Closed or open intramedullary nailing of femoral shaft fractures? A comparison with conservatively treated cases.

intramedullary nailing of femoral shaft fractures, first introduced by Hey Groves in 1918 and later popularised by K#{252}ntscher (1940, 1958, 1967), B#{246}hler (1951), Street (1951) and Lottes ( 1953), is in most current textbooks described as a routine surgical operation. It is regarded as the method of choice in transverse and short oblique fractures of the femoral shaft (B#{246}hler 1951 : Muller, Allgower and Willenegger 1965) where good to excellent results have been reported. Nichols (1963), reviewing the results of rehabilitation after femoral shaft fractures, also reported better end-results after intramedullary nailing than after any other method of treatment. Perusal of the literature reveals, however, some dissatisfaction with the method. The technical performance of the operation is far from uniform, and obviously it often falls far short of the standard demanded by KUntscher (Rehm and Uebing 1963). Chronic osteitis, delayed union and non-union are sequelae frequently reported after intramedullary nailing (Lauritzen 1949, Palmer 1951 , Charnley and Guindy 1961 , O’Brien 1963). Dencker (1965), reviewing the results of different methods of treatment of femoral shaft fractures in Swedish hospitals from 1952 to 1954, concluded that although many of the nailed fractures did quite well, the rate of complications was so high that conservative treatment with traction should still I given preference in routine work in surgical wards. Recent refinements in surgical techniques have materially altered intramedullary nailing. The introduction of the strong clover-leafed nail combined with the principle of reaming out the medullary canal (KUntscher 1958, 1959) and the development of image intensifiers have revived interest in closed nailing. Both KUntscher(1959)and B#{246}hler(1965)reported encouraging results with such a technique. However, the evaluation ofclosed nailing as a routine procedure has not been possible for lack of comparative studies on selected series treated by other methods. In this report an attempt is made to assess the value of primary closed intramedullary nailing of femoral shaft fractures, as compared with ordinary open intramedullary nailing and with conservative treatment.