M.E.Müller: Atlas: Fracture 32-C3

Femur, Diaphysis,
complex fracture, irregular 0,56% of the total
0,94% of the femur
3,91% of the segment

174 fractures
56,5% group
75%M, 25%F

59 fractures
19,2% group
78%M, 22%F

75 fractures
24,3% group
90%M, 10%F

With two or three intermediate fragments +Q With limited shattering
(<5cm) +Q With extensive shattering
(>= 5cm) +Q

These are complex diaphyseal fractures with two or three intermediate fragments. Ref. Manual of Internal Fixation:
535 - 547. 232 - 251.
Surgeon. RO.

The case shown is a typical example of the biologic internal fixation with a plate. The approach is careful. The straight plate, previously contoured at its distal end, is first fixed to the postero-lateral aspect of the proximal fragment, aligned with its axis. The large intermediate fragment is carefully manipulated in order to reduce it to the plate and fixed with a unicortical screw. The distal fragment is then reduced to the intermediate fragment, thus restoring the length of the femur, and is also fixed with a small unicortical screw. After checking the adequacy of the reduction, the intermediate fragment is fixed to the distal by a lag screw through the plate.

The medial fragments have not been exposed during the procedure, thus preserving their vascular supply as well as the fracture haematoma. Because of the enormous medial cortex bone loss, the bone does not participate in the stability of the assembly and the fracture is stabilized only by the plate.

A race starts at this point between the required stability, given by the plate only, and the rate of callus formation. The theory says, and the case demonstrates, that the callus forms quickly enough to complete the precarious stability of the plate and the fracture heals by a hypertrophic callus. The plate usually does not break since, because of the fracture extent, the bending load is distributed throughout the length of the fracture site and is not concentrated in one spot. However, the great risk of this internal fixation technique is, in fact, the possible failure of this healing forecast process. If the callus does not give enough early contralateral support, the plate will pull out. If the plate pulls out or does not give enough stability, the callus will resorb. This is the great dilemma of the biologic technique and makes it advisable to teach it with some reserve. It requires extensive experience in internal fixation and all of its pitfalls.

preoperative postoperative + 3 month

+ 5 month + 8 month + 8 month

These are complex diaphyseal fractures with two or three intermediate fragments. Ref. Manual of Internal Fixation:
291 - 331. 546 - 547.
Surgeon. Q de LL, XXX (right case).

As it has already been stated, many surgeons believe that the interlocked nailing is the current technique of choice for this fracture group. The illustrated case demonstrates the healing process of a C3.1 fracture treated by this procedure.

Because of the enormous bending loads withstood by its diaphysis, the femur is the paradigmatic example of the columnar theory of Pauwels and of Wolf´s law. The medial cortex is under compression, thus callus formation is favoured; the lateral cortex is under tension,

thus bone resorption is favoured. These biomechanical and biological effects are much more evident in the diaphyseal fractures treated by nailing than in those treated with a lateral cortex tension band plate. The result can be easily appreciated in the X-ray: there is a huge resorption of a lateral cortex segment and ahyperthropic medial callus. We have observed this type of healing in fractures of this group treated by interlocking nails. The following case, corresponding to the C3.2 subgroup, clearly demonstrates the consequences of the process.

preoperative + 3 months + 1 year + 1 year

The case shown on the left represents one of the main problems we have to deal with when these fractures are treated by locked intramedullary nailing either reamed or unreamed. The anatomical reduction becomes impossible and attempting an internal fixation would only fix the malalingment, which we understand is unacceptable: shortening, varus deformity, rotation. The fracture heals and a certain degree of function could be achieved but, the sequela remains.

preoperative + 4 months

preoperative preoperative postoperative postoperative

+ 3 years + 3 years

These are complex irregular fractures that involve a limited segment (< 5 cm.) of the femoral diaphysis. Ref. Manual of Internal Fixation:
229 - 231. 291 - 331. 535 - 547.
Surgeon. JG.

The illustrated fracture was treated by interlocking nailing with an excellent clinical result. However, after removal of the nail 2 years later, fairly substantial bone loss of the lateral cortex became evident and the patient (a sportsman) began to feel some pain, indicative of an impending fatigue fracture. A protective internal fixation with a bridge plate and with the addition of cancellous

bone graft was performed. The pain disappeared and 1 year later the lateral cortex had reconstituted.

The images can be compared with the ones of the previous case as well as with the images of the cases 32-A3.1 and 32- A3.2.

preoperative postoperative + 2 months + 4 months + 1 year

These are complex diaphyseal fractures, irregular, involving an extensive segment of the diaphysis of 5 or more cm in length. Ref. Manual of Internal Fixation:
229 - 231. 291 - 331. 535 - 547.
Surgeon. JG.

Because of their multifragmentation, these are the most serious fractures of the group. In the first illustrated case, the large intermediate fragment shows a longitudinal split. Furthermore, there is an associated basicervical fracture that would contraindicate the intramedullary nailing technique. Even without the associated fracture, we would still consider the plating technique a better option because, as we have been able to verify in many cases, the nail insertion would inevitably split open the intermediate segment.

The open reduction and internal fixation, taking all of the safety measures, allows fixation of the split segment fragments with a lag screw, thus greatly improving the stability of the assembly. The anatomic reduction of the whole fracture is obtained with the same plating technique described for the previous subgroups. When placed on anatomic reductions, like in the distal fracture site of the case shown, the lag screws are extremely important for stability. The addition of bone graft is essential in order to obtain more certain and faster healing of the fracture.

