TECHNIQUE 
0 F 
MARROW NAILING 
by 
GERHARD KUENTSCHER 
'rof. Dr, med. habil# 
RICHARD MAATZ 
Dozent Dr, med, habil. 
Assistants of the Surgical Clinic at the University of Kiel 
With 101 Illustrations 
19 4 5 
GEORG TRIE ME EDITION LFIPZtG 
Translation prepared by: 
Office of Military Government for Germany (U. S.) 
Office of Naval Advisor 
Medical Section Foreword to translation of TFCHNIQUE OF MARROW NAILING 
by 
KUENTSCHER - MAATZ 
This translation is included here for historic reasons al- 
most as much as for medical reasons. It appears to be the first 
b»»k about the Marknagel, Although KUENTSCHER is listed as 
senior author there is good reason to believe that he had little 
to do with the writing of this book* 
MAATZ, who it appears was the author was junior to KUFNTSCHJ 
at Kiel. MAATZ is said to have been educated as an engineer 
before he studied medicine. The multiplicity of ideas and modi- 
fications of the basic concept of the nail have been cited as 
evidence of his engineering background. Certainly in the United 
States he would be spoken of as a"gadgeteer", Without doubt he 
is a capable surgeon and qualified to have his opinions. 
The personality of two people could not be more opposite in 
nature. MAATZ the tense, extrovert rapid fire react- 
ions - KUrNT£CHER the shy scholarly introvert, self deprecating 
and carefully thinking things through. One canrot escape the 
thought that the Surgical Clinic at the University of Kiel must 
have been an interesting place when these two men were debating 
a subject. 
The publication of this booklet was delayed from 1942 until 
in 1944 because of a government restriction on paper. In late 
1944 an edition of 1000 copies was authorized. approximately 
half of these had been distributed at the end of the war. The 
fate of the other copies and the plates in Leipzig is not known. 
There has been no practical way of reproducing the illus- 
trations in the original text* Since many explained by 
line drawings these have been traced. Some have been omitted 
entirely as unnecessary or not suitable for reproduction with 
the facilities at hand, the important details being lost in the 
tracing on a mimeograph stencil* 
Upon the completion of this task the original text with any 
reserve copies of the translation will be sent to the Department 
•f the Navy, Bureau of Medicine and Surgery, Publications Divi- 
sion. 
HARRY J. ALVIS 
Commander MC 
U. S. Navy PREFACE 
The idea that a fracture may be held in good position un- 
til healed by introducing foreign bodies into the marrow cavity 
is not new, Metal wires and pins and even ivory bolts have been 
used for this purpose. Without an exposure of the broken ends 
and the associated danger of infection the introduction of the 
above mentioned foreign bodies could not be accomplished. 
The essential feature of KUFNTSCHFR*s method is the intro- 
duction of a foreign body from a place apart from the fracture 
site. In this it differs essentially from all other methods of 
operative treatment of compound fractures. Through the use of 
a specially shaped, very stable, properly constructed, nail- 
like splint, which forges an elastic union with the inner surface 
of the marrow cavity, the greatest possible stability of the 
fracture should be achieved, so that a further support by plaster 
cast or traction apparatus is not required. By this the disad- 
vantage of a prolonged immobility of the limbs is avoided, 
KUFNTSCHER has extended the principle of the nailing of the 
neck of the femur (SMITH-PETERSEN) to the shaft of bones. 
That KUENTSCHER«s method was at first generally disapproved 
of when he announced it at the Surgical Congress in Berlin, is 
understandable. This disapproval only confirms the conscientious- 
ness of the German Surgeons, Above all they were concerned that 
the introduction of such a large foreign body into the marrow 
cavity of a bone might be harmful to the patient. I hid the 
same apprehension myself, when KUT’NTSCHER expounded his idea to 
me for the first time even aft°r the results of animal experi- 
ments were known. This "instinctive" apprehension was not sub- 
stantiated, Subseouently no undesirable result was observed in 
humans in the marrow cavity or elsewhere. 
The method has now been adopted in numerous clinics and 
hospitals. It is now being constantly developed. In different 
places, not only with us at the clinic in Kiel, surgeons try to 
perfect the construction of the instruments, improve the pro- 
tection of the doctor from X-rays, and the form of the nail. 
Besides all these technical matters th<"re is constantly the 
ouestion of the indications. Gradually it can be ascertained 
whjch fractures are suitable, which are less suitable and which 
are entirely unsuitable for nailing; for which type of fracture 
in spite of the nail, a cast is still required, which fracture 
can be subjected to weight-bearing early and which one late. 
All these matters are still under investigation. To all 
surgeons now engaged in the nailing operation or to those who 
intend to practice it on this treatise should be a help. 
It was written to make them acquainted with the present state of 
our knowledge and besides this to point out the threatening 
mistakes. I would like to point out that only the most 
skilled surgeons acquainted with the treatment of fractures, 
should be allowed to "nail" and even then only when having a 
complete armamentarium at their disposal. The nailing operation 
requires the greatest technical skill. It is my opinion that KUENTSHCER*p method is the greatest 
advance in the handling of fractures given to ihe world since 
the description of the extension nail method of KLAPP, I am 
quite sure that its use will spread throughout the world, 
ii is not difficult to bid this book Good'-speed, as I am 
coovinCed that it will make its own way* 
A, Wi Fischer, Kiel PREFACE 
In December 1942 we had completed for the first time the 
following description of the marrow nail operation. However, 
permission to publish the treatise was not given. When these 
difficulties had been overcome after the lapse of a year, the 
entire material of illustrations was destroyed during a severe 
air raid on Leipzig. By my new assignment to sea duty, contact 
with my publishers and my collaborator has become very difficult. 
For these reasons the publication of this work was repeatedly de- 
layed. Unfortunately we are also not in a position to print an 
annex to this treatise with a short summary of the results we 
have had in the meantime, for, more than 500 nailing operations 
have been performed since this work was written of which about 
400 have been done at the Kiel clinic and the rest in the field 
or in station hospitals. 
In the meantime all of us have learned to resort to makeshift, 
much more. It is not possible at present to get all the instru- 
ments described in this book because their construction had to 
be stopped due to circumstances of the war, Nevertheless it 
is possible to perform nailing operations with all the respons- 
ibility required if the surgeon has at his disposal X-ray appar- 
atus, nails, awls, hammers and block-and-pulley. All the other 
instruments needed can be replaced and are not absolutely re- 
quired. 
Every beginner is urgently recommended to use at first only 
the strict indications and to start only with nailing of the 
most suitable fractures. In this case he will find full satis- 
faction with this wfnderful method. In the course of time the 
indications will extend themselves. In every case one must bear 
in mind the necessity of accomplishing a stable union of the ends 
of the bones by nailing. If this condition is not fulfilled fail- 
ures will not be the fault of the method but of the operator. 
On board a hospital ship 
in the Mediterranean 
August 1944 
M a a t z INDEX 
PREFACE 2 
PREFACE 4 
1* Introduction 7 
2 . Tools 15 
3. The indication and detailed statements about the after- 
treatment 23 
A. The thigh 25 
B . The Leg 27 
C. The upper Arm ., 34 
D. Forearm 36 
E. Collarbone 37 
4. Suitable time and preliminary treatment , 37 
5. Narcosis 3B 
6. Appropriate position and adjustment 39 
A. The thigh 39 
B. The Leg ,. 40 
C. The upper Arm 41 
D. Forearm 41 
7. Fluoroscopy 42 
8. Asepsis 44 
9. Selection of the Nail 44 
Thickness 44 
Thigh 45 
Leg . 45 
Upper Arm 45 
Forearm 45 
Length , 45 
Thigh ,, 46 
Leg 46 
Upper Arm . . 46 
Forearm 4 6 
The longitudinal profile 46 
10, Insertion of the guide rod 47 
Thigh 43 
Ulna 49 
11, Insertion of the Nail 49 
12, The After-Treatment 53 
13, Removal of the Nail 54 
Suitable time 54 
Technique 55 
Thigh .. 56 
leg 56 
Upper Arm , . 5£ 
Forearm 56 
14* Nailing in the case of an open fracture 57 
15, Nailing of gunshot fractures 59 
16, Nailing with delayed formation of callus 60 
17, Nailing operation in pseudarthroses 61 
18, Osteotomy 61 19* Nailing of a spontaneous fracture ,, 
20. The Y-Nail * . * . . 4 > 
21* The supracondylar T-fracture 75 
21, Atypical nailings 76 
23* Bibliography ...... . r3 7 
1*_introducti£N 
Before the surgeon undertakes his first marrow nail oper- 
ation he must have a clear understanding of its main principles. 
Only then will he be in a position to apply the method as widely 
as the present state of the technioue makes it possible. It must 
not be forgotten that it is a case of true nailing. Just like 
the carpenter's nail unites two pieces of wood with elastic 
strength, so the marrow nail is meant to unite the bone ends. 
The nail should be introduced in such a way by strokes with a 
hammer into both portions of the broken shaft of the bone that 
it sticks there and makes it impocBlble to shift either end of the 
broken bone shaft. Only by accomplishing this can one speak of 
an entirely satisfactory marrow nail operation and only then can 
its great advantages over all other methods be turned to account, 
A further securing of the fracture by splints, plaster cast or 
extension will the,n not be required. The limb may be freely 
moved, even bear weight. Wasting of the muscles and disturbances 
of the circulation will not occur, or, if so, only to an unim- 
portant degree. Joint stiffening is not to be feared for the 
joint is kept at rest. The fracture, placed under favorable 
mechanical conditions will be bridged over by bone in a very 
short time, for it is subjected only to pressure while pulling 
and pushing tensions are avoided. 
The nail is held by the friction of the rough inner layer 
of the cavity of the hollow bone cylinder.. Since the inner 
diameter of the bone varies it is of the utm.ost importance 
that the nail should have as much elasticity as possible in 
the cross section. Therefore the nail is U-shaped in the cross 
section. After a successful nail operation the friction bet- 
ween the- bone and the nail may be s« great that the ends of the 
bone are held together by a force whi• h can a pull of 
several hundred kilograms. But not all broken bones may be 
treated under equally favorable conditions. The shape of the 
bone, the shape and location of the fracture and finally the 
possibilities of introducing the nail into the cylinder of the 
bone are all of significance, A thorough knowledge of the forces 
in ouestion in the individual case, both for the indications 
and for the technique of nailing and particularly for the treat- 
ment after the operation is absolutely necessary. 
It will not be possible to achieve the aim of the marrow 
nailing in every case, especially sufficient friction of the nail 
in both ends of the broken bone. But nevertheless, surgeons may 
use this method and successfully apply it. It is only important 
to know how to avoid the wpak points of this method. 
The mechanical factors are simple and easy to understand, 
A bone with only insignificant variations of the diameter 
of the cavity presents the m©st favorable conditions possible, 
(in. i). Illustr, 1 
The location and the shape of the fracture are of no import- 
ance if the two fragments are sufficiently long to give the 
nail a satisfactory hold. In the case of a comminuted .fract- 
ure, however, the nail alone has to withstand all the forces 
tending to produce angulation at the fracture site. While in 
the case of a plain transverse fracture the nail is held by the 
bone in a firm mechanical system so that the nail alone does not 
have to withstand the forces tending to produce angulation at 
the fracture site. 
When the friction between the nail and the bone is in 
sufficient, the nail will act as bolt (ill, 2), 
Ill uvt r, 2. 9 
Indeed, it prevents a longitudinal bending and lateral displace- 
ment, but permits rotation, In this case shape of the fract- 
ure is of decisive importance, A comminuted fracture will short- 
en and a spiral fracture will be distorted. Fven true transver- 
se fractures would not be protected against rotation. On the 
other hand, oblioue fractures usually shorten only as long as 
there are minor faults of rotation, until finally the nail (bolt) 
and bone Jam, (ill, 3) In the case of a gagged fracture the 
111 u st, r. 3 
bone ends can, nevertheless, be united in such a way that the 
bone ends remain firmly fixed together (so-called Hirth-Teeth). 
The muscles press the bone ends of the fracture together and in 
this way rotation is prevented. 
The outlook is not so favorable in the case of a bone with*! 
considerable variation in the diameter of th° marrow cavity. 
If the fracture lies in the narrowest part of th° marrow cav ity , 
a successful nailing can still be achieved uwing to the elastici- 
ty of the cross section of the nail (ill, 4). For the distance 
Titudr.H of several centimeters the nail has sufficient friction in the 
marrow cavity of both fragments. Should this friction be insig- 
nificant the nail will act as a b»lt and will prevent only a 
lateral displacement, In the case of a transverse fracture the 
bone ends, which are in good position and ouite secure against 
lateral displacement will be firmly held togeth-r by the muscles 
and angulation cannot occur, and rotation movements are prevent- 
ed by the interlocking of the jagged If a of bone 
is missing at the fracture site the bone ends cannot stand one 
upon the other longtudihally and will be a tendency to 
angulation (ill. 5j. If the fracture does not lie in the narow- 
a 
Thigh 
111. 5 
i. % • 
% 
Ug 
est part of the marrow cavity the degree of disproportion bet- 
ween the width of the marrow cavity and the thickness of the 
nail will determine whether the displacement c n be overcome by 
the nail or not. If 'the broken ends can be displaced laterally 
by the thickness of the bone cortex we then find the most un- 
favorable conditions. They are: lateral dislocation, distraction, 
angulation and rotation i.e.. which are all the faulty positions 
that can be imagined (ill. 6). 
111. 6 
Unfavorable conditions 
for marrow nailing The situation is ior° complicated when the nail is intro- 
duced into the bone shaft from the side. In the fragment into 
which the nail has been introduced from the side a rotation is 
impossible between the nail and the bone shaft but in the other 
fragment the much desired strong friction uniting nail and bone 
will generally not be achieved, because the nail must be somewhat 
smaller than the marrow cavity (ill, 7), When in this case the 
Illustr. 7 
a - favorable 
b - unfavorable 
fracture is situated at the narrower part of a tap°ring marrow 
cavity, the difference of the respective calibers, which is neces 
sary f©r the introduction »f the nail, is to no disadvantage. 
The greater elasticity of the nail, which is ary for its 
lateral introduction in these cases is an undesirable feature. 
As a further place of friction between the hail and the hen'.; 
we have the spongiosa of the ends of the bones. While in the 
majority of cases the stability ©f the nail in these marts of 
the bone is irrelevant to the stabilization of a fracture, it 
is nevertheless of special significance in sov cases, and one 
must understand clearly how much pressure this soft bone tissue 
can withstand. For example, one may mention the transplantation 
of th» radius to the ulna in the vicinity of the elbow joint, 
A bony healing was not achieved after five months (infection 
preventing the effect of the nail,). The joint was practically 
immobile. The motion that was possible from 100° to 80°, was 
not due to the elasticity of the nail, but as the pictures show, 
the nail had worked a slot in the spongiosa of the bone, in which 
the end of the nail covered a distance of 12 millimeters (ill,8), 
Illustr, 8 The b«ne tissue subjected to excessive pressure rhythmical1y 
or constantly reacts by absorption at the point of pressure. 
While in the tubular part, with pressure of the nail fror* the 
inside and absorption of the bone at the inner wall, the peri- 
osteum prevents a lateral breaking through of the nail by a 
speedy formation of new bone. Such a reaction is not s°en in 
spongy bones. The nail works itself a slot and finally breaks 
out »f the bone (ill,9), Therefore a subtrochanteric fracture 
Illustr, 9 
must not bear weight too early, and the head of the nail must be 
particularly broad for fractures the elbow joint, and, for 
the same reason, it is useless to insert a nail in a fracture 
of the tibia so far that the point of the nail gets a hold, in 
the distal spongy portion of the bone. This hold is negligible 
and unreliable, 
•ur aim and purpose must be the nailing operation. It is 
not always to be achieved. At least the principle of the bolt 
should be guaranteed. It still offers great advantages. If a 
baiting cannot be achieved with certainty the fracture is un- 
suitable for the new method. Of course, even hr re there are 
exceptions to be made and in certain cases one will decide to 
nail the more readily when the fracture can be brought to a good 
healing only with difficulty by the methods used previously. As 
examples one may refer to the comminuted fractures shown in the 
pictures above, which were nailed with the very best results, 
although the mechanical conditions were by na means ideal ones 
<111, 10 and 11), 
In practice the conditions in sore casns may be very com- 
plicated , So, i or instance, rhe analysis of the forces whi ch beet.' 
a tibia fracture in good position with a spread nail is very diffi- 
cult and it is impossible to decide wheth r the security of the 
fractures is due mostly to the principle of the nail, the bolt, 
the Hirth teeth or other factors. The o n 13r real important thin a 
is that the Cioctor should attain sufficient skill to r °co? nize a, s 
soon as possible to which extent a fracture, tr ated in this way 
may be subjected to functional use. For this, it is only poss- 
ible to give directions. Personal experience alone en- 
sures a masie / of this subject. 
The foregoing statements make it clear that one cannot 
speak simply of a.n indication for using the marrow nail. It is 
necessary to distinguish between "strict" and ‘extended'' indi- 
cations. In the first group may be included t-ose fractures Illustr. 10 
Illustr. 11 
which in the following treatise are considered "particularism 
suitable", i.e, those fractures which can be treated by the 
nailing operation much better than by any method. In the 
other group are included the fractures considered "suitable" 
and "less suitable" and at the same time those which do not show 
all the advantages of the new method aft°r they are nailed. 
For the beginner It is advisable to undertake only those 
cases which fulfil the "strict" indications. kith growing ex- 
perience operations may be performed on cases which are classi- 
fied under the "extended" indications. 
While the nail is In place certain changes occur which must 
be taken into consideration. The nail may become loose in the 
bone as early as the first week. The inner wall of the bone is 
then worn thinner by the pressure of the nail. The conseeuence 
is that the friction between the bone and the nail becomes less. 
As absorption of the bone occurs only at the place of the strong- 
est pressure, a groove in the marrow cavity develops, which per- 
mits motion of the fragments in the axis of the bone. Rotation- 
al displacement i s, ho¥fever, prevented by the callus which fills 
the broken ends. Thus there exists the most favorable conditions 
for the healing of the bone, as the nail acts as a sliding splint 
and permits only the forces pressing the ends together to act. 
It stands to reason that the locsening of the nail after a 
couple of weeks may be a great disadvantage, according to the 
form and position of the fracture, therefore it must be con- 
sidered accordingly, 
A blocking effect of the nail is irEelevant if the nail 
provides sufficient stability and has a sufficient hold for the 
fragments. The bone gap will be bridged over in a surprisingly 
short time,. ... . 
If a sufficient stability of the nail or sufficient frict- 
ion between the nail and the bone does not exist the blocking, 
effect of the nail may result in a delayed healing of the 
fracture, The point of the nail, acting as a bolt, produces a con- 
stantly widening slot in the short fragment, and thus a later- 
al piercing by the nail of the periosteal callus which is under 
pressure is prevented. The fragments are not fixed firmly. How 
strong the blocking effect of the nail may be is proved by the 
fact that nails, under the above mentioned conditions, frequent- 
ly begin to move and thus work their way out of bone* 
The moving of the nail is always a proof of an insufficient 
stabilization of the fracture by the nail, A fracture is never 
firm as long as it allows the nail to work itself out. 
Even an apparently well-fixed nail in a fracture favorable 
for nailing may lead to disturbances of the healing process a:d 
finally to considerable delay in th*5 format! n of callus, if 
even a single mistake is made. If in a smooth transverse fract- 
ure in the middle of the leg, for instance, a nail is introduced 
that is too thin, this may permit shearing forces to act at the 
fracture site, which does not permit a bony healing at al" or 
only a very slow healing. The reason is that gradually the nail 
will bend a little, and at the same time the upper part of the 
fracture will move for?/ard and thb lower part backward as much 
as the difference between the diameter of the nail and the marrow 
cavity permits. When the weight is taken off the elastic for- 
ces of the nail will push the bone ends back to their former 
position. Even if the distance is only J or 1 millimeter this 
displacement will be enough to delay a bony healing or even to 
make it impossible (ill, 12). 
Illustr. 12 
Here are some other brief comments important for consider- 
ations in connection with the nailing. 
As the fracture is nailed from a considerable distance and 
the operation wound will be only some centimeters long at the 
most the danger of an infection will be very slight. 
The nailing is not a serious operation which might endanger 
the life of the patient. Just like operations, the nail- 
ing too must, of course, not be done in shock. An insignificant fat embolism is to be expected (MAATZ), 
Clinically it does not appear but even this slight additional 
hazard must not be added to cases already in a precarious state, 
A good formation of callus may be expected only if a stabile 
osteosynthesis has been attained. A very abundant formation of 
callus may be caused by the issue of the marrow at the fracture 
site (KUFNTSCHER). Nothing has said yet about the fixing 
of the fracture. The chemical stimulation by the metal of the 
nail may cause a far reaching disorganization in the nailed bone 
and along with this an abundant periosteal formation of callus. 
