| Abstract|| |
Flexible unreamed nailing, using Ender's nails, was done in 25 patients of femoral fractures with either transverse or short oblique fracture or with unicortical comminution. Only condylocephalic approach was used. Average per-operative blood loss was about 50 ml and average operative time was only 38 minutes. There was no case of nail breakage, infection, delayed union or non-union. Range of knee movement achieved in most of the cases was more than 120 0 . In six patients nails had to be removed after fracture healing on account of distal migration and consequent knee pain before adequate range of knee motion could be achieved. The method is simple, quick and atraumatic.
Keywords: Femur - Diaphysis - Ender′s nail
|How to cite this article:|
Gupta R, Singh M, Gupta N. Ender's nailing in diaphyseal fractures of the femur. Indian J Orthop 2003;37:6
| Introduction|| |
Stabilizing femoral diaphyseal fractures with an intramedullary implant is now generally accepted treatment with emphasis on closed, locked intramedullary nailing. The main limitation to conventional reamed nailing is the patient's pulmonary condition and the risk of ARDS, besides fear of large areas of endosteal avascularity. , It has resulted in emphasis being shifted to unreamed solid nails. Moreover there are many reports recommending dynamisation of a statically locked nail, 810 weeks after the surgical procedure, to promote union of fracture. ,, Dynamic intramedullary fracture fixation using Ender's nails appears to closely meet the objective of achieving osteosynthesis with minimal surgical trauma. Initially designed for trochanteric fractures, they can be used as dynamic locking nails for femoral shaft fractures with relatively stable configuration.  The present study evaluates the authors' experience of multiple Ender's nails in femoral diaphyseal fractures.
| Material and Methods|| |
Between 1997-1999; 25 fractures of distal half of femoral diaphysis were stabilized using multiple Ender's nails. All the fractures were of relatively stable configuration, having transverse or short oblique fracture line or with unicortical comminution. Average age of the patients was 37 years (1867 years) with marked male preponderance (70%). Associated injuries included head, chest or abdominal injury (5 patients) and ipsilateral trochantric fracture (1 patient) with an overall incidence of 40%. The patients were put on skeletal traction through upper tibial pin so as to maintain reduction of fragments pending surgery. Width of medullary canal at isthmus level was taken into account to pre-operatively plan the number and size of Ender nails. An immediate pre-operative radiograph was taken to confirm the adequate correction of overriding of fracture fragments for easy per-operative reduction of fracture.
An ordinary operation table with a radiolucent top was used in all the cases. Fractures were reduced by manipulation and appropriate positioning of pillows and reduction was confirmed under image intensifier. Straight medial and lateral incisions, four to six cm in length, starting just proximal to the knee joint going proximally,were used to expose the medial and lateral femoral condyles. A 4.5mm Ender's nail of appropriate length, suitably curved, was introduced from lateral aspect after making a hole in lateral femoral condyle. It was hammered into distal fragment and negotiated across the fracture into the proximal segment so as to reach the greater trochanter. Second nail was introduced from the medial femoral condyle in a similar manner so as to reach the head of femur. Third nail was again introduced from the lateral aspect. Depending upon per-operative assessment of available marrow space after the third nail, a fourth one possibly of lesser diameter was introduced from medial side. Wound was closed in layers after incurring haemostasis.
Knee bending and quadriceps setting exercises were started as soon as the patient could tolerate it, usually within first 24 hrs itself. Non-weight bearing ambulation was started with in first few days, though partial weight bearing was permitted only after radiological evidence of callus formation. Full weight bearing was permitted only on radiological evidence of firm union. Minimum follow up of the patients was 2 years (average 36 months).
| Results|| |
The average time gap between injury and surgery was 6.64 days (3-15 days). It included the delay on the part of patients (7 cases) in reporting to our institution. While in 19 patients, nailing could be performed in closed manner, remaining six patients required open reduction on account of either soft tissue interposition (4 cases) or failure to negotiate the nails across the fracture site (2 cases). The average operative time was 38 minutes (30-50) and average per-operative blood loss was less than 50 ml, except for cases requiring open reduction where it averaged around 160 ml. Average radiation exposure time was 108 seconds (90 - 150 seconds). In 17 patients we could negotiate three Ender's nails across the fracture site while in 4 patients four nails could be passed. In the remaining four patients only two nails were passed. Total hospital stay ranged from 6-21 days. Additional postoperative external support in the form of PVC thigh brace was used for 3-4 weeks in nine patients on account of either unicortical comminution or fractures stabilized with only two nails. Radiological evidence of callus appeared in most cases by 3-4 weeks. However, it was delayed by 1-2 weeks in all the six patients requiring open reduction of fracture. Partial weight bearing was started by 2-4 week onwards, depending upon the stability of fixation and appearance of callus [Figure 1]. Sound bony union was seen in average time of 12 weeks (10-16 weeks). Seventeen of the patients regained full range of knee movements with the ability to squat.
