Germany (Territory under Allied Occupation, 1945— 
U.S.Zone) -Office of 
Office of the Naval Advisor. 
PROJECT II FOLIO II 
MARKNAGELUNG 
NAGH KUENTSCHER 
(MARROW NAILI NM.ffiDQLLARY NAILINT) 
Part II 
Symposium 
Translation prepared by: 
U.S.Naval Technical Unit, Europe, 
(Medical Section) Office of the 
Naval Advisor, Office of the Military 
Government (U,S,). INDEX 
TITLE 
AUTHOR 
FOLIO I 
Foreword concerning the Marknagel 
I Callus without fracture 
Doz. Dr* med. habil. GERHARD KUENTSCHER 
II The importance of stimulating the marrow-cavity to the 
healing of nailed fractures 
Doz. Dr. MAATZ 
III The significance of fat embelism in the marrow nailing 
method of KUENTSCHER 
Doz. Dr. RICHARD MAATZ and 
Dr. HORST REICH 
IV Concerning the course of bone infection and regeneration 
following marrow nailing of simple and compound fractures 
and osteotomies 
Doz, Dr, RICHARD MAATZ and 
Dr. HORST j|g|0K 
V Mow great is the danger of osteomyelitis with marrew 
nailing of compound fractures? . 
Doz. Dr. RICHARD MAATZ and 
Df. HORST REICH 
VI The indication for stabile osteosynthesis (marrow nailijag 
method of KUENTSCHER) 
Prof. Dr. C. HAEBLER 
VII The restoration of configuration and mechanical relation- 
ship with the marrow nailing method of KUENTSCHER. 
Dcz. Dr. RICHARD MAATZ 
VIII New nail forms for marrow nailing 
Doz. Dr. RICHARD MAATZ 
FOLIO II 
XX The importance of a stabile osteosynthesis to h suc- 
cessful marrow nailing 
X Further experiences with the marrow-nailing-method of 
KUENTSGHER 
Doz. Dr, HEINZ GRIEoSMANN and 
Dr.WILHELM SCHUETTLMEYER 
Jff Comparative investigations concerning the course of frac- 
ture healing with the marrow-nail (KUENTSCHER) and with 
plaster casts 
Dr. HEINZ GRIESSMANE- and 
Dr. HORST REICH 
XII The stable fixation of fractures ("Stabile osteosynthesis") 
and their economic significance 
Prof. Dr. C. HAEBLSR 
XIII Pseudarthrosis of the arm treated by a modified marrow nail 
Doz. Dr, RICHARD MAATZ. THE IMPORTANCE OF A STABILE OSTFOSYa 'HFSIS 
TO A SUCCESSFUL NARROA NAILING ; 
by 
Priv. Doz, Dr. med, Richard MAATZ, Kiel 
Translation prepared by: 
U, S, Naval Technical Unit, purope, (red.I ret.) 
Office of Naval Advisor 
Office of Military Government (U.S.) The success of marrow-nailing d wends on a "stabile 
osteosythesic11 being achieved. Only if the fr ir orbs are 
firmly connected by the nail can we do without an ar' ’ition- 
al plaster cast. Only then can we expect a raoid bony 
union ih good position and only then are we **urtifird to 
nail even compound fractures, to correct the malnos-' t~: 
of older suppurating gun-shot fractures and to treat them 
with the nail. If a stabile union of the f rammer, bs is 
not ach eved by the nail one may expect displacement, de- 
lay of union or even non-union of the fragments. Compound 
fractures wil show severe suppuration, and gun-shot frac- 
tures nailed in a suppurating state will show again and 
again a flare up of the infection. 
It may be easy, it may be difficult or even imposs- 
ible to attain a ’’stabile osteosynthesis" by means of 
the nail. In general the result can be fore- 
seen and th:s alone will have to indicate the treatment 
to be chosen. The suitability of a fracture for treat- 
ment by nailin'7 cannot be judged by the length of its 
shortest fragment. Several factors are of decisive import- 
ance: Site and shape of the fracture, shape of the me- 
dullary cavity, the place whore the nail is to be intro- 
duced, the shape of the nail and its stability, and, 
finally a possible lack of firmness of the bone may re- 
el wire most careful consideration. 
Considerable experience is necessary to judge each 
of these factors. The fundamental rules arc simple. I 
have described them 1942 in the " Formschlues bei 
der Marknagelung," (see this collection of translations). 
Moreover I want to rewort on new forms of nails to- 
day, They have arisen from the endeavor to incre ,se the 
number of stabile osteosyntheses. For years the nails 
have proven to be efficient. They main a successful 
nailing possible even in those casrs in rr'ri ch the nails 
described by KUFNTSCHFR will fail, I have to refuse the 
reproach of complicating a "simple" method. It is not 
most important that it is easy to drive in the nail. The 
point is to accomplish a successful nailing. Besides, 
the spreading nails have remained plain and simple and 
reliable in their shape as must be demanded of so large 
a foreign body in the marrow cavity. 
' As stated by KUFNTSCHFR the marrow nail should unite 
the fragments with the same elastic power as the carpenter's 
nail unites two pieces of timber. The marrow nail, which 
in its cross sect;on is elastic, is slightly compressed Then 
driven into the bone cylinder. Conseruently a considerable 
power of friction will arise between the nail and the bone. 
But these favorable conditions are to be found only in the 
long borw s with an extensive constant cross section of both 
fragments when a straight nail is used. (Ill, l) Under 
these conditions it does not matter how the fracture is 
shaped if only at any place one mart of the one fragment 
may be set upon the other so that a displacement i» im- 
possible , Illustration 1 
Most favorable mechanical 
conditions. Foual cross 
section of both marrow 
cavities ind straight nail. 
If larger pieces of bone have broken out the nail then is • 
no longer encircled and supported by the bone and has to 
stand for itself against all forces threatening to bend 
it. This will demand, a considerable stability of the nail 
and that is why we can find these most favorable conditions 
only in the thi'h wh re the strong straight nail is intro- 
duced into the tubular cavitjr of the bone the cross section 
of, which does not vary. 
A disturbance of the gr owth of callus never has been 
complained of under these conditions. The sometimes re- 
markably trivial formation of callus shown by th roentgen- 
ogram is due to the ideal reducti n and to the absolute 
immobilization of the fragments. 
The conditions become much more unfavorable if the 
cross section of the medullary cavity is not constant. The 
femur too shows in its upper and lower end a irked enlarge- 
ment of the cavity. In its distal end this be ins h': her 
the younger the individual. If the i s situ ited 
between the place where the nail is to bo driver, in and the 
smallest cross sect:on of the cavity there will be no great 
difficulties. For these cases I have recommended the "conic- 
al nail” for subtrochanteric fnctur'S as shown in 111, 2, 
Illustration 2 
Conical nail for subtrochanteric 
fractures. 
inis nail is mao,e from a steel plate thinner than for the 
usual nail. It has a broad surface Garinr; on the soon' iosa 
of the trochanteric area and is ttcH adapted to the narrow- 
ing marrow cavity. Though at this place a delay of union 
is of extremely rare occurrence it is still suitable to 
use since only this nail is able to prevent the fracture 
from rotary displacement, and also to avoid an undesirable 
shortening of the bone in oblique fractures. The conditions are much more unfavorable if the frac- 
ture is situated beyond the met narrov; > ,rt of the me- 
dullary cavity. Here the nail becomes a bolt0 In the distal 
fragment there will never be sufficient friction bet err the 
nail arid the bons. In general if there is a plain trans- 
verse fracture (ill, 3), the fragments will be rendered 
resistent to angulation br the great force o~ the muscles 
pressing them firmly together. By the nail the fragments 
are protected from slipping to the side and so the fracture 
can only be angulated with as much difficulty as t ;o 
cylinders standing upon each other irhich are pressed tor-ether 
bv ,?reat cowers, (ill. A). 
Illustration 3 
The nail as a bolt. 
Illustration U 
Cylinders standing up on- 
each oth-r and pressed 
together ar~ rather re- 
sistant against agulation. 
But the fracture treated in the above manner is protected 
against rotary displacement. Therefore I have utilized the 
fact that the cross section of the cavity in the distal part 
has an oval shape and have recommended a double nail, spread- 
ing at least in one plan©, for suitable cases (ill, 5), 
We have not yet produced an entirely satisfactory spread- 
ing nail for the thigh. We are occupied with further 
experiments. If we have a den.tated fracture under otherwise 
the same conditions as above (ill, 6) the osteosynthesis may 
be stabile because now the fragments are protected, rwainst 
rotary displacement by the principle of the com wheel (Hirth- 
teeth), (111. 7). 
The conditions for an o blieue fracture at once are 
considerably more favorable under what are otherwise the 
same circumstances. The surfaces of the fragments slide 
along each other until nail and bone are firmly fixed. 
The resulting slight shortening in general is of no im- 
portance but the fracture is made resistant against bend- 
ing and angulation by means of the nail. Due to the ob- 
liquity of the line of fracture it is also protected against 
rotary displacement since rotation at the same time means 
a lengthening of the bone and this would have to act against Illustration 5 
Spreading nail for the 
thigh. S c r c ;i s h o v/i np 
in X-ray was left in 
the wound at the tiine 
of removal of a Lane 
plate done in another 
clinic, 
Illustration 7 
Hirth-teeth (secure 
against rotation). 
Illustration 6 
This bolted fracture is 
protected against rotary 
displacement after the 
principle of the Hirth- 
teeth. the tonicity of the muscles ,md the ” statischc Belastung,f 
(other forces of physiological function) (ill. B) 
Illustration B 
Rotation of the frag ents 
of an oblieue fracture is 
prevented because of the 
associated lengthening. 
The disadvantage of the bolting in a medullary cavity 
enlarging in its distal end will only become disastrous when 
the bone cylinders are not standing firmly upon each other 
duo to the breaking off of a third fragment or of several 
pieces of bone. Now they will be liable to tilting and uhc 
fracture will bo angulated (111, 9) 
Illustration 9 
i Caused by a th ’rd. frag- 
ment the bolted fracture 
has anwulated. 
In general the fragments are wedged together thereafter in 
such a way that the growth of callus i s not disturbed. The 
extent of the displacement ad axim is of decisive importance 
for the final result, namely the shape of the bone after 
healing. If there is a considerable tilting of the frag- 
ments an actual delay of the growth of callus may occur and 
even a retardation of bony union, as shown in 111, 10, Illustration 10 I 
Delayed frowth of callus 
in a bolted fracture of 
the thigh. State 6 months 
after nailing* Patient 
treated later by spreading 
nail 111. 5 . 
For months the patient complained of a ’’dangling'1 in the 
fracture and had therefore for a long time been required 
to wear a full length plaster splint. This bolted frac- 
ture had not been stabilised by the nafil. 
All authors agree n tho opinion that the conditions 
for nailing arc by far tho most favorable in the thi.^h. 
Here wc have the long and firm bone cylinder, the cross 
section of its cavity does not vary throughout a consider- 
able length, we have especially strong muscles pressing 
the fragm nts together and we can introduce a strong straight 
nail. In addition to th.e femur only the ulna permits the 
use of a straight nail. But its cavity being rather narrow 
in the middle and often curved in compels us to use a nail 
of special shape if 7/0 want to avoid an insufficiency of 
the nail with resulting delay of union or even severe mal- 
position of the fracture. Fracture of the nail has most 
often occurred in the ulna. We have seen several cases in 
which the nail was bent almost to a right angle. This 
was associated with fractures situated near the elbow joint. 
Hero it is absolutely necessary to select a nail as strong 
as possible and in adaptation ho the shape of the bone it 
must bo conical. Its broader part docs not lie chiefly 
in the marrow cavity but in the spongiosa and this is why 
its broad shape is so desirable (ill, 11) 
Ill, 11 
The nail for 
the ulna, 
florcd at its 
h er„d end. None of the fresh fractures of the ulna, either compound 
or simple, which have b'en treated with sueh a nai1 have 
shown a disturbed growth of callus or a subseru.nt dis- 
placement of the fragments. But if w. want to treat a 
pscudarthrosis of the ulna we must use the marrow spring- 
in addition to the nail. The operative treatment of a 
pscudarthrosis is of necessity associated with a shortening 
of the bone due to the necessary freshening of the frag- 
ments, In general the power of the muscles to press both 
fragments against each other is very poor in the arm so 
that, a separation and a gap between the fragments is not 
unusual. Since this is observed more after the 
operation upon a pscudarthrosis and the formation of callus 
in the forearm not being suitable for bridging over a gap 
between the fragments, as is well known, non-union docs occur 
far too easily. 111, 12 shows one example out of a number. 
Illustration 12 
Pseudarthrosis of the ulna 
after nailing (ps cudart hro sis of 
radius was intentionally permitted 
to persist). 
By the additional use of the marron-spring, the gap be- 
tween the fragments is avoided and the fracture or pseud- 
arthrosis will heal. 
This marrow spring at the proximal end is fastened to 
the nail and at the distal end to the corticalis by a 
special hook (ill, 13). The conical shape of,the nail pre- 
vents its intruding more profoundly into the bone so that 
the spring remains constantly under tension. 
Illustration 13 
Nail for the ulna wi t h rnarrow s p rng, Illustration 14-a 
Pseudarthrosis of the 
ulna, Lane plate in 
position. 
Illustration l^b 
State after nailing 
the bones with 
shortening of the 
radius. The marrow 
spring in the ulna 
is pressing the frag- 
ments together. Illustration 14 c 
(1 & 2) 
Bony union after 
three months 
If we are forced by the shape of the bone and the place 
where the nail has to be introduced to use curved no. ilw> ./hich 
conseouently are elastic, we are confronted vita nevf mechanic- 
al conditions. If we drive the nail from laterally and 
below into the tube of a bone enlar'inp’ in ios upper part, 
as for instance the humerus, we can never expect a gpod 
nFormsch3.uossipkeit( o. term indico.tinp the exactness of 
contact between two objects), (111. 15) 
Illustration 15 
The laterally introduced nail must 
have a smaller cross sector than 
the marrow cavity. During the first days we generally obsrrvr a j->.m- ing of 
the curved nail in the marrow cavity, but all too often 
this will be so unreliable that very so n the fragments 
separate. The result in a gap at the fracture site, which 
in a closed fracture will lead to a delay in the develop- 
ment of callus while in a suppurating fracture will cause 
a pseudarthrosis, If a pseudarthrosis is treated in this 
way, it will be the reason for its further existence 
(111. 16-19), 
Illustration 16 
Delay of the formation of 
callus in a closed frac- 
ture of the upper arm which 
has been nailed, 
Pat, K. 2 months after 
nailing, 
Illustration 17 
Pseudarthrosis after an 
open fracture nailed and 
inf ec ted, 
Pat, Schw, A months after 
operation. 
As a result of the forces of weight bearing not acting and 
the tonicity of the muscles being relatively slight, dis- 
traction .of the fragments is more apt to occur in a frac- 
ture of the upper arm than in fractures of the lower limb 
because the nail itself may act in such a way as to inter- 
fere with the close apposition of the fragments, A block- 
ing effect caused by the nail may easily occur in the 
arm, since here we have peculiar mechanical conditions. The 
point of the nail may very easily become stuck in the marrow 
cavity which thins out in its distal part. The power press- 
ing the fragments against one another are slight (tonicity 
of the muscles) and moreover the weight of the arm acts 
against them. If once a separation of the fr cture has 
occurred these powers are no longer able to overcome the Illustration IS 
Persisting pseudarthro sis 
2 months after freshening and 
nailing, Pat, L, 
Illustration 19 
Persisting pseud art hro si s 
after nailing and wire 
suture in the upper arm. 
Fat. K. 
friction between the rough inner surface of the bone -and 
the necessarily curved nail. In the lower extremity the 
tonicity of the muscles is much stronger, there is the weight 
of the body when standing, and the medullary cavity enlar-cs 
at the distal end of the tibia, as well as of the femur, pre- 
venting the point of the nail from running into the rough 
interior layer of the bone, all of which are factors ex- 
plaining why we do not observe the blocking effect of the 
nail in the lower limb as in the upper limb. In addition 
since the nail must be elastic slight tilting motion in 
the fracture with resulting delay of union or non-union 
may occur. 
All those disadvantages will occur less easily, t-hfe 
more oblique the line of fracture. But since the nailing 
is most urgently indicated for the plain transverse frac- 
ture of the upper arm, the reduction of :> s mai. n- 
tainod only with difficulty, we must try to d ecrrase the 
above disadvantages. If there is a closed fr .cture wc will 
succeed most often if we use a very small d i eter na: 1 
which can never cause a blocking ef ‘ect, if the patient, 
supporting the arm in a sling, complains of pain in the 
fracture during the first days after the operation, a 
splint in abduction will give sufficient additional stability. Illustration 20 
Blocking effect of 
the nail in the 
upper arm with 
seriously delayed 
formation of callus. 
Pat. J. 
For the pseudarthrosis and espcc? ally the pseudar- 
throsis with a loss of substance, the uste 01 the marrow- 
spring is urgently indicated. I shall report on this at 
another place. Here I want only to give an example, 
(111, 21). 
Illustration 21 ~ 
Gunshot fracture of 
the upper a r m w h i c h ha o 
not united in spite 
of nailing, The fre 
fricture. Illustration 21 
Gunshot fracture of the upper arm which 
has not united in spite of nailing, 
2) the fresh nailed fracture 
3) pseudarthrosis 4 months after- 
wards , 
Illustration 21^ 
Same case, bony union 
3 months after freshc-nir 
and insta 1 ' ■.ing a ni:• 1 ar. 1 
marrow spring. Illustration 22 
Pat. W. 
a,h & c -anchoring of a nail 
uhich is too sbort iir 
t h n r a cl i u s , with scri ously 
d e 1 a y e d for re a 11 on or 
callus 
d - only when a Iona nail 
was used did the 
patient yet rid of the 
pain and bony union 
was achieved. As to the formation of callus in general the same is to 
be said for the radius as for the ulna. The bone will 
only very seldom succeed in bridging ov r a loss of 
substance by means of callus, this is why a "ter osteo- 
tomies a.nd operations upon pseudarthroses the close appo- 
sition of both fragments achieved by the marrow spring is 
so important. In general in the forearm this will always 
be achieved sufficiently, by using the spring in the ulna 
alone, -*-he conditions in the tibia are very peculiar. 
This bone expands at its upper and lower end and had a 
real waist in the middle. The elastic nail has to bo .intro- 
duced from the side. 
If the fracture is situated at the most narrow part 
of the marrow cavity a real nailing can be achieved 
(ill. 23). But if a third fragment has broken out the 
fracture is liable to angulation. In this case the 
osteosynthesis is no longer a stabile one. There will be 
tilting movements in the fracture with a delay of the 
formation of callus .as a result. 
Illustration 23 
Favorable conditions for 
the nailing of the tibia 
Illustration 24 
An 1 nsuf cl out st abil- 
izati on of thr t:i bia con- 
s n u. e nt ly c auses a d. c 1 ay 
of t hr formation of c a11us, 
(4 months after nailing,) But if the fracture is located in the area of greater 
cross section of the marrow cavity regardless of whether 
it is in the upper or lower end, this may lead the 
more readily to unsatisfactory displacements, (111. 25) 
Even in the middle of the tibia we observe, under other- 
wise favorable conditions, a d e1ay of u nion when too t h i n 
a no.il ha s been used, le must nob 'or ;et that the 1 ax- nr ally 
introduced nail has considerable elasticity. thus whea 
a thin nail is used in a transverse hr .ctrre of the tibia 
at its most narrow part shearing effects arc loss;;.ble 
(111, 26). 
a 
b 
Illustration 25a & b 
Axial displacement of the nailed fracture 
located in the distal part of the tibia. 
Delay of the development of callus, Pat, 
Sch,, U months after the nailing. 
Illustration 26 
Shearing effect in a pi air 
transverse fracture of the 
tibia caused by too thin 
a nail. If the fracture of the tibia is bearing: weight the nail 
.will bend a bit and as it does not fill out the marrow 
cavity entirely, the lower fragment will fli.de past 
the upper ony to the front side whilst as soon as the 
we i g h t Is t a ke n aw ay the n ai1 wi11 st r aig h t e n and t he 
fragments'will,move in the opposite direction. 
So it is no wonder that under these unfavorable 
mec hanic a 1 circumstances an insufficient st ab 1 i z ator of 
the fracture and consequently a delay of union is to be 
expected rather freeuently in the lower leg. That is why 
in the University Hospital, Kiel when using the simple 
double nail for the lower log (129 oases) we have had to 
treat 50L of the fractures with an additional plaster 
cast, EHRLICH has begun to provide each nailed fracture 
of the lower leg with a plaster cast on principle and 
BOEHL'fR refuses to nail the pseudarthro sis of the lower 
leg because of the delay in the formation of callus for 
the same reason. 
That,is why in the lower ley I use spreading nails. 
Such nails must be of plain shape and they must not bo 
difficult to introduce. Both conditions are achieved and 
clinical experience proves their decisive super?ority 
so that to-day I treat every fracture of the tibia with 
this nail. Of the 4-7 fractures treated with this nail 
only 3 had to have an additional plaster dressing. De- 
lay of union has occurred In no case. 
The rotating spread nail (111, 27 and 28) consists 
of the usual exterior nail as described by XUEtTSCHER and 
of an interior nail which is round and solid, apart from 
two lateral groves for drainage of blood and marrow. It 
is curved in the shape of an S, has a transverse notch at 
the front near the head to facilitate ror. oval, a small 
drilled hole for countertraction when the outer nail 
is being inserted, and on its end a transverse groove 
(like the head of a screw) which makes it Possible to ro- 
tate the nail round its longitudinal axis while it is 
being driven into the bone. 
111, 27 
Rotating spread- 
nail for the tibia. 
At first the inner nail is introduced judiciously 
corresponding to its curving (ill, 29a) 'hen its point 
has passed the most narrow part of the marrow cavity 
the nail is finally driven in by striking on a short 
screw driver set into the transverse notch, at the same 
time rotating it through 180°, 
Previously a wire has to be drawn through the small 
drilled hole which later on is used to prevent the inner 
nail being driven further into the marrow-room as the 
outer nail is introduced. Illustration 2S 
Rotating spread-nail in the tibia 
with a transverse fracture belorr 
the middle. 
Illus tr'a ti on 29 
Rotating spr - ,d nail for 
the t i bi i to br uscd for 
transverse nrd short ob~ 
lirue fr .cturcs, 
a, i n t r o d u c t o n o f t h c i 1: o r 
nail shortly b e f ore t he 
rotation, 
b, introduction of the outer 
nail with- appropriate dis- 
placement of the fragment; 
the inr r nail being pro- 
tected, by countertraction 
from taken with te 
outer nail. Illustration 30 
Spreading nail with inclined plane 
for the tibia - to be used for 
longer oblicue fractures. 