This occurrence is to be considered as undesirable. The fixing 
of the fracture may even be prevented (MAATZ). Therefore th15 ncf. 
should be made of corrosion-pro$f metal. 
The most careful consideration of the following technical 
directions is urgently recommended. The nailing operation is a 
kind of operation which owing to its technical character is not 
in the line of every surgeon. There are easy as well as difficul 
cases of nailing and one should always be prepared for the lattei 
Never make the mistake of considering a case of a nailing oper- 
ation afinfinished and dene with”. For a swccec.aful nailingoperataton a 
ways requires a careful clinical and ambulatory observation to 
meet every complication wh'-ch may occur in the course of time, 
only can the new method show how vastly superior it is in 
comparison with the nitherco used methods, 
TOOLS 
N.l'LS 
The above described mechanical conditions of the marrow 
nailing operation make it clear that the marrow nails now avail- 
able do not make it possible to obtain a stabile osteosynthesis 
in every case. The nail lies close to the inner wall of the 
bone shaft not only at the fracture site but also beyond it as 
for as possible. To attain this end the nail must have great 
elasticity in the cross section because the diameter of the 
marrow cavity varies considerably. This required elasticity 
in the cross section is much greater than that attainable by 
the most favorable cross-'section design of the nail if the thick- 
ners of the metal is adeouate, Therefore nails must be cr 
structed which can be spread at the desired spots and, further d.. v' 
which make it possible to furnish the nails with cams at the re- 
quired spots. cams are meant to entr into the inner wall 
of the bone in order to prevent a rotation of the fragments. 
When constructing nails of new shapes one must consider that any 
complicated construction is of no value and must therefore be 
rejected. One must.nev°r forget that the nail must be strong 
enough to bear heavy mechanical pressure, breaking of a nail 
should be an extremely rare occurrence and that the nailing of 
the marrow should not be reserved for some few highly skilled 
specialists, but should be available for the use of a majority 
of surgeons. 
The circumstances of war with the scarcity of labor and th 
difficulties of getting the necessary material have of course de- 
layed any further development so that we hav~ to reckon only wit' 
the instruments presently at our disposal and so have to get 
al«ng with some disadvantages. Unquestionably we are at the be- 
ginning of a new development. Under the prevailing conditions it will be neither possible nor advisable that every hospital or 
clinic adopting the method of the marrow nail operation will 
have supply of complete sets of nails. The most commonly used 
sizes must suffice for th° present and the nails needed for 
special cases must be ordered by cable. The postponement of the 
operation caused by this circumstance is only a matter of a short 
time and there is no euestion that it is justifiable. 
Nails for the thigh, 
The cross section is approximately V-shaped. The thickness 
of the metal sheet, reeuired for the stability of the nail, is 
somewhat at its back so that the two sides of the nail may 
easily approach each other (ill, 13). In this way the nail pro- 
Illustr. 13 
vided for particularly wide marrow cavities (to 16 millimeters) 
may be constructed of a thinner m'tal. Accor "ingly the elastic- - 
ty of the cross section is increased considerably. 
Customary sizes are: 
Adults : Lengths: 30, 34, 36, 40 and 42 centime- 
ters. Cross Section: 8, 9 and 10 millimeters (c.oncial sizes of 
11 - 16 centimeters are often used). 
Children: Lengths: 24 - 32 centimeters (at inter- 
vals of 2 centimeters). Cross Section: 6 and 7 millimeters. 
For the subtrochanteric fracture a conical nail is provided 
corresponding to the form of the marrow cavity to prevent a la- 
teral displacement with transverse fractures, and to 
prevent an inevitable shortening when a nail that is too thin is 
used (111. l/)_ 
Illustr. 14 
If a bone is to be nailed in which callus is to be expected 
in the marrow cavity (f.i. refracture or a delayed formation of 
callus) and if one does not wish to lay open the bone, one may 
make use of a nail which has serrated teeth at its point (111,15). 
Illustr. 15 
Nail with serrated teeth By means of those teeth the nail can work a bed into the bone 
for itself, b'ith them the introduction of the nail may be im- 
possible, (Fditors Note: In such a case, where callus fills 
the marrow cavity, it is customary to perform the "open" nail- 
ing, exposing the fracture site and reopening the narrow cavity 
with a drill or an awl). 
The Y-nail is a conical thigh marrow nail of 32 millimeters 
length and a V-shaped cross section of 10 millimeters* A nail 
which in its cross section is shaped like a T and stands at an 
angle of 45 degrees to the axis of the long’ nail is introduced 
through a slot in the marrow nail into the head and the nee1" of 
the femur. The middle of this slot is about 8 centimeters be- 
neath the end of the nail head. The cross nail (i-shaped) is 
11,5 centimeters long and its he d stands out of the nail about 
2 centimeters in order to find sufficient hold in the cortical!s 
drill hole (ill, 16)* 
Illustr* 16 
For the pertochanteric fractures of -groups III and V the 
marrow nail must be constructed according to the measurements 
of the bone because it must lie in the thigh bone so snug that 
it cannot turn round. 
The directing_apparatus for the Y-nail, which permits a 
percutaneous introduction of this nail, will be described in 
chapter 19, 
or_t ho_ 
Nails for the leg ar® double nails. Their cross section 
*s U-shaped. They are curved, the radius being shorter at the 
ends, and in the middle almost oo (111, 17) 
Illustr, 17 Adults : Lengths: 24 - 39 centimeters at intervals of 
centimeter. Greatest diameter 8 and 9 millimeter^. 
Children: Lengths: 15 - 27 centimeters at intervals 
of 1-J- centimeters. Greatest diameter 7 millimeters. 
With spread^nails, two different shapes been used with 
success: the double nail with an inclined plane and the turn- 
spread nail. The former one is a regular double nail for the 
leg which can be spread in its distal part by an inclined plane 
and the turn-spread nail. The former one is a regular double nai.n 
for the leg which* can be spread in its distal part by an in- 
olined plane attached to th© outer nail (ill, 18). The inclined 
Illustr. 18 
plane (a) and the back wall of the bone tube (b> form the la- 
teral supports which bond off the inner nail backwards. The 
location of the inclined plan7* is of the utmost importance for 
the effectiveness of the nail and must therefore be determined 
very accurately after studying X-ray, A spread nail having 
the width •f 8 millimeters and the length of 32 centimeters the 
inclined plane of which is 6 centimeters from the nail tip, is 
described as U-Schenkel-Sprois 32/6cm./8mm, 
The double^nail with an inclined plane is a v~ry stabile 
syst°m, that reason it must always be in all those 
fractures located distally to the narrowest w rt of the marrow 
cavity, the fracture li of which re more eblioue or, in 
those which have a tendency to angulation because of a breaking 
off of bone particles especially at the front edge. 
The turn-spread nail ilso consist j cf v;o nails. The outer 
nail corresponds to a norm .1 nail, The ' inn nail has a round 
ernes s ction and is in its longitudinal profile S-shaped 
(ill. 19}, The lower part of the nail is introduc'd in' such 
a way that its concave part points w aa" front. After that the 
nail-is to be turned by 180 degrees • :w:n.3 of a screwdriver. 
The outer nail is driven in wh le the aimrr nail is secured by 
a crcsspin or a supporting wire against an;' further penetration. 
Illustr. 19 
The turn-spread nail is suitable only for transverse fract- 
ures or short oblicue fractures the fragments of which stand 
one upon the other as soon as they are bolted. This nail can act 
only as a bolt, because the inner nail lies comparatively loose 
in the marrow cavity and because of its great'r elasticity it 
does ntt offer sufficient resistance to a stronger lateral press- 
ure£lll. 2t). 
Nails f»r_the_ Arm above tjhe Elbow, 
They correspond to the leg nails for children. Illustr. 20 
Wedge for the Arm above the .Elbow and_the,..LegJ. 
They are intended for fractures proximo- to tao middle ox 
these bones. For the present they can only be made to measure 
(111, 21) 
Illustr, 21 
Nails_for_the_ForeaTm, 
The cross section is V-shaped. The nails are furnished 
straight and are arc shaped by the surgeon according to the bone 
form (111, 22), 
Illustr. 22 
Lengths: 10 - 24 centimeters at intervals of 1 centimeter. 
Diameter (for the above noted lengths): 3, and 4 milli- 
meters. 
The special nail for the ulna fracture (near the elbow-joint), 
has a length of 20 centimeters, its diameter is 6 millimeters 
in the third near the head end; in the third near the tip, however, 
it is millimeters. The corresponding tapering is in the middle 
third. The last three millimeters of the head end are flat and 
broad. 
The g u i d e red, 
For the thigk: cross section round and solid, for 
children’s thigh nail three-edged. Lengths: 3 and millimeters. 
(111. 23). 
For the Firearm: Length: 25 centimeters dia- 
meter: 2 - 2-J- centimeter. 111. 23 
The Awl. 
The bayonet-shaped awl, the tip of which is square-edged* 
has proved most suitable for the leg, (ill* 24)* 
Illustr, 
24 
Nail sets^ 
The nail_set for the thigh nail is simply a piece of a thigh 
nail 20 centimeters long. It is put upon the thigh nail when the 
nail head end has not yet reached the head end of the guide rod 
and the rod must hot yet be removed, 
/ 
Nail set II f«r the thigh nail fulfils the requirement that 
the nail should project out of the great trochanter. The hollow 
case slipped over the nail is pressed firmly upon the bone. The 
bolt is then pressed firmly upon the nail he id, bolt which 
can be moved in the hollow is graduated at its upper part. The 
number of centimeters the nail stands out at the time can be read 
at the top. The hollow case is wide open on one side so that it 
and the b»lt can be firmly gripped in order to prevent the hollow 
case from slipping back at the moment of the stroke (ill. 25). 
IT ustr, 25 
The nail set for the plain leg double nail facilitates the 
driving in of the nail because it renders it pos ible to direct 
the stroke according to the chief direction of the principal axis 
of the nail. By this a strong springing of the nail is orevcnt- 
ed (111. 26). 
Illustr. 26 A metal bolt of 10 centimeter in length with a diameter of 
1,5 centimeter serves as a simple nail set for the last strokes 
upon the leg nail the forearm nail and the upper arm nail. 
The split hammer is the bcst tool for striking out even firm- 
ly fixed nails. The force of the stroke is transmitted to the 
nail directly and in a straight direction. For the big nails 
the long hocks are used, for the small nails the shorter ones 
(111, 27). 
Illustr, 27 
Pull and stroke are combined in the tool constructed by 
KUFNTSCHFR. To prevent any chipping of the bore at the point 
of contact a separating disk acting on a ball and socket is 
used. The threaded spindle with a spring acts as a "relay11 
which has to be reset aft-r a couple of hammer strokes. The in- 
set must be inserted when the nail stands out of the bone for 
some distance. 
For removing the second piece of a straight nail, broken 
in the marrow cavity (thigh, forearm) the same hammer is used 
togeth~r with a removal hook of a length of 75 centimeters, the 
so-called nail_catcher (ill, 28), It must be introduced into 
the marrow cavitv at the site of the nail insertion. After 
Illustr. 28 having reached the broken nail it must be pushed into its cavity 
carefully so that the hook finds sufficient space in the open 
side of the nail. when the hook comes out at the ->nd of the nail 
it must be turned by 120 degrees (not by 180 derrees, see 111. 
29) and the nail must then be extracted or struck out. For the 
a- during insertion 
b- extracting of the 
no.il 
Illustr, 2S 
ulna nail the nail catcher is slightly and elastic, and is 
ihtroduced by the hook closed side of the nail. The hook catche 
the nail tip behind at the moment when it leaves the nail, A ro- 
tation is not necessary in this case. 
The extraction hook is suitable for nails which can be re- 
moved easily (upper arm and forearm(111,30), 
Illustr. 30 
The nail bender (111. 31) permits the necessary shaping 
of the nail (with the exception of thigh nail) without da- 
maging the polished nail surface an event wh'-ch may happen very 
easily when using pincers. 
Illustr. 31 
The comparison-scale (ill. 32) serves to ascertain the 
diameter of the marrow cavity. It is attached to a belt with 
a balancing weight and is put upon the limb before the first 
X-ray in all cases of fractures which to be suitable for 
nailing in such a way that the scale is on a level with the 
middle mf the bone. The central beam of X-rays has to be half- 
way between the bone and the scale. bach grade corresponds to 
2 millimeters. 
Illustration 32 
The isolating .wire frame for the thigh and the leg serves to 
facilitate the asepsis. It erects a "wall" 4 centimeters high 
between the aseptic and septic parts and leaves open only a seal1 
area of the skin for the small operation wound. 
The re Jo si t i.o ning apparatus (MAATZ) is used for the re- 
positioning of the fracture fragments * Practically it is a 
lengthening of the arms of the operating surgeon. The apparat- 
us stands on the floor without any connection with the extension table. Since the forces acting upon the extremity nearly neu- 
tralize each it is not necessary to fasten it to the floor. 
The floor friction is sufficient. The rough adjustment brings 
the grasping arms to the desired level. The movements of the 
lateral levers are transmitted by a universal joint to a gear 
mechanism in such a way that strength is saved though the extent 
of motion is less. By of this apparatus interlocked frag- 
ments may be fr~ed, moved around each othr and put together in 
the most favorable position for the fracture as reouired for long; 
oblique fractures and spiral fractures. The crepitation of the 
bones touching each is transmitted so well by the instrument 
that it is imparted to the hand of the manipulator. Each plane 
can be fixed by an adjusting screw. This advantage is of the ut- 
most importance especially with transverse and over-extended ob- 
lique fractures. 
The semicircular jDadj; can be changed, according to the thick- 
ness of the extremity. The leather strap which has two big holes 
must be pulled over the ends of the pads in such a wav that the 
leather strap and the pads form a complete ring and that this 
ring is formed at any diameter half by the pad and half by the 
strap. In this way a firm grasp of the extremities is achieved, 
The straps must be tightened very firmly because any slackening 
will diminish the effect of the manipulations too much. The 
pads are mounted on a joint that may be turned to that they stand 
nearly vertically to the axis of the leg or the arm. Thus the 
fracture site remains uncovered for the X-ray, 
Fractures that can be reduced only by using very strong 
force (i.e. supracondylar femur fractures) cannot be replaced 
in the normal position with this apparatus. In that case it will 
be better to use a regular block-and-tackle that can be attached 
to h*oks in the ceiling and the wall. Other adjusting devices 
have been constructed by HERZOG, LINSENMEYER, ZOTTL and WITTMOSER, 
2* THE indication__and detailfd_statements 
ABOUT_THE__AFTER^TRdATMENT~ 
The following possibilities for the use of the marrow nail 
are given. The indications may be: 
1# Every fracture suitable for the nailing operation may 
be treated with the marrow nail, or 
2. the procedure is reserved for those patients who are 
particularly endangered by confinement to bed, plaster cast or 
extension treatment, or 
3. those fractures which present great difficulties in 
treatment may be nailed, such as plain transverse fractures wh:ch 
often heal in lateral displacem nt and which show the tendency to 
refracture, or 
4. the nailing treatment may be used for those fractures 
that may be replaced in the normal position but the fragments of 
which can by no oth°r method be kept in the proper oosition and 
which slip again and again. These fractures would otherwise re- 
auire an open fracture treatment. Here the indications for marrow 
nailing are the possibility of avoiding the opening of the fracture 
with all its dangers and disadvantages. These cases are not un- 
usual . 
5. A special indication is given fsr spontaneous fractures in the cases of tumor metastasis. Strange to say the majority 
of these fractures are subtrochanteric, • The patients concerned 
must be treated with plaster cast and confinement to bed for life 
because these fractures do not tend to heal, not even by frequent 
irridiation or other forms of treatment. With the marrow nail 
treatment these patients can at least stay in bed without pain, 
in some cas-s they may even become ambulatory although there is 
no hope for a bony healing of the fracture. 
In this way every surgeon who wishes to become familiar with 
the use of th6 new method has a rood chance of starting with the 
strictest indication possible and extending the indications 
constantly with growing experience. Since its introduction the 
new method has proved its value to such an extent that the dis- 
position to treat every suitable fracture with the marrow nail 
can be considered as justified. The ouestion "Which fracture can- 
not be cured conservatively?" considered under the influence of 
the marrow nailing leads to the further ouestion "Which fractures 
cannot be nailed?". 
The indication is different with children. the 
fractures will heal very ciuickly, stiffening of the ioints neod 
not be feared, danger by cast or confinement to bed is of no 
serious importance, minor defects in the position are compensated 
for on to an astonishing extent. The indications may be 
the more strict the younger the little patient is. With the 
baby there is only the smooth transverse fracture of the thigh 
bone which does not regain the normal position in a suspended po- 
sition. But ,the oldac. the child is the easier it will bn to decide 
for nailing a fracture in order to shorten the time of confinement 
to bed, the stay in the hospital and the duration of the disease. 
None the less the indication will always be more strict than with 
adults for reasons mentioned above. Technically it is ouito 
possible to nail even babies. 
The following statements are based on the proposal to nail 
every fracture suitable for the marrow nail. 
The ouestion whether a fracture is suitable for the marrow 
nail operation or not depends on the shape of the bone tube, and 
the shape of the fracture. The situation is somewhat complicated 
in many cases and the gradations of suitability vary so that it 
seems to be advisable to distinguish the following groups: 
"very suitable" 
"suitable" 
"less suitable" 
and "unsuitable". 
It must be emphasized that these general directions are given 
with respect to the present stage of the marrow nail technique. It 
may be hoped and is to be expected that with the further develop- 
ment of this method' the general conditions will improve greatly, 
At present it is advisable to apply a strict standard because it 
concerns a treatment which is meant to replace other well-tried 
methods, 
Totally excluded are all fractures involving joints because 
the nail may separate fragments which still are in fair position, 
while the nail may not find sufficient hold and the joints are 
endangered by the introduction of the nail. An exception is the 
T-sha ed fracture in the femur section of the knee-joint. It 
will oe dealt with separately later on. The suitability of a fracture for the marrow nail operation 
depends not only on the extent to which a nail may be fixed se- 
curely in the bone ends, considerations may be of great 
importance as for example, with supracondylar fracture. Here the 
conditions for an ideal nailing operati. in are extremely poor. The 
nail $uts out of the wide marrow cavity of th'*' distal fragment as 
a bolt because its diameter is much too small. Additional support 
byaplaster cast is required. But, nevertheless there is no better 
method of treatment, because the fragments cannot be fixed .together 
so well by any other method. 
Therefore it is necessary to discuss the indication in every 
particular case with regard to the limbs and types of fractures. 
The circumstances, on which the suitability of a fracture for the 
marrow nail operation depends determine also the method of the 
after treatment. Therefore we must discuss the essential facts 
together with the indications in order to prevent any unnecessary 
repetition. Nevertheless, the general directions will be dealt 
with in a special chapter of this book. 
A, THE THIGH. 
The femur of the adult resembles most a bone tube which has 
the same diameter throughout, A straight nail can be introduced 
from the trochanter. That means that the conditions are very 
favorable r 
aJL Pertrochanteric fracture, 
,T unsuitable” 
because the head end of the nail does not find sufficient 
hold in the upper part of the 
trochanter. Suitable for 
treatment with the Y-shaped 
nail (111. 16). 
O 
hi- Subtrochanteric fracture 
"very suitable” 
Secure against bending 
of the axis. Slight lateral 
displacement can be prevent- 
ed by a conic nail. 
Secure arainst rotation 
because the nail finds a firm 
hold in the spongiosa in the 
proximal sector because of its V-shape, while in the distal frag- 
ment conditions are favorable for sufficient friction. 
Additional support not required. Height bearing not advis- 
able until the lapse of three weeks. With a premature weight 
bearing the nail might work itself out laterally through the 
spongiosa of the proximal fragment. 
w 
Y.SI s e__and_o bl i£ue_ f r ac t ur ejs # 
The short fragment of which has a marrow cavity suitable -for 
nailing and which is at least 8 centimeters long, 
"very suitable” 
Secure against angulation lateral displacement and shortening. 
The danger of rotation depends on the amount of friction between 
the nail and the bone and is less with a jagged fracture or with 
an oblioue fracture and which is greater with a smooth transverse 
Illustr. 33 
lirastr.34 fracture. Additional support is retired only if rotation occurs. 
Weight bearing is possible immediately, (ill, 35) 
d) Spiral fracture 
"suitable" 
Secure against bending of the axis and 
lateral displacement. Shortening occurs 
simultaneously with rotation faults because 
the smooth fracture ends 
will slide past each 
other with weight bear- 
ing, (111. 36) 
Additional supp- 
ort is required only 
when rotation occurs. 
Weight bearing 
not before the lapse of 
three weeks, 
e) Comminuted fractures 
1, The largo fragments_are 
intact in their full leng- 
th in one, arean. 
