Interlocking Intramedullary Nailing for the Treatment of Tibial Fractures J. O'Beirne, P. Seigne, J. P. McElwain Meath Hospital, Heytesbury Street, Dublin 8. Abstract Thirty-seven tibial shaft fractures in 34 patients were treated with the Grosse-Kempf interlocking intramedullary nail over a two year period. Thirty-six tibiae were consolidated at a median of 17 weeks; one had re-fractured following nail removal in a separate injury, but was now uniting on conservative treatment. Using very detailed clinical and radiological analysis, and excluding the patient who had re-fractured, the results were excellent in 19, good in 8, fair in 6 and poor in 3. The most significant complications were haematoma formation and additional comminution during nail insertion. Overall, we found tibial nailing to be a satisfactory procedure, facilitating rapid rehabilitation with early weight bearing and resulting in predictable fracture healing in good alignment. group. Ages ranged from 15 to 68 with a median of 23. Eighteen of the injuries were as a result of road traffic accidents, seven were sports injuries, three were work injuries and the remaining six were due to miscellaneous causes. Twenty patients had a fracture of the right tibia; eleven had a fracture of the left tibia and three patients had bilateral fractures. Thirty-seven of the fractures were closed; of the ten open fractures, three were grade I, five were grade II and two were grade III(7). The fracture types are summarised in Table I and zones involved in Fig. 1.
Introduction Fractures of the tibial shaft are among the commonest injuries encountered in orthopaedic practice. Traditionally, closed treatment in cast has been used, but this can lead to long episodes of disability, and high incidence of residual joint stiffness and deformity(I6}. The common alternative to closed treatment has been plate fixatio,!, but on account of the superficial location and tenuous periosteal blood supply of the tibia, this has carried a high risk of infection(6,18,22). Until recently, treatment of tibial shaft fractures by intramedullary nailing, although an acceptable modality of treatment, was applicable only to transverse or short oblique fractures of the mid-shaft, when the nail could get adequate purchase on both fragments and there was no risk of telescoping with resultant shortening10° >15° >15° >20° >3cm
Range of knee motion Flexion Extension deficit
>120° 5°
120° 10°
90° 15°
15°
Range of ankle motion Dorsi flexion Plantar flexion Pain Swelling
>20° >30° none none
20° 10° >10° 30° 20° >20° sporadic signif. severe minor signif. severe
Results Thirty-six tibiae were consolidated clinically and radiologically at a median of 17 weeks. With the exception of prolonged healing time in one alcoholic patient with bilateral tibial fractures, the healing time ranged from 7 to 24 weeks (Figs. 2 and 3). One patient with a complex open tibial fracture with segmental loss requring postero-Iateral bone grafting united initially, but subsequently suffered a refracture at the upper graft-bone interface in a separate injury. This fracture was uniting on conservative treatment. Using the criteria of Ekelarid el af S), and excluding the patient who had recently suffered a re-fracture, the combined clinical and radiological results on the remaining 36 fractures are summarised in Table IV. Three patients had poor results. Ofthese, 2 also had serious head injuries with residual neurological dysfunction which significantly compromised their rehabilitation. The third was a 68 year old man who had suffered multiple additional injuries to the same limb, including fracture of the acetabulum, femoral neck, femoral shaft, supracondylar femur, and tibial plateau. His tibial fracture united, but with considerable knee stiffness. There were 6 fairresults, 3 ofwhom had valgus angulation at thefracturesite of between 5 and IO degrees, and 3 had knee flexion ranging between 90 and 120 degrees. (Ranges 0£0° - 90°,0° - 100°, and 0° - 110° respectively). The mean time to commencement ofpartial weight bearing was 4 weeks (range a few days to 13 weeks), and to full weight bearing 14 weeks (range 6 to 40 weeks). Symptoms Nine patients complained of some persistent discom fort at the fracture site, and nine complained of discomfort at the patellar tendon. The majority of these patients had been recently operated upon. Six patients remarked on numbness in the area of distribution of the intra-patellar branch of the saphenous nerve. None of these patients, however, were severelly handicapped by their symptoms. TABLE IV OVERALL RESULTS (COMBINED CLINICAL AND RADIOLOGICAL ASSESSMENT) Excellent Good Fair Poor
19 8 6
3
Vol. 161 No.1
Interlocking intramedullary nailing 7
Fig. 2A - Mid-shaft tibial fracture with some comminution in a 15 year old boy.