When the outer nail is driven in later a momentary 
appropriate displacement of the fragments may be necessary 
by lateral traction in order to render the introduction of 
this nail into the distal part of the marrow cavity possible. 
This nail has a rather great elasticity due to this 
spreading system, it is therefore only suitable for the 
transverse and short oblicuo fractures. 
On the contrary the spread legs of the spreading nail 
with the inclined plane are nearly inflexible. Therefore 
this nail is to be used for longer oblicuo fractures and 
especially for fractures where pieces of bone have been 
broken out demanding a nail of great stab lity (ill, 30), 
The spreading of the two nails is effected b}*- a 
wedge of steel fastened to the exterior nail at the 
appropriate place. It is evident that this pair of 
nails will get a firm hold in the bone and consequently 
will stabilize all fractures which are not located too 
far distally as the spreading of the'nail is produced 
only by the counter-pressure of the bone cylinder. 
Here of course the outer nail is to be introduced 
first and during the introduction of the interior nail and 
appropriate displacement of the fragments may bo necessary 
lest the second (inner) nail will miss the medullary 
cavitv of the distal fragment (ill* 31)* 
I1lustration 31 
Introduction of the inner nail with the 
necessary momentary dislocation of the 
fr aaments, 
Here too counter-traction prevents the n*\il introduced . 
first frop intruding too fir into the medullary cavity. 
The inclined plane must bo situated at the very place '■..'here 
the cross section of the marrow-room is the same as the 
cross section of both nails tornth r, Illustration 32 „ .. 
i C,1 & 2 
ComR’inuted fractures of the lo’T.r 
leg with spread in"'1 : v'l with. in- 
clined plane, very s .ti sfictory 
position and undisturbed forretion 
of callus, 
a) Pat. R, Triangular frlament is 
seen only in view of nailed frac- 
ture 
b) Pat, St. bl 
Illustration 32,-. . 
Dl 6* 2 
Illustration 32,--, „ . 
b3 cc 4 LITF R -- T U R E 
BOEHLER , Z sc hr. orthop.u.Grenzgeb. 75. Bd, H.4. !944 
' I 
« Orthop. -Congress ' ien 1944 
KUENTSCHER .... Klin, Wschr. 1940 l/ll 
» Zbl. Chir. 5-94-0 1145 
n M " 1941 . 1 
s» Chir. 1942 H,6 
" .... Zbl. Chir. 1942 1337 
KUFNTSCHER and MAATZ,, Die Tech, d, Marknagel. Leipzig 1944 
KAATZ .... Chir. 1943 H.9 
!l .... Zbl, Chir. 1943 1260 & 1641 
» .... Orthop. Kon-qrress «7ien 1944 
n Chir. Congress Buren/lestf. 1946 From the Surgical Clinic of the University Kiel 
Director Representative: Professor Dr. ANSCHUETZ 
FURTHER EXPERIENCES WITH THE 
MARROW-NAILING - METHOD OF 
KUENTSCHER 
at the Surgical Clinic of the University Kiel. 
by 
Private Dozent Dr. med. Heinz Griessmann 
Senior Physician of the clinic 
and 
Assistant Dr. med. Vilhelm Schuettemeyer 
of the clinic 
To Professor Anschuetz at his ?6th birthday. 
Translation prepared by: 
U.S.Naval Technical Unit, Europe, (Medical Section) 
Office of the Naval Advisor 
Office of the Military Government (U.S.) This report is about the further experiences on the marrow- 
nailing method by KUENTSCHER made at the surgical clinic of the 
University of Kiel. These marrow-nailings were done during the 
period between 1st Jan 1944 and 1st May 1946* 
The technic Itself will not be discussed in this report, 
except that when another technique than usual was used for special 
reasons it will be mentioned in the appropriate place* For all 
details concerning the general technique we refer to the 
(publications of KUENTSCHER, MAATZ and FISCHER* 
During this period 155 marrow-nailings were performed. These 
155 marrow-nailings include 49 of the femur, 64 of the leg, 14 of 
the upper arm, 28 of the forearm (see table 1)* Three cases treated 
by MAATZ following a new technique are not included as MAATZ will 
reoort on this matter elsewhere* 
Table 1 
1 
1 
} 
1 
{Lower 
1 
legs \ 
Thigh 
nArms above* 
jthe elbow \ 
Forearms 
1 
1 
I 
Total 
! 
1 
x 
{Simple fractures j 
46 
• 
] 
35 
i 
t 
10 
i 
j 
16 
1 
1 
10? 
{Compound 
i 
t 
i 
i 
i 
i 
i 
i 
1 
1 
{fractures 
i 
i 
15 
i 
i 
, 7 
i 
* 
- 
i 
i 
2 
1 
24 
|P s Gud art hr o s g 
s 
2 
i 
i 
i 
i 
2 
i 
i 
10 
I 
1 
14 
L 
I 
L 
| 
1 • 
» 
1 
{ 
T 
1 
[Osteotomies 
1 
1 
- 
i 
2 
1 
1 
— 
l 
I 
— 
1 
1 
2 
t"“•rnamm.mm — 
• 
{Metastases 
1 
1 
- 
i 
i 
4 
1 
1 
1 
i 
i 
- 
1 
1 
5 
I ~i m. 
iLate nailings 
in 1 
i 
i 
1 
1 
i 
i 
1 
1 
Jtho presence... 
of J 
1 
i 
t 
1 
1 
| 
1 
i 
I 
- 
1 
1 
3 
[purulent infections 
t 
t 
1 
1 
i 
i 
1 
1 
i — 
{Total 
i 
i 
64 
I 
l 
49 
I 
I 
14 
i 
i 
28 
I 
1 
155 
|- — 
I* MARROW-NAILING OF THE LQVTR LEG. 
Altogether 64 fractures were treated by means of the marrow-nail 
of KUENTSCHER* All fractures of the leg are nailed in so far as 
they are suitable for nailing according to the directions of the 
book of KUENTSCHER and MAATZ. 
In cases of children the nailing of legs is made only if the 
fracture cannot be fixed in any other way* The indication in 
children is much less frequent because of possible disturbances 
of growth and a greater danger of infections (osteo-myelitis)• 
It is only in a very few cases that great and lasting distur- 
bances of the joints of children have been observed, when the 
splint method was used; thus in these cases the great advantage 
of the marrow nailing method is not very important, namely the 
possibility to move the limbs quite early after the operation. 
One boy was nailed, who was very strong 14 years, and 
whose fracture was not cured though several attempts had been made 
at another hospital* The remaining cases included individuals 
between 18 and 81 years old of both sexes* All fractures of the leg were nailed as early as possible after 
the arrival of the patient at the clinic. If the nailing could not 
be performed immediately because of shock or severe additional 
injuries or on account of nails not being available or for similar 
technical reasons, the patients were at first provided with traction- 
apparatus or wire extension in suitable splints* If the nailing 
could not be performed for the same reasons In cases of compound 
fractures,.the nailing was usually done after wound had closed# 
The 64 nailed fractures of the leg include 46 simple fractures, 
15 compound fractures, 2 pseudarthroses, and 1 late nailing in the 
presence of a purulent infection. 
a) Simple Fractures. 
42 simple fractures of the leg were nailed immediately after 
the arrival of the patient ax the clinic, 4 at a later time. Two 
of these last 4 cases were brought to our clinic not before 8 and 
21 days after the accident. The third patient ras not nailed earl; 
because of luxation of the tarsus and its fracture, and the fourth 
patient because of an additional fracture of the femur and severe 
collapse* The 46 simple fractures included 29 fractures of the 
lower third of the leg, 13 fractures at the middle, and 4 double 
fractures* 
Table 2* 
Simple fractures in the lower leg• 
46 
Site and kind of the fracture* 
: i 
Medium third ! Lower third j Double 
13 *29 1 fractures 
transverse oblique I transverse oblique \ 4 
fracture fracture J fracture fracture [double fracture 
9 418 21 t , 4 ; 
i! 1 \ 1 » _t 
[cable} in- [turn-pouble-in- [turn-double* in- [turn-'double j in- £um- [douhlej in- spread 
nail dined spread nailciined spread nail iclined Ispreed bail 5diMsp:ead»nail cllnsd nail 
plane; j nLane J | |p!aie} j [plane; | {plane! 
7 1- 1 2 « 4 1 - 1 - 1 5 » 1 1 2i 3 • 14 1 4 1 3*1 1 “ 
1 1 _ 1 1 i 1 1 1 1 1 1 1 1 1 
- • Q 1 / •© 1 /«9 1 1 r*9i / »9 1 f *9 if r 1 ri»i r »? 1 r 
• 1 • I • 1 *1*1 •!»!•! •! • 1 • f • 1 • 1 » 1 « 
-t—r-’-*—-1——1—«—1—»—r-T—i--t—i--*r—1 uTTr“r“TT'rrrT““:r“i—~—• 
3 • 1 1 — •— 1 ?•« * 2 *2 1 — • — 1 - 1— *5 1 1* — 1 2 • — * 2*1 ii4m 3*1* 2* 11 1 e- f - ■*- 
Legend; / stabile 
© not stabile 
The 46 leg-fractures are indicated in table 2, showing their 
number, location and the kind of fracture* This arrangement is 
regarded as important to answer the question, whether different 
shapes of nails are absolutely necessary to obtain a stabile 
osteosynthesis in any case* 
This table shows beyond doubt that the double nail regularly 
leads to a stabile osteosynthesis in transverse fractures of the 
middle third (111* 1). In 6 of the 7 fractures in the middle, stability was obtained. 
In cases of transverse fractures in the lower third treated with a 
double nail, adequate stability could not be obtained, not even in 
one case. It was always necessary to provide the fracture with an 
additional fixation bandage. It is apparent that the spread nails 
can be used to obtain good fixation in transverse fractures in the 
middle of the leg (111. 2) 
In cases of oblique fractures in the middle of the leg the 
double nail does not always provide absolute stability, as can be 
learned from the tables. The three transverse fractures of the 
lower third of the tibia treated with spread nails were stable (111.3 
The oblique fractures of the lower third of the leg, which are 
the most frequent and most difficult to treat, may in some cases be 
provided with a rigid system of spreading, and when this can be 
accomplished it is not necessary to apply additional fixation (111,-1 
This condition will be obtained most successfully with the 
spread nail with inclined plane. The turn-spread nail is more of 
a. spring-elastic system, which is sufficient in trans" erse fractures 
in the lower third of the leg, as at that place there is little 
danger that the fracture may be dislocated.All 14 oblique 
fractures in the lower third treated with a nail with inclined 
plane obtained a stabile osteosynthesis in every case, as the table 
shows. Both kinds of spread nails are recommended by MAATZ. The 
double- and turn-spread nails failed in one case each of oblique 
fractures in the lower third. VTc want especially to point out 
here, that the location of the inclined plane has to be calculated 
as well as the diameter of the nail according to the kind of 
fracture, as it is reported by MAATZ. 
In case of a comminuted fracture the middle fragment has to be 
"strung" (as pearls are strung) and usually only a double nail can 
be used. In that way 3 of the 4 comminuted fractures could be 
nailed and a stabile osteosynthesis be obtained. But even if no 
stability can be obtained the marrow-nailing method is an advantage 
in these fractures, as no considerable dislocations will occur 
in any case. 
All these facts hitherto reported prove that the double nail 
can be used only in simple transverse fractures in the middleT if 
it also is situated at the narrowest part of the marrow cavity, and 
that in all other cases the turn-spread nail or the spread-nail with 
inclined plane has to be used according to the kind of fracture. 
We are aware that this limitation is a disadvantage in that 
a hospital, willing to perform the marrow-nailings according to 
these proven points of view, has to have in stock not only 
spread-nails of different sizes, but among the spread-nails those 
with inclined plane as well, and which have the inclined plane 
attached at different locations. Generally it is sufficient to use 
nails with the inclined plane fixed on them at distances of 5 cms, 
6 cms, or 7 cms from the tip of the nail. 
But we regard even the simple nailing with the double nail 
as having considerable advantages over other methods of treatment; 
1# because of the impossibility of any great dislocation occurring, 
and 2# because of the short time during which an additional nlaster- 
bandage will be necessary. It would be a mistake to fail to provide 
additional fixation when a marrow-nailing does not obtain a stabile osteosynthesis, as harmful forces could have an influence on the 
healing of the bone, whenever possible we try to obtain a stabile 
osteosynthesis, not only because of the advantage that we do not need 
additional bandages so that the adjacent Joints can move freely, but 
especially because only the force pressing the fragments together 
which is favorable for callus formation can act and not the forces 
tending to cause lateral dislocation which delay the callus formation* 
The difference in the callus formation between fractures which were 
nailed and those which were treated only with plaster bandages, 
was shown in animal experiments by GPIESSMANN and REICH. 
The general principles have not changed in the marrow-nailing 
of leg fractures. 'The nailing is performed in the BOEHLFR screw-' 
traction apparatus, starting at a small incision placed above the 
tuberositas tibiae. For the most part a reposition was obtained 
by the suspension in the apparatus thus making it only necessary 
to resort to manual assistance in some cases and avoiding the 
necessity of using traction. 10 - 15 minutes were generally 
sufficient for the operation. 
If the narrow cavity is 30 narro?; at the so-called waist-lino 
(Taille) that the nail cannot pass this place* and if the fracture 
is located distally from that narrow place* it will also be possible 
to insert the marrow nail from the Inner., side of.the ankle pone# 
In this style 01 operation the marrow nail has only to be driven 
into the marrow cavity as far as the narrow place. For this reason 
we have twice inserted the nail from the inner side of the ankle 
bone, which was accomplished without difficulty. All cases were 
sufficiently narcotized with Evipan except 2 which were treated 
with lumbar anaesthesia and 2 with ether-narcosis. 
The healing of the wound at the place, where the nail is driven 
in was in simple fractures per priman except in 2 cases. 1 case, 
which healed secondarily will be discussed among the complicated 
cases* The other was transferred to another hospital immediately 
after the nailing, so no details are available* In cases of simple 
fractures the time of first weight bearing will usually be deter- 
mined by the additional injuries. If stability was obtained the 
patients were advised to start exercising the whole leg the very 
first day after the operation. When the healing of the wound was 
complete, no large haematoma nor any additional fractures being 
present elsewhere, we allowed the patients to be ambulatory. Under 
the most favorable circumstances the fracture could bear weight 
after 5 days. Our table shows an average time of 24 days of 
confinement to bed for all cases of nailed simple fractures of 
the leg, before the leg is first exposed to weight and strain 
whereby the cases treated with the spread nail were exposed to 
weight after 22 days and those treated with the double nail after 
26 days. During the period covered by this report re had to transfer 
almost all the patients to auxiliary hospitals in the vicinity of 
Kiel a short time after the nailing, and we got to see them very late 
again because of difficulties of transportation and other circum- 
stances of the war* Thus the statistics show 4 cases with confine- 
ment to bed for 81, 48 in 2 cases and 40 days, without any reason 
being given for this unusual length of time. The statistics under 
normal circumstances will probably be more favorable* 12 cases of 
simple fracture were of necessity provided with additional support, 
10 of them because of an unstable osteosynthesis, 2 of them because 
of an additional fracture of the ankle bone. 
If a plaster bandage was applied because of an unstable osteo- 
synthesis, it was generally sufficient to bandage the leg for three 
weeks* We will report separately on cases which had to be provided with additional plaster bandage for a longer time because of 
delayed callus formation. 
The average time the patient had to remain in the hospital - 
that is in our clinic and in auxiliary hospitals - was ?4 days for 
simple fractures. But 1 case of most severe arthrosis of both ankle 
and knee-joints with 120 days, and 2 cases of delayed callus format- 
ion and secondary healing with 120 and 150 days, have a very dis- 
advantageous influence on the statistics. Except in these special 
3 cases the average time of hospitalization is shortened to 29 days. 
The average time in our clinic was 10 days for all simple fractures. 
At the time of the transfer from our clinic to other hospitals most 
of the patients could have been sent home to be treated ambulantly 
for the remaining time, but that was not possible because of the 
frequent air raids and the difficulties resulting from them. 
The situation during war-time made it impossible to examine 
half of the patients after their recovery, thus not allowing us 
to give exact statistics about the time when the patients were 
able to work again. Of 22 cases concerning which we received 
information, 21 cases were reported to have started work again. 
In 1 case only that of an elderly (60 years) female patient with 
serious arthrosis deformans, the contrary was learned. These 21 
patients, among whom were some with delayed callus formation, were 
able to resume work again within an average time of 3 months after 
their discharge from the clinic. 
The decrease of the capability of earning average wages was, 
among the observed cases, between 10 and 30 per cent, and even this 
only for a period of J- to 1 year. Only 1 patient with secondary 
healing and later resection of the fibula, (this case will be dis- 
cussed here under "nail mishapes") was after 15 months stated to 
be unable to perform regular work for an additional period of 6 
months with a decrease of 40 per cent of earning capacity. 
The nail was usually not removed earlier than 3 months after 
the operation, even when the X-ray showed good callus formation. 
Only one nail, which was driven in from inside of the ankle bone, 
had to be removed (after 9 weeks) because of beginning disturbance 
of joint movement. But this time the fracture showed bony consolida- 
tion by clinical and X-ray examination. For the removal of the 
nail the patients were kept at the clinic for 3 or 4 days or, 
in many cases, the patient continued ambulatory. Complications 
occurred in only 3 cases. In 2 patients the nail was inserted 
so far proximally and was driven into the bone mass quite deep, 
so that the bone had to be forced open with a chisel.- This 
procedure resulted in an effusion in the knee joint. In the 
third case the wound healed by secondary intention and 14 days 
later an abscess developed at the site of the fracture. The 
fracture itself was completed bony. All 3 patients could be 
discharged as cured. 
The cases of 22 of the 42 patients with simple•fractures 
could be followed up and 18 of them had no further troubles, 
nor did they show any pathologic symptoms, 1 of the other four 
cases was the previously mentioned patient with arthrosis deformans. 
The second case was a 65 year old male patient, whose oblique 
fracture in the lower third was treated with a double nail and was 
not stable. In addition he had a fracture of the ankle-bone. Thus 
he had to be treated for a considerable time in bed with a cast, 
because of an internal rotation defect. An examination If year disclosed pain at the place of fracture, objective swelling of the 
soft parts and muscle atrophy of 2i cms, although the fracture 
showed bony healing. 
The different pains of the third patient were not due to the 
nailing (varices at both sides). 
The fourth, a female patient, was treated for oblique fracture 
of the lower third of the leg by means of the spread-nail with 
inclined plane. Stabile osteosynthesis could be obtained. At the 
same time she suffered from a fracture at the ankle-bone which 
required an additional plaster cast. At the cost-operative 
< examination, 5 months after the accident, we found unimportant 
circulatory disturbances and a healed fracture. 
We wish especially to remark that none of the 22 patients 
examined post-operatively showed any limitation of motion of the 
concerned joints, and in one case only was there a measurable 
muscle-atrophy. Except in the two cases mentioned no abnormal 
edema of s oft parts or other disturbances of the circulation were 
found. 
Three cases with a delay of callus formation had occurred, 
requiring a resection of the fibula. One of these patients had an 
oblique fracture of the middle of the tibia treated with a double 
nail, which was not stabile. The other two cases had oblique frac- 
Itures in the lower third provided with a turn-spread nail and were 
clinically considered stabile. In spite of that finding a delay 
of the bone-healing occurred, thus indicating that no absolute 
stability was obtained and minor disadvantageous forces could 
work. These facts prove our statement previously made, that 
oblique fractures in the lower third have to be provided with a 
rigid spread-system, that is the spread-nail with inclined olane. 
A resection of the fibula was undertaken after 8 or 12 weeks, 
if no callus formation could be detected. Only the fractures 
treated with a double nail required the use of an ambulatory cast 
after the resection. All three fractures showed a bony union in no 
longer than 8 weeks after the resection. The blocking effect of the 
fibula does not occur in fractures of the tibia alone, which case 
the fibula causes a blocking effect in every case, but it may 
occur also, if the fibula was broken too, as was the situation in 
our three cases, because the fibula healed more quickly than the 
tibia. 
We are sorry to have to record 2 cases of death among the 
46 patients. One of these cases was that of a 57 year old man 
who had, in addition to a simple fracture of the left leg, a 
compound luxation on fracture of the right ankle-joint, superficial 
injuries of the skin on both knees, and lacerations of the scalp, 
as well as a fracture of the left patella. At first the fracture 
of the tibia was provided with a marro?/-nail in the typical 
manner, and the wounds on the other ankle-joint and the skull were 
treated primarily. After 8 days, the wound at the place where the 
nail was inserted being healed primarily, the patella was sewed with 
wire. After 8 more days an infection arose in the region of the riglk 
ankle-joint with the fbrmation of a joint-empyema and a phlegmon 
of the calf. 3 days after the joint-empyema was opened and the 
phlegmon was incised the operation-wound of the left leg started 
to discharge pus associated with an empyema of the knee-joint 
*Thich also had to be opened. Amputation was considered because of 
the great suppuration of pus in the area of the luxation-fracture. but the general condition did not allow the intervention. The 
patient died 5 weeks after the accident. No relation of the 
yarrow nailing of the leg with the death could be detected because 
of the severe complicated infections in other parts of the 
in addition to the place where the nail was inserted. 
The second case was that of a 81 year old patient, who had a 
fracture of both thigh and leg on the right side with a commotio 
cerebri. We intended not to perform the marrow-nailing on 
Recount of his age and the very weak general condition of the 
patient, and placed a wire-extension on calcaneus and femur. The 
patient was very excited and left the bed with splints and 
extension. We decided to nail after 5 days. 4 days after the 
nailing the patient died. The autopsy showed; vast confluent 
broncho-pneumonia of both lungs, thrombosis of the vena femoralis, 
embolus of a great branch of the right pulmonary artery, lung- 
infarct with infarct-pneumonia, fibrinous pleuritis, moderate fat- 
embolism of the lungs, and vast arteriosclerosis of the aorta, the 
coronary arteries, and vessels of the extremities. The reason for t. 
death of this 8l year old patient was definitely the pneumonia, 
embolism, and infarct-pneumonia. The medium strong fat-embolism 
is not an unusual association with 2 fractures of tube-bones. It 
even must be conceded that every marrow-nailing causes an_additional 
release of fat into the free flowing blood-stream, but this does 
not do any harm, as has been clinically proven by several hundred 
cases. See the publications of MAATZ for further consideration 
of this subject. 
Out of the 46 simple fractures 4 comminuted fractures dbill 
have to be discussed. 
All these four fractures were located in the upper or middle 
third. Three of the fractures were provided with a double nail, 1 
with a nail with inclined plane (111. 5). 
Table 2 shows that in one case only stability could not be 
obtained. No disturbances of the wound healing occurred. The 
fractures were put under weight and strain after an average of 6 
weeks. In 2 cases a delay of callus formation was distinctly seen. 