"very suitable” 
Lateral displacement.js impossible. Se- 
curity against angulation depends solely on 
the stability of the nail. Shortening is 
impossible because the large fragments are 
intact in their full length in one area. 
Rotation ouite possible because it is pre- 
vented only by the friction between the nail and the bone, as the 
fracture is not jagged. 
Additional support necessary only in case 
•f danger of rotation. Weight bearing possible 
immediately, (ill, 37) 
2. Intsft bone tube in thie third fragmentf 
"very suitable", 
conditions as under e,(111,38) 
3, Comminuted compound fract- 
ure , 
"suitable" 
Secure against lateral 
displacement. Protected a- 
gainst angulation solely by the 
stability of the nail. 
Danger of shortening and 
rotation is very great because 
it is prevented only by the 
friction between bone and nail, 
(See also: gunshot fractures) 
Illustr, 35 
Illustr. 36 
Illust? « 37 
Illustr.38 Additional support by wire extension probably- 
reciuired. Weight bearing after a sufficient for- 
mation of callus, (111, 39) 
.§uoracondylar_f r act ur e 
"very suitable" 
because it is difficult to treat by other 
methods. 
The nail prevents the small fragment from 
slipping out of position. Small displacements 
are possible in eve- 
ry gradation, because 
the nail lies as a 
bolt in the marrow 
cavity which is too 
wide 4 
A reduction as 
ideal as possible should be striven for. 
Additional support (high plasto* cast for the 
leg, sometimes only Braun*s solint) always required f#r four weed 
Weight bearing possible after six weeks* 
£l_Si2E tii^condyl^r^opaxatioHjL 
(Y-fracture) 
"Unsuitable" for the simple marrow nail. As it is very 
difficult to treat such a fracture by the methods hitherto custor 
ary and as success is uncertain, 
the treatment with a special nail is 
recommended, 
The younger the individual conc'rr. 
ed the less favorable will be the con- 
ditions for the nailing of the th: gu, 
since the marrow cavity shows a fair- 
ly marked narrowing in the middle of 
the shaft during the years of growth. 
This fact has to be taken into con- 
sideration as regards the indications and the after treatment. 
The fractures suitable for the marrow nail operation generally 
are limited to the middle third of the bone. This fa.ct is not 
of so much importance in children because most fractures are 
usually situated in' that third. 
Illustr. 40 
Illustr* .39 
Illustr. 41 
B. THE LEG 
In the leg the situation is comparatively much more un- 
favorable than with the thigh, even with adults. The marrow ca- 
vity shov/s a co-'1 siderable waist-like tapering in the middle. The 
nail must be somewhat bent because it must be introduced later- 
ally, At the same time the nail has to be flexible and elastic 
to such a degree that it may prove a great disadvantage for the 
stabilizing of the fracture. As the nail must be introduced later- 
ally in front, its curve must be concave shaped to the front. 
Leg fractures lying in the middle third of the shaft nuite often 
will show a tendency to recurvation. The nail which must have > 
sim-liar slight curve will often not be strong «nough to counter- 
act the forces of recurvation sufficiently. Therefore this most The fragments are protected only against rotation and not 
against the other possible kinds of displacement. During the 
insertion the nail tends to push the lower fragment backwards. 
It is very difficult to prevent this dislocation and in many 
cas«s it will be impossible to counteract it even with an ex- 
ceptionally wide curved radius in the upper section of the nail. 
Even a successful repositioning; of the nail will not protect 
the bone cylinders from sliding off again, Even if the frag- 
ments do not slide off a stabilization by the flexible nail 
will always be t *o slight because the latter lies almost “loose" 
in the marrow cavity so that it cannot neutralize the disadvan- 
tageous forces existing in that part of the bone. 
The forces disadvantageous to bony healing, are very great. 
This is proved by the fact that compound fractures near that 
place are often observed. This fracture is suitable for a nail- 
ing operation by the use of a wedge which must be driven in bet- 
ween the inner and the outer nail. By this a very good "bolting" 
is achieved so that the fragments stand firmly together, 
b) Tfap ence between tfyc dipmeter of the marrow cavity 
and the thickness of tile nail is smaller than the thickness of 
the bone mantle^ 
al. .Transverse fractures /in the upper third). 
(m - k) 
"less suitable" 
A sliding off of the fragments is impossible 
(111. 44). It is protected against rotation in the 
upper fragment by a lateral nail bed, in the low- 
er fragment by the friction between the bone and 
the nail, and in addition by any bone"teeth"® 
The reason for its being "less suitable" is 
the fact that nail, owing to the insufficient 
friction between it and the bon'', do~s not stabi- 
lize the fracture sufficiently at the fracture 
site to guarantee a quick bony healing without 
additional fixation. 
Plaster cast is recuired. 
Weight bearing with the plaster cast is 
immediately possible, 
A safe nailing may be achieved by utilizing a wedge, driven 
in between the inner and the outer nail, 
iJL Oblique fractures (in the upper third) 
(m-n<k) 
"less suitable" 
A slight lateral displacement and shortening to 
a small extent, will always occur, (ill. 45) 
It is well protected against all further dis~ 
placement because of the great friction between 
the bone and the nail (at x). By this a suffi- 
cient stabilization at the fracture site is 
achieved. 
IJLlustr. LL 
111.45 Additional support not recuired. 
Getting up after three weeks oossible* 
It is recommended to use a Y/edge, 
c) Spiral fractures (in the upper third) 
(m-n<k) 
‘•less suitable" 
Hero we hav° the same conditions as with obli- 
que fractures (2b)$ Strong torsion forces are ad- 
ded whi ch cannot bo compl-tely neutralized bvr the 
nail, because the distance between the upper nail 
bed and the marrow cavity wall is too large in 
the distal fragment. 
Additional plaster cast for the log is 
required. Getting up with the cast is not advis- 
able until the of three weeks. Use of a 
v/cdge is recommended, 
<LL .Cpmminut ed_f r aciur e s_Xi22_ii}G„up.per_t hirdj 
(m-n-k) 
"unsuitable" 
By the breaking out : of lirger or smaller par- 
ticles of bone, the most essential factor which made 
a nailing operation effective in the upper third no 
linger exists, i.c,, the standing of the fragments 
one upon the other. By this the fracture slides off 
or, if this does not occur, the result will bo angul- 
ation to the side, whrro a piece of the bone has brok- 
en out, caused by the missing support ff the fragments 
on th° side. The stability of the nail which is not 
supported by the bone is insufficient(111, 47). 
mpound_f r actnr c s 
(in the upper third) 
"unsuitable" 
In this case a considerable aggravation of the unfavorable 
conditions prevailing v/ith the compound fractures 7/ill occur, 
2. Fractures in the middle third. 
sssfsssssssssrssssssssasssrsssssrsssssEsssatssassssssss 
Since the diameter of the marrow cavity is either ciuite the 
same or about the same as the thickness of the nail, all these 
fractures are suitable for a marrow nail operation. Thinks to 
the elasticity of its cross section the nail will fit tightly 
into the marrow cavities of both fragments and sufficient fract- 
ion will be achieved. 
Transverse fractures (in the middle thi Eil 
"very suitable" 
Lateral displacement 
and shortening are imposs- 
ible. Bending of the axis 
will be unlikely, owing to 
the stability of the nail, 
above all owing to the stand- 
ing one upon the other of the 
bone tubes. 
Ulus tr. 
46 
Illustr* 47 
Illustr. 48 nail does not suffice to prevent angulation with absolute cer- 
tainty. Particularly unfavorable is th“ situation in case 0f 
the breaking out of a triangle in front, since the curving of the 
nail will often result in a displacement in the nature of a re- 
curvation. 
In using the simple double nail an additional leg cast 
is nearly always renuired. 
Weight bearing (during wearing of the cast) according to the 
shape of the fracture but not before the lanse of 
three weeks. A better stabilization will be achiev- 
ed by the spread nail with an inclined plane so 
that additional bandages are not required. 
In case of a double fracture of the tibia 
(111. 52), i.e. in the case of the breaking out of 
a fairly long bone tube, marrow nailing is abso- 
lutely indicated. The central fragment is strung 
upon the nail. If the two fragments are in a 
place favcrable for nailing, the situation is 
very favorable. If, howevr, on° of the fractures 
is situated in an unfavorable place this dis- 
advantage must be accepted. At least one of the 
fractures is thQn kept in a favorable position. 
An additional plaster cast protects the other 
fracture against excessive displacement, so that 
the advantages of the nailing are still para- 
mount, B»th the wedge and spread nail are suit- 
able, ac ording to the shape and th° site of the 
fracture, to stabilize these fractures without an 
additional plaster , 
C CUMi23lit ed_c omjDO r j.c ( i n_t|i.Q_cg;ut ral..gtja:\rcQ 
"less suitable" 
The fracture can be stabilized sufficiently by 
the mere solidity of the nail. 
Lateral displacement is impossible. All 
other possibilities of displacement must be elimin- 
ated by the application of a plaster cast (leg and 
thigh) . 
Weight bearing not advisable before a suffi- 
cient formation of cal us has taken place, Other- 
wise the fracture might be shortened. 
In any case the application of a spread nail 
with an inclined plane is indicated, 
3 „ Fractures in the lower third. 
asrsaasBsasassasssasxgtassgBsssssssssssBssssssaBsssssssssssSM 
Here, again the suitability of thn fractur® for narrow nail- 
ing depends decisively on the amount of the disproportion between 
the diameter »f the marrow cavity and the thickness of the nail. 
That is why the use of the spread nail in such cases plays a 
very important part. The double nail, forking in its lower part, 
may have a much greater diameter than the narrowest part of the 
marrow cavity about the middle (center) of the bone shaft. While 
the simple double nail may be used for fixing toothed transverse 
fractures above the point wh°r° the above mentioned difference 
is less than the thickness of the bone cortex, the spread nail 
can be used with good result in many more cases. [’hwrefore, the 
Illustr. 52 
Illustr, 53 use of the spread nail is presupposed in discussing fractures in 
t he lower third of the tibia. 
§) Transverse fractures (in tjie_lower_t|].3jrdJ 
Shortening not oossible. Protected against 
lateral displacement by th® nail, against rotation 
by teeth and occasionally also by the nail, against 
angulation by the pressing together of the frag- 
ments by the muscles, occasionally also by the nail. 
Additional support not reouired, 
Getting up after the lapse of a fortnight. Turn-spread nail 
is recommended, 
b) Oblirue fractures (in the l»wer thircQ 
I* The fracture plane leans oblirue- 
ly downwards towards the dhner or outi 
part, 
a) Difference between the dia- 
meter of the marrow cavity and 
the thickness of the nail great',- 
than the thickness of the bone 
cortex. '’Unsuitable'1 for the 
simpel double nail because dis- 
placements of all types are poss- 
ible. The spread nail with in- 
clined plane protects the fragments sufficiently if the 
spread plane comes to lie to the frontal plane (see in- 
sertion of the nail), 
b) The difference between the diameter of the marriw 
cavity and th° thickness of the nail is less than the 
thickness of the bone cortex, 
’’Suitable1’, After the only possible 
displacement has taken place, accompani- 
ed by slight dislocation sidewards re- 
sulting in a shortening, a jamming of the 
nail and the fragments takes place. A 
further lateral displacement is prevent- 
ed by the nail, a bending of the axis by 
the bone tubes standing one upon the 
other and rotation by Hirth-teeth and all 
the muscles, v/hich counteract a lengthening of the bone. 
Plaster cast not reouired. 
Getting up after the lapse of three weeks. 
Spread nail with inclined plane recommended. 
II4 The fracture plane l»ans obliouely downwards to the 
front or to the back. 
Without spread nail the same situation prevails as with I. 
When using this nail (spread nail with inclined 
plane) the diameter of both nails together will 
be large enough to prevent a slipping of the frag- 
ments. So we find here the Same situation as with 
lb. The closer the outer nail lies to the bone in 
front, and the inner nail to the bone behind, the 
better will a sliding off of the fragments be pre- 
vented , 
111. 
54 
Illustr. 55 
111 u s t r r 
56 
Illuc 
57 Plaster cast not required. 
Weight bearing after the lapse of three weeks* 
ed._fraqture_and comminuted compound fracture 
vi£_the_l£wer_t 17 
"unsuitable" 
In either case the nail may perhaps b.e of a Certain value to 
protect a large fragment against a greatter dislocation by protect*- 
ing it laterally* Generally it will hot be possible to ascertain 
this by the X-ray beforehand, so that s. nailing may be performed 
only at a great risk. On the other hand, the greater part of the 
comminuted and comminuted compound fractures in the lower third 
of the tibia show the tendency to involve the joints or affect 
one or both malleoli. That is the reason why the nailing is con- 
traindicated, in order not to endanger the joint, or becomes un- 
suitable, because only the malleolar fracture makes the treatment 
with a piaster cast inevitable. 
«. THE UPPER ARM 
It is not possible to introduce a straight nail into the 
upper arm without endangering the shoulder-joint. The lateral 
introduction of an elastic flexible nail at the as we 11 as 
at the lower end of the mar ow cavity, however, is possible. A 
very broad indication for the nailing results fro- thus. A very 
short fragment, either the elbow- or the shoulder-joint, may 
be laid hold of by the nail and this way a sliding of this fragmer 
may be prevented. 
Therefore all fractures which in their shorter fragment have 
a marrow cavity at least a couple of centimeters long are ’’very 
suitable" because there is no better method of protecting the frag 
rnents from lateral displacement. The top of the nail may be drive 
into the spongiosa of the head in order to obtain better protectic 
In this way a fracture in the surgical neck may be treated by u- 
sing the marrow nail with the best result. 
Site and shape of the fracture, important only as re- 
gards the technioue of the introduction of the nail (whether from 
above or below), and at the same time for the after-treatment. 
Seldom will it be possible to achieve an "ideal" nailing, because 
of the necessity of inserting the nail laterally. In most cases 
the thickness of the nail will not be sufficient to achieve a 
strong friction of the nail and the bone for some distance. (see 
"general" part. For this reason it wil1 in many cases be possible 
to decide which kind of after treatment will be re- 
quired only after the nailing. An important indic- 
ation of insufficient stabilization of the fracture 
is a continued tenderness, aft- r the initial wound A 
pain has decreased. Insignificant motion near the 
fracture site cannot be ascertained by any other 
method, 
The kind of after-treatment depends also on 
the age of the patient. The arms of children and 
juveniles may be treated with the "Desault" bandage 
without any hesitation. Adults and especially eld- 
erly persons must have an adduction splint or an 
abduction cast because the shoulder may be in dang- 
er of becoming stiff.. 
It is known from experience that the danger 
of a postoperative torsion of the fracture ends is 
very small.. Therefore a special consideration must 
111. 53 be given to this only in very few cases, Fvidently the very 
flexible shoulder joint constantly yields so much that a dis- 
placement by rotation the fracture site does not occur. 
It is hardly possible to mention all the kinds of fractures 
of the arm above the wlbow and it is unnecessary. Therefore, we 
may select only a few examples. It will not be difficult to 
apply the principles to other fracture shapes appropriately* 
For the nailing technioue it has been proved practically to 
divide the bone into four sections, the first of which lies near 
the elbow joint* 
3jL Transverse fracture in thp third section 
"very suitable" 
Nailing from below, to give the nail a sufficient hold in the 
short fragment. Most favorable conditions because the 
nail finds sufficient friction at many spots of the 
marrow cavity though its thickness is necessarily in- 
sufficient. Thus the fracture is sufficiently stabil- 
ized. Bending of the axis is possible only to a neg- 
ligible extent* 
Additional support is not required. 
Exercises are possible immediately. 
Transverse fracture in the section. 
"very suitable" 
Nailing from below, since in this way only the ex- 
posure of the fracture can be avoided, while the top of 
the nail wil}. find an additional hold in 
the spongiosa. 
Additional support is seldom reauir- 
r ed, 
Exercises are possible immediately* 
c r a v e_ sl c jb_ur e__ 1. n__ t. fo s e c n # 
"very suitable" 
Nailing from above, because the distal fragment 
ment is too short, It is well protected 
against lateral displacement and probably 
also against rotation. The thickness of 
the nail must be much smaller than the 
diameter of the marrow cavity. The nail 
must not reach the distal end of the 
marrow in order to prevent a firm 
jamming. The nail is meant to act merely 
as a pin preventing a lateral displacement. 
Abduction cast for three weeks. After that, the 
cast must be cut open like a shell. Active exercise of 
the arm. 
The cast is to be removed after five weeks. 
i.1. OomminntQd fyaqtures in the.,.secondhand 
third_sactions# 
"suitable" 
Nailing from below or above. Fracture secure against lateral 
displacement, probably also against rotation. Stabilization of the 
111. 
t; q 
111. 
60 
111 
61 nail sufficient, because the forces acting upon the axis with the 
possibility of bending it are not gr«at, Shorten- 
ing improbable because forces shoving the parts to- 
gether are inconsiderable. 
Additional support (abduction cast) not always 
reouired. Nevertheless it is recemmended in every 
case. 
D. THE FOREARM 
The indication and the kind of after-treatment 
for fractures of the forearm are comparatively sim- 
ple. Thus, it may suffice to give here the general 
directions. 
All those fractures are suitable for the nail- 
ing operation the short fragment of which has a 
marrow cavity which is long enough that the nail 
may get a firm hold (ill, 63)* 
In the case of the typical ra- 
dius fracture the boundary is 
near the wrist at the ulna near 
the elbow joint, because the 
nail finds sufficient hold in 
the spongy bone of the olecra- 
non. If both bones are broken, both of them must be nailed. An 
additional bandage will be required very seldom if the nails pene- 
trate nearly the whole length of th-> marrow cavities. In that ca 
it does not make any difference, the "racture lies. The 
marrow cavity of the ulna as well as that of t radius arc shaped 
conically. Only v/ith a long nail wil1 .'it be possible to 
achieve a sufficient friction with the bone. Even if the forces 
leading to a displacement are very slight it was surprisingly 
often observed that' short nails inserted into the olecranon and 
at the styloid, process will work out. A bending of the axis is 
almost impossible, since nailed fractures support one another. 
Some examples: 
§,) fpaqfrurp l.Qt of tjhe..foge^riTi 
"very suitable11 
It is well protected against al1 kinds of displacement by the 
friction between the nail - 
and the bone, Hirth-teeth, 
by the standing one upon 
the other of the bone tu- 
bes and by the fact that 
the two bones support each 
other, 
Additional bandage not 
Exercises immediately oossible, 
hi- of tfoo foreprm near the elbow-joint 
"very suitable" 
Nailing of the radius in a typical way. For the ulna a specie1 
nail is required which must be considerably strengthened in the 
third near the head end. The reason for this is that strong bend- 
ing forces will be active with this fracture which must be neu- 
tralized exclusively by the nail, A short thick nail is not so 
111 
62 
Illustr. 63 
Illustr. 64 suitable because it shows the tendency to wander out of the bone 
because of the slight frict- 
ion in the long fracture 
piece. Besides this the nail 
end must be very broad (see 
page 19 ). 
The fracture is well 
protected against all kinds of displacement. 
Additional bandage not required. 
Exercise possible immediately, 
E. COLLARBONE 
The indication for the nailing of the clavicle will be given 
only occasionally. In nearly all cases a purely functional treat 
ment will lead to a nuick and satis- 
factory healing. If the surgeon does 
want to nail in of that It must 
be taken into consideration that vn r- 
few collarbones have a marrow cavity 
big enough for the nail and that in 
cases it will be necessary to . drill 
hole into the. bone for the nail. o.n 
very few cases will the r -position be 
possible without an exposure of the 
ir .cture site, 
4A.§UITABLE-TIME-AND_PRELIMINARY_TRFArMENT. 
As a rule the nailing operation will be the easier the ear- 
lier it takes place the accident. In any case a shortening 
of the muscles must be prevented. If this does occur it might be 
impossible to obtain sufficient extension, in spite of the applic- 
ation of great force, to permit the reduction of the bone ends, 
especially in a fracture of the femur. The reduction will be 
most successful within first few hours aftrr the accident. 
There will then be no difficulties at all. If the operation must 
be postponed for a couple of days, a wire extension is to be re- 
commended for the thigh fracture. The traction apparatus is in- 
sufficient and freciuently causes ulcers by the pressure. This 
will happen very easily, because the most freeuent cause for a 
postponement of the nailing operation will be the shock effect 
upon the patient, The patient must not be nailed during shock. 
This corresponds to the general rules of surgery, of course, 
Even shortly after shock the patient must not be nailed, because 
the indication for the nailing is never urgent. As experience 
has shown the danger is very great even for some time after re- 
covery from shock. 