Fig. 2B - Intramedullary nailing with static locking
Fig. 3A - Fracture of the mid to lower tibial shaft in a 19 year old female. This fracture was treated by intramedullary nailing with dynamic distal locking.
Tibial Length Six tibiae were short at review, but all by lcm or less. Five of these had sustained comminuted fractures and one was spiral. Com plications These are listed in Table V. There have been no non-unions and no cases of metal failure. The most troublesome complication was the occurrence of haematoma at the fracture site following nailing. In these four patients, the haematoma was surgically drained; subsequent healing was slow, but no pathogenic organisms were identified on repeated cultures. In one patient, periosteal elevation was noted, raising the suspicion of bony infection. All four fractures healed; in all patients the discharge eventually settled
Fig. 2C - Solidly united fracture at three months
Fig. 3B - Three months later, the fracture was solidly united.
down after removal of the nail in two of the four. In five patients, additional comminution occurred at the time of insertion of the nail. These all healed up satisfactorily. One subsequently telescoped, leading to 1cm shortening at the time of union. This could have been avoided if it had been TABLE V COMPLICAnONS Local Complications Haematoma Superficial wound infection
4 2
Technical Complications Additional comminution during nailing 5 Telescoped with shortening 2 Proximal migration of nail (without shortening) 4
IJ.M.S. January,l992
8 O'Beirne et al. recognised and statically locked at the time of surgery. Telescoping with shortening occurred in two patients; one has already been alluded to; the other had a comminuted fracture which was dynamically locked distally. In four other patients, some proximal migration ofthe nail occurred with no loss of length. Discussion In general we have found the inerlocking intramedullary nailing to be very useful for the treatment of tibial shaft fractures. -All fractures healed; the median time to union of 17 weeks accords well with the experience ofother authors(I,2,21). Moreover, rehabilitation is enhanced by the possibility of early weight bearing. Bone and Johnson(2) reported a mean interval of4 weeks to full weight bearing; Alho el afJ ) reported a mean interval of 37 days for non-comminuted fractures and 52 days for comminuted fractures. Our patients did not return to full weight bearing quite as rapidly as this, but often the delay was due to caution on the patients' part rather than any instability or delay in union. Alignment was almost uniformly well restored, and the infection rate has been very low, as might be expected from a closed procedure(9,12). The largest series of tibial nailings reported(12)quoted an infection rate of 2.2%. The results ofour clinical and radiological assessment have been encouraging; the 3 "poor" results could hardly have been avoided given the concomitant injuries. The 6 "fair" results were in patients who failed to meet the quite strict criteria we adopted in our dealil1gsof "good" or "excellent". Therefore, for the application of a single surgical technique across the whole spectrum of tibial shaft fractures, we feel the overall results have been satisfactory. The results of nailing have been particularly gratifying with segmental fractures, which up to now have been among the mostdifficlilt oftibia fractures to treat04,23). It has been held that a fracture which has been statically locked should be converted to dynamic locking ("dynamisation") by removal ofthe locking screws from one end of the bone, some weeks after the initial procedure, on the basis that the cyclical loading so induced should promotefracture healingCs.ll). However, the validity of this theory is now being called into_question, and it had been suggested that such a step is not after all necessary(3,20). We did not routinely follow a policy of converting static locking to dynamic, and despite this, fracture healing progressed just as well as in those that were dynamically locked or unlocked. The major problem with the Grosse-Kempf tibial nail in this series has been the occurrence