There was no incidence of proximal migration or breakage of nails. Perforation of the femoral cortex opposite the site of entry occurred in two patients. However, the nail was withdrawn and reinserted in proper direction without any residual problem in both of them. In addition, two patients had post-operative bending of nails either because of early weight bearing or on account of re-trauma. In both cases manipulation under anesthesia was done, the nails straightened and postoperatively PVC thigh brace was used for four weeks. Both the fractures eventually healed with good functional result. Shortening of 1-2 cm was observed in two patients. In six patients there was distal migration of the nails resulting in knee pain, requiring nail removal.
Final evaluation of the patients was done on the basis of Thoreson et al criteria.  Fifteen patients had excellent, five good, three fair and two patients had poor results.
| Discussion|| |
Among the various modes of treatment of femoral shaft fractures, internal fixation has become the mainstay of treatment, with emphasis largely on intramedullary fixations. Concept of interlocking nail has further widened the indications of intramedullay fixation to include fractures approaching the ends of femur. Reports in literature indicating adverse effects of reaming like increased incidence of pulmonary complications and disruption of vascular supply of inner 2/3 rd of cortex, have resulted in increased popularity of unreamed nails for fixation of such fractures. ,
Flexible unreamed intramedullary nails have long been used to manage diaphyseal fractures of long bones. These nails rely on three-point fixation in the medullary canal and provide favourable mechanical conditions, as the forces are evenly distributed along the entire length of nails. , As the fixation by these nails is not rigid, therefore some amount of micro-motion occurs between the two fragments which in turn stimulates fracture healing. These nails do not ensure sufficient longitudinal stability in grossly comminuted or long oblique fractures with resultant shortening. ,
Manual traction was found to be equally effective and safe with the additional advantage of avoiding complications like femoral, pudendal and sciatic nerve injury, pressure sore in the groin region etc. reported in literature with the use of fracture table.  The rationale behind not using fracture table includes ease of set up, the ability to perform multiple procedures with single positioning of the patient and elimination of the morbidity associated with its use.
Operative time in Ender's nailing ranged from 32-70 minutes .,, On the other hand reported operative time for Kuntscher nailing is 1.7 - 2.6 hours and 2.5 hours for closed intramedullary nailing of femur. , The procedure can be done without major blood loss, thus obviating the need of blood transfusion and its possible complications. Average blood loss in reamed nailing of femur with or without locking has been reported to be 400-2100 ml ,, Image intensifier exposure time in the present series ranged from 1.5-2.5 minutes. After passage of one nail from either condyle, not much of exposure was required for subsequent nails. In reamed locked nailing of femur, average exposure time has been reported to be ranging from 2-20 minutes. ,,,
Pankovich et al on the other hand have used 2 nails in most of their cases and only one nail in two of their patients. However 16 of their 60 cases required postoperative cast brace or traction.  Higher number of nails provides better stability because of better nail-cortical contact besides decreasing the chances of stress fracture of the nails. Moreover, using more number of nails with both medial and lateral portals ensures better rotational and angular stabilization of the fracture thereby permitting early weight bearing. ,
As Ender's nails are flexible, weight bearing leads to axial micro motion at the fracture site thereby, stimulating the external callus formation  and early partial weight bearing by 1-4 weeks can be allowed without any complications of bending or breaking of nails. ,, Muckle and Siddiqi however allowed weight bearing only at 10 12 weeks, probably because they used only medial portal of entry in all their patients.  However it is desirable to protect these fractures from weight bearing if number of nails used is two or less or fracture line is unstable, as it may lead to angulation as happened in one of our cases. In such cases it is desirable to use a cast brace for initial 4-6 weeks to avoid such complications.
More than 90% acceptable results have been reported in femoral fractures managed by interlocking nails. ,, However, this could be explained by the fact that patients with locked nails can do knee physiotherapy earlier and in a better way. Moreover, distal migration of interlocking nails or pain at later stage is not observed in these cases, which was found to be one of the limiting factors of Ender's nailing. However, simplicity of the technique, adequate rotational stability and regaining the knee range of motion following removal of the Ender's nails more than compensates for the same.
Closed intramedullary fixation using Ender's nails therefore appears to be a simple, safe and effective method of treating femoral diaphyseal fracture of relatively stable configuration. However, the method has its limitation in that it cannot be used in unstable comminuted fractures on account of its relatively poor longitudinal stability.
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