The entering of small particles of fat into the lungs must 
be expected (MAATZ). It is, however, so negligible that with 
patients who are in good conditions of health, that It never 
appears clinically after the nailing unless there are additional 
severe injuries. With endangered patients with multiple fractwrr 1 
however, it may prove fatal. Therefore, an additional operative 
shock and an additional fat embolism must be prevented. If an un- 
usual bruising of fat-tissue of th* thigh (kind of trauma, marked 
edema of all the soft parts with large contusions) is to be 
Illustr. 65 
Illustr. 66 
Marrow-Nail in the 
c oll.ar bone supposed the patient must not be nialed even if he does not show- 
signs of a fat embolism. During the nailing operation the tissu 
must be moved more or less violently and handled. By this a 
massive displacement of fkt may oocur* The insertion of the for- 
eign body into the marrow cavity wil1 probably be only of subor- 
dinate significance. 
The closed thigh fracture will therefore bo treated terapora 
rily with a wire (skeletal) extension if the nailing cannot be 
performed on the day of the accident* 
f 
he adjustment of the fracture ends thus b^?ng made easy 
the surgeon will save much time and trouble by this comparatively 
small operation, while th° oeriod of waiting is tolerated much 
better b~r the patient. 
If an old thigh fracture with considerable shortening must 
be operated, it will be indispensable to apply first a wire 
extension. Even if the fractures are many months old, and if the 
fracture ends stand far from other an adjustment of their 
lengths v/ill be possible in a few days by the use of the skeletal 
traction apparatus. 
The leg, the forearm and the arm above the elbow may be con- 
served by applying the Kramer or Volkmann splint. An early 
nailing is recommended also for the leg. It v/ill be easier to 
nail before a more marked swelling sets in. Blisters caused by 
the nailing will occur only seldom and the earlier the fracture 
is ideally reduced by nailing the less freouently will i necrosis 
by pressure occur. 
5^._JARC0SIS 
The kind of narcosis to be used depends on the expected 
duration of the operation and the necessity of obtaining complete 
relaxation of the muscles for the reduction of the fracture. In 
the thigh a neiling will be impossible without sufficient re- 
laxation of the muscles. For this purpose th~ spinal anaesthesia 
will be very useful. Children, juveniles and adults under 40 
years are to be treated v/ith ether narcosis only when the spinal 
anesthesia is considered to be an unnecessary daugr to pati'nts 
of that ago. In the leg, the forearm and arm the elbow 
Evipanrausch (short 1 vipan anaesthesia) will usually suffice and it 
may be extended to an eth-r narcosis if necessary. Children must 
be treated only v/ith As a return of thp tonus of the 
muscles is to be desired (see after-treatment) the narcosis shoul 
not last any longer nor should it be deeper than necessary. All 
these considerations have to be taken into consideration, when 
the question has to be decided to what kind of narcosis should bo 
applied. It will, of course, be influenced largely by the cu- 
stom of the hospital concerned. 
So far only nailing of the forearm has been attempted under 
local anaesthesia. Infiltration at the place of the insertion 
of the nail and fracture site suffices. Our knowledge of the s 
sitiveness to pain of the marrow cavity is still rather insuffi- 
cient, Some patients have no trouble at all, oth°r complain about 
intense pain. # 
The proper arrangement of the patient should make possible 
a good extension, permit easy insertion of th<= n iil and leave room 
enough for the X-ray and the repositioning apparatus. Thus a free 
suspension of extremity concerned will be superior to the 
position in extension splints. Hooks in the walls and ceiling and 
block-and-tackle are very useful. Too much attention cannot be 
to the proper arrangement of the patient in order to obrain 
a good extension. Before speaking of the different positions and 
the various devices and gadgets reouired for the several bones t'v 
fundamental technique of the reduction of th~ fracture must be d s 
cussed. A reduction by hand before the fluoroscopic screen may je 
possible in some cases. but it cannot be a prolonged procedure 
because injurious effects upon thrt hands would be inevitable. 
Apart from this there are which require a lateral force foi 
the reduction of such strength as cannot be achieved by hand. 
Many difficulties will be encountered1 in maintaining the right 
position in the one plane during the radioscopy and reduction in 
the second plane if all this is done by hand, Therefore special 
tools are required. The simplest device of course are two straps 
which may be held in the appropriate position by or more 
persons (traction and counter traction). In many cases thn sur- 
geon will get along with this arrangement very In order to 
be successful in every cases better tools wil1 bn reouired. The 
above mentioned repositioning apparatus has proved to bo groat 
help. The handling of it is very simle. 1ts grasping hands are 
practically lengthened arm of the individual car ying out the 
reduction. hen reduction is obtained in onn plane the position 
may be held by a regulating screw while the fixation in the second 
olane is accomplished. The apparatus does not ~rork with rough 
force but allows a skilful loosening of jammed fragments and 
free manipulation o-f the fragments in order to achieve the most 
favorable position for the reduction of the fracture. T-qg 
manipulation will be decribod in detail under the heading "Tools'-. 
This apparatus will be unsatisfactory only when sufficient ex- 
tension of the fracture cannot be achieved, and in cases where 
great force is reouired. 
In these cases or, if a repositioning apparatus is not 
available, a block-and tackle will be a veyy great help, A 
femur fracture near the knee-joint may reouire a strong lateral 
force to align short fragments. Often this force may be achieved 
only by using a block-and-tackle. If a sufficient extension of 
the fracture cannot be achieved the reduction of the freture ends 
can sometimes be attained only by a strong bending at the fract- 
ure site on the principle described under osteotomy (ill. 67) 
The reduction of the fragments should 
not be undertaken until one is ready to in- 
sert the guide or the nail into the distal 
fragment. Thus an unnecessary ~nrolonged mani- 
pulation of the soft parts is avoided, apart 
from the fact that in some cases the inserted 
nail may well serve as an aid for the reduction, 
A fracture is to be operated with 
the patient lying on his side (111. 68), The 
lit. fcl 40 
patient must rest on the sound leg. The hips are bent a little. 
This posture makes the extreme adduction of the thigh unnecessary. 
This arrange- 
ment makes 
the nailing 
possible ev- 
en in abduc- 
tion. This 
will be of 
special sig- 
nificance in 
the case of a 
stiffened hip- 
joint. The 
legs are 
spread. In 
t his way it 
will be poss- 
ible to apply 
various forces, 
ts reduce and 
to X-ray comfortably. On almost every extension table one can 
improvise such an arrangement, The essential factor is that 
both legs are attached to the same extension bar, or , that 
both extension bars may be moved to the same side of the table. 
It is recommended to construct a particularly broad pelvis 
supoort which allows a lateral posture of the pelvis. A stockir 
bandage stuffed with cotton-wool must be wrapped round the hip " 
the injured thigh for counter-traction. the interposition c 
spring scales it must be fastened sideways on the upper end of t'• 
table. In this way one can measure approximately the force of 
the traction produced at the fracture site. Mth a correct pre- 
liminary treatment (early operation or previous putting of the 
fracture in a wire extension) 60 kilograms will seldom ha.vo to 
be exceeded. The traction itself is attached to the foot by a 
canvas anklet. 
One of the X-ray tubes must be put between the legs and 
the other at the stretched side of the thigh so that the sur- 
ge.on may work near the bent side. 
The reduction is then done according to the technicue descri. 
at the beginning of this section at the very moment when th° guid. 
rod is to be inserted into the marrow cavity of the oedistal 
fragment. In special cases another tochnioue must be applied. 
With fractures near the hip joint only one arm of the reposition- 
ing apparatus is used. It guides the long fracture oi~co whilst 
the short one is guided by -.he surgeon with the inserted nail. 
With comminuted compound fractures the use of the reposition apoa 
ratus and block-and-tackle at the same time may be desirable in 
order to provide sufficient control for the central fragment. 
In order to keep accessible on all sides it should 
also rest on the extension table. The patient lies on his back. 
The injured leg is put into a leg support. The knee-ioint is 
bent by about 45°, the leg is extended horizontally. The leg 
support lies near the thigh with its longer section in order to 
kr ep the leg free. Counter traction is not recurred. The 
traction apparatus is attached to the leg with anvlet made of 
canvas. 
The X-ray apparatus as well as the reoositioning apparatus 
may be readily used. The sound leg hangs down vertically. 
Illustr, 6B If a repositioning apparatus is not available or if the 
reduction requires stronger force (old fracture, application of 
a spread nail), a modified Boehler-extension apparatus may be 
used with excellent result. The apparatus is supplemented by 
some longitudinal bars to which movable hooks are attached. 
Small anklets and block-and tackle allow an easy and secure ad- 
justment. They can be worked in four different planes (gene- 
rally only two will be required). To overcome a strong resist- 
ance which may be encountered with old fractures th:s method is 
to be preferred to the use of the repositioning apparatus. The 
use o£ jthe gluoroscope screen is somewhat difficult. A small 
screen is reouired. The requirement is based upon the special 
situation in the leg nailing, as d°alt with in detail in the 
chapter "After-treatment", 
The_arm_above_the_elbow also must be nailed with the pahi-.n 
in a sup$ne position. The patient lies on a firmly fixed strel 
cher, the shoulder-joint of the injured arm touches the end of 
the stretcher. The traction ap 'aratus is attached to a wristba... 
The arm is extended in the wlbow joint and stretched away from 
the body at an angle of 45%. The counter traction apparatus is 
attached to the armpit on the same side by a broad padded linen 
strip. The belt runs across the breast and back in a direction 
opposite to the pulling force. 
Gen-rally the reduction will be made easy by using this 
apparatus. If the place of insertion of the nail and the fractn 
site> are close togeth r it is recommended that the arm be drape:1 
aseptically, A smal1 hole in the cloth keeps the skin free at 
the operation site. The operating surgeon and his assistant 
work aseptically. Sometimes the reduction is done by hand. In 
that case the reduction may be facilitated effectively by some 
side traction apparatus, attached and tested previously. This 
procedure is described, in detail for th«= forearm, because it is 
of greater importance for it. The asepsis of the assistant 
will be of great advantage in the nailing of the arm abovo the 
rtlbow, because the help cf an assistant is needed especially for 
drilling a hole In the bone. 
The reduction of the_forearm ipust be done with special 
care, since, owing to the lack of sufficient space a maximum uti- 
lization of the space available is required. As good facilities 
as possible should be available for the application of the re- 
positioning apparatus, because the adjustment of the fracture en 
is very difficult in many cas^s. 
The patient lies on his back on a firmly fixed stretcher. 
The arm above the elbow is extended at right angles to the body. 
The elbow joint is bent at right angle. The traction apparatus 
grips all the fingers by en-called "devil-finger". The pulling 
force is distributed equally upon the fingers by threading a 
cord to and from through small wheels at the rings attached to 
the devil fingers and the traction apparatus. The block-and- 
tackle then attaches to the handle of the traction apparatus. 
The counter traction apparatus is attached to the arm the 
elbow by a broad padded linen strip..and traction is exerted in 
the direction of the body axis towards the head. An additional 
counter traction is applied to the foot of the op "osite side and 
anklet and traction is exerted in the direction of the body-axis 
towards the feet with a block-and-tackle in order to fix the body 
of the patient who will stretch when traction is applied at his 
hand. 42 
The block-and-tackle applied to the hand works parallel to 
the body axis in the direction of the feet. If the sO-called 
"Goose-neck"(X-ray apparatus *f Pohl) is not available, the tube 
of which can be inserted into a narrow space the arm must be 
moved around maintaining the 96° angle at the elbow joint until 
there is sufficient space for a larger X-ray apparatus so as to 
make a horizontal radioscopy possible. 
He who forgets the counter traction at the foot will 
gradually drag the whole body of the patient across the taut 
counter traction apparatus at the olecranon and extension will 
be achieved only for a few seconds. 
The repositioning apparatus will be used with excellent re- 
sult in the case of a typical forearm nailing i.e., when the nail 
must be introduced percutaneously at the olecranon and at the 
styloid process radii and if the fracture lies in the central tb:’ 
If the fracture lies near the elbow-joint or near the wrist it 
is recommended to use auxiliary straps which may be worked by 
hand. They are applied to the skin with the varnish ,fMastisoln 
before the beginning of the operation. The forearm must be 
stretched well and securely in order to prevent a lateral dis- 
placement. Their suitable direction must be tested thoroughly. 
They take ef ’ect at the v°ry moment the guiding rod is inserted 
into the marrow cavity of the second fragment. The time expend- 
ed on the preparations will be saved during the operation. Ex- 
posure of the fracture site commonly to be observed especially 
with the forearm may thus be prevented. An interposition of 
soft parts must no$ be a justification. 
7^FLU0R0SC0PY 
It may seem surprising that a whole section of this book 
should be devoted to fluoroscopy. Observations made both in 
our own and in other hospitals, however, led to the con- 
clusion that it is not superfluous to do so. 'hen the technieue 
of the marrow nail operation is adopted by a hospital so many 
demands will be made on the attention and the energies of the 
staff by technical Questions concerning the operation that gene- 
rally the fluoroscopy will be somewhat neglected. In compar- 
ing the different precautionary measures observed in the X-ray 
stations with the methods adopted during the marrow nailing the 
latter will seem positively ruthless. This almost grotesoue 
difference can be explained only by the fact that people no 
longer realize sufficiently the injurious effect of radioscopy 
upon the body. 
To the patient the danger is certainly not so great because 
the operation is a solitary event in his life. The operating 
surgeon, the assistant and the rest of the staff concerned, 
however, are exposed to a great risk nearly every day, just as 
with cases reri radioscopy. 
But the patient too may come to grief. In some difficult 
cases the reduction may require as long as two hours, especially 
if it is done by unskilled personnel. In many cases the patient 
will be exposed to the X-ray beams far too long. The tube is 
generally brought rather close to the limb in order to get a 
distinct picture on the screen. Thus the patient may often 
get an overdose so that the skin may be hurt. Therefore the 
operating surgeon is urgently reeuested not to overlook this fact 
because of the great technical difficulties involved in some cases. 43 
Besides this we must not forget that are some X-ray 
apparatuses with which the covering of the tube heats up after 
protracted use, and this may lead to thermic burns of the skin. 
The sound thigh especial’y is greatly endangered because it lies 
close to the tube during the fluoroscopy. An insulating layer, 
f. i. made of cellulose may prevent this* 
The operating surgeon and his assistant are certainly en- 
dangered much more* The war conditions will not allow for some 
time yet a joining of all transportable X-ray apparatus with the 
fluoroscopyc scr or their bring furnished with the reouired 
protective screen (made of lead sulphide). Many beams will reach 
persons near the observing doctor. Therefore it is ouite 
wrong to use a screen as small and as light as possible for reasons 
of convenience. The larger screen will afford a better protection. 
The situation is favorable, when the tube can be brought so close 
to the fracture site, or tohen the screen is so large that no beams 
can pass its rims. Nevertheless, the number of secondary beams 
will remain alarmingly great* 
'the following directions are to be given under the present 
circumstances: 
The time required for the fluoroscopy must be as short as 
possible. It would be advisable to instruct the technical assist- 
ant to flash up every view for one second only. For a skilled 
individual this time will suffice for his orientation. 
For this purpose, good adaptation is required. It is ad- 
visable to operate in dim white light or better even in red 
light. AH manipulations of the operating surgeon are possible 
in dim light. 
Tube and screen must be brought so close together, or the 
light should be turned off so much that the beams reach only the 
screen. If necessary a small diaphragm ma"e of lead should be 
constructed. 
The creen must be carried with the hand well protected by 
lead gloves. 
All persons working near th~ patient should wear a lead 
apron. 
A transportable X-ray apparatus is absolutely required. It 
is still better to have two, because one may not wor£. If the 
surgeon does not want to expose the fracture it will often be 
necessary to interrupt the operation. The easiest way is to nail 
the leg without X-ray control. This should, however, be done 
only if absolutely necessary, nor will, it always be successfull, 
Fspecially suitable are the so-called uSehwanenhaelseM ( 
swan’s necks) furnished by the firm of Pohl. They are a small, 
efficient X-ray apparatus. Thanks to the small size of the tube 
and to three joints attached to the apparatus, the tube may be 
inserted into very small spaces, no loss of space being caused 
by the support of the apparatus. M 
8a_ASEPSIS 
The asepsis may be endangered by the fact that one has to 
work in the dark during the fluoroscopy and above all by the smal~ 
space at one’s disposal. If the fracture is reduced by hand the 
assistant may work aseptically too. In that cas° the whole secticn 
of the limb must be wrapped up aseptically. The asepsis is con- 
siderably endangered by the fluoroscope or the fluoroscopic screen , 
Therefore a elean separation of the space required by the operating 
surgeon and the reducing surgeon is desirable. This separation is 
absolutely necessary if reduction is not done by hand. The 
more exact it0is the easier it will be for each to keep within 
his limits, therefore it is recommended to erect a separating 
"wall" (in the proper sense of the word) , The wire frame which 
is covered with a cloth has a separating wall 4 centimeters high 
near the aperture in the cloth. From outside the screen may be 
put against this little wall even in the dark. The 
cloth with the aperture and the wire frame must be pasted broadly 
over the trochanter with mastisol. The side on which the operatin' 
surgeon works must be screened off by a large cloth. During the 
fluoroscopy reouired for ascertaining tine position of the guiding 
rod a small cloth which must be renewed each time must be put 
over the site of the operation, since the screen encroaches on the 
space reouired by the •perating surgeon. control will be 
reouired less often as the surgeon becomes more experienced. He 
will then be able to "feel" his way into the marrow cavity, so 
that control of the position of the guiding rod within reach of 
the repositioning surgeon i.e. near the fracture site in the non- 
aseptic area, is quite sufficient. 
Also in the case of thigh fractures near the body a separation 
of the operating surgeon working aseptically and the surgeon who 
does the reducing and who works non-aseotic illy is to be r ec onmouc - 
ed, The latter has to direct only the fracture oioce distant from 
the body, whereas the surgeon doing the nailing directs the one 
near the body. 
The above described separation is easily achieved when the 
leg is concerned. The cloth-covered wire frame covers up the 
bent knee-joint. 
In the arm above the elbow and the forearm one will prefer 
a complete protective cover the closer the place of the insertion 
of the nail to the fracture site. The small space available 
makes a separation difficult. Nevertheless, it must be accomp- 
lished when using the repositioning apparatus. See chapter " 
Proper position of the fracture ends". The traction straps des- 
cribed there must be fastened before the protective cover is 
attached and they must be tested as to their capacity. For the 
operation wound, slits in the cloth 1-2 centimeters long, will 
suffice. Here also the cloths must be pasted upon the skin near 
the aperture. The auxiliary traction straps must be covered up 
too. Their ends will of course project from the aseptic area. 
The length, thickness and shape of the nail depend on the 
thickness and shape of the bone as well as one the position and 
the kind of fracture. It must he <wnphasizod once more that the 
success of the nailing operation depends on the nail being fixed 
in the marrow cavity of the two fragments as firmly as possible. 
In using a thin nail the operation will be " a s y of course but >45 
success is not certain. Therefore, the diameter of the mar ow 
cavity should be ascertained accurately at its narrowest part. 
At a focal distance of 75 centimeters the average record on the 
plate will amount to about 1 millimeter. It is also possible to 
hold the probably suitable nail beside the limb, when taking 
another X-ray so that it will be possible to take a comparative 
measurement, as the distorsion will be the same (EHRLICH). To 
use a "Metalltrepee" (a scale made of metal) will be even better, 
because it is simpler. It is furnished with a strip of leather 
and a counterweight and is put on the fracture at the level of 
the bone, when the first X-ray is taken. The same record will 
be obtained when the central beam is put between the scale and 
the middle of the bone. Each grade of the scale is 2 millimeters 
long* The grades run in the direction of the axis of the extre- 
mity, In this way the bending out of line of the scale will 
not become a source of mistakes. So, even with the first X-ray 
the width of the marrow cavity can bo read. 
For the thigh it is preferable to us~ a thinner nail. The 
marrow cavity which is largely of the same v/idth affords a 
sufficient friction. With a nail which is too thick, however, 
the friction may become so strong that the nail jams. During 
every operation all the three different widths of the selected 
nail should be available (see insertion of the nail). 
For the_leg it is recommended to us- a nail as thick as 
possible. the marrow cavity is narrow only for a short 
distance. The nail may be driven in >ith some force because it 
will enter easily thanks to the elasticity of its cross soction. 
So there is the advantage that the nail jams in the marrow cavity 
to as large an extent as possible. 
For E-.lhoyr_the_elbow it will seldom be possible to 
solect a nail corresponding to the diameter of the marrow cavi- 
ty since its latoral insertion is rather difficult in this case. 
If, however, the surgeon selects a nail which is some millimeters 
thinner than the measured width the nailing will be successful 
and the two nails will provide a sufficient hold. If the fract- 
ure lies near the elbow joint the nail should be so thin that is 
certainly cannot jam in the tapering marrow cavity at the el- 
bow joint. For the stable osteosynthesis the jamming will not 
suffice anyhow, a plaster cast will reeuired and. the jamming 
to be feared would lead to a blocking caused by the nail. In 
such a case we have to sp*ak of a ‘'bolting”. 
