JBJS | Conversion of External Fixation to Intramedullary Nailing for Fractures of the Shaft of the Femur in Multiply Injured Patients*

The Journal of Bone & Joint Surgery, Volume 82, Issue 6

Articles | June 01, 2000

Conversion of External Fixation to Intramedullary Nailing for Fractures of the Shaft of the Femur in Multiply Injured Patients*

Peter J. Nowotarski, M.D.†; Clifford H. Turen, M.D.‡; Robert J. Brumback, M.D.‡; J. Mark Scarboro, B.A.‡

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Investigation performed at the Section of Orthopaedic Traumatology, The R Adams Cowley Shock Trauma Center, The University of Maryland Medical System, Baltimore, Maryland
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Department of Orthopaedic Surgery, University of Tennessee, 923 East Third Street, Suite 1203, Chatanooga, Tennessee 37421.
‡Shock Trauma Orthopaedics, The R Adams Cowley Shock Trauma Center, 22 South Greene Street, Room T3R64, Baltimore, Maryland 21201-1595. Please address requests for reprints to C. H. Turen, c/o Elaine P. Bulson, Editor. E-mail address for Elaine P. Bulson: ebulson@smail.umaryland.edu.

The Journal of Bone & Joint Surgery. 2000; 82:781-781

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Abstract

Background: From 1989 to 1997, 1507 fractures of the shaft of the femur were treated with intramedullary nailing at The R Adams Cowley Shock Trauma Center. Fifty-nine (4 percent) of those fractures were treated with early external fixation followed by planned conversion to intramedullary nail fixation. This two-stage stabilization protocol was selected for patients who were critically ill and poor candidates for an immediate intramedullary procedure or who required expedient femoral fixation followed by repair of an ipsilateral vascular injury. The purpose of the current investigation was to determine whether this protocol is an appropriate alternative for the management of fractures of the femur in patients who are poor candidates for immediate intramedullary nailing.

Methods: Fifty-four multiply injured patients with a total of fifty-nine fractures of the shaft of the femur treated with external fixation followed by planned conversion to intramedullary nail fixation were evaluated in a retrospective review to gather demographic, injury, management, and fracture-healing data for analysis.

Results: The average Injury Severity Score for the fifty-four patients was 29 (range, 13 to 43); the average Glasgow Coma Scale score was 11 (range, 3 to 15). Most patients (forty-four) had additional orthopaedic injuries (average, three; range, zero to eight), and associated injuries such as severe brain injury, solid-organ rupture, chest trauma, and aortic tears were common. Forty fractures were closed, and nineteen fractures were open. According to the system of Gustilo and Anderson, three of the open fractures were type II, eight were type IIIA, and eight were type IIIC. Intramedullary nailing was delayed secondary to medical instability in forty-six patients and secondary to vascular injury in eight. All fractures of the shaft of the femur were stabilized with a unilateral external fixator within the first twenty-four hours after the injury; the average duration of the procedure was thirty minutes. The duration of external fixation averaged seven days (range, one to forty-nine days) before the fixation with the static interlocked intramedullary nail. Forty-nine of the nailing procedures were antegrade, and ten were retrograde. For fifty-five of the fifty-nine fractures, the external fixation was converted to intramedullary nail fixation in a one-stage procedure. The other four fractures were associated with draining pin sites, and skeletal traction to allow pin-site healing was used for an average of ten days (range, eight to fifteen days) after fixator removal and before intramedullary nailing. Follow-up averaged twelve months (range, six to eighty-seven months). Of the fifty-eight fractures available for follow-up until union, fifty-six (97 percent) healed within six months. There were three major complications: one patient died from a pulmonary embolism before union, one patient had a refractory infected nonunion, and one patient had a nonunion with nail failure, which was successfully treated with retrograde exchange nailing. The infection rate was 1.7 percent. Four other patients required a minor reoperation: two were managed with manipulation under anesthesia because of knee stiffness, and two underwent derotation and relocking of the nail because of rotational malalignment. The rate of unplanned reoperations was 11 percent. The average range of motion of the knee was 107 degrees (range, 60 to 140 degrees).

