Femur fracture nonunion with leg length discrepancy: a treatment strategy for difficult post-traumatic problem. *Updated with New Images

This month’s case features a 40-year old healthy man who, unfortunately, was struck by a vehicle 13 months earlier.  He sustained a closed femoral shaft fracture in the distal metadiaphyseal region.  He was treated at an outside facility with open reduction of the fracture followed by antegrade trochanteric nailing.  Suboptimal placement of the initial distal interlocking bolts was not appreciated until 5 weeks postoperatively, at which time the bolts were revised and placed accurately through the distal interlocking holes in the nail.  

Approximately one year from the date of his injury, he presented to Harborview Medical Center for an opinion regarding his ongoing pain and limitations.  His complaints include significant weightbearing and activity-related pain located to the distal thigh and anterior knee area.  While this pain was a predominant symptom, his most frustrating problem was the perception that his left leg was shorter than his right.  He is otherwise healthy and was previously an avid athlete, particularly involved in long distance running and bicycle riding.  He is a nonsmoker, and takes no medications on a regular schedule.  He has been unable to wean himself off of a walking aid because of continuing lower thigh discomfort and the inability to correct his “limp”.  He has been unable to participate in any of his running or bicycling activities.  The physical examination demonstrates well-healed surgical scars at the left hip and distal thigh regions.  The quadriceps musculature of the left thigh is atrophic.  Clinically, there is an approximate 2cm leg length discrepancy with the left leg shorter than the right.  There are no significant rotational abnormalities.  The passive hip and knee ranges of motion are symmetric to the contralateral side.  The pedal pulses were palpable, and the patient’s motor and sensory examination was normal, within the limitations of pain.  Initial bloodwork demonstrated a number of normal values, including the white cell blood count, ESR, C-reactive protein, and bone metabolism profile.

The presenting anteroposterior plain radiographs of the left femur demonstrate a well-aligned hypertrophic metadiaphyseal nonunion.  A trochanteric antegrade femoral nail is identified, and the single distal interlocking bolt is noted to be broken.  The long leg standing radiographs confirm an approximate 2cm leg length discrepancy with the left femur shorter than the right.  The operative records from the index procedure confirm the size, length, and manufacturer of the medullary implant, and also indicate that the femur fracture was reduced using an open technique prior to the placement of the nail.

The diagnosis is a well aligned, but clinically shortened, hypertrophic, aseptic distal metadiaphyseal femoral nonunion. 

The patient was extensively counseled regarding the options regarding the treatment of this problem.  Typically, the well vascularized hypertrophic nonunion develops because of fracture site instability.  Enhancing the stability of the fracture/nonunion site with a traditional compression plating technique typically results in predictable and rapid healing of the nonunion site.  Unfortunately, this strategy, by itself, does not correct the significant and clinically bothersome leg length discrepancy.  Alternatives include contralateral shortening osteotomy of the femur to equalize leg lengths, ipsilateral oblique osteotomies to regain length while still compressing the nonunion, or lengthening through the nonunion, either acutely or gradually.  Each of these options comes with risks related to healing and increased surgical complexity.  Given the patient’s desire to restore his anatomy as accurately as possible, we decided to treat this problem with acute lengthening through the nonunion site followed by stabilization with a locked reamed medullary nail with plate augmentation.   

The patient was medically stable and cleared for surgery.  A general anesthetic was administered and he was positioned supine on a radiolucent operating table.  The patient was supported with a soft left-sided lumbo-sacral support.  The entire left lower extremity was then included in the sterile operating field, and the preoperative patient/procedure verification was completed.  Antibiotic prophylaxis was withheld until deep cultures of the nonunion site were obtained.
The patient’s pre-existing trochanteric femoral nail was removed percutaneously.  Through the same skin incision, a piriformis fossa start point was obtained and an entry hole created into the proximal femur in the appropriate trajectory.  A curved ball-tipped guide wire was then placed down the femur, across the nonunion site and into the distal femur beyond the endpoint of the previously placed nail.  The canal was enlarged with sequential reaming to a total of 13mm.  The anticipated nail length was estimated using a two-guide rod technique taking into consideration the additional 2 cm of femoral lengthening.  Multiple specimens of fibrous tissue and reamings from the endosteal surface of the femur were sent for culture and sensitivity.  Subsequent to this, prophylactic antibiotics were administered.
The curved ball-tip guide rod was then retracted into the proximal femoral segment and the nonunion was then approached with a lateral extensile exposure to the femur.  After elevation of the vastus lateralis, the nonunion itself was exposed using an osteo-periosteal technique as described by Judet and Judet.  Two 2.4mm Steinmann pins were placed into the anterolateral surface of the femur on either side of the nonunion.  The distance between these two pins was measured and recorded.  Peripheral to these pins, two bicortical 5mm Schanz pins were placed and attached to a large Universal Distractor.