For the__forearm__ in most a rather thin nail must 
be selected for a typical nailing operation, since ulna and 
radius have rather thin marrow cavities in their tapering parts. 
This disadvantage will be offset by the fact that long nails 
may jam at many points of the marrow cavity along the whole 
length of the bone. Short nail, however, inserted from the side 
and nearer'to the fracture site should and may be thicker. Their 
being inserted from the side will, however, make it impossible 
to utilize fully the thickness corresponding to the diameter of 
the marrow cavity. The hold provided by such nails is not 
sufficient. Here, also we have to sp-ak of a ''bolting”. 
Tjie_lengtji of the nail is of some importance only in con- 
nection with fractures near the joint, which are ,t t'l-' same 
time distant from the place of insertion. In such a case one 
must not miscalculate. vven one millimeter may be valuable or 
cause trouble. •46 
In case of all other fractures one should bear in mind 
that too deep an insertioh of the nail into the peripheral fract- 
ure piece can only be superfluous and will never cause trouble 
or be disadvantageous. The length may be meaHured best on the 
sound extremity, at tho thigh from the end of the trochanter 
to the slit of the knee-joint. From the slit of the knee-joint 
upwards one has to subtract 3 centimeters. Au the trochanter 
one must add 3 centimeters for the part of the nail sticking 
out so that the measured length corresponds to the allowed length 
of the nail* 
On the leg one measures from the dimple between the sinews 
of the extensor digitorum lon?us and the tibialis anterior muscle 
at the heigh of the ligamentum cruciatum curis to the middle of 
the tuberositas tibiae. Because the nail should be at least 
always 1 centimeter distant from the joint plane of the foot, 
the measured distance corresponds to the desired length of the 
nail. For the bending 1 centimeter must be allowed. The leg 
nail should be as long as possible. 
Special attention must be given to the selection of the leg 
spread nail. chiefly matters is that the inclined plane cf 
t he outer nail, which pushes the inner 
nail backwards should have the right • * 
position. If the inclined plane comes 
to lie in that part of the marrow 
ty v/hich is too wide it will be in- 
effectual because the counter pressure 
of the bone will be lacking. The end 
of the inclined plane lies at the spot at wh ch the marrow cavi- 
ty is just sufficiently wide for the two nails \e.)m It will 
be advisable to measure it distally, i.e, fro the foot' joint 
plane. Since tho nail point should be 1 centimeter distant from 
this spot, that centimeter must he subtracted (f-1 centimeter 
- distance of the end of the inclined plane from the nail tip) 
(111.69) 
In the__arm__above__the_elbow the distance from the intended 
insertion place to the usual insertion place near tho elbow joint 
should be measured if the nail is introduced from above, as 
the marrow cavity ends there. If the head of the arm bone is 
to be taken hold of too, i.e., if the nail must be inserted in 
an upside-down direction, tho measure should be applied at the 
corresponding spot. 
For the__forearm it is preferable to take a nail as long 
a® possible if it is a case of a typical nailing. In thiB way 
the fractures are best secured. A wandering out of the nail, ob- 
served especially in the forearm near the elbow joint as well 
as at the wrist, is made impossible. For the radius the nail 
must reach from the styloid process as far as 2 centimeters from 
the head of the radius, and in the ulna from the olecranon as 
far as 2 centimeters from tho styloid process. 
Tfoe longitudinal profile of the nail is generally dctor- 
mined”and prescribed. Nevertheless, it is recommended to modi- 
fy that shape in special cases. In Northern Germany the straight 
thigh nail is generally used. It is easy to insert in the 
slightly bowed bone. In other parts of Germany the bones are 
sometimes bent so much that the nail too has to bo bent before 
its insertion. But one cannot depend on its following the shape 
of the bone. If the fracture site is near the greater curvature 
of the bone there is the danger of a splitting of the bone. 
Fven though the splitting of a straight thigh bone by a jamming 
marrow nail is hardly possible, a large piece of the cortex may 
ILL.. 47 
easily be broken off of the greater curvature of a bowed ''one, 
if the nail is driven only against one side of the bone. 
In the leg the middle part of the nail 
should always be straight, in order to prevent 
a recurvation. It is recommended to give to 
the inner nail a stronger curve than to the outer 
nail, in order to achieve a better jamming. It 
should be emphasized that the surgeon who is not 
yet fully skilled in this operation will do well 
to insert the double nails one at a time. Later, 
when greater skill has been acnuired they can 
be driven in at the same time. 
The nail for the arm above the elbow too 
should be as straight as possible in its middle 
part. If a short fragment is entered for only 
a short distance by the tip of the nail that 
tip should not be curved. 
With the forearm the nail 
f*r the radius only should be 
bent somewhat at the head end. 
Thus no forces can act upon the 
wrist when the nail is once fix- 
ed. In order to facilitate the 
insertion the nail should be 
bent only after about two thirds 
of it have entered the bone. 
Otherwise the nail remains 
straight. For the ulna a nail 
of a straight shape is always 
used. (111. 71) 
For a fracture near the 
elbow-j»int a special nail is 
used, which is thicker than forearm 
nails and tapers at its end . 1 his shape is 
reouired since the nail should be fixed very 
firmly ai the fracture site. At the same time it must be driven 
into the ulna so deep that it cannot work itself out of the bone. 
The nail end must be particularly broad so as to find sufficient 
hold in the spongy bone, A thin nail will cut the soft spongiosa 
(see chapter I). 
III .^0 
III/) I 
OF THE GUIDE ROD 
In order to facilitate the introduction of the nail into 
the proximal marrow cavity a guide rod is used for the nailing 
of the femur and the ulna. At the same time this has the ad- 
vantage that the guide rod can easily be pushed forward at the 
moment of a successful reduction in order to maintain the re- 
quired position of the fragments. When the nail is driven in 
by blows with a hammer an unintentional displacement of the 
fragments may easily occur. Whereas a guide rod wrongly placed 
may easily be taken out again* the striking out of a nail may 
offer considerable difficulty especially in the thigh. In a 
nulling of the ulna it will be a great advantage if the guide 
rod is inse ted into the distal marrow cavity a short way at the 
moment of a successful reduction. This technieue would be help- 
ful also in the radius. Here, however, it wil1 be advisable 
not to use the guide rod, in order to avo d all the stress not 
absolutely reeu"red which might cause a breaking of the bone 
at the bone at the styloid process near the wrist. 48 
Both guide rod and nail must have the necessary free play, 
0 nly. sui t a1'le sized instruments may be used. If the guide rod 
is^fixed too tight in thQ nail a jamming may occur the moment the 
na.il is inserted, since the na.il shows a tendency to adapt itself 
to the shape of the bone and must be free to bend more or less. 
For the insertion of the guide rod at the thigh the direction 
of the marrow cagity must be indicated on the lateral and posterior 
sides of the thigh with a skin pencil. Those lines are determined 
during the horizontal and vertical radioscopy. To protect the 
ha.nds from exposure to the X-ray beams during the radioscopy it is 
recommended to use a long guide rod which must be brought into 
the direction of the marrow cavity. The lines will then be marked 
upon the skin accordingly. It is obvious that the direction of the 
marrow cavity of only the proximal fragment is important. The 
lines are extended and distally for the entire length 
•f the thigh. If the radioscopic planes are correct both lines 
must meet near the trochanter and at the insertion snot of the 
guide rod. Nevertheless it will often occur that the point of 
intersection is farther in the dir-ction of the trunk. So it is 
of no value for determining the spot for insertion of the guide 
rod. It will be better to go by the palpation finding. The 
trochanter tip can be felt easily pvon with corpulent people, 
A stab incision 2 centimet rs lorn? is made slightly in the direct- 
ion of the head and mddially from the tip. Then the guide rod is 
inserted into the trochanter. One may also drill a little h#le 
into the bone with the awl, that the guide rod is pushed 
forward by hand, turning it slightly. In this way the guide r»d 
will not jam tio much in the trochanter, and it will be much 
easier for the surgeon to feel whether the guide enters into the 
marrow cavity, or whether it is in a wring direction or not. The 
direction lines of the marrow cavity indicate how the guide rod 
is to be held. The upper part of the thigh being covered with 
sterile drapes andthemarcation being covered up also, the marcation 
lines should be extended onto the lower part of the thigh as 
described above. 
The guide rod must not be too sharp at its tip. Otherwise 
it may occur that it jams laterally in the corticalis. This 
fact must bo taken into consideration especially with children’s 
bones. 
After a short time the surgeon will get an excellent sense 
of whether the guide rod is in the right position or not, so 
that additional radioscopy is reouired only v/hen the tip of the 
guide rod approaches the fracture site. If, however, the in- 
sertion should prove difficult, it will b-" to desist from 
making further attemtps and to ascertain right position using 
the screen, In case it is faulty it will be advisable to make 
another insertion. Otherwise the guide rod might slip again and 
again into its former position. There can e no objection to push- 
ing the- cruide rod forward by slight hammer strokes. As soon as 
the surgeon has a certain esperienen the sound of the instruments, 
and the success of each stroke of the hammer will indicate to him 
whether he is making satisfactory progress or n»t, 
. - - . ' • * ' ". a • * 
The insertion of the guide rod, may be rather difficult-, in 
the case of a fracture very high in the upper- pArt. of the bone. 
If short fragment is. in abduction i£ will.in rare. cas.es be 
necessary to use a strong so-called,. Schanz Dorn (a. pr>ick-.puhch 
constructed* by Schanz). If inserted percut an.eously. and laterally 
into the trochanter it. will, be a convenient handle until the , 
guide rod. is introduced and the reduction is achieved. If the 
short fragment stands in an adducted position this may lee.d to an 
increased adduction of the guide rod. The tip #f the guide rod 49 
then shows a tendency to jam in the corticalis (outside). A 
vicious circle will be the consequence. The insertion of the gui d ' 
rod will, however, be considerably facilitated if a traction strap 
is attached to the short fragment before the operation, which by 
pulling in an outward direction will give a certain stability 
to the short fragment. 
It will not be difficult to introduce the nail into the 
distal fracture piece after a successful reduction. In the ulna 
the guide rod is inserted through an incision in the skin 
meter long, at that point of the olecranon wh're the extended marrc 
cavity of the bone is supposed to be. There the gu de rod must 
be drilled in or driven in. This spot can easily be detormined 
by touch, for, the center of the bone can be felt distinctly. 
Appropriate X-ray control in both planes will be a good protection 
against any mistake. 
11. THE INSERTION OF THE NAIL 
By way of introduction something shall bo said about the tech- 
nique of nailing* Generally the surgeon wi1 1 be inclined to 
introduce the nail with many light careful strokes of a hammer. 
It is better, however, to insert the nail with some powerful 
strokes driving the nail well home* Thus the bone Is not shaken 
so much. A continuous striking upon the bon.'' will often lead to 
an infiltration of fat into the blood vessels (LARSRN). Besides 
that the striking in of nails in a workmanlike way is less tediou: 
and much more elegant. 
It is not at all difficult to insert the nail into the 
thigh, as soon as the selection of the na.il and the position of 
tha guide *nd are correct. It does not make any difference, 
whether the guide rod is inserted first into the two fragments 
or into the proximal fragment after the distal fragment has been 
pierced slightly by the guide rod. The latter method is prefer- 
able only when the fracture-piece near the body is short so that 
it must be guided with the nail during the reduction. 
The nail being elastic and flexible on all sides it is of 
n» importance at all to which side its open part is directed, Trr 
resistance is fairly strong, while it is in- 
serted into the trochanter. As soon as it has 
entered the marrow cavity in the right way it 
will penetrate about 2-3 centimeters with 
each stroke of a hammer weighing about -g- kilo- 
grams. A splitting of the bone is not to be , 
feared, more likely it will get stuck in the 
marrow cavity. One must, however, see to it 
carefully that the nail is not driven in sub- 
trochanterally through the compacta. This 
may happen when the guide rod driven in by 
hammer strokes first pierces the compacta 
and reaches the marrow cavity only after- 
wards, In such a case there is danger of 
splitting the bone (ill. 
Since the degree of friction between 
the nail and the bone depends largely on the 
small ridges in the marrow cavity, it may 
happen again and again that the thickness of the selected nail 
proves to be unsuitable. If the nail tends to get stuck or if 
it has not sufficient friction it is preferable to take it out 
again and to replace it another nail. The trick is to find 
III <?2 50 
out in time, when the nail first shows a tendency to jars, i.o. 
when it can still be struck out without difficulty. No doubt 
this is somewhat risky especially for the beginner. He cannot 
be careful enough. Therefore it is recommended that the begin- 
ner should use a comparatively light hammer, a hammer of half 
the weight of the normal hammer. The danger that the ener*?v of 
the hammer will not be sufficient is very slight* 
If the head end of the nail is flush with the 
end of the guide rod so that the removal of the 
guide rod is not possible the nail set I for the 
thigh nail should be used, (111* 73). 
The guide rod may be removed as soon as the 
nail has penetrated into the distal fragment for 
some centimeters. The extension is relaxed or 
taken off altogether so that the fracture nieces 
stand firmly one upon the other. The chief 
thing is to eliminate any possible faulty rota* 
tion and to insert the nail definitively strong- 
ly pressing the distal section of the limb 
against it. It should stick out of the bone 3 centimeters in the 
case of an adult and 1-2 centimeters with children according t. 
their ages. It is very easy to maintain the right distance with 
the nail set II for the thigh nail. 
The leg_nail is inserted into the marrow cavity in front at 
the tuberositas tibiae. The tuberositas must be exposed by a 
medical or lateral incision. The loose skin is to bo turned 
back and held with a towel clip. The incision should be made 
in such a way that the lower angle of the wound corresponds to 
the point of insertion spot 
on the bone. In this way 
any unnecessary injury to 
the wound edges near the 
by the nail or the 
guide rod which are insert- 
ed obliquely is avoided. The 
awl is applied at the level 
of the tuberosity and in the 
middle of it, in a more or lcs 
vertical direction. As the 
awl penetrates deeper into thr 
soft bone the handle should be 
lowered. The bayonet-shaped 
awl allows a rather tangential insertion (111. 74). In this way 
the insertion of the nail is considerably facilitated, Ivon 
with the first strokes the head end'of the nail should *be lowered 
as much as possible in order to facilitate an"Jeasy sliding along cf 
the nail on the inner back wall of the marrow cavity. The na^l0 
should point toward the second toe. A well skilled"surgeon will 
easily find out whether the nail is in the right or wro nm positio- 
by the resistance encountered in the cavity. If the X-ray control 
shows th t the nail-is following al#ng the back wall, a further 
A-ray in the second plane will be superfluous. 
Since the double nail is not uniformly curv'd, its bending 
radius being amallerat the ends and the central part nearly 
straight, the inner and the outer nail must be inserted at the 
same time. Otherwise A very disagreeable jamming may occur. The 
insertion is greatly facilitated by the nail s~t, which transmits 
the force of the hammer-strokes in the direction of the central 
part of the nail. (111. 75 ) 
ILL TH 51 
Aft er the nail has pene- 
trated into the distal marrow 
cavity one must try to achieve 
as ideal a reduction as poss- 
ible, which is important for 
the leg especially with regard 
to any lateral displacement. At 
the same time the extention is 
relaxed a little and the fract- 
ure fragments are pressed strong- 
ly together. 
The insertion of a spread nail may be difficult, especially 
if the spread nail with an inclined plane is used, and in cases 
where the second nail, i.e. the inner nail tends to break out 
laterally through the fracture site. Therefore it will be ad vis." 
to insert completely the outer nail which bears the inclined 
plane first. A good protection against a further pene- 
tration of this nail into the marrow cavity is the wire counter 
traction with attached 
weight* A dislocation 
of th~ fracture with 
traction and counter 
traction may then be 
reouired (modified 
Boehler-apparatus with 
block-and-tackle), in 
order to facilitate 
the insertion of the 
inner nail into the distal marrow cavity (111* 76)* Should the 
outer nail penetrate too deep which will definitely occur if the 
inclined plane lies to far proximally - in that case a piece of 
the wire counter traction will have to be left deep in the wound 
as a loop in order to facilitate the later extracti n of the 
nail. If the plane of the spread is intended to lie in the fron- 
tal plane the nails must not 
be inserted in the middle of 
the tuberosity but rather by 
the side of it , and it will 
then be no difficulty at all 
in putting the bending plane 
of the nails and as well as 
the spread plane in such a 
way as seems to be most suit- 
able ff>,r the shape of the 
fracture (ill. 77) 
When the turn-spread 
nail is used the inner nail 
must be introduced complete- 
ly first, and in the begin- 
ning in such a position that 
its distal part is concave 
shaped to the front. As 
soon as the point of the nail 
lies in the wider section of 
the lower marrow cavity the 
nail is turned round 180° 
using a screw driver. This 
turning must be made before 
the point of the nail has penetrated into the spongicsa of the 
distal bone section. During the insertion of the outer nail the 
completely inserted nail is then protected against further pene- 
tration by a holdfast wire or cross-pin which is inserted into an 
ILL 1 S' 
mu 
ILL.'/1 52 
an oblique hole *. - 
at the nail head 
provided for this 
purpose and which 
finds a firm hold 
on the tuberositas. 
If, however, the 
outer nail should 
show a tendency to 
w»rk ito'way out 
of the fracture-slit in front, suitable dislocation must be made 
during its insertion into the marrow 
cavity (ill. 7$). 
I In the arm above the elbow the 
nail may be introduced at tw® places 
i,e, near the elbow joint, cr near the 
shoulder joint. Both places are easy 
of access and the choice will depend 
on the site ®f the fracture. Two con- 
sideiiations are decisive; In the firs4: 
place the nail is t® find a firmer hclc: 
in the short fragment by penetrating 
the corticalis laterally. In the 
second place an exposure of the fract- 
ure hematoma should be avoided. The., 
fire a very short fragment should not 
be nailed from the side of the hema- 
toma ®therwise the fracture site would 
be exposed. Fractures in the second 
and fourth section of the bone should 
be nailed from above, all the other 
fractures from below (ill, 79), 
The upper insertion point must be exposed by an incision 5 
centimeters over the deltoid muscle. The muscle must be split 
longitudinally with a crown-gimlet and a hole must be drilled from 
the side into the corticalis, so that the marrow cavity is opened 
up. Then the two nails can be inserted obliouely. They .should 
project out of the bone for l-g- centimeter. 
If the nail is inserted ?,roin below the drill hole is situated 
about 2 centimeters above the fossa ®lecrani. Here the marrow 
cavity may be so flat that an extension of the drill hole upwards 
may be required. At that spot the nail should project out of the 
bone for about one centimeter. 
If the nail inserted from above is too long it must under no 
circumstances be inserted too deep. Otherwise it would jam in 
the marrow cavity near the elbow. It thus push the second 
fragment al#ng before it and might cause a gap. If in such a case 
the nail head end should stick out of the bone too far the nail 
must be changed. In order not to loec t h e reduction a thin guide rc 1 
must be inserted before the nail is removed ( if need be a Kirsch- 
ner - wire may be used), 
A special description of the nailing of the ulna is not need- 
ed. The straight nail may be inserted with the help of a thin 
guide r®d. 
At the radius the insertion ooint for the nail lies between 
the sinews of the extensor poll, longus and brevis. Over the 
middle of the styloid process radii a stab incision 5 centimeters 
long must be made and a tiny hole must be drilled oolieuely inuo 
the marrow canal with the awl. X-ray control while taQ awl is 
put t® the bone will ensure the finding of the right -pot. The 
Illustr. 78 
III. 53 
nail is always inserted with a slight pressure of the finger away 
from the wrist. The nail head end is bent before its final insertii 
(see shape of the nail longitudinal profile). The cutaneous wound 
is closed with a stitch-suture. 
12^thf_aftertrfatmfnt 
Only a few words need be said about the aftertreatment of a 
successful nailing. If the oossibllity of a displacement of the 
fracture ends is out of the ouestien the moment of the first move- 
ment of the limbs and the time for th° first weight bearing depend, 
tn the general condition of the patient and the extent of the very 
painful bruising of the soft parts. Fffusions of blood into the 
adjacent joints which used to occur much less freouently when the 
old methods were ih vogue, and which are only partly caused by the 
forcible extension during the operation may demand a long confine- 
ment to bed. Whan making up a list of a number of cas-s one is 
surprised to find how few patients with thigh fractures can or may 
get up within the first week after the nailing. The number of 
attendant njuries among which concussion of the brain or skull 
fractures are particularly frecuent, is astonishingly gr~at. 
