Comprehensive global evolution of intramedullary nailing of diaphyseal fractures

Abstract

The treatment of midshaft fractures of the long bones has significantly evolved in the last 150 years. This paper will trace the timeline and evaluate the treatment of these fractures which has evolved through from the sixteenth century. The first and second world wars had amputation as the surgery of choice until the development of the Kuntsher Nail (1939) for femoral shaft fractures. Then followed interlocking nails, Ender nails, the telescoping nail and lastly the elastic intramedullary nails used in childhood and adolescents (1). It will also touch on the development of interlocking nails for other long bones; the humerus, tibia and the forearm bones and most recently intramedullary nails for small bones of the hand and feet. This paper touches on the historical reasons for the different techniques and how they have improved patient outcome. To the early surgeons, stabilization of diaphyseal fractures was difficult more so in open fractures and dilemma was which way to go – Amputation by the radical surgeons or conservative treatment to save the limbs. At that time the surgeons had only the above two options. During the American Civil War, Smith’s anterior splint was used but led to ulcerations and malunion and was not popular. It was clumsy with the leg suspended from the ceiling and traction obtained by moving the bed forwards/backwards. The next was Hodgers Cradle splint which was a wire splint suspension device to ensure complete extension of the limb and prevent contractures. Then followed the famous Thomas Splint used in the first world war (2). Advances in asepsis in 1856 by Pasteur, and introduction of X-rays in 1895 further improved management of these fractures. The first allowed clean surgery while the latter allowed closed reduction of fractures. The discovery of Penicillin by Alexander Fleming in 1928 further contributed to a decrease in fracture infections, morbidity and mortality (2). The history of intramedullary (IM) nailing for the treatment of long bones fractures and non unions is old and interesting. The earliest recorded examples are from Mexico in the 16th Century (3). Since then, there has been great changes in design, materials and basic science principles which have led to well accepted and successful methods of intramedullary nailing of diaphyseal fractures. Throughout the history of IM nailing, these advances in methods, principles and design appear to go hand in hand with advances in radiological and aseptic techniques thereby allowing easy operative care of fractures and thereby get acceptable outcomes. Intramedullary nailing is now the gold standard of the treatment of most diaphyseal fractures of the lower limbs and is gaining hold on humerus and forearm fractures. Introduction of the technique was met with skepticism and hostility in Europe and America during the early twentieth century but later has become accepted as the main therapeutic method of choice and has greatly improved the patient outcome. The beginning of intramedullary nailing: In the beginning, a 16th century anthropologist named Benadino de Sahaqun traveled to Mexico and witnessed and recorded the first account of intramedullary device. He saw Aztech surgeons placing wooden sticks into the medullary cavity of patients with long bone non unions (3). In 1887 Bircher (4) and Konig (5) both recorded the first intramedullary fixations followed by Gluck in 1890 (6) who recorded the first description of interlocked intramedullary device. It consisted of an ivory intramedullary nail that contained holes at the end through which ivory interlocking pins were passed. In 1897 Nicolaysen of Norway described the biomechanical principles of intramedullary devices in the treatment of proximal femoral fractures (7