All these 4 double fractures were provided with a plaster cast for 
security for the first period of the leg being used. As a matter 
of routine exercise of the leg was started very early after the 
operation, when still in bed* 
Two double fractures healed with bony union after 6 and 7 weeks 
(111* 6), but in two cases, among them the one that was not stabile, 
the fibula had to be resected on account of delayed callus 
formation and blocking by the healed fibula. The fracture was 
cured also in these 2 cases after 4 more weeks* had the chance 
to examine 3 of these cases at a later time and detected in only 
one case a shortening of 1 cm and a limitation of the bending of the 
knee-joint to 90°. All 3 patients could unrestrictedly perform 
their regular work, without any decrease of the ability to earn 
their ordinary wages* The fourth case had to be discussed 
especially later among "nailing-mishapes". 
b) Compound Fractures of the lower leg* 
The 64 narrow-nailed fractures of the leg included 15 compound 
fractures* 12 of them were nailed immediately after admission to 
our clinic following the care for the complicating injuries; the 
other 3 at later time* Table 3. 
Compound fractures in the lower leg 
15 
Site and kind of the fracture 
*1 
Medium third j Lov’er third • Double 
7 t 7 1 fractures 
transverse oblique j transverse oblique j 1 
fracture fracture » fracture fracture double ftactoe 
7 | 3 4 | 1 
oiile j in- 
is. 1 plined 
jplane 
— 
tum-|dcuhle j in-Jturn-Rouble 
greadinail kilned Sgjreadjnail 
. 1. r i. 11 
r s T r 1 1 • 
I in- |tum- double} in- jturn-j inclined 
plined thread Inail Iclined spread 1 plane 
plane 1 | jplane j 
| 2 | - | I J i J 2 | 1 
—w r J —1 
r|e I /:© ! / 
e! / 
e ! /:e j /•© 
[ • 
1 • 
1/:© 1 /;© I/!© | /;© j /fo j / so 
1 • 1 • 1 • 1 • 1 f 1 • 
4 ~ ~ ~ f. — t—~ w ~ 
2j -j- jl| if- j 2«- j 1 : - 
L-i—L.2—i-i—!. J- 
Ul !-•- I - 
E-l-I-JL-i 
1 
lIj.1 
. j : ! • 
- J *| 
L * L_j 
1 • 
Legend 
: / stabile 
Q not stabile 
Table 3 shows again the location and kind of fracture as well 
as the kind of nail used for the different fractures. The transverse 
fractures in the middle could be stabilized with a double nail, 
-except for one case; but the fractures in the lower third and the 
one case of a double-fracture could be put in stabile osteosynthesis 
in all cases with a spread-nail. 
The wounds at the place where the nail was inserted as well as 
the compounding wounds healed per priman in 7 cases. In 6 cases 
the wound at the fracture site became infected. In 2 more cases 
the wound at the place where the nail was inserted was infected 
too. However, in one case the wounds were so extensive that it 
was possible only with great difficulty to cover the wound by 
using incisions to relax the skin around the wound. In the second 
case the wound was located in an old scar-area which rendered it 
impossible to treat the wound primarily. All cases could be cured 
; without difficulties by means of opening the wounds and small 
counter-incisions, thus preventing any bone-inflammation, except 
in one patient who died and whose case will be reported on at the 
end of our publication. In only 4 cases was it necessary to currette 
the fistula which developed after approx. 6 weeks at the fracture 
site due to small sequestra. The fractures which did not show 
disturbances of the healing of the wound could be ambulatory after 
approx. 4 weeks without an additional plaster cast. In all the other 
cases it was possible for the patient to be ambulatory according to 
the severity of the infection. But even in these it was necessary 
in only one case to provide the patient with a plaster cast for 
walking during 4 weeks. The average time of hospitalization was not 
longer than for the simple fractures. Only one compound fracture 
which could not be stabilized with a simple nail, and in which an 
additional disturbance of the wound healing occurred, had to be treated in bed for 9 months because of fistula formation and blocking 
of the fibula. The average time of hospitalization is longer than 
with simple fractures only in cases with delayed callus formation 
and severe wound infection. 
Because of a delayed healing of the bone fracture in 3 cases, 
the rapidly healing and blocking fibula required resection. The 
nail was not removed earlier than 3 months after the operation. 
As a matter of course the nail had to remain in the bone considerably 
longer in cases of fractures with delayed healing. It must be 
pointed out, however, that it will not give as good results to leave 
the nail alone if the stability is not satisfactory as if the nail 
is removed and the operation repeated so that a satisfactory 
stability is achieved. The patients with the ordinary compound 
fractures (except those with chronic infections and delayed healing 
of the fracture) were able to start to work again after the same 
time as patients with simple fractures. 
Two of the 15 compound fractures are still under our care, 7 of 
them were examined later and none of them showed any disturbances of 
the free motion of the joints adjacent to the fracture* 
From the fatal cases the first was that of a 45 year old female 
patient, who was treated, as recently mentioned, with incisions 
to remove the tension of a wound 21 cms long. But an infection of 
the wound occurred anyway. After 3 weeks of feeling rather well 
'without temperature, but with a suppurating wound, the Patient 
died due to a lung-embolism. 
The second case was that of a 44 year old patient, who was 
delivered to the clinic in severe shock with an injury due to a 
bomb-raid. He was treated at first with a wire extension in the 
calcaneus. After 14 days the patient had recovered rather well, 
the temperature varied between 37 and 38°C during the first days, 
but later decreased to the normal level. The wound of the calf 
showed some necrotic areas. We regarded the patient as able to 
stand the marrow-nailing because of his fever-free condition and 
undertook the operation 14 days after he was delivered to the clinic. 
The operation itself was easily completed in a few minutes. 
Immediately after the nailing a severe collapse of the circulation 
occurred, 48 hours after the operation the patient died. We are 
sorry not to have been able to undertake the autopsy due to the 
conditions of the war. After all we want to remark that the nailing 
of this patient should have been postponed to a later time without 
concern about the position of the fracture. 
One of the compound double-fractures of the leg was provided 
with a spread-nail with inclined plane. Though fractures like that 
in the middle or lower third of the leg are stabilized in the distal 
fragment by using a spread-nail without harmful effects, fractures 
of the upper third may show some pushing and transverse forces due 
to the width of the marrow-cavity of the leg at this place, as the 
marrow-nail cannot have the same width as the marrow-cavity* In 
this way the distal fracture healed in this case very quickly, but tfc 
proximal fracture showed a delay of the healing of the bone, and 
for this reason a resection of the fibula was necessary. It is 
advised, in those double fractures, to drive an additional short 
nail into the proximal fracture, which nail fills the marrow-cavity, 
and stability may be obtained that way. c) Forms of callus. 
In his dissertation for the doctor-degree ALSLEV has 
examined more than 100 cases and all different kind of KUENTSCHER- 
nailings at our clinic. He found that several kinds of callus- 
formations may be observed: 
1. cloud-callus, 
2. trivial callus in the case of ideal reposition and quick healingr 
3. favored callus-formation on one side, 
4. extensive periosteal reaction. 
We understand a cloud-callus to be a plentiful callus-formation 
but one which appears weak in the X-ray picture, which begins to fo:-n 
after a very short time (111. 7)* It is extended far more than thz 
callus ordinarily need to be. This kind of callus-formation is 
found in fractures which have not been nailed only in those cases 
where several small fragments occur. This kind of callus occurs 
in nailed fractures even in cases without the presence of a number 
of fragments, but only in the femur. Also ALSLEV observed the 
cloud-callus only in fractures of the femur. No cloud-callus was 
ever detected in X-ray pictures of the nailed fractures of the 
lower leg* 
The second form, the trivial callus-formation with ideal repo- 
sition and quick healing, is found, for the most part, in nailed 
fractures of the lower leg (111. 8). Checking 43 nailed fractures 
of the lower leg we found this kind of callus formation 35 times* 
Only 43 X-ray pictures could be investigated in this regard as all 
the other pictures have been lost on account of war events* 
The very trivial callus formation is observed in all patients 
with quick bony healing of the fracture, when a real ideal location 
of the fragments and a stabile osteosynthesis was obtained by the 
marrow-nailing. 39 of the 43 X-ray control pictures showed an 
anatomically ideal position. 35 of these 39 patients showed trivial 
callus formations, but 4 patients showed a periosteal reaction 
extending far beyond the fracture, two of these 4 patients having 
been provided with a double nail, and 2 with a spread-nail (111. 9)-> 
This widely extended periosteal reaction was supposed by 
KUENTSCHEB to be caused by the mechanical and also chemical irritatuir. 
of the marrow-nail (Callus without Fracture, FUENTSCHER). We believe 
today, that this reaction occurs only in youth, as MAATZ has also 
reported at the German Congress of Surgeons in 1944. This fact : s 
possibly related to the circumstance that the elastic periosteal 
layer is lifted from the bone for a wide extent by the fracture- 
mechanism. The cases mentioned by ALSLEV are those of youths in the 
age group of 7 to 20 years* Also our 4 cases were of patients in 
their youth, namely 17th, 17th, 19th, and 20th year. 
The favored callus formation at one place is observed in 
fractures, of which the fragments did not have axial position (111-,111 
We know that callus formation depends to a rather great extent- 
on mechanical rules, and there is no doubt that forces pressing the 
fragments together act favorably to callus formation, but continuous 
distraction retards it. Thus, we find in an angulated fracture a 
stronger formation of callus on the concave side, viz. the place of 
greatest pressure, in comparison with a weak callus formation on the 
convex side. After the healing of the fracture two patients had a 
valgus-position and one patient a'recurvation of the iowef log* ■- In these three patients an Increased callus formation was observed 
on the concave side. 
d) Pseudarthroses. 
The first of the two cases of pseudarthrosis of the lower leg 
treated by nail was that of a 20 year old man with amputation of 
the left femur and pseudarthrosis in the lower third of the right 
lower leg (111. 11). The distal fragment was completely dislocated 
to the rear and a filthy wound the size of the palm of the hand lay 
over the proximal fragment. The injury occurred Ij- years before. 
After the excision of the ulcer both ends of the fracture were 
freshened (the surface cut or curretted away to &rm the same con- 
ditions as after a fresh fracture), and the fracture was then 
provided with an especially strong spread-nail with inclined plane 
on account of the width of the marrow cavity (111. 12). 
Ordinarily ire prefer the oblique freshening (GUENTZ) so as to 
create larger planes of contact. In that case the pseudarthrosis was 
located too close to the joint, and we had to perform a transverse 
freshening as otherwise it would not have been possible to use a 
marrow-nail. As might be expected an infection occurred, some 
bone splinters separated and the suppuration of pus caused a 
loose fit of the nail. Thus it was necessary to apply an additional 
plaster cast. The patient is still under our care, but he is already 
able to walk without the plaster cast with an orthopedic shoe and 
orthopedic splints. After the complete fixation of the fracture 
no additional splinting will be necessary. The advantage of the 
marrow-nailing in that case was the prevention of greater dislocations 
during the healing period and it was possible to use the leg earlier 
than it would have been when treated some other way. 
The second case is that of a 25 year old girl with a pseudar- 
throsis in the lower third. In this case we could perform the 
oblique freshening, the fracture was fixed with a double nail, stabile 
osteosynthesis was obtained, and no additional fixation ras necessary 
(111. 13)• The wound was not closed after the operation and we 
left it to heal per granulationem. After 6 weeks the wound had 
closed sufficiently so that the patient was able tn use the leg 
and to walk without a cane after a short time. 
e) Late nailing in the presence of purulent infections• 
We will report on the only case of late nailing in the presence 
of infection at the end of our article. 
f) Complications of the nailing. 
One patient had a transverse fracture in the lower third, of tbo 
tibia and was supposed to be treated, with a turnspread nail; but the 
elastic round part of the nail bent, when turned around for 180° ap 
necessary, like a serpentine (see in the technic; KIJENTSCHEP and 
MAATZ), so that its effect as a spread nail was not obtained. There- 
fore the turn-spread nail was replaced by a double nail. 
In a second case a normal strong turn-spread nail was to be 
Inserted. It occurred that, at a relatively narrow point but not 
(too narrow marrow-cavity, when the second nail was driven in, both 
hails blocked in such a way that the nails could not be driven in 
any further nor pulled out again, thus the second nail, which should 
have boen driven in 4 cms farther had to be broken off by force. Fhen 
it was attempted to drive the nails in with force the fracture happened to bend and the surfaces did not come together (111. 14). 
After 2 months both nails were removed with great difficulty and 
replaced by a simple thin nail, as no callus had formed because of 
the distraction. 
In a third case, with a refracture occurring 3 weeks after the 
marrow nail was removed, due to another accident, a too strong nail 
was choosen by mistake, which could neither be driven past the site 
of fracture n6r pulled out again. Also this nail had be cut off 
at the entry of the nail. Both these cases show distinctly, that 
the directions of KUENTSCHER and MAATZ must be considered carefully, 
and in case of doubt, a smaller nail should be preferred to an 
attempt to drive in the nail by force if it is blocked. Furthermore, 
care must be taken that, if ever the nail starts to block, it has 
to be drawn out again in time. If the nail can not be driven in b> 
ordinary hammer-strokes for a distance of approx. 2 cms at every 
stroke, and if a changed sound occurs, it is advised to pull the 
nail out at once. It must always be cautioned to never drive the 
nail in with great force under any circumstances. If the nail has 
blocked after being driven in by great force, it takes hours of 
troublesome difficult work to get the nail out again, by any 
(block-and-pulley etc.). Those attempts are needless and in addition 
the operation is lengthened considerably. Therefore the correct 
nail has to be carefully chosen, so that the nail goes in smoothly 
: and with the correct sound, to prevent such situations. If blocking 
i ever occurs, it is advised to cut or saw the nail off and to 
I terminate the operation as soon as possible. 
g) Recapitulation. 
This view of simple and compound fractures of the lower leg 
shows, that the shape of the nail has to match the kind of fracture, 
to obtain a stabile osteosynthesis. For this reason the double 
nails which were generally used in the beginning are only to be 
used in some single exceptional cases. The use of the different 
spread-nails is recommended. Only if a stabile osteosynthesis is 
obtained, is no additional fixation necessary. An ideal reposition 
was obtained in most of the treated fractures; the results are 
anatomically and functionally excellent. Almost always within 3 
months after release from the hospital the patients were able to work 
again. It was only in some few cases necessary to give a pension 
to the patient for a limited time. No pseudarthrosis has been ob- 
served. In some cases the blocking fibula had. to be resected due 
to delayed healing of the fracture. The average time of hospitalizat- 
ion was 34 days. The nailing of fractures of the lower leg has 
considerable advantage over other methods of treatment, most -of all 
the possibility to move the joints and train the muscles very early. 
Only by this method of treatment is it possible to use the leg 
early, the healing usually progresses quickly, without muscle-atrcphy 
or stiffening the joints. The sources of danger and cases of deatn 
at the nailing will be discussed later. The operation is, with some 
exceptions, very easily and quickly performed, in a few minutes. 
2. MAKFOW-NAILING OF THE FEMUR. 
During the period of this report, 49 fractures of the femur were 
nailed, 35 of them Fere simple fractures, 7 compound fractures, 4 
metastases or bone-tumors, 2 osteotomies, and 1 late nailing in the 
presence of infection. Patients of sexes and of the ages group 
of 4 to, 70 years Fere nailed. Every fracture of the femur nailed, 
except if the nailing was not recommended because of the kind of 
fracture (close to the joint or reaching in the joint) or to other additional complicating injuries or diseases, in cases of adults. 
In cases of children we only decided te nail if no other method of 
treatment (SCHEEDEfs vertical suspension, extension, or plaster-cast 
treatment) could bring about a satisfactory fixation (111.15,16,17)» 
As a satisfactory reposition can generally be obtained without 
great ‘difficulty in juvenile fractures, minor faults of fixation 
regulate themselves later on, and no restriction of movement of the 
joints has been observed. Thus the many advantages of the marrow- 
nailing method can be considered not so important in the case of 
children. If an infection occurs in a compound fracture this will 
stay restricted to the place of the fracture in the case of adults* 
but in the children a true osteomyelitis may develop. This is one 
more reason to be cautious about the nailing of femur fractures 
of children. 
Whenever possible the nailing was performed immediately after 
the delivery of the patient into the hospital. The immediate nail:' ', 
was not undertaken if it was a case of a shock, or one of extensive 
injuries of soft parts (because of the threat of fat-embolism). 
If the nailing cruld not be performed immediately, for the 
other reason, a wire extension was applied, to prevent any shortening 
of muscles and thus making difficulties at a later repositioning. 
The technic formerly used at our clinic is still performed. 
We regard it necessary to point again to the fact, that the choice 
of the nail has to be made very carefully, and that in case of doubt 
it is better to take the thinner nail than the thicker one. The 
choice of the correct thickness of the nail is not possible if only 
a partial X-ray picture of the femur was made! To determine the 
width of the marrow-cavity X-rays of the entire femur have to be 
made from two planes. As the repositioning may cause considerable 
difficulty in persons with strong muscles, far more than with the 
other long bones, a suitable repositioning device has to be avail- 
able as well as the facilities to apply traction in every direction. 
The use of traction or of a repositioning device may, as it occurred 
to us, do considerable harm to the surrounding soft parts. Thus 
we observed earlier in a juvenile patient with a fracture of the 
femur a twisting off of the elastic periosteal coat for almost 
the entire extent of the femur. A good possibility for directing 
the proximal piece can be obtained if a marrow-nail is inserted in 
it before the reposition is performed. By this procedure we have 
not needed any repositioning device recently. 
For more details we refer to the book of FUENTSCHER and MAATZ. 
a) Simple fractures of the femur. 
Of the 35 cases of simple fractures, 2 were patients with 
fractures on both sides, 32 fractures were in the middle and upper 
third, 3 in the lower third. A stabile osteosynthesis was obtained 
in 27 cases. Two of the fractures, which were not stabile, were 
located in the lower third, where no stability was expected anyhow 
on account of the width of the marrow-cavity at this place. Three 
more cases were not expected to be stabilized on account of extensive 
comminuted fractures or large pieces of the corticalis having been 
broken out. In three of the unstable cases the leg was only placed 
on a BRAUN splint for some time. In three other cases, which might 
have shortened in spite of the nail, it was necessary to attach an 
additional wire-extension (111. 18, 19). In nne case n° stability 
was obtained on account of the choice of a nail which was too thin, 
thus enabling the distal fragment to rotate. Disturbances of healing at the place where the nail was inserted 
•occurred in only 2 cases: 1st in the patient with the fracture on 
both sides; the infection was minor; 2nd, another patient with 
extensive infection and finally exitus. This case will especially 
be reported on. 
The marrow-nailing operations in children were made under ether- 
narcosis. 2/3 of the adults received Evipan narcosis and the rest 
lumbar anaesthesia. 
In 2 cases fractures of the femur of children, which were not 
suitable for nailing at first on account of a fragment sticking in 
the fracture cleft, had to be nailed and the reposition performed 
after the fracture was laid open. The healing of wound and bone was 
completed without complications. The fractures of these children 
required nailing, as they could not be corrected by extension-treat- 
ment. 
Patients with stabile osteosynthesis and without infection may 
use their leg on an average in 24 days after the operation; the 
shortest case was 7 days, the longest 42 days. If no stability 
was obtained it took 8-12 weeks (average 70 days). The only 
patient with infection was able to use the leg 84 days after the 
operation (Table 4). 
Table 4. 
— 
Average first use and weight bearing 
in days: 
[ Average tame 
in hospital 
j ... _ - , . 
i stabile 
1 fractures 
i 
i 
r t — — 
mot stabile [infections 
1 fractures 
i i 
i i 
r 
j stabile j not stabile 
ifractures ! fractures a. 
j infections 
acturesin 
5 femur 
LapXe and 
npound) 
i 
i 
i 
i 
24 
I 
i i 
i i 
i i 
70 | 84 
i i 
i i 
i i 
i i 
t i 
40 | 120 
i i 
i i 
were only able to follow up the cases of those persons who 
did not at all or youths, therefore we can not give any 
facts as to when the patients were able to start mark again. But 
all the examined persons were free of any disturbances after an 
average time of months. No limitation of the movement of the 
joints or muscle atrophy was found of a degree worth mentioning, 
after the discharge from treatment. 
These findings are nearly the same as those given by KOIKY 
in his thesis completed at our clinic (Report on the first 89 
simple fractures at the femur; (111. 20, 21;. 
As can be seen in table 4 the average time of hospitalization 
was 40 days in cases of simple fractures of the femur which were 
stabilized. The average time for the fractures which were not 
stabilized, including the only case with infection, was 120 days. 
The nails were removed in the early cases 4 months after the 
operation. Some patients did not have the nail removed after more 
than a year, one patient even after more than 2 years, without any 
harm. SCHDETTEMEYER will report on examinations of the blood picture of nailed patients. For the most part the patients returned 
to the clinic for 4 or 6 days to get the nail removed. If there 
were favorable conditions at the patients home it was possible to 
remove the nail and allow the patient to go home. 
We are sorry to have to report one fatal case in several 
hundred with the nail removed. It was the case of a patient with 
fractures of both femurs, which had healed well both functionally 
and anatomically. When the nails were to be removed after more 
than a year a very difficult situation occurred on one side becauru 
of the very deep insertion of the nail. The trochanter major had 
to be opened with a chisel to facilitate the extraction. An 
infection of the wound, occurred with an empyema, of the hip-joint, 
which had to be opened, and a phlegmon of the thigh developed, 
followed by a sepsis, which was the cause of the patientfs death.. 
b) Fatal cases. 
A 25 year old patient, delivered at the clinic with a commotio 
cerebri, fractures of the femur and the radius, was nailed under 
Evipan narcosis 4 days after he came to the hospital. The operatic: 
was completed without complications. Failure of circulation occurj 
and the patient died 2 days post-operative. 
Another patient with commotio cerebri, fractures of the femur 
and vertebrae, was nailed 8 days after his admission to the hospital 
Also'this operation was completed, without complications. This 
patient too died a few days after the operation owing to failure 
of circulation. 
These cases indicate that a patient with a must net be 
nailed, even if the commotio is subjectively and objectively not 
causing any trouble at the time of operation, or even if the commotl , 
as in our two cases, was only of slight degree. 
In a third patient it was the case of a compound fracture of the 
head of the tibia in addition to a fracture of the femur of the other 
leg. An empyema occurred at the knee-joint of the leg which was not 
nailed, and a general sepsis developed. This patient died after 
3 weeks. Death in this case certainly was not caused by the nailing. 
The nailing of the simple fracture of the femur of a 54 year 
old patient was undertaken. The operation itself did not lead to 
any complications. The fracture was located in the lower third 
and a stabile osteosynthesis was not obtained. Therefore the thigh 
had to be placed on a BRAUN splint. Because of air raid defense 
the patient had to be transferred to an auxiliary hospital, 80 kms 
distant, one day after the operation. 10 days later an erysipelas 
occurred at the place where the nail was inserted, the secondarily 
healing wound was opened wide. It was not possible to bring the 
patient back to our clinic until one month after that event, when 
abscesses of the thigh were opened immediately. The patient died 
few days after this* We are certain that in this case death wonV 
not have occurred, if it had been possible to control the patient 
daily at our clinic. 
c) Compound fractures of the femur. 