of haematoma at the fracture site, which can result in slow wound healing following drainage. This haematoma arises because extravasation of blood through the fracture gap at the time of reaming and insertion of the nail. It becomes readily apparent because of the superficial location of the tibia. Bone and Johnson(2) suggested that this complication could be avoided by delaying the operation until at least 3 days after the fracture. However, the four patients who had the problem in this series did not have their surgery within this period, and in fact, for one patient, there had been a delay of 19 days between the
occurrence of the fracture and the operation. At present, our approach to the problem is to routinely apply ice packs to the fracture site after surgery, and maintain high elevation of the limb. Should a haematoma occur, our preference is to continue this conservative treatment until it settles down. Drainage of the haematoma may still be required if the skin is under excessive pressure from within, but even then, we endeavour to make the surgical wound as small as possible. In conclusion we have found our experience with tibial nailing very encouraging. The procedure has facilitated rapid rehabilitation with early weight bearing, and has resulted in ;predictable fracture healing in good alignment. References
'I. ATho, A., Ekeland, A., Stromsoe, K., Folleras, G., Thoresen, B. O. 2. 3. 4. 5. 6. 7.
8. 9. 10. 11.
12. 13. 14. 15. 16. 17. 18. 19. 20. 2 I.
22. 23.
Inlramedullary nailing for displaced tibial shaft fractures. 1. Bone Joint Surg. (Br.) 1990: 72, 805-809. Bone, L. B., Johnson, K. D. Treatment of tibialfractures by reaming and intramedullary nailing. J. Bone Joint Surg. (Am.) 1986: 68-A, 877-887. Browner, B. D. Pitfalls, errors and complications in the use of locking Kuntscher nails. Clin. Orthop. 1986: 212,192-208. Court-Brown, C. M., Christie, 1., McQueen, M. M. Closed intramedullary tibial nailing; its use in closed and type I open fractures. J. Bone Joint Surg. (Br.) 1990: 72-B, 605-611. Ekeland, A., Thoresen, B. 0., Alho, A., Stromsoe, K., Folleras, G., Haukebo, A. Interlocking intramedullary nailing in the treatment of tibial fractures. Clin.Orthop. 1988: (231), 205-215. Fisher, W. D., Hamblen, D. L. Problems and pitfalls of compression fixation of long bone fractures: A review of results and complications. Injury 1978: 10,99. Gustilo, R. B., Anderson, J. T. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones. Retrospective and prospective analyses. J. Bone Joint Surg. (Am.) 1976: 58A, 453-458. Hindley, C. J., Evans, R. A., Holt, E. M., Metcalf, J. W. Locked ,intramedullary nailing for recent lower limb fractures. Injury 1990: 21, 239-244. Kaltenecker, G., Wruhs, 0., Quaicoe, S. Lower infection rate after interlocking nailing in open fractures of the femur and tibia. 1. Trauma 1990: 30, 474-479. Kempfe, I., Grosse, A., Lafforgue, D. L'apport du verrouillage dans l'enclouage centro-medullaire des os longs. Rev. Chir. Orthop. 19789: 74,635. Kenwright, 1., Goodship, A. E., Kelly, D. J., Newman, J. H., Harris, J. D., Richardson, 1. B., Evans, M., Spriggins, A. J., Burroughs, S. 1., Rowley, D. 1. Effect of controlled axial micromovement on healing of tibial fractures. Lancet 1986 Nov. 22: 2(8517), 1195-1187. Klemm, K. W., Bomer, M. Interlocking nailing of fractures of the femur and tibia. Clin. Orthop. 1986: (212), 89-100. Kuntscher, G. Practice of intramedullary nailing (fans. H. H. Rinne). Springfield, n. Charles C. Thomas. 1976: pp. 85-96. Melis, G. c., Sotgiu, F., Lepori, M., Guido, P. Intramedullary nailing in segmental tibial fractures. J. Bone Joint Surg. (Am.) 1981: 63-A, 1310-1318. Merle, D'Aubigne, R., Maurer, P., Zucman, J., Masse, Y. Blind intramedullary nailing of tibial fractures. Oin. Orthop. 1974: (l05), 267-275. Nicoll, E. A. Fractures of the tibial shaft - A survey of 7905 cases. J. Bone Joint Surg. (Br.) 1964: 46-B, 373. Olerud, S., Karlstrom, G. The spectrum of intramedullary nailing of the tibia. Oin. Orthop. 1986: (212), 101-112. Puno, R. M., Teynor, 1. T., Nagano, J., Gustillo, R. B. Critical analysis of results of treatment of 201 tibial shaft fractures. Clin. Orthop. 