The nonunion site was mobilized then distracted 2cm and confirmed accurate by repeat measurement using the 2.4mm Steinmann pins.

The nonunion site was then stabilized with a posterolateral locking plate using screws strategically placed to be out of the way of the anticipated nail pathway.

The 2.4mm Steinmann pins, the 5mm Schanz pins, and the Universal Distractor were then removed.  A straight insertion rod was then placed through the piriformis fossa nail entry point and positioned into the distal femur, followed by the definitive statically locked medullary nail.  A portion of the anterior and anterolateral aspects of the hypertrophic nonunion were removed with an osteotome, morselized and reinserted into the nonunion gap created by the lengthening.  The wounds were then closed and final clinical and radiographic assessments in the operating room demonstrated symmetric leg lengths, angulation, and rotation.

The patient had an uneventful postoperative recovery course and the intraoperative specimens sent for microbiologic examination demonstrated no growth of organisms at the two week mark.  Six weeks postoperatively, he was progressed to from touchdown to full weightbearing.  He had no pain and full knee range of motion.  Twelve weeks postoperatively strengthening exercises  were initiated and the patient was weaned from his walking aids.  Two months later, the patient began light jogging and workouts with a stationary bicycle.  Approximately one year postoperatively, the patient has no pain and is back to his recreational activiities, including completion of the “Escape From Alcatraz” triathlon.

Authored By: David P. Barei.,M.D

Minimally Invasive Manipulative Reduction and Fixation of Pelvic (Pubic & Sacral) Fractures

This month's case features a 19 years old male who was injured in a high-speed automobile accident. He was the driver of the vehicle and medics at the scene noted significant intrusion of the driver’s side of the car. He was extracted from the vehicle, complained of pelvic and back pain. On presentation to the emergency department, he was awake and alert, and continued to complain of severe left sided low back and hip area pain. He was initially hemodynamically unstable but responded to routine volume resuscitation. His physical examination revealed left pelvic and back pain with any attempted passive movement. Compressive pelvic exam identified pelvic mechanical instability and related exacerbation of his complaints. There was no pelvic deformity or abnormal other findings. The lower extremity neurological and vascular examinations were within normal limits, excepting muscle power limitations due to pain.

Plain pelvic radiographs and a computed tomography scan demonstrated displaced left sided pubic ramus and sacral fractures. The axial CT images demonstrated the fracture and deformity details. The left hemipelvis was flexed and internally rotated relative to the uninjured right side.  The patient was fully resuscitated and evaluated. He and his parents were counseled regarding the various non-operative and operative treatment options, as well as the risks and benefits of each. They opted for attempted manipulative reduction and percutaneous fixation if possible, and agreed to open reduction and internal fixation if needed.

On the day after injury, the patient was medically stable and cleared for surgery. He was anesthetized, positioned supine on the radiolucent operating table, elevated on a soft lumbo-sacral support, and the entire abdomen and bilateral flanks were included in the sterile operating field. After the preoperative patient/procedure verification was completed and antibiotic prophylaxis administered, a simple 2 pin anterior oblique pelvic external fixation device was applied using bilateral 5mm pins inserted into the right iliac crest and left supra-acetabular areas. The single bar oblique frame was oriented to correct the left hemipelvic flexion and internal rotation deformities. The compression-distraction device was applied to the bar remote from the injured areas so to not obstruct pelvic fluoroscopic imaging.  The manipulative reduction was assessed using fluoroscopy until satisfactory ramus and sacral re-alignment reductions were achieved.  Then antegrade superior pubic ramus medullary screw and iliosacral screw fixations were placed percutaneously through small stab wounds under multiplanar fluoroscopic guidance. The postoperative imaging confirmed the reduction accuracy, deformity correction, and screw safety. On the day after surgery, he was comfortable and began his rehabilitation including weight of limb protected weight bearing using crutches, and isometric exercises for the subsequent 6 weeks. He returned for follow up evaluation with no complaints, radiographic union of his fractures, and was released to his normal activities 3 months after injury.