7 compound fractures of the femur were nailed? 4 of the patients 
did not*show any difference in the process of healing, period of 
hospitalization, and time of the first use of the leg, in comparison 
with the figures for the simple fractures« The wounds healed per priman. One patient was nailed immediately after he was delivered 
at the clinic, 3 patients had to wait until the wound had healed. 
In 3 of the 7 patients a stabile osteosynthesis was obtained* 
One patient with a gun-shot fracture of the femur, could not be 
stabilized. He was provided with an additional wire extension and 
the fracture healed with 3 ems shortening (111. 20, 21). 
The 5th patient, with the fracture in the lower third of the 
femur, had a complicating wound close above the patellar As no 
stability was obtained on account of the location of the fracture, 
a plaster cast of the pelvis was applied for 3 weeks, during which 
time the wound healed-, j.n the area of the wound, which healed 
primarily, considerable cicatrization of soft parts occurred with 
severe limitation of motion of the knee-joint. 
The 6th and 7th patients were children of 5 and 6 years of age.-. 
After the nailing, undertaken primarily during the wound treatment,. 
an infection of the wounds occurred. In both cases after 3 monthsex 
suppuration of pus, a typical ring-sequestrum formed, as has been 
described by FISCHEE and REICH. Both cases showed marked periostea.' 
callus formation. The nails were removed after 4 months. The 
fracture was consolidated in both cases after the sequestrum was 
removed* 
No limitation of the action of the joints or muscle-atrophy was 
detected in either child after the removal of nail and sequestrum. 
d) Mailings of metastases and spontaneous fractures• 
A brown tumor was detected in a 10 year old boy 1 year 
previously, located in the area of the trochanter minor of the 
femur. The boy suffered a fracture at that same place caused by 
a slight trauma* No satisfactory position could be obtained by 
wire-extension and bed rest. Therefore the marrow-nailing was 
performed without exposing the fracture (111. 22, 23)* After 
14 days a strong formation of callus was observed, and the nail 
could be removed 4 months later. 
In 2 older persons the nailing of the femur was performed 
prophylactically because of metastases at the upper third of the 
femur, following an amputation of the breast because of carcinomas 
(111. 24)* In addition to this the patients were treated with 
irradiation, as we had seen in two earlier cases that the patients 
reacted well to this treatment, with freedom from pain; they could 
also walk again, and the metastases were no more to be seen in the 
X-ray picture* 
Another very interesting case is that of a 32 year ole1 colleague* 
who had a fascia-sarcoma removed from his femur 12 years before* 
After the operation an intensive X-ray irradiation was started, 
though it had been thought advisable to disarticulate the femur 
on account of the histological picture. X-ray damage occurred to 
the skin, which made skin grafts necessary. The colleague then did 
not feel any disturbances until October 1945. He continued 
engaging in sports and was at the front during the war until the 
Fall of 1945. In November 1945 a spontaneous fracture suddenly 
occurred at the femur, without any X-ray evidence of a metastasis. 
The muscles on the outside of the thigh were atrophic to a high 
degree* A broad rough area of scars was found at that place, the 
other muscles were in good condition. It cannot be ascertained quite clearly ivhich factors caused the spontaneous fracture. It 
might have been a case of fatigue fracture (Ermuedungsbruch) 
due to the effect of muscle pressure, or just as well a belated 
damage due to radiation, a kind of osteo-radionecrosis, or, the 
spontaneous fracture may have been caused by a combination of both 
these factors* The fracture was treated in a hospital outside 
the town with a wire-extension traction cast for 32 months* Then 
the patient was allowed to walk with a cane. Fhen the patient 
first asked our advise, we found a bent femur, of the form of a 
varus, due to the effect of muscle pressure from one side with 
good callus formation on the concave side and absolutely no callus 
formation on the convex side* The fracture was elastic and we 
advised the patient to consent to a marrow-nailing. This was 
performed without exposure of the log at the site of the ftacture 
(111. 25, 26, 27)* After 10 days the patient was able to stand on 
this leg for the first time without suffering any pain. After 4 
weeks he was able to walk for 2 hours, supported by a cane. After 
5 weeks distinct signs of a callus formation were detected at the 
outside of the femur fracture. After 7 reeks the patient started 
work again (111. 28). 
e) Osteotomy. 
In a 22 year old patient a femur fracture was treated with 
wire-loops in another hospital. A shrinking of the leg of cms 
occurred, with angulation of the axis in the form of a varus (111,29? 
An osteotomy and marrow-nailing Was performed (111. 30). The 
wound healed without complication. The previous shortening could 
be overcome except for a difference of li cms. 
Ina63year dd patient with a double fracture of the femur 
healed with considerable bending of the axis and shortening, an 
ideal position was obtained with a correcting osteotomy. 
Unfortunately, however, the patient died, owing to post-operative 
shock. 
The treatment of both the patients was primarily carried out in 
an hospital outside the town. 
f) Late nailing in the presence of infection. 
This case, nailed when already suppurating, will be discussed 
at the end of this report. 
g) Forms of callus. 
The different kinds of callus formation have already been 
discussed by us when dealing with the fractures of the leg. 
Vast periosteal reactions are nearly always observed in any case 
of a fracture of a juvenile femur (111. 31)* The trivial formation 
of callus and the kind which we called "cloud callus" are found 
just as frequently in femur fractures* 
h) Recapitulation. 
The procedure of the marrow nailing of the femur usually does 
not cause any difficulties* It*is advised that the marrow-nail 
should be inserted into the proximal fragment before the repositionin' 
is made, thus avoiding the use of traction or repositioning 
apparatus, as it is possible in this way to direct the fragment and 
to reposition it easily. In almost all cases a stabile osteo- 
synthesis will be achieved, which has the advantage that the joints can be freely moved early and the muscles trained. For this reason 
we usually do not find any limitation of the motion of the joints 
or a muscle atrophy. Therefore the time of treatment is much shorter 
than with other methods of treatment. The average of the time that 
the marrow-nailing method saves in respect to other methods is 50 
per cent less than the time-indexes given by BOEHLER for other 
methods of treatment. 
Even in pases of fractures which are not completely stabilized 
„nd required an additional wire-extension, the marrow-nailing method 
has the advantage that no severe dislocation of the fragments can 
occur, as occurs frequently, because of the traction of the 
gastrocnemii in the lower third of the femur. 
A juvenile femur is nailed in case all other methods fail 
to stabilize the fracture. Extensive bruises of soft parts, 
commotio cerebri, or shock forbid the nailing under any circumstance. 
.Compound fractures require care for the wound and immediate 
hailing* Poorly positioned fractures can be corrected even after 
they are healed without very much danger of shortening the leg 
by performing corrective osteotomy and final nailing. The removal 
of the nail should not be made before the X-ray picture definitively 
shows an absolute bony healing of the fracture. It has proven not 
to be harmful when the nail rests in its place for as long as two 
years. 
when bone metastases are proven in the femur a prophylactic 
marrow-nailing is proposed. 
3. MARROW-NAILING of the humerus. 
a) Simple fractures in the humerus. 
The 14 operated fractures in the humerus included 10 simple 
fractures, 2 pseudarthroses, 1 nailing because of bone metastasis, 
and one case concerned a compound fracture which was nailed after 
several months in a purulent state. The latter will be discussed 
together with similar fractures of the other long bones at the end 
of this article. 
The age of our patients was from 19 to 86 years. All the cases 
were treated under Evipan narcosis except the 86 year old patient 
who received local anaesthesia. 
7 of the patients were nailed immediately after admission to the 
hospital, 3 other patients after 2f 9 and 14 days respectively. 
The simple or double nail, adapted to the width of the marrow-cavity 
and the length of the humerus, was used. 
According to the site of the fracture in 7 cases the nail was 
inserted from above and in 3 cases from the fossa olecrani, following 
the directions of KUENTSCHER and MAATZ. The technique has not changed 
recently, but we regard it as necessary to point out the fact, that 
the hole in the corticalis where the nail is inserted, must be larger 
than usual and inclined, as otherwise the insertion of the nail would 
be rendered difficult and a bursting of bone around the hole could 
occur. 
No stabile osteosynthesis was obtained in one fracture with a 
triangular separated piece of bone at the site of the fracture. 
All the other nailings were stabile after the nailing. The healing of the wounds was in all cases per primam. No additional bandages 
were necessary. 
The average time of hospitalization was 11 days. No fatalities 
occurred. No special complications occurred. All fractures healed by 
bony union. The follow-up examination showed a restriction of 
rotation of 1/3 in the 8? year old patient, but that did not keep him 
from splitting firewood every day. No muscle-atrophy or limitation 
of movability was found in the other patients. 
We observed in nearly all cases of fracture in the humerus 
a slight callus formation. Only infrequently was a considerable 
callus formation found. 
In all cases the nail was removed when the X-ray examination 
showed bony healing. 
b) Pseudarthroses* 
A pseudarthrosis due to gun-shot injury was treated after the 
site of fracture had been laid open and the surfaces of the pseu- 
darthrosis freshened on an oblique plane. The bone-splinters which 
were chiseled off, were fixed at the proper location with wire loopse 
, A stabile osteosynthesis was obtained. The wound healed per primam. 
I An additional abduction cast was split in the shape of a basin after 
11 days and could be removed after 4 weeks. The pseudarthrosis 
i healed by bony union. 
The second patient was nailed in another hospital in January 
1945 because of a fracture of the humerus. The patient worked very 
hard and soon afterwards the wound had healed. In September 1°45 
he felt an abnormal irritation in the middle of his arm above the 
elbow. X-ray investigation showed a pseudarthrosis with a wide cleft*. 
The marrow-nail had broken at the site of tie fracture (111. 32)# 
The pseudarthrosis was laid open, the broken marrow-nail was 
removed and replaced by a stronger nail, after the pseudarthrosis 
planes had been freshened transversely. Moreover a bone graft from a 
rib was also placed in a slot chiseled into the (111* 33)* 
The wound healed per primam* The arm was placed at rest for a short 
time after the operation with a splint. The patient remained under 
ambulatory treatment after he had been discharged from hospital a 
fortnight after the operation. The graft healed in the consolidating 
fracture* No limitations of motion were found in the arm* 
c) Metastases* 
In a 71 year old colleague we found 2 large metastases in the 
left arm above the elbow with bronchial carcinoma, causing a 
spontaneous fracture (111* 34), The marrow-nailing was performed* 
The patient was able to begin motion a short time after the operation 
without additional bandages and without pains. Nothing further can 
be said about the process of the healing, as the patient did. not show 
up for follow-up examinations. 
d) Recapitulation* 
The marrow-nailing of the humerus has an advantage over other 
methods of treatment in that no additional abduction or extension 
bandages are required. The joints can be used immediately after the 
operation and thus no limitation of motion results* The time 
required for treating the patient in hospital is very short* 4. MARTOW-NAILING OF THE FOREARMS. 
Altogether 28 nailings were performed at the forearm; 16 of them 
were simple fractures, 2 compound fractures, and 10 pseudarthroses. 
Patients of both sexes were of the age from 16 to 62 years. The 
simple fractures were nailed primarily except 3« In 2 cases we could 
not nail immediately because of shock. The third patient was 
provided with a plaster-cast at first and then discharged, as he had 
been injured in a bomb-raid and. °n account of this attack we had 
been kept busy with a great number of patients. As the fracture 
showed a poor position we nailed it after 3 weeks. 
All dislocated forearm fractures wore usually nailed. Of course 
no fractures could be nailed which were located too close to the 
joint. The technique has not changed recently. v'e refer to the 
report of MAATZ during the Congress of Surgeons in 1943. Especially 
important is the correct choice of the length and thickness of the 
palls, for if no stabile osteosynthesis is obtained distraction and• 
lateral dislocation forces are easily produced at the fracture site, 
i and these lead to pseudarthrosis. 
a) Simple fractures of the forearm. 
Among the 16 fractures in the forearm were 10 cases with both 
bones broken, 4 of the cases showed only the ulna and 2 only the 
radius broken. More frequently than in the other long bones the 
reposition causes difficulty because of the narrow marrow-cavities. 
In 6 of the 16 cases the fracture had to be exposed, among them were 
the cases nailed late after the accident and which had to be exposed 
anyhow. 
The wounds healed per primam except in one case. The operation 
was completed in Evipan narcosis except in one case in which plexus 
anaesthesia was used. 
In only 2 cases of the simple fractures stability could not be 
obtained, and therefore a plaster cast was applied for 2 and 3 weeks. 
The period of hospitalization averaged a fortnight in all cases 
of simple fractures. In patients whose fracture was not exposed 
the average time was 5 days. 
Bony healing occurred in all cases except one. In this patient 
a fracture of the ulna was nailed primarily with the nail Placed 
ideally (111. 35). After 4 weeks the patient started again with his 
heavy work as a locksmith. months later the patient felt pain 
again and asked us for advice. we found the nail broken at the site 
of the fracture and a distinctly visible cleft in the ulna (111.36). 
The broken nail was removed, the pseudarthrosis freshened, the 
fracture nailed again, and a graft from the tibia inserted in 
addition. 
The mistake had been made in this 21 year old patient to allow 
him to start too early with his heavy work• The fracture showed no 
complete bony healing, and, even though the nail was chosen as care- 
fully as possible, there were sufficient forces acting to shift the 
fracture, because of the continuous use of the arm. This process led 
to changes in the forming bone-tissue and finally to pseudarthrosis 
and breaking of the nail. Even though the forces shifting the fracture are not very great, 
as this case demonstrates, they can cause considerable complications. 
Sometimes, as we can observe in cases where too short a nail was 
chosen for the radius or ulna and thus in sufficient friction was 
obtained, the nail wanders out of the bone. Especially in cases of 
ulna fractures near the elbow the nail is likely to be forced, out. 
Therefore MAATZ proposed that conical nail should be used, for this 
type of fracture. Even though it occurred in two patients that the 
nail wandered out of the bone, a bony healing was obtained, after 
the nails had been driven in again. 
In one case an extensive bridge callus formed with a good heal- 
ing of both the forearm bones, thus completely preventing a rotation 
The bridge callus was removed operatively and a fat-lobe inserted. 
Rotation was obtained, again although it was limited in amount. 
In a 60 year old woman the nailing could not be performed until 
10 days following the accident, as she was admitted to the hospital 
in shock caused by bomb injuries and with numerous wounds in the 
head. The wound healed at first per primam, after an abscess in 
her face had drained; but one month later an abscess developed in 
the place where the nail was inserted into the ulna, followed by 
disturbances of the blood circulation in the soft parts and. a 
SUDECK dystrophy in the forearm bone. A limitation of the motion 
of the wrist joint was left after the fracture had healed by bony 
union. 
In the other patients no muscle atrophy occurred after the bony 
healing nor a limitation of motion in the joints. The shortest time 
of removal of the nail was 7 weeks after the operation, but usually 
not before 3 months. 
The callus formation is usually very slight. The cleft at the 
fracture site is frequently visible for a long time, though the 
fractures are stable after the removal of the nail. 
Many patients resumed their light work again after the wound of 
the stitch-incision healed (7 days), but it is not advisable, for the 
reasons mentioned before, to let the patient start with any kind, of 
heavy work before the 12th week. 
No pensions were paid. Even the 60 year old woman, whose 
fracture had healed with limitation of the motion of the wirst-j^int, 
did not receive a permanent pension. 
b) Compound, fractures in the forearm. 
In the first a defect fracture occurred in the ulna with a 
complicating soft-part injury of the size of the palm. The nailing 
was performed immediately and. the wound left to heal secondarily 
(111. 37, 38). 
The wound healed comparatively soon. The patient was in the 
clinic only 2 days and was then treated anbulantly. It was most 
astonishing that the 4 cms defect was bridged over with a bony bar 
(111. 39). 
The patient resumed hi§ work. Changes in the area of the bony 
bar occurred, even though the nail was left in its place. A 
pseudarthrosis developed (111. 40, 41). In the second patient, 16 years of age, an open fracture in the 
left forearm had occurred, and in addition to this a fracture in the 
head of the left arm above the elbow and a number of skin wounds in 
the area of the entire arm and the face. Because of the wounds it 
was at first decided not to nail. But the fracture in the forearm 
could not be stabilized. Therefore we decided to nail at least one 
bone and chose the ulna. A chronic suppuration occurred which pushed 
out several sequestra. We were not able tn follow up the case of 
this patient as he was an alien. 
c) Pseudarthroses. 
The pseudathroses included 6 isolated ulna Pseudarthroses, 3 
isolated radius pseudarthroses, and rne pseudarthrosis in both the 
forearm bones* The pseudarthrosis in both forearm bones was trans- 
versely freshened, provided with a marrow-nail in both brnes, and it 
healed by bony union without complications. The follow-up examination 
after six months showed absolute free motion of the stabile forearm. 
Very unsatisfactory prospects for healing are to be expected in 
the isolated pseudarthroses of radius or ulna, as in either of the 
cases the corresponding sound bone causes blocking and no pressing 
forces are able to act. In only 3 cases of split-pseudarthrosis 
was it sufficient to nail and split the according to the method 
proposed by KIHCHNEB. In one of these 3 cases the healing progressed 
very slowly* We had to perform an additional BECK drilling after 
some months* Then this pseudarthrosis also healed by bony union. 
In one case of a defect-pseudarthrosis in the ulna no healing 
could be obtained after the nailing was performed only after splitting 
open the bone and without bone graft. In the other pseudarthroses 
of ulna or radius an additional chip of tibia or rib was transplanted 
when it was nailed. If possible a chip of a rib should be used to 
prevent the patient from lying in hospital too long and to permit 
his being ambulatory early. 
In one isolated defect-pseudathrosis of the radius a freshly 
resected piece of fibula was placed the freshened ends of the 
fragments and kept in place while "strung” on the marrow-nail (111.42* 
When the corresponding bone was in a 'wrong position an 
osteotomy was performed on that rne too (111. 43, 44). 
In all these patients bony healing could be obtained. We could, 
however, not follow up these cases of 2 of the patients rs it was 
not possible to get hold of them any more* 
The operation lasted on an average 2 hours, if an additional 
graft was transplanted, and was nearly always performed in Avertine- 
ether narcosis. Although the ordinary marrow-nailing does not cause 
any great difficulties to a skilled person, the rather difficult 
marrow-nailing of forearm pseudarthroses requires a considerable 
technical knowledge, and this operation should only be performed by 
surgeons who have the necessary experience in the field of marrow- 
nailing and bone-surgery* 
In three cases the wound healed secondarily, but this did not 
delay the healing of the bone fracture. The suppuration in these 
cases lasted only a short time. In the other case the suppuration 
lasted several weeks and no bony healing could be obtained (this case 
has already been mentioned above)* In all these cases an additional plaster-cast was applied, 
although stability was obtained, and the cast remained until the 
healing of the wound tras completed. 
The patients with primarily healed wounds remained in the 
hospital for an average time of 1-2 rreeks, but the 2 patients with 
secondarily healing wounds had to remain 4 and 5 weeks respectively 
in hospital treatment. 
4 cases, which could be followed up, showed anatomical and 
functional first-class results with the joints free. 
d) Recapitulation. 
The marrow-nailing in the forearm is the most difficult of all 
marrow-nailings, as can be seen by the high percentage of cases which 
required that the fracture should be exposed, by which a great 
advantage of the marrow-nailing method is given up. No disturbances 
of wound healing were observed in simple fractures. In all cases 
an excellent anatomical and functional result was obtained. Usually 
no additional bandages are required for closed fractures. The 
marrow-nailing allows one to obtain an ideal fixation in the treated; 
of defect-pseudarthroses, as renewed dislocation cannot occur. For 
bridging over isolated ulna or radius pseudarthroses it is usually 
necessary to attach a bone graft, as the sound second has a 
blocking effect and prevents the healing. 
5. LATE NAILING IN PURULFNT FRACTHPES. 
In January 1944 a 44 year old. patient suffered a compound frac- 
ture in the left lower leg during an air-raid. A chronic fistula in 
the area of the fracture occurred and no bony healing was obtained 
even after 4 months. The fracture did not show a satisfactory 
position. The intact fibula acted, had. a blocking effect. Therefore 
after 4 months we decided to nail the fracture, after resection of 
the fibula and freshening of the surfaces of the fracture, though 
the fracture was suppurating and high temperature occurred frequently 
(111. 45). An additional plaster-cast was applied. Nine months 
after the nailing, when the fracture was bridged over with bone, 
the nail was removed (111. 46). 
The Patient was able to walk 8 weeks after the nailing, provided 
with an ambulatory cast which was left for 2 months. Then 0116 patient 
walked without the cast, but the fistula did not decrease until the 
nail had been removed. The patient did not feel any discomfort and 
walked with a cane. After the nail had been removed the patient had 
to be admitted to the clinic again, to remove small sequestra. He 
then was discharged as healed. In the beginning he received a pension 
of 30 per cent. 
Thus, the situation did not lead, as one might have expected, to 
a general suppuration of the bone-marrow, but the formerly heavy 
fistulization from the fracture site decreased very considerably when 
the latter had been stabilized by the marrow-nail. Not having 
healed before for 4 months, the fracture, after being nailed, healed 
by bony union within 3 months. 
The inserted nail acts in those cases as a ("rain-pipe. As a 
matter of course neither the place where the nail was inserted nor 
the wound must be closed. The temperature steadily decreased until 
it became normal after the nailing, as in the following two 
cases. The second patient had a gun-shot fracture in the right femur in August, 1945 (111. 47). 
A comminuted fracture was found with a wound the size of the 
palm. The patient was brought to our hospital from a clinic in 
another place with a wire extension. A very strong suppuration set 
in. The wound which had been the size of a hand grew smaller very 
slowly. The patient constantly had high temperature, up to 39° and 
40° C* No satisfactory position of the fragments.was obtained. 
Several X-ray examinations showed progressing angulation. Therefore 
it was decided to nail, after almost 4 months, even though dis- 
charging freely. The fragments were exposed, great sequestrated 
bone pieces were removed and the fracture fixed with a marrow-nail 
(111. 48)* An ideal reposition was obtained after the nailing. 
The wounds were left wide open. The severe suppuration subsided 
very quickly and the temperature decreased thus making the patient 
feel well again for the first time. After 5 months the fracture 
showed complete bony union. 
7 weeks after the nailing the Patient started to walk about. 
About eighteen months after the nailing the nail and some small 
sequestra were removed from the small fistula. The contrast-medium 
outline of the fistula after the removal of the nail was seen to 
extend along the previous marrow-nail canal, which we know to be 
separated from the marrow-cavity by connective tissue. 