1986: (212), 113-121. Rommens, P., Schmit-Neuerburg, K. P. Ten years of experience with the operative management of tibial shaft fractures. J. Trauma 1978: 27, 917-927. Sledge,S. L.,Johnson,K. D., Henley,M. B., Watson,J. T. Intramedullary nailing with reaming to treat non-union of the tibia. J. Bone Joint Surg. (Am.) 1989: 71-A, 1004-1019. Werry, D. G., Boyle, M. R., Meek, R: N., Loomer, R. L. Intramedullary fixation of tibial shaft fractures With AO and Gross-Kempf locking nails: A review of 70 consecutive fractures. J. Bone Joint Surg. (Br.) 1985: 67-B, 325. Wilson, J. N. In: Watson-Jones. Fractures and Joint Injuries - 6th Edition, Edinburgh, London, Melbourne, New York. Churchill Livingstone 1982. Zucman, J., Maurer, P. Two level fractures of the tibia - Results in thirty-six cases treated by blind nailing. J. Bone Joint Surg. (Br.) 1969: 51-B,686-693.
Introduction Fractures of the tibial shaft are among the commonest injuries encountered in orthopaedic practice. Traditionally, closed treatment in cast has been used, but this can lead to long episodes of disability, and high incidence of residual joint stiffness and deformity(I6}. The common alternative to closed treatment has been plate fixatio,!, but on account of the superficial location and tenuous periosteal blood supply of the tibia, this has carried a high risk of infection(6,18,22). Until recently, treatment of tibial shaft fractures by intramedullary nailing, although an acceptable modality of treatment, was applicable only to transverse or short oblique fractures of the mid-shaft, when the nail could get adequate purchase on both fragments and there was no risk of telescoping with resultant shortening10° >15° >15° >20° >3cm
Range of knee motion Flexion Extension deficit
>120° 5°
120° 10°
90° 15°
15°
Range of ankle motion Dorsi flexion Plantar flexion Pain Swelling
>20° >30° none none
20° 10° >10° 30° 20° >20° sporadic signif. severe minor signif. severe
Results Thirty-six tibiae were consolidated clinically and radiologically at a median of 17 weeks. With the exception of prolonged healing time in one alcoholic patient with bilateral tibial fractures, the healing time ranged from 7 to 24 weeks (Figs. 2 and 3). One patient with a complex open tibial fracture with segmental loss requring postero-Iateral bone grafting united initially, but subsequently suffered a refracture at the upper graft-bone interface in a separate injury. This fracture was uniting on conservative treatment. Using the criteria of Ekelarid el af S), and excluding the patient who had recently suffered a re-fracture, the combined clinical and radiological results on the remaining 36 fractures are summarised in Table IV. Three patients had poor results. Ofthese, 2 also had serious head injuries with residual neurological dysfunction which significantly compromised their rehabilitation. The third was a 68 year old man who had suffered multiple additional injuries to the same limb, including fracture of the acetabulum, femoral neck, femoral shaft, supracondylar femur, and tibial plateau. His tibial fracture united, but with considerable knee stiffness. There were 6 fairresults, 3 ofwhom had valgus angulation at thefracturesite of between 5 and IO degrees, and 3 had knee flexion ranging between 90 and 120 degrees. (Ranges 0£0° - 90°,0° - 100°, and 0° - 110° respectively). The mean time to commencement ofpartial weight bearing was 4 weeks (range a few days to 13 weeks), and to full weight bearing 14 weeks (range 6 to 40 weeks). Symptoms Nine patients complained of some persistent discom fort at the fracture site, and nine complained of discomfort at the patellar tendon. The majority of these patients had been recently operated upon. Six patients remarked on numbness in the area of distribution of the intra-patellar branch of the saphenous nerve. None of these patients, however, were severelly handicapped by their symptoms. TABLE IV OVERALL RESULTS (COMBINED CLINICAL AND RADIOLOGICAL ASSESSMENT) Excellent Good Fair Poor
19 8 6
3
Vol. 161 No.1
Interlocking intramedullary nailing 7
Fig. 2A - Mid-shaft tibial fracture with some comminution in a 15 year old boy.