Though experience has shown that the aftertr»atrent does not 
give much trouble either to the surgeon or to th° nursing personnel 
the vigilance of the surgeon must be all the greater. In case 
of insufficient care the number of persons discharged too early 
only to return to the hospital after few weeks with unexpected 
dislocations will not be small. Malpositions must be detected at a 
time when they may be corrected during the "Rausch" (anaesthesia) 
in order to prevent a later osteotomy. 
The aftertreatment begins sft°r the wound has been closed i.e 
while the patient is still under the anaesthetic. 
1. With nails less difficult to bend (leg and forearm) the 
proper shape of the nail must be verified using the fluoroscopic 
screen. The leg nails in particular may require some correction 
as they very often get bent in the form of a recurvation of the le 
during the insertion. 
2. The possibilities of a displacement of the fracture ends 
must be examined as soon as the nail has been inserted, If a bend- 
ing of the axis is still possible, an additional plaster cast is 
urgently reouired. 1f rotation is possible, an additional plaster 
cast must be applied if the shape of the fracture makes is prob- 
able that even the return of the muscle tonus the principle 
of the Hirth teeth is out of the ouestion. If a fixation by the 
Hirth teeth may be expected a splint which will prevent a tipping 
of the limb until the end of the narcosis will suffice. The 
examination to be made the following day is decisive for the fur- 
ther kind of treatment. In this connection it may be pointed out 
that, while a large log cannot be dragged with a jerk nuickly throw' 
viscous mud, this will be easily done with little expenditure of 
force, if one only has sufficient patience. The friction between 
the nail and the bone shaft may be strong enough to prevent a 
cuick rotary movement of the unstable foot and stil1 not be strong 
enough to withstand the constant though small force of the twisted 
f o#t, 
3. After any smoothening off of the sharp-edged fracture 
ends the effect of the Hirth-teeth must be disregarded. 54 
4, After the lapse of a couple of tha nail will get 
ltose*in the marriw cavity., If conditions are favorable the 
fracture ends may slip longitudinally on the nail without -any 
great danger of rotation. Nevertheless the possibility of an. 
rotation displacement rust be taken into consideration. 
To avoid unneeessary repetition detaiIs about the data of 
the aftertreatment will be given in the chapter on nIndications" 
for the same factors which make a fracture more or less suitable 
for the marrow nailing determine the kind of aftertreatment. 
By way of general directions it must be mentioned that active 
and painless exercises will create the best conditions for the 
healing of the fracture and the conservation of the strength of 
the 3-imb. Baths and heat cradles should be freouently used. 
Complications during the healing of the wound must be de- 
tected early. It would be wrong to delay if a suppuration of the 
insertion spot is suspected. A prophylactical"y opened wound 
wil1 heal quickly, whrle a wound opened too lat« may cause in- 
flammation of the fracture hematoma if the lies near the 
nail insertion spot. A slow spread of the inflammation along the 
nail is not to be feared if the wound is opened early enough. 
The time reeuired for treatment in the hospital deoends on 
many external factors. Surgeons not yet fully acquainted with 
the new method are urged to leave the patient in the hospital as 
long as possible. 
The duration of the patient’s stay at the hospital depends 
on many external factors* It is important what profession 
the patient has and. what attitude he takes. An office clerk 
f.i. with a w~ll treated thigh fracture may easily go to his 
office at hiw own reouest a fortnight. A workman, howev i 
will n»t be able to go t# work again befor- the lapse of 6-8 
weeks even under the most favorable conditions. Of course the 
clinical finding still will be decisive. It is the responsibi 11 •. 
of the surgeon to suggest to the patient the right attitude of 
mind towards his disease with regard to the new treatment of 
fractures and the shorter duration of the disease. The surgeon 
as well as the patient must get used also to the much lower rate, 
of sickness-benefits paid in favorable cases. 
Special attention must be oaid to the progress of an "asepti. 
inflammation of the fracture, until sufficient experience has 
been gained (Sudeck), Even when the nailing was successful 
a dys trophic phase may dwveltp (painful swelling, heat, cyanosis, 
perspiring skin). * Early*.weight boaring seems to bring on these 
complications, ' The best treatment for these are rest and the heat 
cradle* 
ll^-THF^R^IfOVAL^OF^THE^NAIL 
In general a nail should be removed the lapse of three 
months since a firm bony consolidation of the fracture must be 
expected by that time. 
An earlier removal may be advisable. Reasons for this are; 
1, The fragments hav- become displaced and the nail hind- 
ers a new and exact reposition (anvulation or rotation). 55 
2# The nail wanders and endagers neighbouring joints or 
the soft parts covering the nail head end. 
3. The nail is bent. 
4* The nail is broken. 
5• ith children to attain a ou ck°r healing of the fract- 
ure. Suppuration near the insertion spot or fracture site, how- 
ever, (osteotomy, complicated fracture) are not indications for 
a removal of the nail. In th- case of a fistula at the nail in- 
sertion spot the extraction is even undesirable. It will be ad- 
visable to wait as long as5 possible in general since such fistular 
will eventually disappear, whereas an early extraction may lead 
to a late suppuration near the fracture site. Obviously, the 
suppuration will spread along the marrow cavity much more easily 
when the nail has been extracted. 
The nail must lie in the bone for more than three months if 
it is suspected or certain that the fracture has not yet healed 
properly. 
A late consolidation may be caused by; 
1. Infection. 
2. Distraction of the fragments due to jamming of the nai.1 
3. Insufficient mechanical stabilization of the fracture 
by the nail. 
4- All the other factors which may load, to a delayed for- 
mation of callus (Diabetes, Lues and so on). They generally 
known from the science of fracture treatment and need not be 
repeated h^re. 
5. With an osteotomy performed because of a faulty posit."., 
after breaking the bone it may be advisable to leave the nail 
in for a longer term than three months since the normal balance 
of the muscles is reestablished only slowly. Besides this osteo- 
tomy wounds achieve a slower bony healing then recent fractures 
nailed percutaneously. 
The adequate bony healing of the fracture is ascertained by 
X-ray control. The nail may be extracted as soon as the fracture 
fissure is bridged over the bone sufficiently and as soon as the 
callus shows a satisfactory formation of the little streaks. 
If this cannot be ascertained beyond, doubt the nail should 
be left in the bone for eVon though with some fractures the fract- 
ure fissure is to be recognized euite distinctly and. though it mr.y 
be firm from the clinical point of view and suitable for weight 
bearing, this cannot be ascertained beyond doubt as long as the 
nail is in the bone. Therefore it is better to leave it in. Xai' _ 
inserted two years previously - not caused any particular harm 
to the patients concerned. though the X-ray picture shows a 
vigorous formation of callus at the fracture site, it will not be 
advisable to remove the nail while the design of the callus is 
soft and cloudy. Cal1us which appears soft and cloudy In the 
X-ray is often soft and flexible so that an angulation may occur 
after the extraction of the nail. 
Fven though a newly inserted nail may be extremely difficult 
to extract, nails inserted a couple of weeks or even months before, 
are generally easy to remove. Loose nails may be extracted under 56 
l*cal anaesthesia (q.rm above the elbow and forearm) while firm- 
ly fixed nails should be removed tinder pan-anaesthesia. 
For the_th_igh the patient must be operated while lying on 
his side; It may be difficult to find the nail hole if the nail 
head is covered by a callus cap. The "Siemens" metal-finder by 
KUENTSCHFR is very useful for a ouick orientation* If the nail 
sticks firmly and if the surgeon intends to manage without a large 
incision of the skin it will be better to use a hammer for re* 
moving the nail. ./ith its help dvory nail will be easily removed. 
If spread nails with an inclined{plane haye been used the inner 
nail must alwayd be removed fiifst. If the turn spread nail has 
been used the outer one first, Since dotation of the inner nail 
may be impossible because of the marrow The nail which 
is deformed may raouire considerable force for its removal* 
A broken th?gh nail must be removed as soon as possible 
after this accident has occurred. The will soon go to 
see his doctor, because of the pain at the old fracture site. 
Frequently an angulation of the thigh will occur. The fracture 
site is not yet firm, otherwise the nail would not have broken. 
The break in the nail is not always situated near the fracture 
site of the bone. The proximal part of the nail is removed firsi, 
then the nail catcher (see t*ols) is introduced and as soon as 
it has "caught” the remaining piece the nail must be extracted or 
hammered out, A bending at the fracture site must first be ad- 
justed. The insertion of a fresh nail will not give any trouble. 
The finding of the nail head in the leg may be difficult, 
if it has worked itself deep into the bone, which will happen 
frequently. Here also the "Siemens" motal-finder will prove very 
useful. If it is not available it will be advisa le to insert a 
small pin before the screen or to make a small X-ray picture 
(a-p) with the pin in the right position for the nail head must 
be sought for beneath the patellar tendon. Sometimes it is 
perfectly amazing how many centimeters th° nail is to be- found 
distant from th~ place t was supoos d to be either laterally 
or medially. By the described procedure unnecessary injuries to 
the patellar tendon are avoided and the associated continuous 
irritation of the wound, which wi Zl occur frequently if the 
ion of the na: 1 in the leg is not done carefully. using 
a spread nail with inclined plane it must be borne in mind that 
the nails must be removed one after the oth°r and that the one 
with an inclined plane can be removed only after the other nail 
has been extracted. 
A broken aail in the leg must also be removed as quickly as 
possible and must be replaced by a new nail with the same diameter. 
In order to avoid disturbances at the fracture site the surgeon 
may desiflt from an exposure and extract the distal piece of the 
nail first -ith the nail tip. The nail tip is exposed at the ex- 
tensor side of the tibia, then a hole must be drilled into it and 
it must be extracted in an oblique plane. This is mane possible 
by the elasticity of the nail. 
In the arni_aboye the elbow there ar" no difficulties to be 
encountered either in finding the nail or in extracting it. In 
general it can be removed with a hook. An exact X-ray location 
of the nail head end is recommended if the nail has wandered and 
has completely entered the marrow cavity, and if the metaT. finder 
is not available. If this is the case the marrow cavity must be 
opened laterally and the nail must be pried out by leverage and 
extracted on an inclined plane. As regards the__forearm only the 
removal of the radius nail at the ulna which was inserted at the 
styloid process must be specially meni oned, since during its 
insertion as well as during its removal an injury to the wrist 57 
must be avoided in any case. Every movement with the lever must 
be executed in such a way that the bone is not pushed towards 
the wrist and gets broken. This can be achieved with some care. 
It must be taken for granted, however, that the nail was correct- 
ly formed before its insertion during the first operation, so that it 
does not show any tendency to winder into the bone. The radius 
nail as well as the ulna nail call., be extracted easily with the 
hand after the first loosening strokes. 
Breaking of nails was observed alro with ulna fractures 
near the elbow joint. This fact proves how strong the forces 
ar° which act at that spot. Since th~re is a straight nail in 
the distal nail fragment may be taken out with the smal' 
nail catcher (see tools). 
14^_MI1IIG_IN_TH^_CA£F_0F_AN_0PFN__FRACTURE 
The advantages of marrow nailing are thp samp both for closed 
fractures and for those which a primary healing of complicated 
wounds. Probably primary healing will occur much more frequent- 
ly with the new method than with th'' old on^s} sr'nce bony wounds 
and thos~ in the soft parts are‘immobilized better by the nail 
than b any other method. 
The new method shows the following great advan ages in the 
case of a suppuration in th© front.of the fracture site : 
1. The fracture has been ideally fixed. A spreading of the 
suppuration of the soft parts to the bone is not easily possible 
If the bone wound is affected by the inflammation the suppurati 
will proceed more favorably by reason of the fixation. 
2, The extremity is easy of access on all sides. So it 
can be watched every day and incisions reeuired can be made 
early. 
Disadvantages of the method are: 
1* Suppuration may proceed along the nail. In this case 
it is restricted to the marrow cavity and does not affect the ben» 
tissue (A. W, FISCHER and REICH). Fven after the lapse of weeks 
such an inflammation at the insertion site of the nail may lead 
to the formation of an abscess under the primarily healed operatic: 
’wound. After the opening of the abscess the nail acts as a drain 
for the often very active discharge of pus. 
2, At the fracture ends crown-seauestrum or ring seouest- 
rum may develop. 
The sequestra are covered by enveloping callus which must 
be removed after the fixation of the fracture. For the nailing 
of the marrow cavity of compound fraetures the following direct- 
ions may be given (MAATZ and RFldH): 
( 
The nailing operation should be done as soon as possible. 
A limit of hours cannot be fixed but during the course of an in- 
fection a nailing must not be performed. 
After the subsidence of the initial violent inflammation 
thp comes another moment favorable for the nailing. After hav- 
ing attained a sufficient immunization from the germs in question 
and after the suppuration has reached the so-called "cold stage" 58 
the body appears to be able to endure a surgical intervention 
without any injurious consequences (see gunshot fractures). 
Additional injuries to the complicated wounds in the soft 
Parts should be avoided in the nailing. Therefore a technique 
similar to percutaneous nailing is to be recommended. The guide 
rod should not be inserted in an upward direction as :n the ease 
of an osteotomy. Fven if th~re :s no X-ray apparatus available 
the guide rod can be inserted precutaneously the surgeon 
has some experience. The r duction and the insertion of the 
nail into the distal marrovj cavity can be control1 ed by the eye. 
In the case of small wounds too this should bo done before the 
fluoroscopic screen in order to avoid opening of these wounds 
further, 
If possible complicated wounds should be treated after the 
rules for the primary excision of wounds with subsequent suture. 
If the wound is very dirty and if it is impossible to excise it 
with subsequent suture a debirideirteat must be performed, i, e, 
the worst dirt and crushed tissue must be removed and then the 
wound must be left wide open and covered loosely with gauze. In t 
the case of a formation of pockets a squcerization of the wound 
is to be recommended, in order to prevent a damming of the secret- 
ion. Apposition-sutures are to be rejected. By doing so the 
wound will be cleaned in the quickest way and secondary healing 
will be achieved. The latter can be accelerated by later nappo- 
sition-sutures”, Thus a progressive downward extension of the 
inflammation is prevented. 
The advantage of the accessibility of the limb must be ful- 
ly utilized in the course of the further treatment of the wound 
and one should adhere to the principle that by leaving the wound 
open the discharge of the secretion should be secured early. 
An additional cast should be avoided if possible. This, 
however, will result in a narrowing of the indications. The 
advantages of the treatment of complicated fractures with the 
marrow nail depends on the complete stabilization of the fragments 
and the accessibility of the extremity. If an additional cast 
seems to be required prior to the nailing there is no indication 
for the nailing operation. The success of the nailing of an 
open fracture d-pends essontailly on whether it will be possible 
tc achieve a stabile osteosynthesis wjth the nail. 
I 
Tn general the extremity must be fixed on a splint, as it 
is the rule with inflammation processes of the soft parts. In 
this way a changing of the bandage is easily secured. 
The nail should be kept in its position as long as possible, 
i,e. until a bony healing is achieved. Fven a very violent 
suppuration which seems to be caused by the presence of the nail 
should not be a reason for a premature removal o_f the jaai-1, at 
least never during the first 'eight to ten weeks. rven though 
V2A tr V4A steel is the least irritant metal to the human body, 
known so far, the body will cover it with a connective tissue 
membrane and will try to eject it by suppuration after an in- 
fection has occurred. The advantages of nailing are still so 
great, that an increase of the suppuration can certainly be risk- 
ed. The formation of callus is certainly not delayed by the 
nail. Nevertheless, suppurating fractures with an inserted 
nail will frequently not show the formation of any callus for 
months. In such cases it is not the nail which is responsible for 
it but the suppuration. It is always wrong to extract the nail 
as long as a displacement of the fracture may stil1 occur. This 
may happen even after th° lapse of some months. If a fracture 59 
is well protected against lateral displacement either by cica- 
trization or calnus, a removal of the nail may be allowed if a 
particularly violent suppuration is to be stopped. The securing 
of the fracture against angulation must be achieved by an addit- 
ional cast. Our aim must, however, always remain the bony heal- 
ing with the inserted naili Sometimes it will be important not 
to patience and nover to forget that complicated fractures 
will sometimes supourate for months even v/ithout a nail and may 
not Show a tendency to form any callus at all. The most favor- 
able conditions are still achieved by the nail* 
.FRACTURES 
Any comparison with open fractures must be avoided. Where- 
as a wound excision and suture may freouently be mare with these, 
it is not permissible with open fractures. 
Owing to the peculiarity of the situation some general rules 
should be considered: 
The nailing operation should be performed as soon as possi .. 
One is, however, not limited to certain hours. A successful 
operation may be performed at any time (KUENTSCHER), Patients 
with violent sup uration and high fever will recover astonishingly 
auickly after the fixation by the nail (KUENTSCHER). Wot only 
a careful operation but also a v/ide opening of all the wounds 
is necessary. The insertion spot must be larger than usual and 
must not be closed by sutures but must no loosely covered with 
gauze. Adeauate drainage must be secured by sufficient counter- 
incisions, The use of a wound spreader may perhaps be necessary. 
In the case of gunshot wounds causing bone defects a metal 
spreader ehbuld be inserted into the nail slit in such a way 
that the bone ends are at the desired distance from each 
(KUENTSCHER). The spreader S'rvos at the same time to keep the 
wound open. 
The insertion of the guide rod from the fracture site is 
to be avoided because an unnecessary spreading of germs is to 
be feared an experienced surgeon will easily find the marrow 
cavity from the trochanter even without X-ray control. Inex- 
perienced surgeons should not nail gunshot fractures at all. 
Reduction before th- fluoroscopic screen is not advisable, since 
any maltreatment of thn tissue must be avoided. It will be better 
to widen the wound by a straight incision as explained before, 
in order to bn able to control the infection. 
;<ith gunshot fractures just as with open infected fractures 
a favorable course of the inflammation and an undisturbed for- 
mation of callus are to be expected only aft'-r a stabile osteo- 
synthesis . 
After the cleaning of the wound the healing may be accelerat- 
ed by secondary sutures or by drawing it together with adhesive 
plaster, 60 
LJNG_WITH^DELAYFD^FORMAT10N_OF_CALLUS 
In the case of a delayed formation of callus the nailing 
is "causal therapoutics" because the slow stabilization of the 
fracture is in most cases due to mechanical conditions. The 
nail counteracts the dangerous forces causing lateral displace- 
ment and favors the pressing forces which are so beneficial to 
a bony healing. 
A delayed formation of callus will very seldom result in 
a formation of false joints (BLOCK). It never does so if the 
fracture site gets favorable mechanical conditions. That is why 
the technioue of nailing with delayed formation of callus differs 
fundamentally from the procedure in the case of a formation of 
false joints. It is not necessary to create a new situation 
able to the formation of callus or to break the bones aeain, to 
freshen the fragments or to treat them by the so-called nKirsch- 
ner splitting open", Beck’s drilling or "Brandi sc her1s sawing 
open". The insertion of the nail and the stabilization of the 
fragments by way of the marrow cavity will be sufficient. If 
the fragments are in good position i.e. if the marrow cavities 
of the two bone fragments are in a good direction the fracture 
site must not be exposed and percuntaneous nailing should be 
tried. Otherwise the danger of an infection would be consider- 
ably increased. An infection is to be feared especially in thos- 
cases of compound fracture, which for some reason or other were 
not nailed primarily which, however, after the soft tissue heal- 
ing still should be nailed. 
In general the t-chnioue of th- nailing does not differ muc: 
from the usual procedure. The reduction of the fragments may, 
however, reeuirc special measures, if the openings of the mar- 
row cavities are not sufficiently protected. The required dis- 
pla cement will then not be possible either manually or with the 
repositioning apparatus. Good results were achieved with the 
extension apparatus by Boehler which was modified by FISCHER- 
MAATZ. If those forces do not suffice the osteoclast may be 
of great help. The pains taken will not be wasted if an exposure 
of the fracture can be avoided. Nevertheless this will not be 
aviodable in every case* 
A sharpening of the nail tip has not answered the purpose , 
A blunt nail will penetrate the young bone and tissue scar at 
the fracture site without difficulty and will ent r into the 
distal marrow cavity much more easily than a sharp nail, A 
sharp nail will injure the compacta and penetrate it. It has 
proved to be very serviceable to fix some sawtooth immediately 
below the nail tip (see tools). 
If the nail is in good position and if it provides suffi- 
cient hold to the fragments the patient should expose the fract- 
ure to weight bearing as soon as possible because weight bear- 
ing is the best therapeutics for a delayed formation of callus. 
In the leg a resection of the fibula is to be considered 
in order to remove its jamming effect (distraction). 61 
12a-ISE-.NAILING__0PERATI0N IN PSEUDARTKROSES 
The amazingly quick and abundant formation of callus in 
nailed fractures and the bridging over of larger gaps between 
the bone suggested the idea of stabilizing pseudarthroses by a 
nail, was to be hoped that after the lapse of some time a 
bony bridging over of the defect along the nail would take place. 