The discharge of pus was inconsiderable. 
The patient was able to walk very satisfactorily in a relatively 
short time, feeling really well for the first time, and. was dis- 
charged without untoward results. A shortening of 2 cms and a 
limitation of the motion in the knee-joint (bending only up to 100°) 
remained. 
On account of the critical general condition, the large 
complicating soft-part injuries and the marked suppuration, we 
considered amputating the leg several times before the nailing. re 
were able not only to save the leg of the patient by the marrow- 
nailing, but could also at once influence the general condition 
for the better. 
In a third patient we found a compound fracture of the humerus, 
multiple rib-fractures, fractures of the scapula, and a Paralysis of 
the ulna. The very extensive and dirty wound of the arm above the 
elbow could not be cleaned thoroughly. A primary nailing was not 
performed on account of the rreat number of persons injured at the 
same time* The arm was at first only placed on a KRAMER splint and 
provided with a wire-extension. Later on, as the temperature in- 
creased, an abductjon-cast was applied to keep the limb at rest. 
The fracture was in poor condition. Therefore it was decided to nail, 
after 4 weeks in spite of the suppuration (111. 50). A chronic 
infection occurred and. sequestra formed in the area of the fracture. 
After the removal of the sequestra a consolidation was obtained 
finally in an anatomically ideal position of the fragments (111.51)* 
In this case also amputation was considered# Even though we 
do not have great experience in the late nailing of purulent fractures 
we venture to say that the suppuration subsides when a really ideal 
resting position is obtained* The general condition usually improves 
immediately. Also the experiences of FT1ENTSCHER collected during 
the war in a large number of patients prove this assumption 
(Congress of Surgeons 1944). 6. GENERAL RECAPITULATION. 
The marrow-nailing of 155 fractures is reported. The tables 
show the distribution of the cases among the different long hones 
and the kind of fracture. In general we maintain formerly 
reported experiences that the marrow-nailing method has considerable 
advantages over other methods of treatment, above all in the 
possibility to nse the Joints again very soon, and thus train the 
muscles before they atrophy. Therefore the patient may considered 
to be really healed and able to work after the fracture is healed 
by bony union, and no lengthy physiotherapy follow-up treatment 
is necessary. 
The aim of every marrow-nailing is the stabile osteosynthesis. 
This can be obtained, as the examinations of the fractures in the 
lower leg have proved clearly, only with the utilization of spread- 
nails. 
If only the simple nail is used for nailing the lower leg the 
results will be decidedly worse. This explains the fact that some 
surgeons decline to perform the nailing in the lower leg. 
The technically most difficult nailing is the nailing of the 
forearm. This should therefore be left exclusively to surgeons 
familiar with the marrow-nailing. 
The period of hospitalization and the time by which the patient 
was able to work again was much shorter than the time stated in care 
of all other kinds of treatment. 
The hazards of marrow-nailing and how to avoid them has been 
pointed out in the various sections of this paper. Illustration 1 
Stabile osteosynthesis in a 
transverse fracture of the 
lower third. Spread nail 
with inclined plane. 
Illustration 2 
Transverse fracture in, 
the middle of the ley, 
(Spread nail). 
illustration 3 
Oblioue fracture of the 
lower third of the tibia 
after r err oval o the 
spread nail. Illustration U 
Oblioue fracture in the lower 
third. Spread nail with inclined 
plane. Stabile osteosynthesis 
Illustration 5 
Double fracture of the tibia. 
Treated ,,rith double nail. 
Illustration 6 
Condition after healing of a 
nailed double fracture. Illustration 7 
Cloud callus, a plentiful 
callus formation which 
appears weak in the X-ray 
and begins to form after a 
very short time. 
Illustration 8 
Trivial callus formation with 
ideal reposition and ouick heal- 
ing’. Most often found in nailed 
fractures of the lower leg 
Illustration 9 
Fxtensive periosteal reaction 
with a juvenile patient. Pe- 
riosteal reaction hardly visible 
on the copy. Illuatration 10 
Favored callus formation of 
the concave side with a slight 
valgus position of the lower 
leg. 
Illustration 11 
Pseudarthrosis in the 
lower third of the riffht 
tibia. 
Illustration 12 
The same fracture after 
treatment with especially 
strong spread nail with 
inclined plane. Illustration 13 
Nailing of a pseudarthrosis 
after oblirue freshening. 
Illustration 14. 
By attempting to drive 
the nails in with force 
the fracture bent and 
the surfaces did not 
ctme together. 
Illustration 15 
Fresh fracture of the femur. Illustration 16 
Same fracture after nail~ 
ing, (bilateral nearly 
equal fracture of a child, 
7 years old) 
Illustration 17 
Condition aft~r healing, 
shortly before the removal 
of the nai1. 
Illustra11 on IS 
Fractur' of- the femur, with a 
large piece of the cortical:s 
brtken out. fracture uas not 
stable. ?ixation thro”: b. 
a d d i t j o n a 1 w i r e - e t r r Bio n. Illustration 19 
Comminuted fracture of the 
femur. Additional fixation 
was necessary (wire-extensr 
ion) 
Illustration 20 
Gun-shot fracture of the 
femur * 
Illustration 21 
Same fractur after marrow- 
nailing, Additional wire- 
extension necess'.rjr, fract- 
ure ealed with 3 centimeters 
shortening.* Illustration 22 
Spontaneous fracture of 
the femur. 
Illustration 23 
Same fracture. Condition 
after hailing* The nail- 
ing was performed without 
exposing the fracture. 
Illustration 24- 
Metastasis in the femur. 
Condition after marrow- 
ns i lin, 
Illustration 25 
Spontaneous fracture in 
the femur. / 
Illustration 26 
Condition after a wire- 
extension lasting for 
months. 
Illustration 27 
Condition after marrow 
nailing 
Illustration 2B 
After 5 weeks, distinct 
si ,n o 7 a callus ■'or mat ion 
at the outside o? the fr ;.et- 
ure, 
Illustration 29 
Angulation of the axis in 
the form of a varus. The 
leg was shortened 5ig 
meters, Illustration 33 
Same fracture. Healing 
pseudarthrosi s with a bor. 
graft from a rib. 
Illustration 3U 
Large metastasis in the left 
arm above the elbow from a 
bronchial carcinoma. Con- 
dition after marrow nailing. 
Illustration 3 5 
Fracture of the ulna, 
nailed primarily with nail 
placed ideally. Illustration 36 and 36a 
Pseudarthrosis of the ulna. 
Nail broken at the site of 
the fracture and a d. tnnet- 
ly visible cleft in the ul- 
na . 
a) Conditions after nan ling 
of the pseudart hro si s with 
a graft from the tibia in- 
serted in addition. 
Ill, 36a 
(Editors Note: Illustrat on 37/38 is missing.) 
Illustration 39 
Defect gun-shot fracture 
of the ulna. The U centi- 
meters defect was bridged 
ever with a bony bar. 
Patient got up after 2 
days. 
Illustration 4,0 
Same fracture. Changes in 
the area of the bony bar 
occurred , Illustration 4-1 
A pseudarthrosis developed :n 
the area of the bony bar. 
Illustration 4-2 j 
Isolated defect pseudarthrosis, i 
A freshly resected piece of 
fibula was placed between the 
freshened ends of the fragments | 
and kept in place while 11 strung" 
on the marrow nail. 
Illustration 4-3 
When the corresponding 
bone was in a wr ora 
position an osteotomy 
was performed on that 
one too. Illustration 44- 
Condition after correction 
of the wrong position and 
marrow - nailing 
Illustration 45 
Condition after the nail- 
ing of a suppurating fract- 
ure. 
I on 46 
Same fracture, 9 mouths 
after the noillino' ,,the 
fracture was bridged over 
with bone and the nail 
was removed. Illustration 1*1 
Gun-shot fractuv e of the 
femur. Comminuted fract- 
ure , 
Illustration I* B 
Condition after marrow-nail- 
ing of a comminuted fracture. 
Ideal reposition. 
illustration I*9 
Same fracture, ?racture 
healed. 1 arrow-nail removed. 
Fistula of the marrow-cavi- 
ty. Illustration $0 
Condition after the na.1 ling 
of a hea1ing suopuratin 
fracture of the arm alo’-c 
the elbow. 
Illustration 51 
Healed fracture after re- 
moval of the nail. Ideal 
reposition. Special Print from 
"Archiv for Clinical Surgery" Vol.205. 3 part.1944.P£o455-474 
Edition Springer, Berlin W 9 
(From the Surgical University Clinic, Kiel.) 
(Director; Prof, Dr. A. W, FISCHER) 
COMPARATIVE INVESTIGATIONS CONCERNING THE COURSE 
OF FRACTURE HEALING WITH THE MARROW-NAIL 
(KUENTSCHER) AND WITH PLASTER CASTS 
by 
Doz. Dr. mcd. habil. HEINZ GRIESSMANN and Dr. rued. HORST REICH 
Assistants of the clinic 
With 13 Illustrations in the text* 
* The microscopical views could not be 
reproduced, an attempt had been made 
to trace the X-rays on the stencils. 
(Submitted September 1943) 
Translation prepared by; 
U. S. Naval Technical Unit, Europe, (Medical Section) 
Office of Naval Advisor 
Office of Military Government (U. S.) In spite of numerous experiments with animals and investigations 
in men the question has not yet been settled as to which tissues are 
most important to the healing of bone fractures, particularly, which 
tissue is the decisive element in the union of the fragments. 
DUEAMEL was the first to recognize the bone-constructing 
efficiency of the periosteum. Later DUPUYTREN reinforced this 
concept and deduced that not only does the periosteum form callus, 
but also the fracture surfaces of the bone itself and sometimes 
even the surrounding soft-parts take part in the process. 
According to the investigations up to the present time it is 
assumed that the formation of callus depends on the activity of 
cells originating from different tissues, but always of mesenchymal 
origin# Every mesenchymal tissue is able to produce bone under 
certain conditions and so the problem of callus-formation has become 
a problem of differentiation. 
At the present we speak of the many potentialities of the 
mesenchymal germinating tissue, from which connective tissue, 
cartilage and bone can be differentiated. 
The activity of the colls is directed by different factors, 
which may be physical, chemical, hormonal, endocrine and alimentary. 
We do not intend to discuss the numerous chemical, hormonal, 
endocrine, and alimentary factors, which may disturb the healing 
of a bone-fracture, as it would be too lengthy for this article. But 
it is necessary to point to the physical factors in the healing of 
a fracture, as there is no question that these factors are of 
decisive importance. 
The ROUX law says, that forces pressing the fragments together 
act as formative stimulants on the bone substance, but forces 
causing lateral displacement act destructively. Therefore, ROUX 
has pointed out that with the traction treatment for fractures 
pseudarthroses are more liable to develop. 
As KROMPECHER showed the normal development of a bone will 
be chondrogen when influenced by pressure, desmogen when traction 
force is acting, and angiogen when neither of these forces acts. 
KROMPECHER examined the bones of the lower legs of dogs treated 
in compressing and traction apparatuses to determine the reaction 
of the bone regeneration to these factors# His observation on normal 
bone development proved that under the effect of pressure cartilag- 
inous callus is formed from which bone is produced. Under the effect 
of traction he found a change of the undifferentiated mesenchymal 
germative-tissue into temporary connective tissue callus. Additional 
cells lie between the collagen fibrils. These develop into 
osteoblasts which surround the connective tissue bundles with 
bone substance as the grovrth of bone progresses. He came to the 
conclusion that a cartilaginous callus is formed, which, when 
the fracture ends are pressed against one another with slight 
force during the healing process, changes into chondric bone-callus 
as the chondric bone-formation progresses. This chondric bone- 
callus is structurally especially capable of withstanding pressure. 
If, however, the ends of the fragments are continuously separated fro: 
one another, by traction during the healing process, connective tissu. 
callus will be formed. The desmal bone thus developed is rather 
compact, but the connective tissue kind of bone-healing is 
structurally unable to withstand pressure. KROMPECHER tried to 
support his opinion by the findings in a fracture healed with angulation at the site of fracture. The regeneration of the 
concave side which was under pressure was endochondral, on the 
convex side, however, which was under traction, desmal, BIEBL 
found in ideally corrected wire-sutured fractures of the femur a 
strong formation of callus on the rear and inner side of the femur, 
and slight callus formation on the front and outer side. He ex- 
plains these observations by the formation of callus being favorably 
influenced by pressure on the concave side whereas the formation 
of callus is hindered by traction force on the convex side. 
But the problem is not so simple as the Investigations of 
KROMPECHER make it appear. The point of view of present day 
pathologists is, that desmal healing of the fracture is considered 
to be normal, at least in adults, and cartilaginous callus is creatm 
only as a result of special conditions (LAUCHE), Even with fracture, 
healed in a plaster cast under pressure, desmal healing is considero< 
to be normal. This assumption is contrary to that of KROMPECHER. 
The question then arises whether It is Possible to obtain an experi- 
mental condition which permits only one of the forces to act either 
pressure or traction and which eliminates all forces tending to cans- 
lateral displacement. It is unanimously acknowledged that thedc 
latter forces are harmful, and therefore they should be eliminated a. 
much as possible by the therapeutic measures. 
KUENTSCHER was able to prove with hig procedure of the extensi; 
lines that the LOOSER reconstruction zones are found exactly at the 
places of strongest traction-tension, the peak of traction-tension. 
If, however, even the healed bone is especially sensitive to tractif w 
stress, then the growing bone or callus must be effected all the 
more by this same force. 
PAUWELS has convincingly proved in fractures of the neck of 
femur how much mechanical factors influence the healing of bone 
fractures. He further showed that this mechanical problem can be 
solved with suitable counter-measures. In the case of a fracture of 
the neck of the femur the mechanical stress may act as a free 
lateral displacement force according to the angle of inclination of 
the plants of the fragments to one another and thus prevent bony 
healing, or acting as functional stress may bring the fracture to 
bony healing. Thus PAUWELS has demonstrated in case of a great 
angle of inclination caused by a wedge shaped subtrochanteric 
resection of the upper portion of the femur, that the action of the 
forces can be changed in such a wav, that instead of a freely acting 
lateral displacement force a functional pressure comes into effect. 
Thus bony healing, even of pseudarthrotic fractures of femur-nedks 
can be obtained. 
When we observe our present methods of treatment from these 
mechanical points of view we can state that none of the procedures 
fulfills the ideal conditions which are required for an undisturbed 
course of healing, namely the elimination of all harmful distraction 
forces as well as forces causing lateral displacement. It has to 
be mentioned that even the KHOMPECHER experimental distraction- and 
contraction-apparatus is not able to eliminate completely those 
forces causing lateral displacement. BLOCK, who made experiments 
similar to these of KROMPECHER, also assumes that these forces 
always disturb the conditions of the experiments. 
In the extension-treatment harmful distraction forces can act 
'when the extension is not applied in the correct amount'. All the 
other methods prevent much of the harmful forces- tending to produce 
lateral displacement, especially the plaster-cast and the ambulatory cast, but they never eliminate them completely. Only the marrow- 
nailing procedure, introduced by KUENTSCHER, enables the surgeon to 
obtain complete rest in those fractures, which are suitable for this 
method, and eliminates all of these undesirable forces causing lateral 
displacement which hinder callus formation, and permits the forces 
pressing the fragments together to act freely and thus leads to the 
healing of the fracture. Cases especially suitable for marrow-nan 1i ru 
are the transverse fractures of the long tube-benes located in the 
middle of the shaft in which a "stabile osteosynthesis” (KUENT3CU?'- 
may be obtained by the marrow*.nail acting as an internal splint. 
One might object that the narrow-nail destroys the entire 
marrow in the bone over a large area and this wound delay the 
reconstruction of the bone. But it has to be remembered that the 
marrow-nail does not act like a piston in a syringe because of its 
being V-shaped and therefore does not push all the marrow out 
of the cavity when inserted, but only a small portion of it is 
displaced and squeezed out through the fracture cleft. Furthermore, 
experience showed that in cases ideally suitable for marrow-nailing 
the healing of the bone is not disturbed. On the contrary a quicker 
consolidation of the bone fracture is achieved. The marrow-nail 
made of V2A-steel, neither hinders callus formation as a foreign 
body, nor is it harmful to the tissues. 
From all recent clinical and X-ray investigations, finally also 
from the histological examinations of FTJENTSCHEE, definite pictures 
were obtained of the situation at various stages which permit one 
to observe the events in the tissues, but did not an explanation 
concerning the course of these events in detail. 
By means of experiments in dogs the course of healing was invcst 
gated in fractures treated with a Plaster cast and those treated 
with a marrow-nail and the changes occurring in the tissues r,erc 
recorded* 
PLAN OF THE EXPEPIMENTS 
8 adult dogs of almost similar weight were used for the experi- 
ments. In all the animals the tibia fractured in the middle of 
the shaft subcutaneously, by means of an osteoclast, in such a way 
that the fragments were left in their anatomical position whenever 
possible, to prevent a rough dislocation in the fractures which 
. were not to be treated with a marrow-nail, and thus obtaining 
rather similar conditions for the experiment. 111. 1 show’s in 
lateral position the fractures of the tibia approximately in the 
middle of the shaft treated with and without the raarrowT-nail, 
experiment 1. 
To save space we did not add further X-ray illustrations. The 
A-P X-rays of experimental pair No. 1, killed 7 days after the 
fracture of the leg, showed an anatomically ideal position for the 
entire period of the experiment. 
The plaster casts were always applied so that they extended over 
both the adjacent Joints. X-ray pictures of all the dogs were made 
every 8 days. The first pair of dogs were killed after 7 days* 
the second pair at 14 days, the third pair at 5 weeks, the fourth 
pair at weeks after the leg was broken. 
All operations were done under somnifone-ether narcosis. 
The marrow-nailing was made with V-shaped V2A-marrow-nails. As we expected, the anatomic position of the fragments could not 
be maintained* as at the beginning of the experiment in those animals 
treated with plaster casts. An effort was made to correct the 
position by changing the casts. We will report on the details of the 
dislocation when discussing the respective pairs of dogs. Thus the 
conditions were similar to those occurring with the usual methods 
of fracture-treatment, i.e. the forces tending to cause lateral dis- 
placement which are harmful to the healing of the fracture could not 
be eliminated in the animals treated with the cast but in the 
fractures treated with the marrow-nail only those forces pressing 
the fragments together acted from the beginning. 
FINDINGS: 
1. The first couple of dogs, examined 7 days after the fractu < 
showed an ideal position of the fragments in the X-ra.y picture (III.' 
but no formation of callus was observed. The fracture cleft was 
distinctly visible in both bones. 
After the removal of the soft parts surrounding the bone noitbe: 
of the broken bones showed anything unusual to macroscopic exami- 
nation. In both, the site of the fracture-hematoma could be soon. 
Comparable sections of the broken bones were taken and these were 
examined microscopically in the cross-section. The entire bone 
(Including the fibula) was sectioned from the head of the tibia 
to the ankle to make it possible to observe the areas at some 
distance from the fracture site. For comparison the uninjured bone 
of the other side was examined at the same level. The bone-particles 
were dyed with hemotoxylin-eosin after the method of VAN GIESON, 
iThe following reports always relate to analogous parts of the bones. 
Microscopic examinations of the tissue of the 7 day old 
Fracture in the leg, treated with plaster. - cast. 
The bone of the uninjured lower leg shows a normal structure. 
The bone of the broken leg shows above as well as below the fracture 
site, at a distance of 6 cms,a very slight reaction in the periosteum 
A slight swelling of the lamellas is found, and the periosteal 
vessels are increased in number in comparison with the healthy bone. 
No perivascular reaction is detected. The periosteum is a thin 
lamella-like tube next to the compacta, as is usually found in heal'd■, 
bones. The compacta shows an orderly formation without any remarkable 
signs of resorption. Some widened HAVERSIAN canals are found in 
which no destruction of the compacta has taken place. (111. 2) 
The bone-marrow consists of fat-marrow. No other findings worth 
noting are seen in the marrow. No reaction in the connective tissue 
of the vessels was seen. In the area close (3 cms) to the fracture 
a more marked swelling of the periosteal tissue is associated 
with an increase of the number of fibrils. The number of vessels 
is also increased. The compacts, and the marrow are unchanged. Quite 
close to the fracture site (1 cm) a formation of nsteoidal spicules 
arises in the entire periosteal tube, surrounded by strong, well 
stained zones osteoblasts. On the concave side of the bones i.e. 
the side of strongest pressure, the formation of osteoids is the 
most complete. These osteoidal spicules are arranged almost exactly 
radially. (The position of the fracture was ideal during the 
entire period of the experiment!). Their network is penetrated by 
blood-vessels, their gelatinous substance, in which no collagen fibrils 
were detected, is stained slightly blueish by hematoxylin-eosin. In 
these places the compacta shows only slight lacunary resorption, 
the bone-marrow, however, shows a beginning br in th< form of fine osteoide spicules appearing like those of the periosteum. 
Organization of the fracture hematoma can be detected paraosteally. 
The fracture site itself shows paraosteally a connective tissue 
arranged longitudinally with numerous vessels and perivascular 
infiltrates. Next to it comes a high layer of osteoids, stained 
a faint blue with hematoxylin-eosin. The osteoid-layer shows a 
network construction. Furthermore the osteoid-layer is often inter- 
rupted by deposits of blood-pigment and tissue-debris. Osteoid 
spicules extend almost to the compacta, which in the immediate area 
of the fracture shows more resorption. In the narrow a rather active 
osteoid-formation is found, especially in the peripheral marrow 
area. Intermediary fresh connective tissue is seen changing into 
osteoid, the tissue next to the marrow being very edematous. The 
findings below the fracture site are similar to those found above it. 
Examination of the tissue of the 7 day old fracture in the leg, 
treated with a marrow-nail.' 
The uninjured bone does not show any unusual findings. At a 
distance of 6 cms from the fracture analogous t~ the sane area as th< 
fracture treated with the cast, we found, in this case, even this 
early, a marked periosteal reaction in the way of a formation of 
osteoid spicules with a definite swelling of the periosteal substance 
and proliferation of the vessels. In the compacta only a very few 
HAVERSIAN canals are distended and. contain edema fluid. Aside from 
this the compacta is unchanged. In a surprising manner a tissue 
similar to connective tissue is found compressing the marrow around 
the osteoid. The fresh osteoid lies around the nail slot in a thin 
shell-like layer (111. 4). 
Closer to tlie fracture site (3 cms) the osteoid substance formed 
from the periosteum shows a considerable increase of height. Just 
as seen 6 cms above and below the fracture site, it is arranged in an 
orderly radial pattern of spicules (viz. 111. 5 & 6). The 
compacta appears as it does more distant from the fracture site 
and does not show any remarkable evidence of resorption. Around the 
nail-bed there is a coat of connective tissue constructed by the 
marrow with fresh osteoid spicules arranged more or less in thin 
layers* There are no symptoms of infection. The closer the sections 
are to the fracture site, the higher is the osteoid layer of the 
periosteum, with a preference for the concave side of the bone* 
Also here in the compacta there are marked changes. In the 
fracture-cleft itself, besides a high periosteal osteoidal layer, 
beginning necrosis of the ends of the fragments is to be seen, 
appearing as a spreading edema. The seems to have been nibbled 
and no bone cells are to be seen. Cells dissolving the brne were 
not found. The fracture cleft is bridged over by connective tissue. 