Conclusions: We concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Early fixation by closed intramedullary nailing is the currently preferred method of treatment of fractures of the shaft of the femur in multiply injured patients^5,7,16,17. However, a small percentage of multiply injured patients are too critically ill to tolerate the surgical stress or the operative duration involved with an intramedullary nailing procedure. Injuries or clinical conditions that may preclude immediate intramedullary nailing include aortic rupture, coagulopathy, hypoxia, severe intracranial injury, and solid-organ injuries. Patients with concomitant fracture of the shaft of the femur and ipsilateral vascular disruption require osseous stabilization as quickly as possible to expedite emergent vascular repair. In these selected clinical circumstances, patients may benefit from immediate external fixation of the shaft of the femur with planned early conversion to intramedullary fixation.

External fixation is an expedient and minimally invasive method of long-bone fracture stabilization, but there have been reports of high rates of complications when fractures of the femur have been treated with this method until union^1,8,13,18. Although there have been numerous studies on the efficacy of conversion of external fixation to intramedullary nailing for fractures of the tibia, we are aware of only two small series in which such treatment conversion was performed for fractures of the femur^6,22. We postulated that treatment of fractures of the shaft of the femur by immediate external fixation and early conversion to intramedullary nailing in selected patients is a safe and effective method. The purpose of this retrospective review was to determine whether planned two-stage treatment is an effective alternative for management of femoral fractures in patients who are poor candidates for immediate intramedullary nailing.

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Fig. 1-A:: Figs. 1-A through 1-F: A twenty-eight-year-old woman with an Injury Severity Score of 27 who sustained a type-IIIC open fracture^9,10 of the left femur, multiple fractures of the contralateral lower limb, and a pneumothorax in a motor-vehicle accident.
Fig. 1-A: Preoperative anteroposterior radiograph showing the displaced left supracondylar femoral fracture.

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Fig. 1-B: Arteriogram showing an injury of the superficial femoral artery.

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Fig. 1-C:: Postoperative anteroposterior and lateral radiographs showing the fracture of the femur reduced and stabilized with a uniplanar external fixator before vascular bypass grafting.

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Fig. 1-D::

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Fig. 1-E:: Follow-up anteroposterior and lateral radiographs, made six months after the injury, showing the healed fracture of the femur. The external fixator had been converted to an intramedullary nail seventeen days after the injury and the emergent application of the fixator. The patient had no complications and, at the time of final follow-up, had more than 120 degrees of knee motion.

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Fig. 1-F::

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

From 1989 to 1997, 1507 fractures of the shaft of the femur were treated with intramedullary nailing at The R Adams Cowley Shock Trauma Center. During that same period, 112 patients underwent initial external fixation of 118 fractures of the shaft of the femur. Of these 112 patients, thirty-three (thirty-three fractures) died of multiple injuries without a change in the fixation method and sixteen (sixteen fractures) either were treated by external fixation until union (seven fractures) or had conversion to plate fixation (nine distal fractures with supracondylar and intra-articular extension, three of which were associated with vascular injury). The remaining sixty-three patients (sixty-nine fractures) were treated by conversion of the external fixation to intramedullary nail stabilization. Of the sixty-three patients, nine (ten fractures) were lost to follow-up, leaving fifty-four patients (fifty-nine fractures) in our study group. The minimum duration of follow-up was six months (average, twelve months; range, six to eighty-seven months). The fifty-nine femoral fractures represent 4 percent of all of the fractures of the shaft of the femur treated with intramedullary nailing during the study period. Data were compiled from the hospital's computerized trauma registries, medical records, telephone interviews, and a review of radiographs.