Fig. 2B - Intramedullary nailing with static locking
Fig. 3A - Fracture of the mid to lower tibial shaft in a 19 year old female. This fracture was treated by intramedullary nailing with dynamic distal locking.
Tibial Length Six tibiae were short at review, but all by lcm or less. Five of these had sustained comminuted fractures and one was spiral. Com plications These are listed in Table V. There have been no non-unions and no cases of metal failure. The most troublesome complication was the occurrence of haematoma at the fracture site following nailing. In these four patients, the haematoma was surgically drained; subsequent healing was slow, but no pathogenic organisms were identified on repeated cultures. In one patient, periosteal elevation was noted, raising the suspicion of bony infection. All four fractures healed; in all patients the discharge eventually settled
Fig. 2C - Solidly united fracture at three months
Fig. 3B - Three months later, the fracture was solidly united.
down after removal of the nail in two of the four. In five patients, additional comminution occurred at the time of insertion of the nail. These all healed up satisfactorily. One subsequently telescoped, leading to 1cm shortening at the time of union. This could have been avoided if it had been TABLE V COMPLICAnONS Local Complications Haematoma Superficial wound infection
4 2
Technical Complications Additional comminution during nailing 5 Telescoped with shortening 2 Proximal migration of nail (without shortening) 4
IJ.M.S. January,l992
8 O'Beirne et al. recognised and statically locked at the time of surgery. Telescoping with shortening occurred in two patients; one has already been alluded to; the other had a comminuted fracture which was dynamically locked distally. In four other patients, some proximal migration ofthe nail occurred with no loss of length. Discussion In general we have found the inerlocking intramedullary nailing to be very useful for the treatment of tibial shaft fractures. -All fractures healed; the median time to union of 17 weeks accords well with the experience ofother authors(I,2,21). Moreover, rehabilitation is enhanced by the possibility of early weight bearing. Bone and Johnson(2) reported a mean interval of4 weeks to full weight bearing; Alho el afJ ) reported a mean interval of 37 days for non-comminuted fractures and 52 days for comminuted fractures. Our patients did not return to full weight bearing quite as rapidly as this, but often the delay was due to caution on the patients' part rather than any instability or delay in union. Alignment was almost uniformly well restored, and the infection rate has been very low, as might be expected from a closed procedure(9,12). The largest series of tibial nailings reported(12)quoted an infection rate of 2.2%. The results ofour clinical and radiological assessment have been encouraging; the 3 "poor" results could hardly have been avoided given the concomitant injuries. The 6 "fair" results were in patients who failed to meet the quite strict criteria we adopted in our dealil1gsof "good" or "excellent". Therefore, for the application of a single surgical technique across the whole spectrum of tibial shaft fractures, we feel the overall results have been satisfactory. The results of nailing have been particularly gratifying with segmental fractures, which up to now have been among the mostdifficlilt oftibia fractures to treat04,23). It has been held that a fracture which has been statically locked should be converted to dynamic locking ("dynamisation") by removal ofthe locking screws from one end of the bone, some weeks after the initial procedure, on the basis that the