There is no development of osteoid in that place, 'only a conden- 
sation and swelling of the connective tissue fibres with proliferation 
of the vessels. A strong reaction of the connective tissue is seen 
paraosteally but only by the proliferation of vessels, again strongest 
at the concave side. 
Comparing the staining quality of the osteoid substance of this 
bone with the one treated with the cast, it appears that in the marrow- 
nailed bone the stain is more intensively blue. This may be caused 
by a greater precipitation of calcium-salts in this fracture* 
COMPARATIVE SURVEY: 
In the fracture kept at rest by means of the cast no periosteal 
reaction occurred distant from the fracture site, butin the marrow- nailed fracture a distinct osteoid-formation can be detected at a 
distance of as much as 6 cms. Only close to the fracture site does 
the periosteum start to osteoid in the fracture treated with the 
plaster-cast, the osteoid being as thick as it is in the same place 
in the nailed fracture. In both the cases the osteoid shows a 
regular construction, only in the area of the fracture treated with 
the cast the osteoid-formation appears more irregular than the 
corresponding place in the nailed fracture. The cmpacta of the 
fracture treated with the cast shows more resorption; the marrow 
starts forming a marrow-osteoid in the immediate area of the’ fraetu. 
The marrow-nailed fracture, however, reacts with a formation macro. •• 
osteoid at a great distance from the fracture (6 cms). The nail-sl •• 
is surrounded by connective tissue. In both the tibiae the concave 
side of the bene which is under the strongest pressure shows a more 
prominent formation of osteoid. In comparing these findings it has 
to be taken into consideration that the anatomical position of the 
fragments of the fracture treated with the cast was maintained during 
the entire period of the experiment, thus stronger forces tending to 
cause lateral displacement were eliminated. 
2. The second pair of dogs, examined 14 days after the fractin' 
showed in the X-ray a transverse fracture in the middle nf the tibia, 
and fibula. In the marrow-nailed fracture an ideal position of the 
fragments was maintained during the period of the experiment. The 
leg fracture kept at rest with a plaster-cast showed an ideal 
position in. the beginning, but after 8 days a dislocation occurred 
in a lateral direction for almost as much as the diameter of the 
shaft. This latter position was maintained until the end of the 
experiment. After the experiment a spindle-shaped callus-formation 
I was observed in the marrow-nailed fracture extending over 5 cms in 
the tibia which was 16.5 cms long. The cast-treated fracture showe-'1 
only slight evidence of callus-formation in the X-ray picture. 
Both fractures were still loose. 
The examination of the bones was performed in the same wav as 
in the first pair of dogs. 
Microscopic examination of the tissue of the 14 day old- 
fracture in the leg, treated with the Plaster-cast• 
The bones of the uninjured legs are without any Pathological 
findings. At a distance of 9.5 cms and 6.5 cms from the fracture the 
periosteum does not show irregularities except a slightly thicker 
outer general layer and vessel infiltration. The comnacta shows only 
a low grade irregular resorption. The marrow is without findings.At 
a distance of 3 s cms from the site of fracture we find a high periosteal 
callus-formation. It is surprising that also paraosteally a string 
connective tissue-like reaction can be seen, especially between the 
surrounding muscle bundles. The osteoidal snicules show fresh calciur 
infiltration identifiable by the light fine-grained color. Its 
arrangement appears irregular. It lacks the impressive radial- 
stripped arrangement verticle to the compacts-as was found in the 
marrow-nailed or ideally repositioned fracture of the first pair of 
dogs. The compacts is without findings, except slight irregular 
resorption, at this level (3i cms from the site of fracture). However, 
a rather strong formation of callus is found in the marrow. Near the 
fracture site the compacts participates in the increased disorganisat- 
ion. Resorptive processes are found on damaged Particles. The 
> formation of marrow-callus is very active. In the osteoid spicules a 
beginning calcification can be detected. The general impression is 
that the tissues at the fracture site appear irregularly arranged. 
Besides fresh calcified osteoid of the periosteum wc find cartilaginous tissue and the beginning change from cartilage into b~ne-tissue can 
Ido observed. /The periosteal bone-deposit in the fracture-site is of 
various heights. The periosteal callus is frequently interrupted 
by cartilage-islands which are forming bone by themselves. Further- 
more, a tense fascial tissue is seen containing abundant nucleae. 
In general there is no uniform tissue reaction in the periosteal 
tube. In the fresh callus of the periosteum and of the marrow 
ovidences of disorganization can be found. The intermediary callus 
originates from the marrow as well as from the periosteum. As 111. 7 
shows the periosteal osteoid grows into the fracture cleft and 
unites there with an csterid network formed by the marrow. 
Microscopic examination of the tissue of the 14 dav rld 
marrow-nailed fracture in the leg. 
The uninjured bone is without pathological changes. Marrow-nailc 
leg-bones The periosteal callus formation starts even at a distance 
of 9 ems from the fracture, therefore immediately below the knee-joint 
Starting at this point the calcifying periosteal osteoid-layer is of 
increasing thickness up to the site of fracture and is the most heavy 
in the area of the fracture. 111. 8, which represents a transverse 
section at a level of 6 ems above the fracture site, shows the 
Dsteoidal spicules well arranged in a radial direction. They re- 
present the stage of change from osteoid into genuine bone-substanc , 
Because of that we find areas of osteoid which still show osteoblast, , 
especially in the peripheral area? but for the mast part, preferably 
close to the compacts, it has already changed into genuine periosteal! 
formed which is proved by the small bodies of bone now observed. 
The greatest degree of calcification is found close to the compacts 
(see 111. 9)« The compacts shows at all levels only a slight 
irregular resorption in the peripheral areas. The marrow contains 
some genuine marrow-bone, which sur?ounds the tissue of the nail-bed 
arranged more or less in layers (111. 10). This marrow-bone is 
found for the entire length of the nail? at soots °f the marrow 
a resorptive activity appears. 
COMPARATIVE SURVEYs 
In the X-ray a distinct spindle-shaped callus-formation can be 
detected around the fracture cleft in the marrow-nailed bones of the 
lower leg; in the fractures treated with the plaster-cast only slight 
callus formation can be found close to the fracture cleft. 
In the microscopic examination the great difference between the 
callus formation is especially surprising. The cast-treated fracture 
shows periosteally formed callus only in close proximity of the 
fracture-cleft, but in the nailed fracture even at a considerable 
distance from the fracture cleft, immediately below the knee-joint. 
In the comparable level of the leg treated with the cast no periosteal 
reaction of any consequence can be detected, and in the area of the 
fracture treated with a cast we find an irregular formation of tissue. 
Besides the periosteally formed callus one can observe considerable 
cartilage changing into bone and much compact connective tissue. In 
the marrow-nailed fracture the fracture-site shows a perfectly regular 
tissue-arrangement. Only a calcifying high osteoid tissue is found 
arising from the periosteum. It shows some osteoblasts peripherally. 
Wear the compacts it has already changed into bone particles. 
In both fractures a moderate irregular resorption is found in 
the compacts* The marrow of the fracture treated with the cast shows callus 
produced from the marrow only in the immediate area of the fracture. 
The marrow-nailed brne of the lower leg shows, over the entire 
extent of the nail-bed, a rather strong callus formation, and it 
is astonishing that this callus is much more developed than in the 
bone treated with the cast. This callus even shows the appearance 
of completed bone# 
3# The third pair of dogs, examined 5 weeks after the fractures 
of the leg bones, shows a transverse fracture in the tibia and fibula 
of the middle of the shaft. In the marrow-nailed fracture an ideal- 
position of the fragments was maintained during the period of the 
experiment. The fracture treated with a plaster-cast shewed at first 
a slight dislocation laterally for almost 1/3 of the diameter of the 
shaft, 4 weeks later a further slight dislocation of the axis had 
occurred. The observation of the callus formation by means of 
X-rays was rendered difficult because of the plaster-cast. Beginning 
callus formation could definitely be detected only after 3 weeks# 
After 5 weeks there was good callus formation and bony healing of th- 
fracture. The fracture cleft was still distinctly visible. In the 
marrow-nailed fracture distinct spindle-shaped callus formation was 
formed after 3 weeks. After 5 weeks there was bony fixation of the 
fracture and the cleft of the fracture was hardly visible (111. 11'. 
The examination of the bones v as made in the same*way as in the 
other experiments# 
The tissues of both fractures are 5 weeks and in a. more 
advanced stage# Therefore we do not give a detailed description here* 
Our findings are described in the comparative survey. 
COMPARATIVE SURVEY; 
In both dogs bony healing of the fractures was achieved after 
5 weeks# The marrow-nailed fracture healed in anatomically ideal 
position# The fracture treated with the cast healed with a. lateral 
dislocation and angulation# As in experiment 2 we also found here 
in the cast-treated fracture an abundant callus formation in the 
area of the fracture# The appearance of the tissue is, compared with 
that in the marrow-nailed bone, rather irregular# In the area of the 
fracture we find excessive originating from the 
periosteum, connective tissue, and cartilage. In the area of the 
fracture abundant cartilaginous tissue is observed; there are changes 
from cartilage into bone-tissue, irregular areas of calcification in 
the cartilage and finally a considerable formation of connective 
tissue in the form of an almost rigid fascial tissue. If there was 
not so much periosteal callus all this might lead to the conclusion 
that a pseudarthrosis had been formed, as there is so much connective 
tissue. The periosteal bone deposit begins only in the immediate 
area of the fracture. Even the'formation of marrow-callus begins 
in that area# These with periosteal callus contribute to the 
intermediary stabilization. The compacts shows a stronger resorption, 
especially at the fracture-site. We have the same finding in the 
area of the periosteally formed callus and the marrow-callus# 
The marrow-nailed fracture shows a considerable variation, 
generally to be considered as the result of the inner splinting of 
the fracture. In this way favorable conditions f~r the healing of 
the fracture was achieved# T--is may be seen by the fact that in the 
microscopical examination an absolutely/ regular arrangement in both 
the callus- and bone-formation is achieved# considerable 
paraosteal reaction is seen# The periosteum is the chief factor in the consolidation of the fracture. A new periosteal bone is formed 
surrounding the fracture site, like a coat. Its bone spicules are 
arranged radially in the direction of the compacta. At all points 
we see well formed fresh bone, the compacta being arranged in layers. 
This deposit however is, by no means, as high as in the 
comparable parts of the cast-treated fracture. Its structure is 
much more regular because the per:osteally formed 
are arranged radially. At all levels we find only this radially 
arranged brne, which is uniformly calcified. Other kinds °f tissue 
are not seen. As in the cast-treated fracture we f?nd hero also 
marked resorptive symptoms in the way of an irregular resorption 
in the newly formed periosteal bone, in the compacta, and in the 
marrow-bone, over the entire extent of the bone, especially in the 
area close to the fracture. 
4, The fourth pair of dogs, examined 6|- weeks after the fractir ■. 
of the leg-bones, showed a transverse fracture in the middle of the 
shaft of the tibia and the fibula. Ideal position of the fragments 
in the marrow-nailed bone during the period of the experiment, and 
a stabile bony healing was achieved after 6§- weeks. The fracture 
cleft was only slightly visible. During the experiment the fractui o 
treated with plaster-cast showed a lateral.displacement of half the 
diameter of the shaft and a rather marked angulation (recurvation). 
A good formation of callus was achieved and the fracture cleft was 
still visible after the lapse of 6g- weeks. 
Examination of the bones was made as in the other experiments. 
Microscopic examination of the tissue of the weeks old 
fracture in the leg treated •'/’ith the plaster-cast• 
The uninjured bone did not show any changes. A rather strong 
periosteal callus-formation is found (about 6 cms distant from the 
fracture-site). At 3 cms distance from the fracture site an 
additional strong paraosteal callus formation is seen. The periosteal 
bone-tissue is not constructed radially. Small cartilage-islands, 
located between the periosteal bone-spicules, are partially calcified* 
Paraosteally a very distinct formation of cartilage is found. The 
infiltration of calcium varies and an extensive formation of 
connective tissue is seen in the form of a rather compact fibrous 
tissue. Rather marked resorptive symptoms can be seen in the 
periosteal and paraosteal bone, as well as in the compacts, with 
symptoms of a disorganization of the tissue. One cm distant from 
the fracture-site and in the area of the fracture itself the 
formation of cartilage and connective tissue is more distinct•(111.12) 
A good formation of periosteal callus can be observed, the spicules 
of which, for the most part, are irregularity arranged. The 
compacta shows a marked irregular resorption in the fracture site 
itself, especially around the border in the direction of the bone 
of periosteal origin. There are different degrees of bone formation, 
going through osteoid and. cartilaginous phases. In the fracture 
cleft there is sufficient connective tissue t ith a beginning of 
bone formation. 
Microscopic examination of the tissue of the 6h weeks old 
marrow-nailed fracture in the lower leg* 
To prevent repetition we summarize the findings* 
As far as 6 cms above and below the fracture site in the 17 cms 
long tibia we see a uniform picture of a normally constructed bone- 
shell. The fracture cleft is bridged over and consistently shows evidence of rebuilding. The same evidences of rec nstruction are 
also to be found in the marginal parts of the compacts. The 
reconstruction of the bone is strongest on the side of the 
physiologically concave curvative of the leg-bones. The outer general 
layer of the periosteum can be seen. An ideal bony healing is 
achieved in the area of the fracture site in such a way that the 
inner layers of the new periosteal are well attached to the 
old compacta. A regular arrangement of the is In 
a very few7 places find snme small calcified bone islands in the 
periosteal bone-shell. Resorptive symptoms are soon in the compact7*, 
in the marrow-bone and in the periosteally farmed bone. The new 
periosteal bone is better developed than the comparable area in 
the case treated with the cast. Its construction is absolutely 
uniform (111. 13)* 
COMPARATIVE SURVEY: 
Both fractures showed bony fixation after weeks. The 
marrow-nailed fracture healed in an anatomically ideal position as 
all the experiments. The cast-treated fracture healed in lateral 
and axial displacement. In the narrow-nailed fracture the X-ray 
showed the sane extent of the spindle-shaped calcified callus as in 
the experiment 3» In "the fracture treated with the plaster-cast 
the callus formation was also considerable. N° spindle-shaped 
callus was found, the margin of this calcified callus is irregular. 
The periosteal reaction observed only in this case (6 ems distant 
from the fracture site) has to be considered as the result of an 
extensive damaging of the periosteum caused by a pronounced 
dislocation of the fracture. The periosteally formed b-ne is 
constructed irregularly and infiltrated by cartilaginous tissue 
which is calcified to a varying degree. Paraosteally plenty of 
cartilaginous and dense fibrous tissue is seen. The findings 
correspond t* those r'f experiment 3* 
The periosteally formed, bone of the marrow-nailed fracture still 
shows very distinctly the radial arrangement of the former osteoid 
spicules. Its inner layers are already built into the compacta. 
Paraosteally no reaction is seen, except small catilage islands. 
Formation of marrow-callus is observed only in the area of the 
fracture in the case treated the cast. However, in the nailed 
fracture the callus can be seen in the entire length of the nail 
surrounding the nail-bed. 
The resorption processes are nrrrc evident ir the cast-treated 
fracture than in the marrow-nailed fracture. The repsm frr this 
is the dislocation and insufficient fixation rf the cast-treated 
fracture. In this experiment the evidence °f resolution is further 
developed in both fractures. This is duo the length of time 
the fractures have existed. 
SUMMARY OF ALL THE FINDINGS: 
In experiments with animals an attempt was made to reproduce 
the arrangements similar tr those in human beings, and the healing 
process of fractures treated with plaster-cast rind those with the 
marrow-nailing was compared at different stages. 
In the treatment of fractures with a piaster-cast it was 
observed that besides the bone-constructive effect ~f the brne itself, 
the paraosteal tissue has participated extensively in the stabilizatia 
of the bone. In the narrow-nailed fracture however the paraosteal 
tissue did not take any active mart. The experiments showed that 
periosteum is of utmost importance for the healing r~f b^ne-fracturcs. In the marrow-nailed fractures the periosteum shows considerable 
hone reconstruction in the area distant from the fracture site. A 
periosteal reaction could not be detected at the corresponding area 
rf the cast-treated fracture. 
In the areas of the fractures treated with the two methods, a 
gaod periosteal bone formation is frund, but it is remarkable tha L 
the callus of the cast-treated fracture shews an irregular picture, 
the marrow-nailed fracture however shows a very regular radial 
construction. 
In both cases the callus shows evidence •-f snotty resyrntimn 
after the lanse of a certain time. This starts earlier with the 
cast-treated fracture. Here the symptoms can be seen more 
distinctly and in a larger area rf the bone. 
In the marrow-nailed fractures the b' ne narrow^ marrow- 
callus along the entire length of the nail. The nail-bed itself 
is surrounded by a coat of connective tissue, i.e. it is demarcate*" 
by connective tissue. In the cast-treated fractures a marrow-callus 
formation is found only in the very area of the fracture, acting 
in the way of an intermediate consolidation of the fragments 
together with the periosteum. 
The callus, formed in marrow-nailed cases, is rf an^absolutely 
regular arrangement and will result in a g°od stabilization of the 
fracture. Therefore it is of great value with regard -' the 
reconstruction of the bone and it is definitely superior to the 
marrow formed in cast-treated fractures. N°t the quantity, but the 
quality of the callus is the decisive factor determining its 
structural value. 
The callus in marrrow-nailed fractures, which is structurally 
better,, results frwm the elimination of all the harmful factors which 
disturb the healing, such as distraction forces, and those forces 
causing lateral displacement. Only pressure comes into effect and 
it is the only force advantageous f-r the formation of callus. 
KKOMPECHER was of the opinion that cartilaginous callus is 
formed by pressure. Our experiments with the fixation ~f the 
fracture by the marrow-nail, which eliminates ail forces causing 
lateral displacement, have proven that a desma1 callus is formed 
under pressure. This corresponds t~ the other findings ~f the 
origin of bone-callus. It is possible, that KROMPECHEF. could not 
eliminate all lateral displacement forces during his experiments. 
The great quantity of cartilaginous tissue, especially paraesteally, 
in rur fractures fixed with the plaster-cast, in which not all of 
the lateral displacement forces could be eliminated, shores that • 
a cartilaginous tissue is produced only under special conditions, 
namely when it is not possible to eliminate these harmful forces. 
The total elimination of the lateral displacement forces during 
the healing process of fractures in the shaft of tube-bones can be 
achieved only by means of the KUENTSCHEF marrow-nailing method. 
The stronger the pressure forces are, the greater will be the 
formation of callus. This can be seen at the place of the strongest 
physiological concave curvature of the bone. The periosteally formed 
callus rather distant from the fracture one1 the extensive formation 
lof narrow-callus around the nail slot may be explained by the 
pressure or the chemical stimulation the inserted nail upon the 
surrounding tissue (rUE-NTSCHEH)• BIBLIOGRAPHY: 
T11ustrations: 
1. Lateral view of c. tibia-fracture in the middle of the shaft 
of experiment 1. Position of the fractures 7 days after the 
end of the experiment. 
2. 7 days rld, cast-treated fracture, at a distance of 6 cms from 
the fracture site. No periosteal reaction. 
3. 7 days old, marrow-nailed fracture. At the level of the fractur* . 
High periosteal osteoid with surrounding connective tissue 
reaction. Pronounced irregular resorption in the compacta. 
4. 7 days marrow-nailed fracture, at a distance of 6 cms from 
the site of fracture. Periosteal osteoid-formation. No 
irregular resorption of the compacta. Marrow-osteoid. Fibrrus 
tissue ar°u d the nail slot. 
5. 7 days old marrow-nailed fracture, at a distance of 3 cms from 
the fracture site. Fell-arranged periosteal oste-id spicule 
system. Very slight evidence of resorption in the compacta. 
6. ? days old, narrow-nailed fracture, same area as 111. 5 in higher 
magnification. Radial osterid spicule-nrtwrTk of the periosteum 
with distinct margins of oSteo-biasts. Resting compacta. 
7. 14 days old, cast-treated fracture. The "vri-stool callus is 
growing into the intermediate area and extending into the net- 
work of the intermediary callus formed from narrow, 
a) periosteal callus, b) internediar callus. 
8. 14 rays old narrow-nailed fracture, at a distance of 6 cms fr°m 
the site nf the fracture. High radially arranged periosteal 
osteoid• 
9. 14 days old marrow-nailed fracture, at a distance of 6 cms from 
the site of the fracture. Close to the compacta the complete 
bone has already farmed. In the areas of the margin of the 
compacta slight resorption is seen. 
0. 14 days old marrow-nailed fracture, at a distance of 6 cms from 
the site of the fracture. Fibrosis of the nail-bed with 
distinct marrow-callus formation. 
I. 5 weeks old marrow-nailed fracture, spindle-shaped callus. 
2. weeks old cast-treated fracture. Site of fracture. Strong 
paraosteal reaction of the connective tissue and of the 
cartilaginous tissue. High perirsteally formed bo.ne with 
strong resorptive symptoms, also irregular resorption in 
compacts and marrow. Network like instruction of the 
periosteal bone. 
6i weeks old marrow-nailed fracture, at the fracture site. 
Regular construction of the periosteal lr\ne. Inconsiderable 
resorption symptoms in the compacts, nr paraosteal tissue- 
reaction, connective tissue like demarkation of the nail-bed. BIBLIOGRAPHY 
BIEBL : Arch, klin. Chir. 194, 171 
BLOCK : Die normale und gestoerte Knochenbruchheilung. 
Neue Deutsche Chirurgie, Bd.62, 1940, 
FISCHER-REICH ; Zbl. Chir. 1943, 299 
KHOMPECHEH : Die Knochenbildung. Jena; Gustav Fischer 193V 
KUENTSCHER ; Arch. klin. Chir, 182, 489 (1935), 
Chirurg 1936, 308, 440; 1942, H.6. 
Chir. Kongr. 1940. 
Zbl. Chir. 1940, 1145; 1941,1,857; 1942, 18; 
LAUCHE : Handbuch der speziellen pathclogischoa Anatr 
und Histologie, Bd. IX, S. 204, 3* Toil. 
MAATZ-REICH ; Bruns* Beitr. 174, 358 (1943). 