In the co.se of a plain pseudarthrosis, however, with joint planes 
and joint cartilage a healing could not be expected even by the 
use of this new method, A bony transformation of broad tissue 
bridges was not to regarded as absolutely impossible, 
Experiments made for this purpose w~r unsuccessful. Therefore 
in the treatment of pseudarthrosis, oven when using the marrow 
nail, one cannot avoid the necessity of creating a fracture area. 
The pseudarthrosis must be resected to that one fresh bone end 
comes to tand upon the other. In this case bone substance should 
be removed very conservatively, in order to prevent unnecessary 
short -ning. It is recommended to open the pseudarthro sis sharp- 
ly or bluntly anc! to remove only enough of thx bone on k with 
’’Luer’s rongeurs” until fresh is exposed. Sometimes a wide- 
ning of the marrow cavity at tho bone ends may b~ necessary. If 
a shortening of the bone is to be prevented an attempt to split, 
to saw or to drill the bone with the Beck apparatus will be justi- 
fied. The technique of the nailing is tho same as usual. With 
tho exception of the thigh it will always be advisable to intro- 
duce th-' nail oercutaneously befor~ the old fracture is exposed, 
lest tho bone wound which is apt to become infected be kept open 
unnecessarily long, a sufficient preparation of the bone 
ends the nail is then inserted under direct visual control. 
iba_osteotomy 
Strictly speaking' osteotomy is the surgical cutting of a 
bone. It ist most often done in the case of badly healed bone 
fractures. The correction b operation of an inborn abnormal 
curvature oi* of one aceuired by a disease of the bone belongs 
as a:'11, With the nailing n of fresh bone fract- 
ures astonishingly great successes were achieved* A large pro- 
portion of osteotomies especially in the leg is made possible 
only by marrow nailing. At any rate the indication for an oper- 
ation may be given in many cases in which one heretofore rather 
desisted from an operation because of the uncertainty of success 
and the di sadvantages to be expected, such as a stiffenipv of the 
neighbouring joints. The reason for a very cautious indie ition 
is the fact that the forces causing lateral displacement which act 
uoon the bone ends are very great an osteotomy. The 
muscles will become unbalanced after an osteotomy e. in the 
case of a curvature of the thigh bone several years old, if the 
fracture has not healed well. The traction and urc exercis- 
ed by the transverse section of the muscles (agonists and anta- 
gonists) amount to several hundred kilograms evnn in th- case of 
a fresh fracture. The way in which bone is affected is de- 
fined as angulation by the technician. it appears as an angulation 
of the fracture site. 1f one of the muscle groups is stronger, 
which happens very with such osteotomies, this angulation 
will occur much more easily. It could not be prevented with the 
contrivances previously at our disposal such as ivory bolts, 
Lane’s plates, wiring, plaster cast or extension. The steel nail 
alone, which is inserted into the marrow cavity, has sufficient 
mechanical stability. 62 
Thor e are five further reasons why ”rith ostnotoinies fracture 
ends r.rr better secured by the nail than by all other methods. 
Firstly, the procedure is techincally much simpler. Secondly 
the danger of an infection is much less, because the skin in- 
cision can be much smaller than with the application of Lane's 
plates on two sides of the bone. In th~ third place, the perios- 
teum need not be removed from the bone, because this is not 
reauired for the insertion of the nail. Thus it is possible 
t» avoid the principle of LANGFN3ECK with its subperiosteal 
operation in the case of an osteosynthesis. This is most im- 
portant for the formation of callus to which the periosteum lar- 
gely contributes. Besides this, the periosteum provides the 
chief blood supply for the outrr bone compact lay r. A removal 
of th° periosteum therefore means, without doubt, a serious dis- 
advantage to the blood supwly and by this to the defensive fore s 
against infection, A11 this cert-.inly is a reason for the easy 
infection of osteotomies. Lastly the removal of the periosteum 
brings about an enlarging of the wounds which a-'ain means an in- 
crease of the danger of an infection. In thp fourth place for- 
eign bodies attached to the fracture site meay easily result in 
a dealyed formation of callus, whereas the nail lying in the 
marrow cavity will certainly not retard the formation of young 
bone tissue. In the fifth and last |lace there arises the fear 
of a renewed injury to the muscles and the joints, caused by the 
necessary prolonged rest of the limb in the plaster cast. 
Osteotomies with mar ow nailing may be made in case of 
1. Bone fractures healed in a faulty position. 1hese are 
above all shortening, angulation and even after the introduction 
of marrow nailing, also rotation. 
2. Inborn abnormal curvatures of the long bone shafts 
(not acquired by bone fracture), espec. knock-kneed legs and 
bandy legs, 
3. Lengthening of bone shafts delayed in their growth. 
4. Shortening of the bone f. i, to achieve a suture 
(BOFHLER) of nerves and vessels, or, in rare cases, the eouali- 
zation of the sound and the diseased side, which may have 
been shortened f. i. by a compound fracture, and on which a 
lengthening osteotomy cannot be made (BAUER). 
5. Resection of bone tumors. 
The inseation of a nail Into the marrow cavity is much 
easier with an osteotomy than with a percutaneous nailing. In 
this the marrow cavity is opened up and the insertion is made 
under the control of the eye. Often the marrow cavity may be 
open already. If not, this can easily be done with the awl, 
gouge or drill, because its closure is comparatively soft. kith 
the leg, the forearm and the arm above the elbow the nail is 
inserted at spots distant from the fracture as in percutaneous 
nailing. The nail tip is visible in the depth of the wound in 
the marrow cavity of one of the bone shafts. It is then insert- 
ed into the marrow cavity of the other fracture, whereupon the 
nail can be driven home. By this the osteosynthesis is complet- 
ed, At the thigh th~ side position may be recommended, the 
patient lying upon the sound lee. In general the skin incision 
will be on the outside which allows easy access to the bone with- 
out endangering larger vessels. In the opened marrow cavity of 
the proximal piece a guide rod is inserted and is pushed to the 
too of the trochanter where it easily and with a sudden move- 
ment penetrates the compacta which is very thin here. Its tip 
can be felt under the skin of the buttock. This tip is exposed by a short 
skin incision (ill, 80), 
The nail is then slipped 
upon the guide rod and 
is driven in, until it 
extends out of the marrow 
cavity of the proximal 
fragment for J- centimeter. 
Usually it is easily poss- 
ible to put the bone 
fragments of the thigh 
together and to drive 
the nail into the distal 
marrow cavity. If, how- 
ever, a shortening cans 1 
by an old, badly healed 
fracture has existed nnr; 
years, especially with 
robust men it will not be possible to equalize'the shortening 
even with the extension apparatus and with the strongest tract- 
ion forces. In most cases the thighs stand in a bowed position. 
After severing the bones at the old fr :ctura site it will not 
be difficult to put the fragments together so that they form an 
angle. The point of the angle is directed outward,s i.e, out of 
the wound. An assistant 
presses this point in- 
wards with great force, 
until the straight po- 
sition of the osteoto- 
my site is achieved 
till, 81), The moment j 
the angulation is over- j 
come the nail must be 1 
driven in. It must 1 
never be done before this 
has been achieved in the 
hope that the nail would 
achieve the required 
straightening of the bo- 
ne by penetrating into 
the distal marrow cavi- 
ty. It cannot do that. 
The inevitable result would be breaking out of large frag- 
ments of the cortex of the distal fragment. A further tech- 
nical trick must be employed in those osteotomies which are lo- 
cated far proximally (at about the height of the trochanter 
minor). Here, it will be advisable not to sever the bone com- 
pletely at once but to open up the marrow cavity. a part 
of the medial wall is kept untouched temporarily. •‘•'hen a small 
guide rod is inserted into the opened up marrow cavity and the 
nail is inserted in thn ‘way described. In the case of a com- 
plete severing of the bone at that place the proximal fragment 
is at once most strongly abducted and bent, because the corres- 
ponding muscle groups preponderate. Bv this the insertion of 
the nail becomes somewhat difficult because one hardly ever 
has sufficient power, even with the guide rod, to correct the 
position of the piece. The intervention 'ill be rendered easier 
by inserting a second nail into the marrow cavity of the proxim- 
al fragment for a short time. Thus one has an excel”ent handle 
for the correction of the position until th‘- nail has been insert- 
ed to the required depth. The periosteum must handled as 
gently as possible. In general it is possible to get at the 
place of the fracture or of the Intended osteotomy by pushing 
aside the muscles. must be admitted, however, that by doing 
so the wound can be examined less easily than when the periosteum 
has been removed more extensively, and that by this the operation 
111.20 
ill oit r. $1 64 
is made somewhat mor- difficult. The severing of two fragments 
will, however, be possible in the case of a thigh fracture heal- 
ed in a faulty position by the leverage of a very strong ras- 
paratory placed between the fragments. Afterwards the fracture 
planes must only be smoothed a little so as to fit well one 
upen the other. Besides that the opening up of the marrow 
cavity, as described above must be made. The jagged edges and 
orojections of the surplus callus and the callus bridge must not 
be touched, in order to avoid injuries to the periosteum and un- 
necessary damage to tissue. They valuable building material 
near the bone fracture* 
If the badly healed fracture is several years old it will 
be necessary to use a chisel and a saw. In this case too only 
the two plants fitting one 
upon the other will be pre- 
pared. This will be achieved 
in the easiest way with the 
circul r saw wh:ch must be 
held with the two hands* The 
position of the severing plane, 
depends on the position and 
the shape of the former fract- 
ure planes. 
In the case of a trans- 
verse fracture the two saw 
planes must stand vertical 
to the axis of the bone shaft 
at the lower end of the upper 
fragment and at the upper end 
of the lower fragment so that 
after the insertion .of the 
* nails the ends fit together 
as well as possible, (ill* 8.2)* In the same way oblique saw 
planes are made with what were originally oblieue fractures. The 
saw planes go through the intact periosteum at the site of the 
former fracture so that the callus caps formed at the fracture 
site are sawed ihtb. They form a broad support at the point of 
coontact which contributes to a speedy and secure healing. The 
planes must not be too high or too low in order to prefent the 
operated leg from becoming shorter or longer than the other 
one. It is to be observed that a part of the bone cortex is re- 
absorbed, so that a little defect remains after the osteosyntlies*- 
is. These saw planes usually open up the marrow cavity. In 
any case 'it will be ea.sy to do so from there. 
After the saw planes have been made the severing of the 
two fragments is completed by strokes with th- large chisel, 
exactly in the direction of the former corpacta borders bet- 
ween the fragments. In this way it will seon b~ oossiblo to 
sever the two fragments by leverage. The nailing operation is 
done in the usual way (ill. 83). Here also the surgeon must 
see to it that no lateral or medial rotation of the distal frag- 
ment is possible 
An •stcotomy advisable because of marked angulation at 
the old fracture site will be performed much more easily, as 
after the sawing off of the fracture ends only a correction of 
the axis will be necessary. 
A rotation osteotomy which formerly was a rare occurrence 
will to-day, after the introduction of marrow nailing, however, 
be reuinred the more freeuently the larger the number of surgeons 
who perform nailinr/ operations without devoting than care to the 
after treatment which is so urgently required. So it will 
hapoen again and again that a faulty rotary position is observed Illoiir, 23 
•nly aftor it has become impossible to correct it during the 
11 ether rausch" . 
The operation is not difficult to perform. First of all 
it must be ascertained by how many degress the leg has turned. 
In the case of a leg bent at a right an ale and slightly bent 
hip both the hip joints are brought to a maximal inner rot ation. 
The difference between the respective position of th° leg is a 
sufficient indication for the number of degrees by wh: ch the 
rotation osteotomy must be made. In many cases it will be ad- 
visable not to perform the osteotomy at the old fracture site. 
It will be better to choose the place which proves to be most 
suitable for nailing, i.e. if possible in the middle of the 
bone. In addition to this a notching of osteotomy spot must 
be made, in order to avoid further rotary displacements without 
using a plaster cast. First the nail must be loosened a little 
with some hammer strokes. After that the bone is severed ex- 
cept the bone bridge by the Gigli-saw (in case of an inserted 
nail), which must be left intact if the blades of the saw are 
guided in a parallel direction during the sawing process. After 
that two kerfs must be made in the bone bridge with the circular 
saw s» that a tenon is left standing either on the upper or the 
lower fragment. The remaining small bone bridges are severed with 
a fine chisel. 
For the bone tenon at the one fragment a corresponding hole 
must bo made in the other one. To achieve this the nail should 
be withdrawn from the place of the osteotomy so that with a corr r~ 
ponding bending the bone end Is kept well accessible for the 
circula saw. The only theng left to do then is the necessary 
turning of the fragments and the reinsertion of the nail (ill, $4)* Notchi ng is safer than the selection of 
a new and thicker nail* For one thing the 
latter may jam in the callus of the fracture 
and in the second place this nail, even if 
it fits in well, may loosen a couple of days 
later, because the planes of the osteotomy 
are ruite smooth and not notched* 
In the case of a congenital bending of 
the long bone shafts, not acquired by a bone 
fracture, marrow nail operation can be 
applied only in comparatively few cases. It 
is the principle of the nailin operation it- 
self to adjust th.° former s h \ae o f the bone 
so to speak automatically. In the c use 
of a late rachitic bowing of the lee the nail 
must folio?/ the curvature :i n both fragments 
and must have a correspondingly strong bend- 
ing at the fracture s:te, as is shown in 
111* 85. &uch osteotomies a r - often apt 
to result in a delayed formation of callus, 
obviously due to the jamming effect of the 
nail* In such cases it cannot fulfuil its 
function to serve as a gliding splint, but 
mostly because under such conditions the 
leg nail must bo fnechan ically insuffici ont 
and th° fracture has become insufficiently 
fixed, 
Bones with a proportionally small bending radius i. e. bones 
with bendings wh?ch 
are only of small 
extent as is often 
the case with ra- 
chitic bandy legs 
may be severed af- 
ter the method of 
HFLFRICH and a 
straight nail may 
be applied with 
good result.(KUEN- 
TSCHER). The ro- 
tary correction, 
often necessary 
in such cases may 
be achieved by 
the removal of a 
bone wedge. 
The nail is 
applied with ex- 
cellent result in 
the case of a 
Supracondylar 
osteotomy which must bo made in the case of a knock-kneed leg 
or a knee contracture (GUFNTZ), Of course a plaster cast is 
absolutely necessary but a shifting of the fragments will cer- 
tainly not occur. The time required for the plaster cast may 
be shortened. The technique of thr nailing corresponds here to 
the usual procedure. Nevertheless it must bo point'd out once 
again that the bone ends should fit one upon t other as well 
as possible, so that their position should determine the axis 
of the bone. The nail prevents a lateral displacement, and the 
better the bone ends stand on" upon earlier it will 
ilL.SM 
III.25 be- possible to re- 
move the plaster 
cast (111, 86). 
The lengthen- 
ing of a bone for 
a couple of centi- 
meters may be done 
even without the 
planned jamming of 
the nail. Two diff- 
iculties are to be 
•vercome in this 
case, first the stretching of the soft parts, secondly, the 
possibility that the separated bone ends may approach each 
other again. 
It is impossible to stretch the soft parts of the the ah 
for four or five centimeters during setting i.e. within 
one hour. The t^chnirun of bending at the fracture site, des- 
cribed above in case of fracture shortened during the healing, 
cannot be applied, for, while in the latt-r cas° two strong 
bone ends are standing one upon the other, here two weak bone 
shafts are involved, which might become fractured again when 
the weight bearing is to« strong. That is why the stretching 
of the soft parts must be done during the neriod of a couple of 
days. A nail which allows such a procedure is in preparation. 
The extension osteotomy can be made ,:’ith the means presently 
at our disposal. 
Illustr. 86 
First operation 
1* Z-shaped osteotomy at th narrowest part of the narrow 
cavity* 
■9 
2. Insertion of the nail after it was found suitable be- 
fore the fluoroscopic screen. 
3. Insertion of a V2A-guide rod from the osteotomy spot 
into the proximal fragment (without a cross handle, with a hole 
near the tip) . Before the tip of the guide rod penetrates the 
skin above the trochanter, the skin must be pulled sidev/ays to a 
great extent. In this way one makes it possible that during the 
second operation one ma.y work a couple of centimeters distant 
from the first incision. 
4. Insertion of the guid rod into the marrow cavity of 
the distal bone fragment* 
5. Applying of a supracondylar wire extension. 
Second operation 
6, Nailing as soon as the necessary length of the bone 
has been attained. For the nailing the tip of the insertion 
guide rod must be exposed. Then the guide rod must be extract- 
ed with forceps far enough so that it is p ssible to insert a 
wire into its hole. The reduction must be done befor- the X-ray 
screen, and in such a way that on no account will the nail 25- 
pinge on distal bone comoacta. Any forcible reduction must be 
avoided in order to prevent a fracture of the "one ends. 7, Removal of the guide rod. 
8. wire extension may be removed or left wi th a 
little weight (load). 
If a second operation is not oossible for some reason or 
other thQ healing in extension must be waited for. The guide 
rod (made of V2-steel) will secure the right position of the 
fragment s, 
In most cases the indication will be given for a suture 
of a nerve, in fewer cases for a suture of an artery. One 
will decide on shortening a sound leg only if the ndrmal length 
of the sound leg cannot be achieved in any way, or, if an ex- 
ceptionally tall patient assents voluntarily and readily to 
the shortening. The incision should be made in an oblicuc di- 
rection (OUF.NTZ), in order to achieve favorable conditions for 
the healing general chapter). 
As an example of a rather case of an indication the 
above illustration of a forearm may be shown (ill. 87)* 
After the resection of a correspondingly 
lang bone segment the osteotomy wound must be 
treated with the marrow nail as usual, In 
order to prevent a subsequent giving way 
of the bone ends (arm above the elbow and 
forearm) one must try to achieve an ideal 
nailing* This is comparatively easy, as 
in general the place for the osteotomy 
may be put at the spot most favorable for 
the nailing. 
After the resection of bone tumors 
the nailing is to be done in much the 
same way as usual, 
LI NG_OF__A__SPONTANFOUS->FRACTURE 
Spontaneous fractures must be given 
special consideration in connection with 
the nailing operation. In most cases they 
are fractures of weak bones, enfeebled by tumor metastasis, in 
rare cases b'' osteoporosis or other factors. Curiously enough 
the tumor metastasis is to be found chiefly in the upper third 
of the thigh, i,c. at a favorable spot. In connection with th,© 
nailing it must be taken into consideration that in general the 
nail is meant to provide a sufficient stabilization for the rest 
of the watients life, because these fractures do not show a ten- 
dency (or only very little) to healing even after X-ray treat- 
ment. In the second place chiefly atrophic bones with a very 
thin compacta and correspondingly large marrow cavities are con- 
cerned so that customary sizes of nails can be used only seldom. 
In the third place the bone is comparatively soft, and in the 
fourth and last place the nail is exposed to little bending force, 
as the patients are usually elderly and frail persons. 
The facts given above make it advisable to a special nail„ 
As the nail need not be particularly proof against bend :ag 
the sheet metal may be somewhat thinner and the elasticity of its 
Illustr. 87 cross section can be all the greater. its hat-shaped cross-' 
section grants to it not only the required, elasticity but has the 
further advantage that the nail touches the bone wall only with 
its three narrow longitudinal plants, its three edges. During 
the first few weeks the bone yields to the pressure of the nail. 
Because of its elasticity the nail formes grooves wh: ch permit 
it to attain its former shape and so become loose. These grooves 
are deep enough to prevent a lateral dispalcement of the fragments 
with certainty. 
Fven a patient who cannot hop© for a bony healing of his 
fracture will be able to walk with his bones in splints without 
any additional protective casts. 
For the rest, the technique of the nailing does not differ 
from the usual method (111i 88 ) * In addition only the softness 
of the bones must be taken into consideration, especially when 
>. ! ■ Y vs --f d p\v f i i 
\ t / < //* \ \ is Vi ■ 
\ / t-K 
1 KA ir do V ! \\\l J ihi\ 
i',\\v 
4 f ; /f X m I p 
\\ i / ■ / / 1 i i* S 
III ,;■'// j|| 
i rl Pi 1 I'1 
*1 | /!■:/ ! •.! 1 f ! : 
i Si ' | h j ; v 
I .« < r 
iilh ; ■ ui.« d* 'i 
!■ » A 
ILL .SS 
inserting the nail into the distal fragment. The axis of this 
fragment must be put into the right position from outside and 
the adjustment must not be left to the penetrating nail, as may 
be done safely with solid bones. 
With bone tumors tissue substances are frequently elected 
with the marrow juice which renders possible a reliable tumor 
diagnosis, because they are suitable for a histological examin- 
ation. 
2£L_the_y=nai£ 
The pertrochanteric fracture demands a special treatment 
with the nail. It is a fracture which does not offer any diffi- 
culties with regard to reduction and fixation. Nevertheless it 
often causes a coxa vara position. It does, however, not snow a tendency to a delayed formation •f callus or pseudarthrosis. 
