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Retrograde Tibial Nail for Femoral Shaft Fracture with Severe

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					Case Report                                                                                                            454




        Retrograde Tibial Nail for Femoral Shaft Fracture with
                      Severe Degloving Injury
    Shih-Chieh Yang, MD; Jiun-Yih Su1, MD; Shang-Won Yu1, MD; Yuan-Kun Tu1, MD
             We report an unusual case involving a motorcycle-vehicle collision, in which a 21-year-
        old woman sustained severe bilateral lower extremity degloving injuries and an associated
        right femoral shaft fracture. The trauma team was consulted to treat this disastrous event.
        Due to extensive contamination of the open wound around the entry site, retrograde
        intramedullary nailing was chosen to fix the fractured femoral shaft in preference to ante-
        grade intramedullary nailing. A tibial interlocking nail was used as a substitute for immedi-
        ate bony stabilization to facilitate soft tissue debridement and subsequent reconstruction.
        The excellent range of motion achieved in the right knee joint, without infection, limb-
        length discrepancy, rotational instability or angular malalignment, was encouraging. (Chang
        Gung Med J 2004;27:454-8)

        Key words: retrograde nailing, tibial nail, femoral shaft fracture.



F   emoral shaft fractures are typically the result of
    high-energy trauma, and thus, are usually associ-
ated with multiple injuries. Closed static locking
                                                                 lower extremity degloving and an associated right
                                                                 thigh deformity. She was sent to the emergency room
                                                                 at Chang-Gung Memorial Hospital and had a brief
intramedullary nailing is the treatment of choice for            period of hypovolemic shock. Her hemodynamic sta-
femoral shaft fractures, with a union rate above 95%             tus was stabilized after emergency resuscitation. The
and low complication rates.(1-3) Retrograde nailing has          diagnosis included a Winquist type III right distal
been developed for successful management of                      femur fracture and a Tscherne grade III injury with
femoral peritrochanteric fractures since 1980, how-              crushing-avulsion-degloving of the soft tissue over
ever, an intra-articular knee entry is used.(4) Long-            the bilateral buttock, thigh and lower leg, constitut-
term degeneration has still not been resolved, and               ing about 20% of her total body surface area (Figs. 1
remains a major concern. Recently, several research              and 2). Urgent debridement and bony stabilization
teams have investigated the indications for, and the             were performed within six hours. Due to extensive
feasibility of, retrograde intramedullary nailing for            contamination of the open wound around the entry
femoral shaft fractures. However, these specifically             site of trochanter, retrograde intramedullary nailing
designed retrograde femoral nails are reserved for               was chosen to stabilize the fractured femoral shaft in
properly selected cases and particular situations.(5-10)         preference to antegrade intramedullary nailing. Since
                                                                 a standard, specialized retrograde femoral nailing
                  CASE REPORT                                    device was not available, the Russell-Taylor tibial
                                                                 interlocking nail was utilized as a substitute. Rapid
     A 21-year-old woman had a motorcycle-vehicle                access through the knee in the supine position facili-
collision and sustained severe injuries, with bilateral          tated retrograde nailing, and allowed several surgical



From the Orthopaedic Surgery; 1Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Taipei.
Received: Jul. 10, 2003; Accepted: Sep. 3, 2003
Address for reprints: Dr. Jiun-Yih Su, Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital. 5, Fushing
Street, Gueishan Shiang, Taoyuan, Taiwan 333, R.O.C. Tel.: 886-3-3281200 ext. 2423; Fax: 886-3-3281520; E-mail: skyyan-
gortho@yahoo.com.tw
455    Shih-Chieh Yang, et al
       Tibial nail for femoral shaft fracture




procedures to be completed in one stage. A T-loop             performed during the subsequent hospitalization
diversion colostomy was also performed to avoid               (Fig. 3). The patient was placed in intensive care in
defecation soiling. Consecutive surgical debride-             the trauma ward until soft tissue recovery was
ments to create an aseptic and suitable soft tissue           achieved. No skeletal complications were noted dur-
environment, accompanied by coverage with split               ing this period. She was discharged one month later
thickness skin graft harvested from the scalp were            after a rather uneventful recuperation.