Note; 
The illustrations accompanying the original text could not 
reproduced with the available facilities since eleven of them art 
microphotographs. The legends for the illustrations will be f< lu 
on the following page. 111 u s t r a t i o n 1 
Lateral van w o f a. tibia- 
fracture in the middle 
of the shaft of experi- 
ment 1, Position oa the 
fractures 7 days after the 
end of the exp ri mont, 
Illustration 11 
5 weeks old marrow-nailed 
fr acturn, spindle-shaped 
callus. Reprint from the 
Zentralblatt fucr Chirurp;ie 
70, Ja hr gang, Nr, 11 - 194-3 
Verlap; von Johann. Ambrosius Barth in Leipzig 
Fr#m the German Red Cross Clinic Clementinenhaus Hannover 
(Director: Prof*Dr,Ci HAFJLER,) and the Surgical Department 
• f the City Hospital RicElingen (Deputy Direct or :Prof,Dr ,C , HAEELEI- 
THE STABLE FIXATION OF FRACTURES 
("STABILE OSTEOSYNTHESIS-') 
AND THEIR ECONOMIC SIGNIFICANCE 
by 
C. HAFBLFR 
Oberfeldarzt d, R, und beratenAer Chirurg beim Luftwaffenarzt 
With 15 Illustrations* 
* Facilities at hand did not 
permit the reproduction of 
the illustrations 3,6,9,11 
and 15. 
Translation prepared by: 
U, S, Naval Technical Unit, Europe, (i'.edical .ection) 
Office of Naval Advisor 
Office of Military Government (U. S.) The objective of fracture treatment is the restoration 
of anatomical shape of the broken bone as early and as ex- 
actly as possible. This should be maintained until the 
healing of the fracture takes place without limiting the 
flexibility of the muscles and joints. 
This ideal cannot be obtained by any conservative method, 
for the Plaster of Paris or the splint method involves a 
more or loss prolonged limitation of motion of tho joints 
next to the fracture. Also, the traction method does not 
permit a completely free flexibility of the joints and it 
by no weans guarantees a complete fixation of the broken 
bone, 
Thus surgeons tried some time ago to obtain the above 
mentioned objective by exposing the fracture in an operation, 
notching it or joining by pins or small splinters of bone 
after the method of a cabinet maker, winding wire around 
the bone, securing it with metal plates by screws and by 
similar methods. This osteosynthesis was not satisfactory, 
however, for’the fixation of the brokeh bone a-as not so stab: n - 
t fiat one could eliminate the use »f a bandage for keening * the 
effected part in a resting position. Thereby the harm by 
metal in the case of usr of unsuitable material, and first of 
all tho danger of an infection by the exposure of tho frac- 
ture was so'considt rablc that many authors, amongst them 
especially BOFHLER, completely denounced the foreign bod'0' 
osteosynthesis as a disastrous innovation, Even the sun- 
porhears of this method advocated that it be used only in 
cases of the strongest -indications, and then only if c»n- . 
servative methods were not satisfactory. 
During the last ten years a change of opinion has 
arisen on account of the extra articula.r nailing of frac- 
tures of the middle portion of the neck of tho femur. The 
successes of this method have been,so outstanding that it 
is ui.disputcdly accepted as the method of choice today, even 
by the opponents of osteosynthesis, 
Compared with the usual osteosynthesis there are 
important differences in case of the nailing of the ncek 
of tho femur; 
A special shaped (three lamellae) nail is used for 
fixing the fracture, which is driven through the trochanter 
and the neck of tho femur right up to the head. As a 
result 01 this design, together voth the wedging which takes 
place after the nail is driven in, the fracture is given 
such stability by this method, that a fixation bandage is 
unnecessary and the patients are soon able to move and to 
use the injured limb arain, KUFNTSCHER has therefore 
described the nailing of the nock of the femur as ;l stabile 
oetaosynthe sisn, 
The second important difference is that the fracture 
cleft docs not need to be exposed. The setting of the 
fracture is done subcutaneously and the wound required for 
the introduction of the nail is far distart from the fr c- 
ture cleft and the hematoma of the fracture. The danger of 
an infection is thereby reduced to a minimum. Infections of the operation wound sometimes arise but 
wc have seen them only twice in more than 80 cases of 
marrow nailing. The infection, however, remains limited to 
the operation wound. Interruptions in the healing ol the 
fracture as arc observed unfortunately often in cases of 
other osteosyntheses, have never been seen by us and have 
not been described by other authors up to the present. If 
they r a.lly ever have arisen the number of these cases is in- 
significantly small. 
Also, in cases of a nailing of the neck of the femur 
injuries dub -to metal arc described. If one removes the 
nail in time no inconvenience will arise. This can be 
avoided by the use of nails of V2A-steel. 
So the "stabile osteosynthesis" of the fracture of 
the neck of the femur practically fulfi 11s all retirements 
for the treatment of a fracture mentioned in the begin, inn . 
With its introduction this particular fracture has lost 
many of its former horrors. The usually very hi' h aorta'1 n ty 
rate has sunk considerably (to 4- - 10A) . The pseud arthroses, 
at one time arising almost regularly, can nowadays be observ 
only occasionally if the operation is done in time and the 
right tcchnicue is applied. 
It is a great merit of KUENTSCHFR that nth his "marrow 
nailing" he developed a method in which th principle of the 
"stabile osteosynthesis" is also used for l‘r cturcs of long 
bones. 
A specially formed, V-shapcd nail is introduced into 
the marrow cavity at some distance from the fracture and 
driven so deeply into the marrow cavity of the distal frag- 
ment, under X-ray control, that it completely fixes the 
fracture* The nail is so rigid, the fixing of the fracture 
so firm, that a bandage to keep the in lured part in a rest- 
ing condition is unnecessary. The patients can move the 
broken limb freely in all joints without pain and a short 
time later they can put weight on it again.* Stiffening 
of the joints is therefore avoided, (see HI, 2,5,8,11 and 14-), 
But what about the dangers of this "stabile osteosyn- 
thesis" in cases of long bones? 
Damages caused .by metilj nhoy need not be feared for 
the nail is manufactured of V2A-stecl and is removed after 
the growth of the new bone during the healing process of 
the fracture. 
Danger of infection? As t h e f r a c t ur e clef t i s not 
exposed, the fracture being repositioned subcutaneously end 
the introduction of the nail r'mires only a s ell "ouncl f ,r 
distant from the fracture, the danger is undoubtedly consider- 
ably less than in cases of other osteosyntheses, r: nn; 
the early days of the marrow nailing we have s'en infect ons 
of the operation wound in 3 cases. The clinic of llfL also 
reports observing this. These infections always- remained 
localized. They have never been the cause of a removal 
of the nail or led to interruptions of the healing process. 
Considering that infections can bo avoided by the use of 
sufficient shill and strict asepsis, the danger appears to 
be so small that it is of no importance compared with the 
advantages, Foot note Is In some cases of compound fractures and 
discharging wounds an infection of the 
marrow cav/ty and sequestrum formation- 
have arisen, especially when technical 
errors were made. The drainage continued 
uninterrupted and free and the fracturcs 
healed solidly. No marrow phlegmon or 
acute osteomyelitis was observed. 
l£t err uptions..of _t he„hc.alingg.of_t hc..fr ac tur cs : ./hen ono 
reads the technique described for the first time one almost 
becomes frightened and thinks of the failures of the use of 
pins made of small bone or ivory which ".re held especial y 
responsible for the damage of the marroTT and the. endosteum, 
KUFNTSCHER has proven by experiments that on account of 
the shape of the nail no such damage has to be feared. First 
of all, the especially harmful factor of the plugging of the 
morrow when pins ar used is eliminated ?■ n the marrow na: 1- 
insr method. The RUFNTSCHFR-nai 1 is strona cnoung to .math- 
stand the harmful bending and shearing effects (which the 
bone pin cannot do), it docs not plu- the marrow cavity, and 
in course of time it, even loosens a bit so that the inter- 
locking of the fra rents will have the full effect of move- 
ment and use of the effected limb. These interlocking 
forces favor the formation and firmness of callus in a re- 
markable way, as is already known. Clinical exp-ricnees 
have already confirmed these theoretical and experimental 
results. Especially in the eases of fractures of the femur, 
one is repeatedly surprised at how rapidly the formation of 
callus can be observed in the X-ray, 
So the marrow nailing method of XUFNTSCHER as a 
"stabile osteosynthesis" fulfills in an almost ideal way, 
all the requirements for the treatment of bone fractures, 
Accor ing to our experience we can fully confirm the point 
of view of the clinic of Kiel; "Every suitable fr .cturo 
should be treated with the stabile osteosynthesis". For 
fractures of the shaft of the femur it is unconditionally 
the method of choice, superior to all others. 
Some examples are now given to demonstrate the econ- 
omic significance of the "stabile osteosynthesis" which is 
especially important days. 
While in eases of a fracture of the neck of the femur 
even the best statistics indicate only a healing of 45b in 
case of treatment with the Plaster of Paris of WHITEKAHN, 
the following percentages of practically complete recovery 
were obtained by the marrow nailing method, which can be 
used in a lancer variety of cases than the Plaster of Paris; 
BOEHLER 74,4/o, FFLSENREICH in 73%, VOGELER in 70%, wo our- 
selves in 72% of the cases of fresh fr ’.ctunes* 
According to BOFHLER the invar a * c durat: on of hospital 
treatment without nailing amounted to 246 day's, whi 1c math 
nailing it amounted to only 26 days since 1936, a number 
which completely agrees with our own and other authors ex- 
periences, This indicates a saving of 220 days, or RI.I 1100,-- 
if a cost of maintenance of RM 5.-- per day is assumed. In the treatment of fractures of the shaft of the 
femur, BOFHLER reports an average period of treatment of 
2A0 days in his clinic during the year of 1927, while in 
the cases treated outside the clinic it averaged 34.0 days. 
The average period of treatment in the clinic amounted 
to 53 days when fractures of the femur were treated by the 
marrow nailing method, for the last three patients it aver- 
ages only 35 days. This means again a savin of 200 to 
300 days, of RM 1000,-- to RM 1506,-- cost of maintenance 
for each patient. 
The duration of inability for work amounted, according 
to BOEHLFR, to 625 days on the av rage for his own patients, 
while it amounted to an average of 1819 days for patients 
treated outside the cl nic by the conservative methods. For 
our patients the time of inability to work amounted 
to 97 days ( A Belgian worker of 60 years of age), after 
this time the fracture had firm bony healin', and the nail 
was removed. In comparison to the admittedly ood results 
of BOEHLFR with the conservative method of treatment this 
means a saving of almost 1 -k- years of inability ’to work. 
\ larger series of statistics is not yet available and 
the number of our own cases of treatment is not 1 ,rgc 
enough to permit a comparison between th final results of 
the "stabile osteosynthesis" and the conservative method 
of treatment. It can already be clearly rccognized, however, 
that tremendous economic advantages can be obtained thereby. 
According to BOFHId'R, the loss of loss than 20% of the capa- 
city of earning one's own living occurs in 5 out of IB cases 
treated outside the accident clinic in the year of 1927, 
Only two patients were fully capable of earning thv.ir own 
living. Out of 1A cases of treatment in the accident clinid 
itself, the los? of the capacity of earning their own liv- 
ing amounted to loss than 20% in 10 cases, out of which, 
however, only U were fully capable to earn their own liv- 
ing,. This was a success of which BOFHLFR could properly 
bo proud* In 17 cases of fractures of the femur where 
a marrow nailing was performed by us, the treatment 
is in so far completed that the final result is established. 
In oni_y one case, where an arthrosis deformans existed in 
the knee joint, a limitation of mover nt of 20° arose. 
This patient was granted a pension of 15% for another 6 
months. All the others arc completely without inconvenience* 
A clinical record will demonstrate oven better the 
advantages of the "stabile osteosynthesis" than all these 
statistics. 
During a railroad collison a 3C> yc r old trr.cV driver 
suffered a transverse fracture of the shaft of the femur 
slightly above the midpoint and in addition a head iniury 
with a concussion of the brain and a fracture of the left 
shoulder blade (ill. 1). On the 7th day aft'r th accident Vae ma r jiv 
nailing operation of the fracture of the femur was per- 
formed. Three days after the operation the patient began 
exercises in the bed, A fortnight after the operation ho 
got up without any bandage (111, 2) and A5 days after the 
operation (55 o.ays after the accident) he was released. 
Ho has no trouble anymore caused by the fracture of the 
femur, walks long distances without a cane and without in- 
convenience, and he can freely move the leg that was injured 
in all joints (ill, 3), This megps that the patient is so__far..as thp_fractyre 
emur..i s_c ore er a per j od_of_.no t_gui tp_2 
JBPMhs, fully capable of working againf Such a result has 
never been and will never be obtained with any conservative 
method, 
Regularly, fractures of the shaft of the 1c- heal in 
case of skilled conservative treatment rithout any incon- 
venience, In any case, 85,26% of the patients treated by 
BOEHLFR did not obtain a pension. The publications of the 
workers association of various trades show, howev r, difVorent 
findings. BOEHLFR for instance found only 17,256 recovering 
without a partial disability pension in the year of 1910/11,. 
Such findings, however * could not be used as a basis for 
judgement, for only the results of well directed clinics 
prove the value of a method. 
The economic advantage of the; n stabile osteosynthesis'1 
dannot be so great with regard to the final results of leg 
fractures as compared to the thigh, but it is ruito worth- 
while in both cas s with regard to the duration of the period 
of treatment in the clinic and the inability for work. 
According to the statement of B07nHLFR, spiral and 
"green stick .fractures reouirc a hospital treatment of 3 to 
A weeks (constant bandage according to the traction method 
or repositioning in Plaster of Paris with extension), after 
this an ambulatory cast will be put on for “ or 6 weeks,, 
"Young people mi aht in some cases as early as throe months 
be able to return to heavy work. For older people and in 
cases of severe fractures it lasts about 4- to 6 mont' s. 
In comparison to this wc offer th clinical report of 
an apprentice of 16 years of a e, when a marrow nailing 
operation was performed: 
Wc had to, deal with a spiral-like fracture of the leg 
with the separation of a Ion? fragment "ithout displace -nb 
(in. u). Two days after the accident he was treated by the 
i! stabile * s t eosynt he s i s11 according to UFPTSCHFR, Because of 
the separation of the fragment a light Plaster of Paris cast 
was put on the leg although the fracture was clinically 
completely firm aft-cr the nailing, ithin 7 days this cast 
became loose and was removed. As no pain was mentioned at 
all during the strain caused by the manipulation and the 
patient could move the log freely, no further bandage was 
put on, 12 days after the accident the patient got up 
(ill, $), -IB days after the accident ho was released from 
the clinic. The joints could be moved completely free. 
He could walk without any assistance with a cane and with- 
out pain, (ill, 6), 6 weeks after the accident the patient 
started to work amain without any inconvenience, B days 
after the beginning of this work ho foil in the rhark and 
suffered a severe hematoma in the ankle joint of the broken 
leg. He had to stop work again. The fracture itself was 
in no way disturbed by the fall. It also was not painful. 
After a further J+ weeks the difficulties of this new accident 
were healed and the patient was again abl to work. The "stabile osteosynthesis" has therefore resulted 
in a saving of at least two weeks stay in the hospital and 
(without the no?/ accident at least 4-5 work days. Put tin's 
case also proves the firmnesfe of the marrow nailing, for a 
refractu.ro would almost certainly have arisen during the 
second accident without the hailing, if the patient would 
have boon walking in an ambulatory cast within 6 weeks after 
the first accident. 
Transverse fractures of the leg can be treated with 
a Plaster of Paris cast immediately after the reposition 
and the patients can be released after being observed a 
furth r 8 days with an ambulatory cast which enables them 
to walk. Generally they arc fit for work after 4 to 5 
months; 
With regard to the treatment in the clinic there will 
be hardly any saving with the "stabile osteosynthesis". 
The patients, however, can gen rally resume work earlier, 
as the following case shows: 
A 38 year old Polish worker was brought in with a 
transverse fracture in the middle third of the leg, (111.7). 
A "stabile osteosynthesis" was done three days after the 
accident. No cast was applied, Exorcises 77 re started on 
the third day after the op ration. He got up on the seventh 
day after the operation and walked about, (The patient 
could have'been released a fortnight after the accident. Be- 
cause of other than medical reasons, however, he remained 
in the hospital). 20 days after the operation he could 
move the leg freely and without inco. vcnicnco, 31 d ,37-3 
after the accident he was released and imrediatcly he 
resumed his work as a blacksmith in agri culture, alfough 
hardly any callus formation could bo seen in the I~ray 
(111, 8 and 9). All joints could bo fr.'el3r moved, ■ scre 
was no edema. The "stabile osteosynthesis'' therefore 
accounted for a saving of at least 90 work days in this 
case. 
In cases of a fracture of the shaft of the humerus 
above the elbow an ambulatory treatment is most often in- 
dicated. The abduction cast, necessary after the reposition- 
ing, must, however, be left on for four to six weeks and 
after physiotherapy is still reouirod before the patient 
can start working again. The "stabile osteosynthesis" spares 
the patient the rath r shameless and often very disagree- 
able abduction cast and enables him to use the arm as early 
as 3 to 4 wc'ks later. 
A school boy of 14 years age with an oblique fracture 
of the shaft of the arm above the elbow (see 111, 10) could 
move his arm without any pain 14 days after the operation 
and do any sort of work, (111, 11 and 12), He was re- 
leased from the clinic 9 days after the operation. 
In this case the “stabile osteosynthcsisir saved at 
least 40 work days. This ease is all the more remarkable 
as we had to deal with a fracture in the distal third of 
the humerus. As is generally kno rn, difficulties concerning 
the flexibility of the elbow joint are especially liable to 
arise in such cases. The nailing of a fracture of the shakt of tho arm- 
above the elbow performed from the upper end brought an 
especially good success in the case of a boy of 11 oars 
of age (ill. 13). 10 days aft r the operation ho could 
move his arm freely and without pain and was released as 
"healed” (ill, 1L and 15). Certainly, children often 
perform astonishing achievements in healing of fractures, 
but never could such a success have been obtained with a 
conservative method of treatment. 
From several sources the opinion was expressed that 
some damage of the nourishment of the bone might be caused 
by th* nailing 02* the formation of callus luxurian. The 
clinic of Kiel discounts these remarks. I also could not 
observe any inconvenience in one way or another in mere 
than 14.0 cases of nailing of closed fractures a; hi oh I 
have seen in my own clinic and in the hospitals of tho 
German Air Force, 
Wo certainly arc still at the beginning and a warning 
must be given not ot use the "stabile osteosynthesis” in 
cases ef fractures of long bones without sufficient oxporicnc • 
and, coually important, without sufficient equipment. The 
above mentioned examples indicate unquestionably that it leads 
to healing and to economic advantages, which make the 
"stabile osteosynthesis” far superior to all co: servativc 
methods of treatment. 
t_u_n n r. r v 
"Stabile osteosynthesis” is the fixation *f a fracture 
•f a bone by especially shaped metal nails. It eliminates 
any cast and permits early free movement of the broken limb 
and weight bearing. In this method the fracture is not ex- 
posed, The danger of an infection is thereby materially 
reduced as compared with the other osteosyntheses, i'o 
interrupting of the healing of the fracture has to bo feared. 
The generally recognized principle of the "stabile 
osteosynthesis”, air ady known for fractures of the neck, of 
the femur,- now becomes available for eases of fractures 
of the shaft of lonm bones by the marrow nailing method 
developed by kUFNTECHFR, 
In more then 70k of the oases of fractures of the neck 
of the femur a complete healing was obtained by the :i stabile 
osteosynthesis”. The time of hospitalization was reduced by 
more than 200 days. In all cases of fractures of the femur no 
difficulty was encountered, th a time of residence in the 
clinic was reduced by more than 200 days and, after 97 days 
in the longest case, the patients wore able to work a ain# 
With the conservative method the average time of inability 
to work amounted at least to 627 days (according to B0EHL' R), 
In eases of fractures of the tibia the time of residence in 
the hospital and inability to work is considerably reduced. 
In cases of fractures of the shaft of the arm above the albow 
the same saving of time applies and in addition the un- 
comfortable abduction bandage can be avoided* The success and economic advantages of the “stabile 
osteosynthesis'’ arc so outstanding, that to-day (1943) it may 
be described as the best method of treatment of certain 
fractures, Illustration I 
R.O, 35 years old 
Transverse fracture of 
the femur. 
Illustration 2 
Same fracture 18 days after 
oo1'ration, 2J+ days after the 
accident; good position, gror:• 
formation of callus, Pat, got 
up L, days ago. 
Illustration U 
E.H, 16 years old 
Spiral fracture of the 
left tibia with a large 
fragment broken out. 
Illustration 5 
Same fracture 13 days 
after the operation, Pat. 
got up 2 days ago, Without 
inconvenience. Illustration 7 
J, B. 38 years old. 
Transverse fracture of the 
tibia in the middle third. 
I nu s t • a t i o n 8 
Same fracture 28 days after 
the operation, 'xccb ent 
position. no remarkable 
formation of callus, Pat, 
got up 21 days ano. 
Illustra.t ion 10 
G,W, 1A years old. 
Oblique fracture in the 
arm above the elbow. 
Illustration 11 
Same fracture 10 days 
after the operation. 
Arm has been moved since 
two days. Illustration 13 
K,N, 11 years old. 
Transverse fracture in 
the middle of the fight 
arnPabove the elbow. 
Illustration 14 
Same fracture after the 
nailing starting from 
the christa tuberculi 
mejoriSj ideal position. 
(Editors Note: Illustrations 3, 6, 9, 12 end 1$ ere missing.) PSEUDARTHROSIS OF THE ARM TREATED BY A MODIFIED MARROW NAIL 
by 
Privatdozent Dr, RICHARD MAATZ, Kiel 
Translation prepared by: 
U, S, Naval Technical Unitr,Europe,(Medical Section) 
Office of Naval Advisor 
Office of Military Government (U.S,) The fate of gun-shot fractures »f the upper arm is 
well-known, I may be permitted to review it in' a few sen- 
tences, Certainly some of these fractures will heal when 
they are treated in the usual manner even if there is a 
loss of substance of the bone, A greater part must pass 
through a long confinement, •> Large, plaster casts must be 
worn until the sup duration abates and only a small fistula 
remains, sustained by seouestra. Recurrence of the in- 
flammation may happen at any time. The seouestra must be 
removed. Perhaps a cavity in the bone causes further se- 
cretion, This will last -for months, perhaps years, and during 
this time the fracture, which is inadenuately stabilized 
by the plaster cast or later on is left without one, becomes 
a pseudarthrosis or a nnew joint”. Meanwhile the neighbor-; 
ing joints will become rigid, especially the elbow, and if 
the radial nerve has been hurt precious time for repairing 
it is lost, ’When enough tj me has passed after the wound 
closes, the pseudarthrosis may be operated upon. Whether 
the fragments are united with wire, plates, screws or an 
implanted chip of bone a new inflammation may arise all 
too freouently and once more everything will start from the 
beginning, A great number of the patients are obliged 
to wear a posthetic apparatus. 