The age of the thirty-five male patients and nineteen female patients in the study averaged thirty-three years (range, fifteen to seventy-one years). Thirty left femora and twenty-nine right femora were fractured. Fifty-five fractures were the result of blunt trauma secondary to (in order of frequency) a motor-vehicle accident, a motorcycle accident, a pedestrian-motor-vehicle accident, and a fall. Four fractures were the result of a penetrating gunshot. Forty fractures were closed. Of the nineteen open fractures, three were graded, according to the system of Gustilo and Anderson^9,10, as type II; eight, as type IIIA; and eight, as type IIIC. According to the Orthopaedic Trauma Association classification system¹⁴, eighteen of the fifty-nine fractures were classified as 32-A; twenty-four, as 32-B; eight, as 32-C; three, as 33-A3; and six, as 33-C2. Two patients had an associated ipsilateral fracture of the neck of the femur that was treated by reduction and screw fixation. The fracture of the shaft of the femur was then treated by external fixation with subsequent intramedullary nailing with a reconstruction nail.

For the patients in the study group, the managing trauma team delayed intramedullary nailing of the fracture of the shaft of the femur because of physiological instability (forty-six patients) or vascular injury (eight patients). Physiological instability was defined as progressive hypoxia, coagulopathy, hemodynamic instability, elevated intracranial pressures (in patients with a head injury), or a risk of disturbing contained solid-organ injuries or aortic disruptions by changes in patient position or by movement during the femoral nailing procedure. The forty-six physiologically unstable patients included fifteen with a head injury and elevated intracranial pressure (average Glasgow Coma Scale score¹⁹, 6; range, 3 to 11) and thirty-one with severe visceral injuries (spleen or liver lacerations).

The Injury Severity Score³ of the study group averaged 29 (range, 13 to 43) compared with an average Injury Severity Score of 21 (range, 9 to 75) for the overall patient group (1507 fractures) treated by femoral intramedullary nailing during the same time period. The Glasgow Coma Scale score for the study group averaged 11 (range, 3 to 15). Forty-four of the patients had additional orthopaedic injuries (average, three additional fractures or dislocations, or both; range, zero to eight).

The treatment protocol involved external fixation of the fracture of the shaft of the femur within the first twenty-four hours after the injury. Forty-six fractures were managed by various configurations of a standard unilateral half-pin external fixator, with two or three five-millimeter half-pins inserted into the proximal and distal femoral fragments and connected in a unilateral frame after fracture reduction. Forty-two Hoffmann external fixators (Howmedica, Rutherford, New Jersey) and four AO external fixators (Synthes, Paoli, Pennsylvania) were used. Thirteen distal fractures of the shaft of the femur were managed with a knee-bridging frame (Howmedica or Synthes) with pins inserted into the proximal femoral fragment and the proximal part of the tibia. The external fixation of the nineteen open femoral fractures was followed by irrigation and dè¡²idement of the fracture site. All pins were inserted with generous skin incisions to avoid skin-tenting.

Intravenous antibiotics (cefazolin, one gram every eight hours) were administered preoperatively and for twenty-four to forty-eight hours postoperatively. Specimens were not taken from the open fracture wounds for culture. The duration of the external fixation procedures averaged thirty minutes for the patients for whom the time for each procedure could be determined.

The external fixator was removed and intramedullary nailing was performed when the managing trauma surgeons deemed the patient to be stable and able to tolerate surgery. A one-stage conversion procedure was considered appropriate for patients with a relatively short duration of external fixation (usually less than two weeks), no signs of systemic infection (that is, if the patient was afebrile and had normal serum leukocyte counts), and no loosening of the external fixator pins or erythema or purulent drainage at the pin sites. Removal of the external fixator, dè¡²idement of soft-tissue pin tracks, and curettage of the bone holes were performed during a separate surgical setup before the intramedullary nailing. A static interlocked nail with reaming was used in all patients. There were forty-nine antegrade intramedullary nailing procedures, with a Russell-Taylor nail (Smith and Nephew Orthopaedics, Memphis, Tennessee) used in forty-two of them and an AO titanium nail (Synthes) used in seven. There were ten retrograde nailing procedures; seven Richards supracondylar nails (Smith and Nephew Orthopaedics) and three AO titanium nails were used for those operations.

