 0 month 0 month

+1 years + 1 years

These are complex diaphyseal fractures with three large intermediate spiral fragments in such a way that, after the fracture is reduced, there is no contact between the proximal and distal fragments. Ref. Manual of Internal Fixation:
122 - 123 (2nd ed).
Surgeon. RO.

This probably is the most emblematic fracture subgroup for the pioneers of the interlocking nail treatment; It certainly is its main indication even though the nail insertion often results in added iatrogenic fractures, displacement of fragments previously undisplaced and, sometimes, in torsional, shortening or lenghthening faults. Some authors advocate unreamed interlocked nailing, that is to say suspending the proximal and distal fragments between the locking bolts while the nail itself only acts as an alignment device.

Accepting the proposal of the second edition of the AO manual, the case shown was treated by open, reamed, intramedullary nailing. The intermediate fragments are reduced as much as possible by careful manipulation. Along narrow straight plate, applied to the postero-lateral cortex with unicortical screws, bridges the broad fracture

site, neutralizes the torsional loads and prevents shortening. Autologous bone grafting and refined surgical technique are essential. The result is a perfect anatomic restoration by indirect callus, boosted by the cancellous graft and including the denuded fragments that will suffer creeping substitution.

The choice of one technique or the other will depend on the general condition of the patient (multiple injuries), hospital aseptic conditions, training of the surgeon and on the degree of requirement for anatomic restoration. The callus formation is more exuberant with the closed intramedullary nailing, sometimes much more exuberant, and this has its pros and cons. The timing for early function is similar with both tecniques but interlocked nails usually allow earlier weight bearing.

preoperative + 4 months + 4 months

+ 1 year + 1 year + 29 months + 29 months

preoperative
preoperative + 4 months + 4 months

These are complex diaphyseal fractures with more than three intermediate spiral fragments. Once the fracture is reduced, there is no contact between the main proximal and distal fragments. Ref. Manual of Internal Fixation:
232 - 251. 254 - 265. 535 - 547.
Surgeon. JG, CS, RO.

As it is for all fractures in the distal zone of the femoral diaphysis, we prefer to use a plate rather than a nail for internal fixation. The plate must be carefully contoured for a perfect fit to the cortical surface. The plate is first aligned and fixed to the proximal fragment; the distal and intermediate fragments are then reduced to the plate.

In contrast with the C1.2 fractures and because of the different quality of the cortical bone in this zone, we advocate the anatomic reduction in this subgroup of fractures. The cortex is thinner at the diaphyseal-metaphyseal area, and the fragments usually include very valuable cancellous bone. The relative bone loss frequently is quite important in these fractures; That is the reason why a generous amount of cancellous bone graft is essential.

In the illustrated case, anatomic reduction was obtained and healed with an hypertrophic callus boosted by the bone graft. However, the anatomic reduction with interfragmentary compression of the distal fragments has led to direct (primary) bone healing. Probably, the internal fixation performed has an excessive number of screws, especially in the proximal fragment, a point that we want to emphasize for comparison with the more recent cases that illustrate the C2 fracture group. Our 30 years of experience have proved the uselessness of filling every hole of the plates with screws, and we have learned to use the minimum number of screws necessary to obtain the required stability for early function.

preoperative preoperative

postoperative postoperative + 8 months + 8 months




						Femur, Diaphysis, complex fracture, spiral	0,34% of the total 0,56% of the femur 2,34% of the segment






These are complex diaphyseal fractures with two intermediate spiral fragments, and after reduction there is no contact between the main proximal and distal fragments.		Ref. Manual of Internal Fixation: 535 - 547. 232 - 251. Surgeon. RO.

In their proximal location, they form a small epiphyseal-metaphyseal fragment of quite peculiar anatomic characteristics that must be adequately utilized in order to obtain a perfect hold of this proximal fragment. In general, the 95º condylar plate is the implant of choice. The illustrated case demonstrates an efficacious treatment alternative using a long straight plate, previously contoured to the greater trochanter. The plate is fixed to the proximal fragment by two cancellous screws that follow the neck axis up to the hard core of the femoral head, one long cortical screw from the tip of	the greater trochanter to the calcar and one small screw holding on to the lateral cortex. The distal and the intermediate fragments are then reduced to the plate. In this case, the two big intermediate fragments could be anatomically reduced without denuding them, making the bone participate in the stability of the assembly. Several screws, placed through the plate, perform interfragmentary compression. No bone graft was used. Healing was obtained by direct callus between the cortices, not visible in the X-rays, demonstrating the perfect stability achieved with this technique.






These are complex diaphyseal fractures with three large intermediate spiral fragments in such a way that, after the fracture is reduced, there is no contact between the proximal and distal fragments.		Ref. Manual of Internal Fixation: 122 - 123 (2nd ed). Surgeon. RO.

This probably is the most emblematic fracture subgroup for the pioneers of the interlocking nail treatment; It certainly is its main indication even though the nail insertion often results in added iatrogenic fractures, displacement of fragments previously undisplaced and, sometimes, in torsional, shortening or lenghthening faults. Some authors advocate unreamed interlocked nailing, that is to say suspending the proximal and distal fragments between the locking bolts while the nail itself only acts as an alignment device. Accepting the proposal of the second edition of the AO manual, the case shown was treated by open, reamed, intramedullary nailing. The intermediate fragments are reduced as much as possible by careful manipulation. Along narrow straight plate, applied to the postero-lateral cortex with unicortical screws, bridges the broad fracture	site, neutralizes the torsional loads and prevents shortening. Autologous bone grafting and refined surgical technique are essential. The result is a perfect anatomic restoration by indirect callus, boosted by the cancellous graft and including the denuded fragments that will suffer creeping substitution. The choice of one technique or the other will depend on the general condition of the patient (multiple injuries), hospital aseptic conditions, training of the surgeon and on the degree of requirement for anatomic restoration. The callus formation is more exuberant with the closed intramedullary nailing, sometimes much more exuberant, and this has its pros and cons. The timing for early function is similar with both tecniques but interlocked nails usually allow earlier weight bearing.






These are complex diaphyseal fractures with more than three intermediate spiral fragments. Once the fracture is reduced, there is no contact between the main proximal and distal fragments.		Ref. Manual of Internal Fixation: 232 - 251. 254 - 265. 535 - 547. Surgeon. JG, CS, RO.

As it is for all fractures in the distal zone of the femoral diaphysis, we prefer to use a plate rather than a nail for internal fixation. The plate must be carefully contoured for a perfect fit to the cortical surface. The plate is first aligned and fixed to the proximal fragment; the distal and intermediate fragments are then reduced to the plate. In contrast with the C1.2 fractures and because of the different quality of the cortical bone in this zone, we advocate the anatomic reduction in this subgroup of fractures. The cortex is thinner at the diaphyseal-metaphyseal area, and the fragments usually include very valuable cancellous bone. The relative bone loss frequently is quite important in these fractures; That is the reason why a generous amount of cancellous bone graft is essential.	In the illustrated case, anatomic reduction was obtained and healed with an hypertrophic callus boosted by the bone graft. However, the anatomic reduction with interfragmentary compression of the distal fragments has led to direct (primary) bone healing. Probably, the internal fixation performed has an excessive number of screws, especially in the proximal fragment, a point that we want to emphasize for comparison with the more recent cases that illustrate the C2 fracture group. Our 30 years of experience have proved the uselessness of filling every hole of the plates with screws, and we have learned to use the minimum number of screws necessary to obtain the required stability for early function.