Today we have the possibility to interrupt this course. 
Whatever the condition of the wound may be wc unite the 
freshened ends of the bone, stabilize the fracture by a new - 
method, and wo are justified in stating that union is ac- 
complished after a comparatively short time. Incidentally 
it may be mentioned that we can operat van Than the frac- 
ture is still in a septic state. 
This new method is based on absolutely new ideas,' The 
principle may be described in a few sent nces, The ends of 
the fragments are freshened carefully avoiding any separation 
of the periosteum from the bone. 1hey are brought into 
proper apposition without regard for a shortening of the 
upper arm if necessary and the ends are pressed against each 
other and stabilized by means of devices introduced into 
the cavity of the bone. 
At the end of the operation the small wound of the bone 
is covered and protected by the intact thick periosteum. 
The flesh wound being left open cleans up very fast and is 
closed after a short time. 
It was KUENTSCHFR who led us upon this way. At first 
his nail wq? intended for closed fractures. On learning 
that even an infection of tfee fracture is not dangerous while 
the nail is lying in the cavity of the bone, we lost our 
extreme respect for the marrow-cavity. Now we know that the 
marrow cavity can be treated as yiq like if only the exterior 
of the bone is not damaged. HEIM was the first to nail 
supourating gun-shot fractures. Other authors followed. 
But soon a preat disadvantage fas noticed, which was 
first published by HFABLFR, even concerning closed fractures 
of the upper arm. Often the fracture shows a distraction 
because the tonicity of the muscles of the arm is not 
sufficient to maintain apposition. By mechanical reasons the curved nail introduced from the side of the bone is 
able to prevent this separation but only for the first 
days (MAATZ), In spite of these conditions a nailed 
closed fracture unites in most cases. As the tonicity of 
the muscles in an infected region is materially diminished 
the separation of the fragments will occur in nearly 
every case, especially if it is a gun-shot fracture with 
a loss of substance. It is evident that a suppurating frac- 
ture is more likely to turn into a psoudarthrosis, 
I also noticed many cases of this kind among fractures 
nailed in other hospitals or by myself. Among the 17 pscu- 
darthroscs of the upper arm I had the occasion to cure by 
this new method, 7 had already been operated upon before with 
the medullary nail but without the desired effect. 
The development of my presently used method, will be 
demonstrated best by the following case. 
Patient Paul M, was injured 31 December 1939. was 
an open fracture of the left upper arm near the elbow. 
Since it had become a pseudarthrosis, it was oper .tod upon 
in 1941. Subsocuently there was a serious inflammation 
in which the joint of the elbow was involved. The wound 
closed during 1942, the joint having become stiff while 
the pseudarthrosis continued. It was in thus st?.te the 
patient was sent to us (ill,2) 
Illtistrat i on 1 
Line of incision 
and extent of re- 
section of the fist- 
ulating pseudarthrosis. 
On 10 November 1943 the ends of the bone were freshened 
and the pseudarthrasis was nailed with a thick straight nail 
introduced through the destroyed joint into the elbow. 
Immediately the inflammation recurred. The nail due to its 
weight began slipping down out of its bed and the fracture 
separated , 
The nail was not removed but its gliding was stopped 
*y applying an clastic wire fixed in the plaster cast, 
''•rcover the ends of the bone were pressed against each 
other by rubber strips which bridged over a circular cleft 
cut into the plaster (111,3), 
All the wounds closed except a fistula at the place 
where the nail was projecting like a drain. 4 months 
afterwards the humerus showed bony union. Illustration 
2a 
Illustration 
... 2b 
Illustration $c 
Illustration 2d Illustration 3 
S up pur a t i ng p s e udr t hr o s i s 
with nail in position and 
additional plaster-dressing 
with rubber strips. 
j,S-Gfigpfthn-t fl fractuye resistant to union 
fpr a Ipng time heal, finally__jf_p^ly_th absolutely 
np.cessc\yy conditions are .realized .na.me.lyj. 
Impossibility of any .movement in the fracture no natter 
ho io n..may_ _c n jfc h cp.yj.ty 
of the bope dpripg the yrfeole time*. 
This led to the idea of transferring the contracting 
elements directly into the bone. 
At first I used only a simple wire but the first cases 
proved it to be insufficient, A small area of the ends of 
the bone will be digested by the suppuration and the cleft 
thus brought into existence is wide enough to impede bony 
union, 
Moreoever thr thin wire cuts through the >oce with 
its curved ends fastened in the corticalis. Therefore, I an 
now using a spiral soring made of steel which is anchored 
in the cortlcalis of both fragments by means of broad hooks* 
(in. u) 
Illustration 4- 
Medullary spira1 
spring with hooks 
to be fastened 
in the cortlcalis This is the place to describe how to treate the usual 
and favorably situated pseudarthrosis of the uooor arm. 
The pseudarthrosis is located in the middle third of the 
humerus. The ends of the bone arc prepared as mentioned 
in the beginning(111. 1), 
Because separating the periosteum from the bone at 
any place is strictly to be avoided, the periosteum must 
be severed with a scalpel the surrounding cicatrical 
tissue round one half of the circumference (ill, 5a), 
This is absolutely necessary because the pseudarthrosis 
after being cut through with a scalpel must be broken in a 
right angle direction and in this moment the periosteum ad- 
herent to the starred tissue likely will be stripped from 
the bone (ill, 5b), 
Illustration 5 
Course of resection of the pseudarthrosis. 
a, line of incision 
b, oblioue freshening of the 
ends of the fragments 
c, opening both marrow rooms 
d, bone prepared for the in- 
troduction of the spring and 
the nail* 
Periosteum shown in black. 
Now it is ouite possible to prepare the ends of the 
fragments with a rongeur (LUER), Hero it is best to level 
both ends as this proved to be the most favorable condition 
for the union to take olace (ill* 5c), Both marrow cavities 
are opened sufficiently wide with a dril'! in order to 
restore the original cavity of the bone (ill. 5d). More 
distant from the fracture this cavity must be opened in 
eac]i fragment by a lateral hole. The wire of the 
spring is pulled through the proximal fragment in the direc- 
tion from above to below. Another wjre doubled to a loop is 
introduced from the distal hole near the elbow in the 
opposite direction (111. 6a). Illustration 6 
Introduction of the spring 
a. In the upper fragment 
the wire of the spring 
is introduced ready to 
be attached to the wire 
loop put through the 
. distal fragment, 
b. Spring in position 
By means of the distal wire which is fastened to the 
proximal one bearing the spring it is possible to pull the 
latter through the marrow cavity of the distal fragment 
(111. 6b). 
Mow the nail may be introduced fro." the proximal frag- 
ment, The open side of the curved nail should it the same 
tine be the concave one as it is necessary to have the 
spring gliding in the cavity of the nail. Otherwise it may 
occur that nail and spring will not have room enough in the 
cavity of the bone. After the fragments ire driven to- 
goth'r with the nail inside, the spring must be stretched 
and the end of they wire fastened at the distal hook. 
All wounds are left open. The operation is concluded. 
Another way of proceeding is necessary when the pseu- 
darthrosis is situated far proximal near the caput humeri. 
There we have only a very thin corticalis and we must 
distribute the power of traction of the stretched spring 
to several places. 
Me do not use one but several hooks (two or three) which 
are fastened to different parts of the corticalis. The power 
of the spring is distributed to the several hooks by means 
of one place of soft flexible wire drawn through each hook 
and through the single ear on the spring. In the distal 
fragment also in these cases one hook' is sufficient but the 
nail has to be introduced from the distal part. It has 
proved to be most efficient to introduce the nail and the 
spring from two different holes since the cavity of the bone 
is too small to give room enough for both on one place, 
i 
In such cases it is possible to bring the idea of 
nst manipulating the exterior of the bone to its climax. 
The holes for the hooks in the upper fragment actually 
situated close to the fracture must be drilled from the 
inside of the bone. This is possible because the diameter 
of the cavity is rather large there. The hooks too may 
be introduced from the inside. Illustration 7 
Case 10, (see table 1) 
vState after the operation 
of a fistulating pseu- 
darthrosis of the upper 
a r n?, 
Illustration 8 
Resected pseud-arthrosis near 
caput humeri. The spring is 
fastened in the corticalis 
of the upper fragment with 
three hooks, Illustration 9a 
Case 11 (see table l) 
Before the opcr ,ti0n, 
Illustration 9b 
Condition after operation 
on 1.,4.6 spring and nail 
in position. 
Illustration 9c 
Bony union achieved. In fact this no longer means nailing in its original 
sense. The bone has grown brittle by the suppuration, It 
is absolutely necessary that all the hol$s and cavities 
in the bone prepared are properly fitted to the nail, the 
spring and the hooks. This may rather be called (montage) 
plastic restoration. 
Therefore and in consideration of the fact that healing 
of a paeudarthrosis of the upper arm is difficult to obtain, 
I think it most commendable to sup iort the healing by an 
additional plaster cast in abduction. 
Of course each case has its peculiarities as the follow- 
ing example will show. It is not alw iy.s possible or necessary 
to bevel the bone ends. Sciagraph picture lo shows a pscu- 
darthrosis with a far greater diameter of the upper frag- 
ment than of the lovrer one due to four antecedent operations 
with resection; Therefore it s emed to fit the lower frag- 
ment into the upper one* 
Another case of pseudarthrosis was characterized by 
a thinning out of the proximal fragment whilst the distal 
fragment was split up like a fork. 
Hero the upper fragment was fitted irto the- lower one 
after freshening only the surfaces which wer- to be brought 
into apposition. 
Sciagraph picture 12 shows a loss of substance of more 
than 10 centimeters. Therefore an autoplastic chip of bone 
was implanted and the pseudarthrosis was nailed, The chip 
did not heal in and therefore further shortening of the arm 
became necessary. Bony union was obtained by applying nail 
and spring. 
Illustration 10a 
Case 13 (see table 1) 
a-c 56 months old psou* 
darthrosis after three 
operations: w ire 
cerclage, nailing •■rith 
bone-chip and nailing. Illustration 10b 
Illustration 10c 
Illustration lOd., 
The ends of the frag- 
ments arc not freshened 
i,puel£ but are fitted 
into each other. 
Illustration lOd-^ Illustration lOd^ 
Illustration IPe 
Pseudarthrosis healed one 
hook embedded in bone. 
In the case of picture 13 a separation of the bones 
by means of a simple wire in addition to the nail was tried in 
vain, 
Up until now I have operated 17 patients in this manner. 
The importance of this new *way of curing the pseudarthrosis of 
the upper arm is shown by the fact th'.t in all cases bony 
union was achieved. How much it proved to be benof. clal to 
the bone is shown by the fact that we did not observe seruestra 
in any case. The size of the callus will depend on the 
amount of trauma to the periosteum and on the amount of 
displacement and of motion during the process of repair. 
All the latest cases operated carefully with technical 
exactness are sho’wing effective bony union without the, develop- 
ment of the least callus tumor (111. 14-). 
The following table gives a survey: £.g^ultg■QPg.ra.t'io^UPS .tjig,t-apper arm. 
Nr, 
Name and ag< 
of the 
patient 
Previous 
operations 
Interval 
between 
injury & 
final 
operation 
£iS§l„operatipr 
Condition 
bate 
C 
c 
a 
ortening 
the upper- 
m 
Healed...af t. 
Soft tissue 
wound s 
SI 
Bone 
Removal of 1 
nail after; 
L 
Remarks 
1 
Sie* 
4.2 years 
none 
«»m ■ —mum ■ — ■■ 
4. weeks 
suppurating shot-frac- 
ture with loss of sub- 
stanc e 
larch 
1944 
£ 
centimeters 
2 weeks 
3 
months 
1 
10 months | 
1 
1 
i- 
- 
2 
J,, Hans 
24. years 
none 
2 months 
septic state, shot- 
fracture in the middle 
8.VI* 
• 1945 
*• 
* 
centimeter 
3 months 
. 
3 
mont hs 
i 
;3 months ; 
Sudeck atrophy 
? 
R,, Otto 
35 years 
nailing 
V 
8 weeks 
near the elbow, nail 
in position,suppurat* 
longitudinal separat. 
16.A. 
1945 
|— 
centimeter 
6 weeks except 
2 small fist. 
— 
3 
months 
8 months 
4 
G,, Walter 
29 years 
none 
6 months 
fisimulating pseudarthr. 
with loss of substance 
in the lower third. . 
3.7, 
1945 
centimeter 
3-g-months except 
1 small fist. 
3 
months 
dismissed ‘ 
with nail 
in posit, f 
5 
H,, Hans 
38 years 
n»ne 
23 months 
fistulating pseudarth- 
rosis in the middle. 
14.7. 
1945 
centimeter 
5 months except 
a more strongly 
4 
months 
9 months 
.»■ - — 
- 
6 
K,, Franz. 
39 years 
none 
4. months 
fistulating pseudarthr, 
with seeuestrum in the 
lower third. 
23.7 
1945 
centimeter 
2 months except 
2 small fist. 
1 
3 
monthw 
8 months : 
paralysis of 
N- rvus radialj 
after iniurv 
7 
K«,Franz 
32 years 
nailing and 
wire suture 
5 months 
septic,state,suppur, 
the el- 
bow, nail in position 
12,9, 
1945 
centimeter 
1 month except 
1 fist. 
3i 
months 
6 months 
1 
par, of N.rad, 
after injury 
8 
P*, Johannes 
22 years 
nailing 
18 months 
fistulating pseudarthr, 
with loss ofsubstance 
nail in position, 
middle of the humerus 
12,9 
1945 
centimeter 
_ . . 1 
2 months ;• 3 
i months 
7 months 
par. of Nirad, 
after injury 
9 
D,,Heinrich 
36 years 
implanting 
cf bone -chip & 
nailing 
14- months 
nail in position, 
wounds recently closed 
24-10. 
1945 
3 centimet. 
3 weeks 
3 
mo nt hs 
7 months 
.... — 
If 
K,,Werner 
21 years 
none 
12 months 
fistulating pseudarthr, 
in the lower third 
26.11. 
1945 
centimeter 
4 months 
3 
months 
6 months 
. - - 
par. of N.rad, 
after injury 
11, 
■H.,Franz 
34 years 
wire cerclage 
15 months 
fistulating pseudarthr, 
with less of substance 
near the caput humeri 
1.3. 
194-6 
centimeter 
7 weeks 
3 
months 
5 montks 
par, of N.rad. 
after ; njury 
12 
H.,0tto 
4.2 years 
nf^ne 
11 months 
% 
pseudarthrosis with 
loss of substance in 
the upper third 
16.3. 
1946 
centimeter 
8 days 
— 
0 1 
months 
J - 1 
5 months 
— —j 
•a. 
— — 
13 
W•,Paul 
34- years 
1) wire-cere lags 
2) &chip 
3 5 nailing 
56 months 
Pseud.near caput hum, 
nail in position 
wounds closed 
1.4. 
1946 
L2 centim. 
2 weeks 
2 
months 
5 months 
■ 
U 
A.,Frwin 
25 years 
none 
14. months 
fi s tulat,pseud,with 
seq,in the upper third 
1.4. 
1946 
I 
centimeter 
6 weeks 
3 
months 
6 months 
- 
15 
G,,Walter * 
23 .years., 
nailing & 
_sMp of bone 
17 months 
supp,pseud,with seo, 
nail in position 
14.5.46 
,, centimeter 
2 months 
zi 
months 
5 months 
■ - 
16 
K,,Heinz 
30 years 
nailing & 
spring 
13 months 
fi stulat.pseud.near 
caput humeri,nail in 
position 
14.5. 
1946 
7 centimeter 
6 weeks except 
one small fist, 
2 
mo-nth s 
7 months 
- 
17 
G,,Helmuth 
20 years 
naili ng 
T A 
15 months 
B L E It 
pseud, after removal 
of the nail in Aug, 45 
24.4. 
1946 
$ centimeter 
3 weeks 
2 
months 
4 months 
The reason f01 
the consider- 
able shorten, 
was the loss 
of sub, of the 
N, rad. 
H e a 1 e d... a f t.gr 
TABLE % Illustration 11 
Case 4 (see table #1) here 
too the ends of the fragments 
are not freshened obliouely 
but are fitted into eacfh other. 
Illustration 12 0 , 
a & b 
a. 6 months old pseu- 
darthro sis of the upper 
arm with groat loss 
of substance, 
b, state after nailing 
and implanting of a 
bone-chip without 
success, Illustration 12 
c & d 
c. Nail and spring in position 
d, Bo'ny union after 3 months 
removal 'of the nail after 
7 months. 
The small fistulae often remaining as long- as the 
nail is in position, all close without exception as soon as 
the nail is removed. 
Illustration 13a 
Case 8 (see table 1) 
Gun-shot fracture pseu- 
d art hr os is with, loss of 
substance. Illustration 13 o. 2 
State aft r introduction of nail 
and simple wire 8 weeks previously 
longitudinal separation * 
Illustration 13 
Nail and spring in position bony union after 3 months. Illustration 13d 
Removal of nail and spring 
after 7 months. 
Illustration 14. _ . „ 
1 & 2 
Scanty development of callus with effective bony union 
after proper resection of the pseudarthrosis 3 months 
previously, lije^Pse^rtlir^sis^of^t^^Fprea^,,. 
The same principle is applied to the pseudarthrosis 
of the forearm, whether one or two bones be injured. The 
healing of this pseudarthrosis is obtained by other methods 
with certainty but very often they need a long period of 
treatment. In many of these cases the nailing has not 
proved to be efficient. The tendency to form callus in 
these bones is but slight and if there is a gap between 
the fragments of the suppur .ting fracture it will bo found 
very often that though the bone is well stabilized by the 
nail nevertheless it is not able to produce a bony union. 
Here too we can interrupt the long period of treatment 
at an early stage by operating upon tho pseudarthrosis using 
the same method as described for the upper arm. 
The pseudarthres®s of the forearm show many varieties 
dependent on their location. 
The operation is more difficult than on the upper arm 
since we have bones united by the membrane intcrossea which 
renders the preparation of the ends of the fragments more 
difficult. Here it is of greatest importance to do no 
damage to the periosteum in order to avoid the danger of 
th,e development of a ring-shaped secuestrum or of a bridge 
callus. It is absolutely necessary to shorten both bones 
correspondingly. The medullary cavity in most cases is 
rather narrow and filled up with dense osseous tissue in 
the neighborhood of the fracture. Thus the bed for the nail 
and the spring must be prepared with the greatest care. 
Therefore wo use a Mmarrow-drill”. Many technical resources 
may be required in order to guarantee the uncomplicated con- 
duct of tho operation. This is not the place to describe all 
these in details. Only one bone, namely the ulna is treated 
with the spiral spring. This has proved to be sufficient. 
Moreover the’ radius is not well suited for the fasten- 
ing by the spring. In the ulna it can be attached to the 
proximal end of the nail. The ulna-nail is flared at its 
proximal end for several reasons: 
1, Small diameter nails have proven not be firm 
enough as we learned from numerous cases whjch have been 
published, the simple nail for the forearm having broken 
or bent# 
2, There must be room enough for the spring in the 
cavity of the nail# 
) , • 
3# The increasing thickness of the nail towards its 
proximal end prevents it being drawn in the distal direction 
by the power of the spring. 
The wire of the spring is fastened to the distal frag- 
ment in the usual way but distal to the point of the nail 
because there is not room enough for both hook and nail at' 
the same place. The arrangement of the nail and the spring 
may be seen in 111, 15# Illustration 15 
Position of nail and spring in 
the ulna. 
Illustration 16 a, „ 
1 & 2 
Comminuted gun-shot frac- 
ture of the r.'.dius’ (March 
1945) 7Tith f ' i 1 uro of bony 
union, 
Illustration 16b 
State after freshening 
of the pseudarthrosis 
and shortening of the 
ulna (Feb, 4-6), Both 
bones are nailed. Bony 
union is not achieved, 
Pseudarthrosis of the 
ulna. Illustration 16 d 
State after operation with 
nail and spring (Apr, 46) 
\ 
Illustration 16 e,p/~ 
1&2 
Healed wa th bony union 
after 8 weeks. Nail and 
spring are removed. Results of the operation unon the fnrn-nrm.s-_ 
ss 
. • 
Name and age 
of the pati- 
ent 
Previous 
’operations 
Interval be- 
tween injury 
and final 
operation 
Final 0 
Condition 
Deration 
Date 
1 
Z,,Julius 
28 years 
nailing 
11 months 
recently ) 
healed fist- 
ula 
16.3.46 
2 
M,,Heinz 
23 years 
none 
12 months 
pseudarthrosls 
of radius and 
ulna 
8.3. 
1946 
3 
H.,Hildegard 
20 years 
nailing 
months 
fi stulating 
pseud.of radi- 
us and ulna 
15.5. 
1946 
4 
F #,Fric h 
32 years 
nailing 
— 
27 months 
fi stulati ng 
pseudarthros, 
of the ulna 
13. 4. 
1946 
5 
M,, Paul 
30 years 
Lane-plate 
(radius)& 
chip of 
bone trans- 
planted 
(ulna) 
3 16 months 
Fseudarthrosis 
of radius and 
ulna 
25.6. 
1946 
6 
B,,Walter 
31 years 
1, nailing & 
chip of bone 
2, nailing & 
marrow-spr, 
25 months 
fi stulati ng 
pseudarthros3 s 
of radius and 
ulna, 
20.7.46 
7 
K,, Alfr ed 
20 years 
~~ ~TI 
none 
16 months 
New joint of 
radius and ul- 
na near the 
wr i s t 
27.7. 
1946 
1 
Shortening 
of the 
Forrarm 
Healed a 
Soft tissue 
f t er 
Bone 
Removal of 
the nail 
after; 
Remarks 
4. centim. 
2 months 
2 months 
3 months - 
- 
I, centim. 
3 months 
3 months 
5 months 
- 
3 centim. 
- 
- 
- 
- 
5 centim. 
U months 
3 months 
5 months 
* 
3 centim. 
8 days 
2 months 
: , 
5 months 
. » 
paralysi s 
of Nervus 
r .dialis 
4 centim. 
1 month 
2i 
months 
4 months 
- 
1 centim. 
1 Lr days 
2 months 
3rr months 
spring with- 
out nai 1 
in ndins 
and ulna. 
i 
j 
TABLE 2 
TAB L E 2 I have operated upon five casps with the marrow spring. 
All cases had previously been treated with the nail but the 
pseudathroses had not been cured. By means of the spring 
bony union ?/as achieved without exception. 
The following table gives a survey. LITERATURE 
BOFHLER Z schr ,Ort hop.u.Gronzsrob, 75#Bd 
4.H. 194-4 
HAEBLER Zbl.Chir, 1943, 734 
HEIM Mil. Arzt 194-3 H,3 
KUENTSCHER Zbl. Chir. 194-1, 1 
MAATZ Zbl, Chir. 1943, 1260 
" Chir. 194-3 H.9