M.E.Müller: Atlas: Fracture 32-C2

Femur, Diaphysis,
complex fracture, segmental 0,42% of the total
0,70% of the femur
2,87% of the segment

73 fractures
32,2% group
75%M, 25%F

125 fractures
55,1% group
73%M, 27%F

29 fractures
12,7% group
76%M, 24%F

With one intermediate segmental fragment +Q With one intermediate segmental & additional wedge fragment(s) +Q With two intermediate segmental fragments +Q

These are diaphyseal fractures with one intermediate segmental fragment. Ref. Manual of Internal Fixation:
291 - 331. 546 - 547.
Surgeon. RO, XXX, JG.

Intramedullary nailing is the preferred treatment for these fractures. Reaming of the intermediate segmental fragment runs a great risk of increasing the devascularization of the segment, dragged along by the rotation of the reamer. For this reason it is advisable to use narrower unreamed nails for alignment of the fragments, even at the expense of a precarious stability. If the nail is interlocked, proximally and distally, it will have to be dynamized at some point. The case below demonstrates what is stated above.

The upper case demonstrates another possibility, a quite didactic one, of the healing process, both the primary bone healing and that of the pseudoarthroses. Five months after internal fixation with a narrow nail that perfectly stabilizes the intermediate fragment with the proximal, there is direct healing between both fragments.

At the same time, the distal fragment maintains some mobility, because of its location at the trumpet-like flare of the femur, and developes a hypertrophic pseudoarthrosis. Changing the nail for another of a bigger diameter, reamed, whether interlocked or not, will result in healing of the pseudoarthrosis after a few weeks.

Another possibility would be performing an anatomic reduction and an internal fixation under compression of the intermediate fragment by means of a straight plate. The plate is first fixed to the proximal fragment and then the intermediate fragment is fixed under compression by indirect reduction, adding cancellous bone graft. The lower segment is also reduced towards the plate but, due to its oblique fracture line, it is first fixed by an interfragmentary lag screw and then screwed to the plate, thus acting as a neutralization plate (protection).

preoperative postoperative + 5 months + 1 year

preoperative + 4 months + 2 years + 2 years

These are complex diaphyseal fractures with an intermediate segmental fragment and additional wedge fragment(s). Ref. Manual of Internal Fixation:
535 - 547. 232 - 251.
Surgeon. RO.

In the following fractures of the groups C2 and C3 we show our preference for the internal fixation with plates versus the recently popular interlocking nails. Our reasons have been expounded throughout this book.

In the illustrated case there is an intermediate segmental fragment that, at its proximal pole, is easy to reduce anatomically and enables interfragmentary compression with lag screws. It is worthwhile to take advantage of this situation and obtain perfect stability of this fracture site

by neutralizing it with a plate. This fracture site will heal by direct healing. The distal fracture site is different since there is a wedge fragment with some fragmentation and displacement, therefore lifeless. It is reduced and fixed to the distal fragment with a lag screw and then both are fixed to the intemediate fragment by a bridge plate with very few screws. Since there is bone loss, bone graft is added to this fracture site that, in costrast with the proximal fracture site, heals by hypertrophic callus.

preoperative postoperative

+ 7 months + 2 years + 2 years




						Femur, Diaphysis, complex fracture, segmental	0,42% of the total 0,70% of the femur 2,87% of the segment






These are diaphyseal fractures with one intermediate segmental fragment.		Ref. Manual of Internal Fixation: 291 - 331. 546 - 547. Surgeon. RO, XXX, JG.

Intramedullary nailing is the preferred treatment for these fractures. Reaming of the intermediate segmental fragment runs a great risk of increasing the devascularization of the segment, dragged along by the rotation of the reamer. For this reason it is advisable to use narrower unreamed nails for alignment of the fragments, even at the expense of a precarious stability. If the nail is interlocked, proximally and distally, it will have to be dynamized at some point. The case below demonstrates what is stated above. The upper case demonstrates another possibility, a quite didactic one, of the healing process, both the primary bone healing and that of the pseudoarthroses. Five months after internal fixation with a narrow nail that perfectly stabilizes the intermediate fragment with the proximal, there is direct healing between both fragments.	At the same time, the distal fragment maintains some mobility, because of its location at the trumpet-like flare of the femur, and developes a hypertrophic pseudoarthrosis. Changing the nail for another of a bigger diameter, reamed, whether interlocked or not, will result in healing of the pseudoarthrosis after a few weeks. Another possibility would be performing an anatomic reduction and an internal fixation under compression of the intermediate fragment by means of a straight plate. The plate is first fixed to the proximal fragment and then the intermediate fragment is fixed under compression by indirect reduction, adding cancellous bone graft. The lower segment is also reduced towards the plate but, due to its oblique fracture line, it is first fixed by an interfragmentary lag screw and then screwed to the plate, thus acting as a neutralization plate (protection).






These are complex diaphyseal fractures with an intermediate segmental fragment and additional wedge fragment(s).		Ref. Manual of Internal Fixation: 535 - 547. 232 - 251. Surgeon. RO.

In the following fractures of the groups C2 and C3 we show our preference for the internal fixation with plates versus the recently popular interlocking nails. Our reasons have been expounded throughout this book. In the illustrated case there is an intermediate segmental fragment that, at its proximal pole, is easy to reduce anatomically and enables interfragmentary compression with lag screws. It is worthwhile to take advantage of this situation and obtain perfect stability of this fracture site	by neutralizing it with a plate. This fracture site will heal by direct healing. The distal fracture site is different since there is a wedge fragment with some fragmentation and displacement, therefore lifeless. It is reduced and fixed to the distal fragment with a lag screw and then both are fixed to the intemediate fragment by a bridge plate with very few screws. Since there is bone loss, bone graft is added to this fracture site that, in costrast with the proximal fracture site, heals by hypertrophic callus.