Fig. 1 Severe degloving injuries of the bilateral lower       Fig. 3 Stable internal fixation allowed extensive serial
extremities.                                                  debridement to create a suitable soft tissue environment for
                                                              skin graft coverage.




Fig. 2 Radiograph demonstrates a Winquist type III fracture   Fig. 4 Radiograph shows good alignment and bony union of
of the right distal femur.                                    the right fractured femur after retrograde intramedullary nail-
                                                              ing with a tibial nail and a locking bolt.




Chang Gung Med J Vol. 27 No. 6
June 2004
                                                                                                         Shih-Chieh Yang, et al    456
                                                                                          Tibial nail for femoral shaft fracture




Fig. 5 The acceptable range of motion achieved in the right knee joint without infection, limb-length discrepancy, rotational insta-
bility or angular malalignment.


     Since discharge, this young woman has been                      properly selected cases, limited use of retrograde
regularly followed up at our outpatient department                   nailing is recommended by most researchers. Ostrum
and has received a supervised rehabilitation program                 et al have suggested, however, that there may only be
(Fig 4). The acceptable range of motion (0-130                       relative contraindications rather than indications for
degrees in extension-flexion) achieved in the right                  retrograde nailing.(7) Retrograde insertion of a reamed
knee joint, without infection, limb-length discrepan-                intramedullary titanium nail through an intercondylar
cy, rotational instability or angular malalignment                   approach was used for femoral shaft fractures in their
(Fig 5). The nail was removed 15 months later, after                 series. Subtrochanteric fractures within three cen-
solid bony union of the fracture site had been                       timeters of the lesser trochanter, skeletal immaturity
demonstrated via plain radiography. After 24 months                  and grade IIIB/IIIC open fractures were the only
follow-up, the patient was able to perform normal                    contraindications. They concluded that antegrade and
daily activities, including squatting, and ascending or              retrograde nailing appear to be comparable as far as
descending stairs without any late complications.                    union rates and bony fusion latency are concerned.(7,8)
                                                                           With the severe crush injuries and the resultant
                     DISCUSSION                                      multiple soft tissue degloving associated with the
                                                                     right distal femur fracture, the present case was espe-
     Retrograde intramedullary nailing, first                        cially complicated, with this complexity extending
described by Harris in 1980, has become common                       across multiple fields. Given the unstable vital signs
recently. For critical patients with multiple injuries,              and potential for neurovascular injuries, general,
femoral shaft fractures can be stabilized quickly and                plastic and orthopaedic surgeons were consulted for
efficiently, and bilateral lower extremity injuries can              the emergency surgery. Retrograde nailing was
be treated simultaneously in the supine position.(5-10)              advised to treat the fractured femur because of the
Although the absolute indications for the use of ret-                advantage of rapid access and feasibility in combina-
rograde nails are still the subject of some debate, rel-             tion with other surgical procedures in the supine
ative indications include morbid obesity, multisystem                position. Particularly, extensive contamination of the
trauma, ipsilateral floating knee and/or tibia injuries,             open wound surrounding the right thigh (only the
bilateral femur fractures, ipsilateral acetabulum                    knee had intact overlying skin), precluded the use of
and/or femoral neck fractures, uncontaminated trau-                  an external fixator or plate. Since no standard, spe-
matic knee arthrotomies, through-knee amputations,                   cialized, retrograde femoral nail was available, a
pelvic ring injuries, pregnancy, gross contamination                 Russell-Taylor tibial nail was substituted in this criti-
around the insertion point for antegrade nailing,                    cal situation. Clinically, the key point is that the tibial
unstable spine injuries, and multiple fractures.(11) For             nail is designed with a 15˚ anterior bend 45 mm from