All eight patients with associated vascular injuries had provisional external fixation of the fracture of the shaft of the femur before vascular bypass grafting with use of saphenous vein autograft (six patients) or vascular conduits (PTFE [polytetrafluoroethylene] Gore-Tex; Gore Industries, Elkton, Maryland) (two patients). Care was taken to ensure that the fracture was stabilized out to length with external fixation before revascularization. During the conversion procedure for the patients with vascular repair, the patient was placed supine on the fracture table and proximal tibial skeletal traction was applied before removal of the external fixator; this was done to decrease the risk of disrupting the vascular reconstruction.

Postoperative management with regard to weight-bearing and the range of motion of the extremity was individualized according to the fracture configuration and stability, the size of the implant, and associated injuries. Routine pin-site care involved cleaning the sites two or three times daily with a half-strength hydrogen peroxide solution (50 percent hydrogen peroxide and 50 percent normal saline solution) with use of a cotton-tipped applicator. Patients were generally advised to restrict weight-bearing on the fractured femur until early callus was noted on follow-up radiographs. Union was defined as a nontender fracture site in a patient who was able to bear full weight and who was seen to have bridging callus on anteroposterior and lateral radiographs.

Results

Introduction | Materials and Methods | Results | Discussion | References

The duration of external fixation averaged seven days (range, one to forty-nine days). In fifty patients (fifty-five fractures) with no evidence of pin-loosening or pin-track infection before the external fixator was removed, conversion from external fixation to intramedullary nailing was performed as a one-stage procedure (that is, under the same anesthesia but with separate preparation and draping procedures). The remaining four patients (four fractures) had draining pin sites and underwent fixator removal, pin-track dè¡²idement, and a period of skeletal traction to allow pin-site healing before the intramedullary nailing was performed. For these patients, the duration of external fixation averaged twenty days (range, ten to thirty-three days) and the duration of traction averaged ten days (range, eight to fifteen days). Antibiotic therapy for these four patients consisted of vancomycin (500 milligrams four times daily) for fourteen days; ciprofloxacin (500 milligrams every twelve hours) for fourteen days, beginning on admission; multiple courses of antibiotics for non-orthopaedic indications with the patient taking Bactrim DS (trimethoprim and sulfamethoxazole) (one tablet twice daily) on discharge; and Ancef (cefazolin) (one gram every eight hours) for two days, starting on the first postoperative day. (One regimen was used for each patient.)

Of the fifty-eight fractures available for follow-up until union (one patient died before union), fifty-six (97 percent) healed within six months without complications (Fig. 1-A, Fig. 1-B, Fig. 1-C, Fig. 1-D, Fig. 1-E, and Fig. 1-F). Two patients (two fractures) underwent dynamization of the construct by removal of distal interlocking screws at four months, and the fracture healed uneventfully within six months after that procedure. At the time of final follow-up, the average range of flexion of the knee for the fifty-three living patients (fifty-eight fractures) was 107 degrees (range, 60 to 140 degrees). Fifty-two patients (fifty-seven fractures) had more than 90 degrees of knee flexion.

There were three major complications. A refractory infected nonunion developed in one patient (1.7 percent) who had had a one-stage conversion; this was the only infection in the series. This twenty-one-year-old man had sustained open femoral and tibial fractures bilaterally in a motor-vehicle accident and had required a contralateral above-the-knee amputation. After several dè¡²idements and immediate conversion to intramedullary nailing, a three-centimeter bone defect was treated with bone-grafting and exchange nailing eight weeks after the injury. Deep infection with Staphylococcus aureus developed, which was thought to have been the result of seeding from open wounds on the contralateral necrotic above-the-knee amputation stump. The patient was lost to follow-up at seven months, at which time he had an ununited fracture with drainage from the fracture site.

One late aseptic nonunion with nail breakage was successfully treated with retrograde exchange nailing with reaming. This nonunion occurred in an obese sixty-five-year-old woman who had sustained an open supracondylar femoral fracture bilaterally. The femoral fractures were initially treated with dè¡²idement and external fixation, with early conversion at two days to retrograde intramedullary nailing on the right side and plate fixation with bone-grafting on the left. She presented eighteen months later, after minor trauma, with a broken nail, and nonunion was confirmed by tomograms. The nonunion healed within four months after the retrograde exchange nailing procedure.