Moreover in nailing the special advantage of the new method i.e. 
that the fracture site is left untouched, is neutralized in 
that case. As the fracture must be exposed, occasional infect- 
ion of the operation wound will in most cases result in a suppur- 
ation of the fracture site. Nevertheless, the applying of the 
Y-shaped nail represents a great progress - it prevents a long 
confinement to bed. and facilitates the nursing. The stability 
of the Y-shaped nail is so great in comparison with the nail- 
ing of the neck of the femur that the patient may get up a corple 
of days after the operation* 
From what has said before the indication is obvious. 
All those patients should be nailed who are endangered by a long 
confinrment -to bed, and the danger of an infection must be accept- 
ed, The advantages and disadvantages of this method must be 
explained to patients not belonging to this croup, so that they 
may decide themselves whether the operation should be performed 
or not. 
The method of inserting the nail depends on the shape of 
the fracture. It will be advisable to obtain an exact knowledge 
of the fracture lines before the operation. It must be admitted 
that in many cases this may not easy. Freouently it will be 
possible to get the necessary clearness only by X-ray pictures 
made before the operation in the extension of the fracture. The 
fragments wedged together before are then detached, and it is 
easier to make out the fracture lines. 
The fractures of the trochanter major and its immediate 
neighbourhood may be suitably divided into six groups for the 
nailing (A. W. FISCHER and MAATZ) (ill, 89) 
Group I, the subtrochanteric fracture is secur'd sufficient- 
ly by a conical nail. 
The other groups should be treated with the Y-nail. The 
shapes of the fragments are very important for the indications 
and the technicue of the operation. 
The operation is very simple in its principal features. 
The marrow nail must be inserted into the femur to the supposed 
correct depth. The corticalis must be pierced 8 centimeters be- 
low the nail head end, and the transverse nail must be introduced 
a little into the slit of the marrow nail. The X-ray pictures 
to be taken then show the fracture reduction probably necessary 
and the correction of th« height and rotation movement still re- 
cuired. (ill. 90), This 
can be done very accura- 
tely, because the shift- 
ing of the marrow nail 
in an upward direction 
to the corticalis drill 
hole which must be wide- 
ned to the corresponding 
side, is executed with 
the chisel or rongeur. After that the marrow nail' 
(with the transverse nail in- 
serted) can be turned to the 
reouired angle in the marrow 
cavity. Further control X-ray 
pictures must then show that 
the transverse nail points to 
the middle of the neck of the 
femur in both its planes. This 
means that it must not be seen 
in the second plane, because 
it is covered completely by the 
marrow nail (ill# 91)* 
This technirue reouires a wide opening of the fracture site. 
For some patients large operation wound will cause a 
most injurious wound Shottk and it will, as is to be expected, be 
in great danger of becoming infected* 
Therefore it was necessary to construct a special insertion 
apparatus which makes it possible to insert Y-nails percutane- 
ously (MAATZ), it has been tested sufficiently, the nail- 
ing of pertrochanteric fractures with it can be strongly recom- 
mended. Injurious effects on the wound were more rarely observ- 
ed and thp wound shock is not greater than with the other methods 
of marrow nailing. Nevertheless, a very strict indication is to 
be recommended, i, e, in the beginning only patients of group 
II should be nailed (to whom a long confinement to bed would prov 
dangerous). The number of persons which can be subjected to this 
operation will afterwards increase nui ckl\r, 
The principle of the insertion apparatus s very simple. 
It serves merely to introduce the transverse nail percutaneous- 
ly into the slit of the marrow nail. It is easy to understand 
that the surgeon will at first feel somewhat uneasy on seeing 
the different drills and handles belonging to the insertion 
apparatus. They are, however, required and the surgeon will 
be fully compensated for all his trouble the moment the trans- 
verse nail disappears in the lateral slit in the skin, and 
makes its way safely through the slit in the marrow nail into 
the femur neck and head. 
' Ne£C£int^on_of_the_inse5liipn-appfirat^3_llllJ._22l 
The clamp (A) must be put on the head of the marrow nail 
with the dovetail (B) in place. It is then fastened with the 
screw pin (C) which enters the hole of the nail. The nail and 
the screw must fit tightly. If, however, a single Y-nail is not 
sufficiently tight the cam (D) may be raised a little by any 
mechanism with a layer of metal and, if necessary, this may be 
removed again. Into the hole (E) a hook can be inserted and 
the nail extracted as reouired in each individual case. 
The tube (G) fixed in the tube holder (F) by a screw ser- 
ves as a guide for the drills and cutters. 
The axis of th° tube is 2,5 millimeters below the middle of 
the slit of the marrow nail.. This variation is allowed because • 
the drill or cutter touching the corticalis oblinuely is forced 
upwards for about 1,5 millimeter even when penetrating slowly, 
and a further millimeter is allowed for any further deviation 
(111. 93). 
Til A transverse nail 
,touching marrow 
nail too far hist- 
ally will invariably 
wand er upwards i * e. 
into the slit, A 
transverse nail in- 
serted too far prox- 
imally will jam and 
force the marrow nail 
upwards, so that the 
previous result of 
the operation will 
be frustrated. As 
a further protect- 
ive measure the tr.:.:. r 
verse nail is round 
shaped at its upper 
leading edge. If, 
however, this nail 
should catch on the 
edge of the marrow 
nail its oblique 
part must be in» 
creased with a file. 
It is necessary that the operating surgeon should know 
that the axis of the tubes . is fixed in the 
above described way as he must ascertain r 
each time before inserting the nail whether 
the insertion apparatus is straight or not. 
Otherwise he may try to correct this inten- 
tional deviation in position. 
The tube (F) extends to the corticalis. 
Nevertheless the first hole must be made in 
the corticalis with a short thick cutter in 
order to prevent a slipping upwards. After 
that the rod with a cutting edge (J), which 
tapers towards the tip, is introduced. In 
order to get a better view of the control 
picture it is made so long that it can pene- 
trate the head of the femur. 
The final drill hole in the corticalis is made with the 
large cutter (K) and it must be removed again when no longer need- 
ed, since the cutter holder must be introduced from outside 
owing to lack of space. The cutter is made of such length that 
damage cannot be caused by the nail and the cutter coming into 
contact, 
A small bone edge is of necessity left standing for the 
time being at the upper edge of the bored hole, which must 
be penetrated by the transverse nail (ill, 94)* The transvers'e 
nail may be inserted easily and this' 
bone edge is not of any disadvantage, 
since the nail is pressed downward by 
it, i, e. in a favorable direction. The 
surgeon must, however, know that 1 vr: ng 
the insertion a certain resistance r.:ust 
be overcome, If it is very strong it 
will bo better to extract the nail again. 
If a faulty contact -ith the upper end 
of the slit in the marrow nail occurs 
this may be observed by a deformation 
of the upper edge of the transverse nail. 
Any,deformation must be removed accord- 
ingly. 
I U_. 1 
III Cl- 
luM The nail or nail lor the neck of the femur (L) 
must be inse3~ted into the slit of the elastic fork (M) , It fits 
well into the tube holder (F) th>~ tube of which has been re- 
moved, and in this way the proper guidance of the nail is 
achieved. It should bo inserted with light hammer strokes. 
The nail must then extend out of the corticalis as far as 
the length of the notch in the nail holder (M)* 
All cutters are connected with the drill rod by an 
inserted piece (N; so that the connection with the shaft is 
possible by simply putting them on during the freouent changes. 
After a sufficient knowledge of the apparatus the nail- 
ing is easy to describe: 
1, The patient is put on the table in a supine position 
as usual for nailing the neck of the femur. The injured leg must 
be left free. It must be brought to a maximal flexion, abduct- 
ion and inner rotation, in order to achieve thr insertion of 
the guide rod and the marrow nail. If the patient is pushed 
towards the edge of the table as far as possible the guide 
rod can easily be inserted percutaneously into the marrow 
cavity oblieuely from below , As soon as the nail has reach- 
ed. the marrow cavity the guide r*d can be removed, because 
it is not required any more, or, rather, it must be removed 
because the head end of the marrow nail leaves no room for it. 
Before the disappearance of the nail head end under the skin 
the clamp is put on, nail is then inserted in such a way 
that 2 centimeters of it stand out of the bone. It is very 
important that the nail should hav~ the right position from 
the very first. One has to go by the position of the knee-cap 
whrch indicates the frontal plane of the leg. The plane of 
the clamp must be 30° posteriorly fro the frontal plane, be- 
cause the neck of the femur points frontwards to the same de- 
gree . (111. 95) 
2, The position of the patient is the same as with the 
femur neck nailing, 
3, Final closure, 
4, Fixing of the tube which indicates the direction of 
the incision. The tube can then be inserted, 
5, The small corticalis drill hole is made with the short 
thick cutter (H). Push it in slowly in order to avoid too 
str-ong a -deviation in the upward direction, 
6, Insertion of the rod with cutter tip (J), 
7, X-ray pictures in two planes for the control of the 
location of the fracture and the position of the sound with 
cutting tip, (ill, 96) - 
8, Make all the necessary corrections# First of all 
the rod with cutting tip must be removed, then the necessary 
correction of the S?*>***nre site must be ma.de, then the correct- 
ion of the height and rotation must be made accordingly# After 
that one can decide whether the tube must bo removed or not 
and a new hole in th© skin made, or, whether the elasticity of 
the soft parts makes th% shifting, of. it possible. If corrections 
are necessary the following procedure is required: ILL.'I S' 
Illdfc 
9. A new opening is made with a gimlet and the rod with 
a cutter is inserted under X-ray control in two planes. 
10, If the sound wire indicates that the direction of the 
tube leads through the middle of the neck of the femur and its 
head, the corticalis drill hole must be made with the large cut- 
ter, 
11, Removal of the cutter and tube. 
12, Insertion of the nail held in the nail carrier with 
light hammer strokes, 
13, X-ray control, 
14* Removal of the clamp and clesing of the wound. 
The short skin incisions may be closed with two stich sutures 
Objections raised at first against the use of the cutter 
without adeouate protection of the surrounding soft parts were 
disproved by the experiences during the operations. Kven the 
large cutter is ouickly covered with soft particles torn from 
the surrounding soft parts, so that serious wound necrosis will 
not occur and practice has whown that the wounds will heal most 
satisfactorily. 
If in the beginning the surgeon is not ouite certain how 
far the marrow nail is to be driven in and in which position 
the use of the sound (just as with the nailing of the nee1: of 
the femur) will be helpful. This must be inserted at the 
supposedly right place in the supposedly r ght direction. By X- 
ray control the necessary corrections are indicated which must 
be made during the later insertion of the marrow nail. The 
position of the clamp must be in accordance with the position of 
the sound , 
It will not be difficult to nail groups I, II and IV with 
the technioue described abov*, Greater difficulties are to be 
encountered with groups III, Va and Vb especially concerning the 
reduction if the axis of the neck of the femur cannot be directed 
towards the middle of the marrow cavity. But this fracture too 
cannit be nailed without reduction. Besides this is must be considered that a normal nail must 
be insufficient, fhese nails are short and conically shaped. 
They provide insufficient protection against rotation as the 
friction between the marrow nail and the bone is not strong 
enough. This m-ans that fractures of the groups III, Va and Vb 
are not protected against rotation for the far end of the trans- 
verse nail is situated either in the fracture slit, so that it 
'kes not find a sufficient hold to prevent a rotation, or the 
second fracture line lies even farther distally; 
In such cases therefore marrow nails must be used which 
are made to measure (up ti a thickness of IS millimeters) ahd 
which secure sufficient friction betw/e-n the nail and the bone. 
It stands to reason that the insertion will be somewhat 
difficult due to displacement of the fracture by stroks with a 
hammer, especially if corrections arn to be made, and moreover, 
there is the difficulty of achieving better position of the nail, 
since the nail can be turned only after it has been almost 
entirely removed. Therefore, th~ greatest care must be taken 
in these cases that th° nail gets its right position in the distal 
fragment at first. At the same time the position of the knee cap 
must be considered. Slight rotation faults can then bo correct- 
ed by turning the nail with the distal fragment. 
Patients treated with the Y-nail may get up as scon as 
their general condition and the wound pain makes it possible. 
The fragments are well stabilized. 
The nail can be removed after the lapue of three to four 
months. For this purpose only slight skin incisions are required. 
The patient lies on the sound side. Then removing the nail of 
the neck of the femur the leg must bo rotated inwards by about 
3® degrees if the operation starts at the old wound. 
This larg~ nail too may safely be left in the bon©, especially 
if the patients are elderly who do not want to undergo another 
operation. Patients who we re operated on three years ago have so 
far net suffered any injurious effect caused by this large metal- 
lic foreign body. 
21jL_THF_SUPRAC0hDYLAR_T-FRaCTURE 
As a reduction and fixation of this most complicated kind 
of fracture is freouently not possible without an operation, and 
as any exposure is dang°"Ous to the knee joint and th° leg, it 
seemed to be advisable to utilize the advantages of marrow nail- 
ing with these fractures. The nail alone, however, will not 
suffice, since it is sure to push aside the condyles and to pene- 
trate into the knee joint, i.e. by itself it always will aggra- 
vate the situation. 
The shattered condyles must bo connected with each other 
by a transverse wire and the tip of the marrow nail must be 
united with this transverse nail, to prevent a slipping back of 
the short fragment. It would be of very great advantage*if.the 
transverse nail could, be inserted r.nto a hole in the nail tip, 
directing the drill according to tie X-ray indications. Cir- 
cumstances, however, make it impossible for the time being to 
•btain that apparatus which is indeed not difficult to construct, 
S« at present we must try to get along with th© following method. !♦ Insertion of a transverse wire and attaching of a Beck 
tension clamp. The wire should be rather near to the fracture 
site, in order to diminish the danger that the marrow nail may 
miss it* 
2, Insertion of a marrow nail, which must have a wedge- 
shaped notch at its tip, is done in the usual way. Its exact 
length should be ascertained with special care* 
3. In general the reduction of fracture is possible 
only by using strong forces. The estension wire with clamp which 
lies in the lower fragment, and a traction strap dn the 
fragment serve as handles. The required amount of traction, must 
be carefully judged, for putting t nail upon the transverse 
wire can be furnished only by a block-and.-tackle, 
The operation is rendered more difficult by the fact that 
one cannot obtain an unobstructed view (the tension clamp ob- 
structs the view). Nevertheless it is worth while trying it. 
During the first six to seven it will be advisable accord* 
to the position of the fracture and th° formation of callus - 
to apply a slight additional extension to the leg (Tuberositas 
tibiae or Calcaneus), for it must be borne in mind that a com- 
pound fracture is concerned, and that the muscular forces act- 
ing upon the fragments (Muscles of the leg and the thagh) are 
very great. The leg must be put on a Braun splint. After the 
removal of the nail and the transverse wire a plaster cast must 
be applied to prevent new displacement of the fragments. 
In the beginning special attention must bo paid to the in- 
sertion site of the transverse nail. As the final position of 
the stretched wire is different from the one during the insert- 
ion, corresponding relieving incisions are recommended, in order 
to prevent the wire from cutting through t skin and perhaps 
causing an infection. 
£2a_ATYPICAL_NAILINGS 
Atypical nailing may be necessary if the broken bone shows 
pathological curvatures or if a neighbouring joint shows a stiffs: 
ing or a contraction, There are many possibilities, some of 
which may be mentioned here: 
1. Transverse fracture of the leg immediately below the 
knee-joint which is stiffened at 135°. The straight nail 
was inserted into the tibia from the middle of the femur 
passing through the knee-joint, A correction of thr* curvature 
of the axis to 160° was achieved. The patient, a woman, was 
able to walk three weeks later without any inconvenience (ill. 97) 
2. A sixteen-year old patient with a stiff strongly re- 
curved knee-joint was subjected to osteotomy. It was performed 
immediately the knee-joint and stabilized in the thigh 
bone with a marrow nail 60 centimeters long, inserted percutaneous- 
iy at the trochanter, and extending to the middle of the tibia . 
The patient was able to get up with a straight leg a fortnight 
later , 3. A subtro- 
chanteric fracture 
combined with a stiff 
hip-joint can be nail- 
ed in the usual way. 
As regards the position 
of the leg it must be 
taken into consideratior 
that in this case the 
distal fragment must 
correspond to the po- 
sition of the proximal 
fragment, i.e. the leg 
must be extended in t’r 
corresponding positio n 
As regards the after- 
treatment it must be 
taken into considerates. 
that the forces which 
have the tendency to 
displace the fragments 
are unusually strong, 
since the hip-joint 
cannot giv~ way, Thei 
fore a confinement to 
bed for at least 4-5 
weeks will be necessar 
During the first few 
weeks a comfortable po- 
sit i in of the patient 
must be achieved and renewed traumas must be prevented, since the 
leg is a large lever which has the power to bend the nail or 
even cause a piercing of the trochanter by the nail, 
4* A pseudarthrosis of the arm above the elbow combined 
with a stiffened elbow joint can be treated with a straight thigh 
nail (here 10 millimeter), as it may pass through the joint. In 
this way the disadvantage of the long arm of the lever is neutral- 
ized which renders healing so difficult in such cases, 
5, Oblique fracture of the leg at the border between the 
middle and the lower third 
in the case of a very nar- 
row cavity (diameter 6 
millimeters). As the turn 
spread nail is insufficient 
and as a nail with inclined 
plane (diameter 6 millime- 
ters) may break easily, a 
conical nail can be insert- 
ed from the inner aspect of 
the bone. Thus the nail has 
a diameter of 9 millimeters 
at the fracture site (111. 
98). 
6, Another poss- 
ibility to apply the mar- 
row nail is to be found in 
the transplantation of bon- 
es. In the case shown here 
the proximal end of the ulna 
was resected because of a 
relapse of osteitis fibfosa. 
Two months later the pro- 
jecting end of the radius 
Illustr. 97 
Iu ’■vc.s divided and the middle piece having become detached in this 
way was transplanted upon the end of the ulna. The bones were 
stabilized with marrow nails. 
Three weeks tho radius osteotomy wound was well 
he led and the transplanted part was well covered with callus. 
Nothing can be said yet about the further development. 
7, An artificial ankylosis was first tried three times 
with a long nail. One of the patients, a tabetic, though sum- 
moned several times did not show up for the after-treatment. 
Owing to the peculiarity of the disease hi s statement that he 
had no trouble at all is not to be regarded as positive proof 
of a bony healing. second patient, a woman died one year 
the operation, before the af t-■ r-tr had started, v/hilr 
the third patient did not show any bony healing. The nail which 
is 60 centimeters long and must be inserted p rcutaneously at 
the trochanter has indeed a great stability, which however,is 
probably not sufficient to neutralize all forces tending to cause 
a lateral displacement at the bone ends, since 
the places at the bones of the leg and the 
thigh which hold the nail firmly are 25 cen- 
timeters apart. Along that stretch the sta- 
bilization nf the extremity depends entirely 
on the stability of the nail. Every movement 
in the nail and every bending motion of the 
nail must result in a bending movement at the 
bone ends, in most cases it must even lead to 
a lateral displacement as each tipping over 
would cause a, lengthening of the extremity. 
All the muscles, and the 
weight of the body, however, 
constantly counteract this 
lengthening so that there 
is no other possibility 
than f«r the fragments t» 
evade this by a movement 
resulting in a lateral dis- 
placement, These movements 
will be the stronger the 
more distant the points a 
and b are from each other 
(111, 99). Therefore the 
proper thing is to make a 
V-shaped resection. The 
bone ends will then be firm- 
ly pressed together just 
as with an oblique fract- 
ure, and any movements 
leading to a lateral displacement will be im- 
possible, (ill. 106) 
8, If a bone has a second fracture and 
in the case of a refracture we have to deal 
with a special kind of nailing operation, In 
that case it must be borne in mind that after 
the removal of the nail, near the aid fracture 
site the «arr#w cavity has become rather 
narrow bv the formation of narrow callus. Unfortunately we have 
to choose a thinner nail than in the first nailing. 
Otherwise the nail would get stuck at the old fracture site , It 
will be more advisable to fit the nail tip with a few jagged 
teeth so that it may create for itself a new bod in the callus. 
IilM 9. In a single case, at the request 
of a patient, we prophylactically stabil- 
ized a thigh bone with the marrow nail in 
the presence of a subtrochanteric metastas- 
is from a breast carcenoma (ill. 101). 
Three months later the metastasis could not 
be observed any more, so that we could re- 
move the nail again. 
10, The subtrochanteric osteotomy 
is performed most successful v/ith a strong- 
ly curved thigh nail. 
By the elastic transformation in its 
longitudinal profile the nail is fixed 
firmly, so that an additional plaster cast 
is not reruired. 
ILl. 
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