Authored By: M.L. Chip Routt, Jr.,M.D

Posterior Wall Acetabular Fracture-Dislocation

A 67 years old factory worker was injured in a high-speed automobile accident while carpooling to work. He complained of left hip pain when medics evaluated him at the accident scene, and they noted deformity of the injured lower extremity. In the emergency room, the injured hip was flexed, adducted, and internally rotated. He had diminished strength of the hip area muscles due to pain but his peripheral neurological examination was otherwise normal. There was a contusion at the anterior ipsilateral knee region, but no effusion. His patella was nontender.

Pelvic plain radiographs and a computed tomography scan identified a displaced posterior wall acetabular fracture-dislocation.  The displaced posterior wall fracture fragment involved a significant portion of the acetabular dome region. The femoral neck was not fractured.

He was sedated with intravenous medications only after consenting to closed or open reduction as needed. The manipulative closed reduction was atraumatic and successful. Skeletal traction was applied to maintain the reduction, and radiographs confirmed the reduction of the femoral head  beneath the intact acetabular dome without obvious articular debris. Two days after injury, he underwent open reduction and internal fixation of the posterior wall acetabular fracture using a Kocher-Langenbeck surgical exposure. The superior gluteal neurovascular bundle and sciatic nerve were visualized, mobilized, and protected throughout the operation. The fracture surfaces were cleansed of hematoma, reduced, and temporarily held in place with K-wires.  The reduction was definitively stabilized using a contoured and balanced malleable reconstruction plate along with interfragmentary screws. Intraoperative fluoroscopy confirmed the reduction accuracy and extra-articular screw locations. The hip joint was stressed under direct visualization to assure fracture stability. The traumatic capsular injury plus the tenotomies of the piriformis and obturator internus muscles were repaired. The necrotic caudal portion of the gluteus minimus musculature was debrided. He began his rehabilitation on the first day after surgery with unrestricted passive range of motion, isometric exercises, and partial weight bearing. Six weeks after surgery he started resistance exercises and progressive weight bearing. At his three months postoperative clinic visit, he was full weight bearing, denied complaints, and had symmetrical hip range of motion. Oblique pelvic radiographs demonstrated a symmetrical and normal hip joint space, no implant changes, and no evidence of ectopic bone formation. He reported a slight limp at the end of each day due to some residual weakness. His hip power returned to normal over the next month and he returned to his previous job.

Authored By: M.L. Chip Routt, Jr.,M.D

Complex Midfoot Injury

A 24 year old fell awkwardly at a Fourth of July celebration, injuring her left foot. She presented to a local community hospital, where X-rays and a CT scan were obtained.
The plain X-rays showed evidence of a non-displaced fracture in one of the cuneiform bones.


The CT scan confirmed a fracture in the middle cuneiform, along with several small bone fragments suggestive of ligament injuries in the dorsal midfoot. A small about of subluxation is seen in the talonavicular joint.


She was placed in a boot type orthotic and instructed to keep her weight off of it. During the course of her follow-up, there was increasing displacement. Nine weeks after her fall, she was referred to the Orthopaedic Trauma Clinic at Harborview Medical Center, where the X-rays showed collapse of the midfoot.

At this point she was diagnosed with dislocation of the navicular at both the talo-navicualr and navicular-cuneiform joints. In contrast to the navicular-cuneiform joints, which are very stable joints without motion, the talo-navicular joint is a mobile joint, known in the foot as an “essential joint”. The architecture of this part of the foot, as well as the motion in the essential joints, contributes to the painless function of the foot. Surgery was indicated to restore the anatomic relationships of the midfoot, and to provide for normal motion in the talonavicular joint.

She underwent an open reduction of the navicular-cuneiform joints, which realigned the talo-navicular joint.


In addition, a stress X-ray was taken in the operating room, and demonstrated significant instability at the first tarso-metatarsal joint, a normally stable articulation. It is important when treating midfoot injuries to identify all sites of instability, some of which may not be immediately apparent. Stress X-rays are helpful in identifiying unstable joints, which may be injured but not significantly displaced. These are typically treated so that displacement will not occur once normal activity is resumed.

The Xrays after surgery show that the stable midfoot joints, the navicular-cuneiform, and tarso-metatarsal, have been reduced and stabilized with several plates, multiple screws, and Kirschner wires. At the same time, the talonavicular joint has been reduced and will stay reduced as long as the stable joints remain reduced.


Nine months after her surgery, she is walking unlimited distances with minimal pain. Once the stable joints have healed more completely, the hardware can be removed if desired.


Midfoot injuries can be challenging to diagnose. Once diagnosed, the goals of treatment are to restore and maintain the normal relationships of the bones. Stable joints must heal solidly, and essential joints must have motion spared in order to optimize the functional outcome.

Authored By: James Krieg, MD