The third patient who had a major complication was an eighteen-year-old man who had sustained a type-IIIC open femoral fracture and an ipsilateral tibial fracture in a motor-vehicle accident. This patient died, ten days after the conversion to an intramedullary nail (approximately two weeks after the external fixation), from a massive pulmonary embolism despite prophylaxis (5000 units of heparin administered subcutaneously twice daily and the use of intermittent pneumatic-compression stockings) to prevent deep-vein thrombosis.

Four other patients required a minor reoperation. Two patients with a bilateral femoral fracture underwent manipulation under anesthesia for knee stiffness. In one, who had a bilateral open supracondylar femoral fracture with intracondylar extension, this procedure resulted in more than 90 degrees of functional motion of each knee. The second patient had a head injury, a severe pelvic fracture, ipsilateral (right) fractures of the neck and shaft of the femur, and a fracture of the shaft of the left femur. Excision of heterotopic bone from the right hip and knee was planned at the time of writing because manipulation had failed to achieve a functional range of motion. Two other patients, with rotational malalignment, underwent derotation and reinsertion of interlocking screws early after the intramedullary nailing. The rate of unplanned reoperations was 11 percent in this series.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

There are many benefits of early fracture stabilization in multiply injured patients: the procedure facilitates patient mobility, improves pulmonary toilet, decreases pain and thus the need for narcotics, decreases inflammatory mediator response, and decreases thromboembolic phenomena. Early stabilization of femoral fractures has been shown to decrease morbidity and mortality^5,17. However, a severely injured patient who remains physiologically unstable may be able to tolerate only the shortest surgical procedure for fixation of a fracture of the femur.

In the current series of multiply injured patients, immediate intramedullary femoral nailing was postponed because of progressive hypoxia, elevated intracranial pressure, persistent metabolic acidosis, coagulopathy, and severe solid-organ or aortic injuries. Patients with lower-limb ischemia from a vascular injury associated with a femoral fracture also had the nailing delayed until external fixation and revascularization was completed. After consultation with the trauma surgeons, anesthesiologists, neurosurgeons, and orthopaedists, it was decided that, for these patients, external fixation was the most expedient and atraumatic means of femoral fracture fixation. The philosophy at our center is that skeletal traction is a poor method of femoral fracture stabilization in this patient population and that early external fixation of the shaft of the femur provides substantial benefits to the patient.

Options for surgical stabilization of fractures of the shaft of the femur include plate fixation, intramedullary nailing with or without reaming, and external fixation. Both open plate fixation and intramedullary nailing entail greater blood loss and require increased operative time compared with closed reduction and external fixation of a fracture of the femur. Although retrograde nailing off the fracture table may afford shorter operative times and decreased blood loss compared with antegrade intramedullary nail fixation, two recent prospective randomized studies^15,20 comparing retrograde and antegrade nailing for fractures of the shaft of the femur demonstrated that retrograde nailing had no advantage in terms of these parameters. In the current series, the operative time for applying external fixation as provisional stabilization of a fracture of the shaft of the femur averaged only thirty minutes.

Unfortunately, definitive treatment of fractures of the femur with external fixation until union is associated with a high risk of several complications. Nonunion in up to 20 percent of patients, deep pin-track infection in up to 20 percent, and knee stiffness in up to 45 percent have all been reported in contemporary series of fractures of the femur treated with external fixation^1,8,13,18. We hypothesized that conversion to interlocking intramedullary nailing before the development of complications related to long-term external fixation would be a good alternative for the management of fractures of the femur in multiply injured patients.

Conversion of external fixation to intramedullary nailing in the tibia has been studied extensively. Two noteworthy early reports condemned this treatment protocol because of infection rates of as high as 44 percent (seven of sixteen); however, in both series the patients had extended periods of external fixation and high rates of pin-track infection before nailing^11,12. By limiting the duration of external fixation and the associated prevalence of pin-track infection, Blachut et al.⁴ and Antich-Adrover et al.² were able to achieve high union rates with low infection rates (less than 6 percent).