                                                                                                     Chang Gung Med J Vol. 27 No. 6
                                                                                                                         June 2004
457    Shih-Chieh Yang, et al
       Tibial nail for femoral shaft fracture




the top of the nail, allowing the device to enter the                          REFERENCES
proximal portion of the tibia anteriorly. As the distal
femur flares into two posteriorly curved condyles,          1. Winquist RA, Hansen ST, Clawson DK. Closed
however, the retrograde tibial nail must be inserted           intramedullary nailing of femoral fractures: a report of
into the medullary canal with the 15˚ bend oriented            520 cases. J Bone Joint Surg Am 1984;66:529-39.
in a posterior direction to keep the nail aligned with      2. Kempf I, Grosses A, Beck G. Closed locked
the distal segment. Accordingly, an unreamed tibial            intramedullary nailing. J Bone Joint Surg Am 1985;67:
nail, with as large a diameter as possible, is intro-          709-20.
duced into the canal along the guided pin. The thick-       3. Wolinsky PR, McCarty E, Shyr Y, Johnson K. Reamed
                                                               intramedullary nailing of the femur: 551 cases. J Trauma
er nail engages the anterior curvature of the femoral          1999;46:392-9.
medullary canal and isthmus, ensuring adequate sta-         4. Harris LJ. Closed retrograde intramedullary nailing of
bility. The locking screw is then threaded to fix the          peritrochanteric fractures of the femur with a new nail. J
distally displaced fragment, avoiding rotational insta-        Bone Joint Surg Am 1980;62:1185-93.
bility and angular malalignment.                            5. Sanders R, Koval KJ, DiPasquale T, Helfet DL, Frankle
      The anterior aspect of the intercondylar notch is        M. Retrograde reamed femoral nailing. J Orthop Trauma
selected as the starting point as in placement of the          1993;7:293-302.
                                                            6. Patterson BM, Routt ML Jr, Benirschke SK, Hansen ST
intramedullary guide rod during total knee arthro-
                                                               Jr. Retrograde nailing of femoral shaft fractures. J Trauma
plasty. In comparison to insertion through the medial          1995;38:38-43.
femoral condyle, damage to the articular cartilage is       7. Ostrum RF, DiCicco J, Lakatos R, Poka A. Retrograde
limited using this insertion point.(6-9,12) The nail is        intramedullary nailing of femoral diaphyseal fractures. J
introduced along an inserted guide pin and counter-            Orthop Trauma 1998;12:464-8.
sunk under the intercondylar notch to preclude the          8. Ostrum RF, Agarwal A, Lakatos R, Poka A. Prospective
possibility of damage to the patellofemoral joint or           comparison of retrograde and antegrade femoral
                                                               intramedullary nailing. J Orthop Trauma 2000;14:496-
other articular structures and resultant late degenera-
                                                               501.
tive joint disease. For our patient, potential compli-      9. Moed BR, Watson JT, Cramer KE, Karges DE, Teefey JS.
cations associated with retrograde nailing, including          Unreamed retrograde intramedullary nailing of fractures
knee stiffness or impaired function, quadriceps atro-          of the femoral shaft. J Orthop Trauma 1998;12:334-42.
phy, articular or cruciate ligament damage, and septic     10. DiCicco JD 3rd, Jenkins M, Ostrum RF. Retrograde nail-
joint, were not detected. Nevertheless, a specifically         ing for subtrochanteric femur fractures. Am J Orthop
designed, commercial retrograde femoral nail is                2000;29:4-8.
                                                           11. Wolinsky PR, Tejwani N. Femur: Trauma. In: Koval KJ
doubtless the ideal device for properly selected
                                                               ed. Orthopedic Knowledge Update. 7th ed. Rosemont:
femoral shaft fractures. A tibial nail is only a substi-       American Academy of Orthopedic Surgeons 2002:453-
tute in particular situations, such as the present case.       63.
In order to rigorously evaluate the feasibility of this    12. Herscovici D, Whiteman KW. Retrograde nailing of the
technique, therefore, investigation of more cases              femur using an intercondylar approach. Clin Orthop 1996;
with long-term follow-up is required.                          332:98-104.




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