Review Question - QID 215475

Fracture comminution has been associated with femoral malrotation when treating femoral shaft fractures with intramedullary nailing.

Femoral shaft fractures are the result of high-energy mechanisms and have a 5% incidence of ipsilateral femoral neck fractures. Treatment with reamed, statically locked intramedullary nails has a reported >95% union rate and enables immediate weight-bearing post-operatively. Femoral malrotation is a well-known complication, with internal rotation being common with the use of a fracture table and fracture comminution. Usually, malrotation less than 15 degrees from the contralateral side is well tolerated.

Ayalon et al. performed a retrospective study of 417 patients with diaphyseal femur fractures treated with intramedullary nailing techniques by either trauma-trained or general orthopedic surgeons. The authors reported femoral version difference to the uninjured extremity to be 8.7° and 10.7° for trauma-trained and non-trauma surgeons, respectively (p >0.05). They concluded postoperative femoral version of diaphyseal femur fractures was not affected by specialty training or surgeon experience.

Liodakis et al. retrospectively analyzed femoral neck anteversion of 220 patients with femoral shaft fractures treated with intramedullary nails. The analysis revealed no difference in femoral version with patient positioning, surgical delay, nailing technique, implant type, or surgeon experience. They concluded better operative techniques are required to control femoral torsion since no identifiable risk factors were found in the study.

Hüfner et al. retrospectively reviewed 82 patients with femoral shaft fractures treated with intramedullary nails. They reported 18 patients to have post-operative malrotation and was only associated with increasing fracture comminution and the surgical time of day.

Figures A and B are the AP and lateral right femur radiographs with a comminuted fracture of the diaphysis.

Incorrect answers:
Answer 1: Fracture comminution has not been associated with increased operative time for intramedullary nailing.
Answer 3: No studies have found an association with hardware failure and fracture comminution.
Answer 4: Varus malalignment has not been associated with fracture comminution.
Answer 5: Anterior cortical perforation has been associated with diameter mismatch of the nail and femur. Also, posterior starting points have been associated with anterior cortical perforation.