We are aware of only two small series in the literature in which planned conversion of external fixation to intramedullary nailing was carried out for fractures of the femur in multiply injured patients. Broos et al.⁶ reported on ten fractures in nine patients with an average Injury Severity Score of 35.5. All of the fractures healed without complications after an average of twenty-one days of external fixation. There were no infections. Wu and Shih²² reported on a series of fifteen open fractures of the shaft of the femur that were treated with an average of one month of external fixation before nailing; there were nine immediate and six delayed conversions. Fourteen of the fractures united, and two (one treated with immediate conversion and one, with delayed conversion) were complicated by infection. All other reports of which we are aware have described intramedullary nailing as a late procedure for the treatment of complications of external fixation of fractures of the femur^1,13.

Our protocol of delayed nailing usually within two weeks after stabilization by external fixation proved to be a safe and effective approach for the management of fractures of the femur in selected multiply injured patients whose physiological instability precluded primary intramedullary nailing. We view the use of this two-stage protocol in patients with ipsilateral vascular disruption as a way to maximize the time available to the vascular surgeon for prompt revascularization of an ischemic extremity. The rates of fracture union (97 percent) and infection (1.7 percent) are comparable with those in previous studies of intramedullary nailing of the femur in similar patient populations^7,21. Although the average knee motion of 107 degrees appears to be less than that in series of primary intramedullary nailing of these fractures^7,21, we attribute this difference to several factors, including the large number of associated orthopaedic injuries (forty-four of fifty-four patients had multiple fractures) and the overall severe degree of polytrauma in our patient population.

Because fifty patients (fifty-five fractures) had conversion from external fixation to intramedullary nailing in a one-stage procedure, a "safe interval" in traction between fixator removal and definitive nailing appears unnecessary. The importance of experienced clinical judgment in determining whether a one-stage conversion procedure is appropriate for a particular patient should not be underestimated. Clinical and laboratory data indicating a physiologically stable, noncatabolic patient without signs of systemic sepsis, pin-loosening, or pin-track erythema or purulent drainage is required. It must be stressed that most patients in our series underwent conversion within one week after the injury.

The possibility of infection after union is of some concern, considering the relatively short follow-up of our study population. However, the only infection noted in this series developed before union, and published reports of late infection after union of fractures of the femur and tibia treated with conversion from external fixation to intramedullary nailing are extremely rare^{2,4,6,11,12,22}.

It remains unknown how long external fixation can safely remain in place before there is an increase in the risk of infection after conversion to intramedullary nailing. However, we have shown that external fixation, as an interim management technique before one-stage delayed intramedullary nailing, is associated with a low and acceptable infection rate. This early conversion procedure provides the benefits of immediate femoral stabilization and prevents the complications associated with traction. We concluded that immediate external fixation followed by early closed intramedullary nailing is a safe and effective treatment method for fractures of the shaft of the femur in multiply injured patients who cannot tolerate immediate intramedullary nailing but who may benefit from long-bone fixation.

References

Introduction | Materials and Methods | Results | Discussion | References

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Antich-Adrover, P.; Martí-Garin, D.; Murias-Alvarez, J.; and Puente-Alonso, C.: External fixation and secondary intramedullary nailing of open tibial fractures. A randomised, prospective trial. J. Bone and Joint Surg.,79-B(3): 433-437, 1997.79-B(3)433 1997

Baker, S. P.; O'Neill, B.; Haddon, W., Jr.; and Long, W. B.: The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J. Trauma,14: 187-196, 1974.14187 1974 [PubMed]

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Bone, L. B.; Johnson, K. D.; Weigelt, J.; and Scheinberg, R.: Early versus delayed stabilization of femoral fractures. A prospective randomized study. J. Bone and Joint Surg.,71-A: 336-340, March 1989.71-A336 1989