If one prefers to perform a biologic internal fixation (that is to say without manipulation of the intermediate fragments) like in the second illustrated case, we feel that it is important to at least reduce the lateral cortex fragment because this allows the exact restoration of the lenght and rotation. The fragment will not resorb in any case because it is protected from the traction loads by the plate, conversely to what happens when an intramedullary nail is used (see C3.1 and C3.2). However, as this case demonstrates, the internal vascularised fragment may not heal (after 10 months), which would force a revision in order to add a traction screw in the middle fragment, reinforcing it with a double plate and adding bone graft. Therefore, a first attempt thought to be "biological" ends up being a massive internal fixation, but then again biological after all, since the fracture heals.

preoperative preoperative + 3 months + 7 months

preoperative + 10 months + 1 year & 6 months




						Femur, Diaphysis, complex fracture, irregular	0,56% of the total 0,94% of the femur 3,91% of the segment






These are complex diaphyseal fractures with two or three intermediate fragments.		Ref. Manual of Internal Fixation: 535 - 547. 232 - 251. Surgeon. RO.

The case shown is a typical example of the biologic internal fixation with a plate. The approach is careful. The straight plate, previously contoured at its distal end, is first fixed to the postero-lateral aspect of the proximal fragment, aligned with its axis. The large intermediate fragment is carefully manipulated in order to reduce it to the plate and fixed with a unicortical screw. The distal fragment is then reduced to the intermediate fragment, thus restoring the length of the femur, and is also fixed with a small unicortical screw. After checking the adequacy of the reduction, the intermediate fragment is fixed to the distal by a lag screw through the plate. The medial fragments have not been exposed during the procedure, thus preserving their vascular supply as well as the fracture haematoma. Because of the enormous medial cortex bone loss, the bone does not participate in the stability of the assembly and the fracture is stabilized only by the plate.	A race starts at this point between the required stability, given by the plate only, and the rate of callus formation. The theory says, and the case demonstrates, that the callus forms quickly enough to complete the precarious stability of the plate and the fracture heals by a hypertrophic callus. The plate usually does not break since, because of the fracture extent, the bending load is distributed throughout the length of the fracture site and is not concentrated in one spot. However, the great risk of this internal fixation technique is, in fact, the possible failure of this healing forecast process. If the callus does not give enough early contralateral support, the plate will pull out. If the plate pulls out or does not give enough stability, the callus will resorb. This is the great dilemma of the biologic technique and makes it advisable to teach it with some reserve. It requires extensive experience in internal fixation and all of its pitfalls.






These are complex diaphyseal fractures with two or three intermediate fragments.		Ref. Manual of Internal Fixation: 291 - 331. 546 - 547. Surgeon. Q de LL, XXX (right case).

As it has already been stated, many surgeons believe that the interlocked nailing is the current technique of choice for this fracture group. The illustrated case demonstrates the healing process of a C3.1 fracture treated by this procedure. Because of the enormous bending loads withstood by its diaphysis, the femur is the paradigmatic example of the columnar theory of Pauwels and of Wolf´s law. The medial cortex is under compression, thus callus formation is favoured; the lateral cortex is under tension,	thus bone resorption is favoured. These biomechanical and biological effects are much more evident in the diaphyseal fractures treated by nailing than in those treated with a lateral cortex tension band plate. The result can be easily appreciated in the X-ray: there is a huge resorption of a lateral cortex segment and ahyperthropic medial callus. We have observed this type of healing in fractures of this group treated by interlocking nails. The following case, corresponding to the C3.2 subgroup, clearly demonstrates the consequences of the process.






These are complex irregular fractures that involve a limited segment (< 5 cm.) of the femoral diaphysis.		Ref. Manual of Internal Fixation: 229 - 231. 291 - 331. 535 - 547. Surgeon. JG.

The illustrated fracture was treated by interlocking nailing with an excellent clinical result. However, after removal of the nail 2 years later, fairly substantial bone loss of the lateral cortex became evident and the patient (a sportsman) began to feel some pain, indicative of an impending fatigue fracture. A protective internal fixation with a bridge plate and with the addition of cancellous	bone graft was performed. The pain disappeared and 1 year later the lateral cortex had reconstituted. The images can be compared with the ones of the previous case as well as with the images of the cases 32-A3.1 and 32- A3.2.






These are complex diaphyseal fractures, irregular, involving an extensive segment of the diaphysis of 5 or more cm in length.		Ref. Manual of Internal Fixation: 229 - 231. 291 - 331. 535 - 547. Surgeon. JG.

Because of their multifragmentation, these are the most serious fractures of the group. In the first illustrated case, the large intermediate fragment shows a longitudinal split. Furthermore, there is an associated basicervical fracture that would contraindicate the intramedullary nailing technique. Even without the associated fracture, we would still consider the plating technique a better option because, as we have been able to verify in many cases, the nail insertion would inevitably split open the intermediate segment. The open reduction and internal fixation, taking all of the safety measures, allows fixation of the split segment fragments with a lag screw, thus greatly improving the stability of the assembly. The anatomic reduction of the whole fracture is obtained with the same plating technique described for the previous subgroups. When placed on anatomic reductions, like in the distal fracture site of the case shown, the lag screws are extremely important for stability. The addition of bone graft is essential in order to obtain more certain and faster healing of the fracture.	If one prefers to perform a biologic internal fixation (that is to say without manipulation of the intermediate fragments) like in the second illustrated case, we feel that it is important to at least reduce the lateral cortex fragment because this allows the exact restoration of the lenght and rotation. The fragment will not resorb in any case because it is protected from the traction loads by the plate, conversely to what happens when an intramedullary nail is used (see C3.1 and C3.2). However, as this case demonstrates, the internal vascularised fragment may not heal (after 10 months), which would force a revision in order to add a traction screw in the middle fragment, reinforcing it with a double plate and adding bone graft. Therefore, a first attempt thought to be "biological" ends up being a massive internal fixation, but then again biological after all, since the fracture heals.