Brumback, R. J.; Uwagie-Ero, S.; Lakatos, R. P.; Poka, A.; Bathon, G. H.; and Burgess, A. R.: Intramedullary nailing of femoral shaft fractures. Part II: Fracture-healing with static interlocking fixation. J. Bone and Joint Surg.,70-A: 1453-1462, Dec 1988.70-A1453 1988

Dabezies, E. J.; D'Ambrosia, R.; Shoji, H.; Norris, R.; and Murphy, G.: Fractures of the femoral shaft treated by external fixation with the Wagner device. J. Bone and Joint Surg.,66-A: 360-364, March 1984.66-A360 1984

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Murphy, C. P.; D'Ambrosia, R. D.; Dabezies, E. J.; Acker, J. H.; Shoji, H.; and Chuinard, R. G.: Complex femur fractures: treatment with the Wagner external fixation device or the Gross-Kempf interlocking nail. J. Trauma,28: 1553-1561, 1988.281553 1988 [PubMed]

Orthopaedic Trauma Association, Committee for Coding and Classification: Fracture and dislocation compendium. J. Orthop. Trauma,10 (Supplement 1): 1996.10 (Supplement 1) 1996

Ostrum, R. F.; Agarwal, A.; Lakatos, R.; and Poka, A.: A prospective comparison of antegrade and retrograde femoral intramedullary nailing. Read at the Annual Meeting of the Orthopaedic Trauma Association, Vancouver, British Columbia, Canada, Oct. 9, 1998.

Phillips, T. F., and Contreras, D. M.: Current concepts review. Timing of operative treatment of fractures in patients who have multiple injuries. J. Bone and Joint Surg.,72-A: 784-788, June 1990.72-A784 1990

Riska, E. B.; von Bonsdorff, H.; Hakkinen, S.; Jaroma, H.; Kiviluoto, O.; and Paavilainen, T.: Primary operative fixation of long bone fractures in patients with multiple injuries. J. Trauma,17: 111-121, 1977.17111 1977 [PubMed]

Rooser, B.; Bengtson, S.; Herrlin, K.; and Onnerfalt, R.: External fixation of femoral fractures: experience with 15 cases. J. Orthop. Trauma,4: 70-74, 1990.470 1990 [PubMed]

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Wu, C.-C., and Shih, C.-H.: Treatment of open femoral and tibial shaft fractures preliminary report on external fixation and secondary intramedullary nailing. J. Formosan Med. Assn.,90: 1179-1185, 1991.901179 1991

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Fig. 1-B: Arteriogram showing an injury of the superficial femoral artery.

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Fig. 1-C:: Postoperative anteroposterior and lateral radiographs showing the fracture of the femur reduced and stabilized with a uniplanar external fixator before vascular bypass grafting.

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Fig. 1-D::

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Fig. 1-F::

Alonso, J.; Geissler, W.; and Hughes, J. L.: External fixation of femoral fractures. Indications and limitations. Clin. Orthop.,241: 83-88, 1989.24183 1989 [PubMed]

McGraw, J. M., and Lim, E. V. A.: Treatment of open tibial-shaft fractures. External fixation and secondary intramedullary nailing. J. Bone and Joint Surg.,70-A: 900-911, July 1988.70-A900 1988

Orthopaedic Trauma Association, Committee for Coding and Classification: Fracture and dislocation compendium. J. Orthop. Trauma,10 (Supplement 1): 1996.10 (Supplement 1) 1996

Rooser, B.; Bengtson, S.; Herrlin, K.; and Onnerfalt, R.: External fixation of femoral fractures: experience with 15 cases. J. Orthop. Trauma,4: 70-74, 1990.470 1990 [PubMed]

Teasdale, G., and Jennett, B.: Assessment of coma and impaired consciousness. A practical scale. Lancet,2: 81-84, 1974.281 1974 [PubMed]

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Peter J. Nowotarski, Clifford H. Turen, Robert J. Brumback, J. Mark Scarboro; Conversion of External Fixation to Intramedullary Nailing for Fractures of the Shaft of the Femur in Multiply Injured Patients*. The Journal of Bone & Joint Surgery. 2000 Jun;82(6):781-781.

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