cyclical loading so induced should promotefracture healingCs.ll). However, the validity of this theory is now being called into_question, and it had been suggested that such a step is not after all necessary(3,20). We did not routinely follow a policy of converting static locking to dynamic, and despite this, fracture healing progressed just as well as in those that were dynamically locked or unlocked. The major problem with the Grosse-Kempf tibial nail in this series has been the occurrence of haematoma at the fracture site, which can result in slow wound healing following drainage. This haematoma arises because extravasation of blood through the fracture gap at the time of reaming and insertion of the nail. It becomes readily apparent because of the superficial location of the tibia. Bone and Johnson(2) suggested that this complication could be avoided by delaying the operation until at least 3 days after the fracture. However, the four patients who had the problem in this series did not have their surgery within this period, and in fact, for one patient, there had been a delay of 19 days between the
occurrence of the fracture and the operation. At present, our approach to the problem is to routinely apply ice packs to the fracture site after surgery, and maintain high elevation of the limb. Should a haematoma occur, our preference is to continue this conservative treatment until it settles down. Drainage of the haematoma may still be required if the skin is under excessive pressure from within, but even then, we endeavour to make the surgical wound as small as possible. In conclusion we have found our experience with tibial nailing very encouraging. The procedure has facilitated rapid rehabilitation with early weight bearing, and has resulted in ;predictable fracture healing in good alignment. References
'I. ATho, A., Ekeland, A., Stromsoe, K., Folleras, G., Thoresen, B. O. 2. 3. 4. 5. 6. 7.
8. 9. 10. 11.
12. 13. 14. 15. 16. 17. 18. 19. 20. 2 I.
22. 23.
Inlramedullary nailing for displaced tibial shaft fractures. 1. Bone Joint Surg. (Br.) 1990: 72, 805-809. Bone, L. B., Johnson, K. D. Treatment of tibialfractures by reaming and intramedullary nailing. J. Bone Joint Surg. (Am.) 1986: 68-A, 877-887. Browner, B. D. Pitfalls, errors and complications in the use of locking Kuntscher nails. Clin. Orthop. 1986: 212,192-208. Court-Brown, C. M., Christie, 1., McQueen, M. M. Closed intramedullary tibial nailing; its use in closed and type I open fractures. J. Bone Joint Surg. (Br.) 1990: 72-B, 605-611. Ekeland, A., Thoresen, B. 0., Alho, A., Stromsoe, K., Folleras, G., Haukebo, A. Interlocking intramedullary nailing in the treatment of tibial fractures. Clin.Orthop. 1988: (231), 205-215. Fisher, W. D., Hamblen, D. L. Problems and pitfalls of compression fixation of long bone fractures: A review of results and complications. Injury 1978: 10,99. Gustilo, R. B., Anderson, J. T. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones. Retrospective and prospective analyses. J. Bone Joint Surg. (Am.) 1976: 58A, 453-458. Hindley, C. J., Evans, R. A., Holt, E. M., Metcalf, J. W. Locked ,intramedullary nailing for recent lower limb fractures. Injury 1990: 21, 239-244. Kaltenecker, G., Wruhs, 0., Quaicoe, S. Lower infection rate after interlocking nailing in open fractures of the femur and tibia. 1. Trauma 1990: 30, 474-479. Kempfe, I., Grosse, A., Lafforgue, D. L'apport du verrouillage dans l'enclouage centro-medullaire des os longs. Rev. Chir. Orthop. 19789: 74,635. Kenwright, 1., Goodship, A. E., Kelly, D. J., Newman, J. H., Harris, J. D., Richardson, 1. B., Evans, M., Spriggins, A. J., Burroughs, S. 1., Rowley, D. 1. Effect of controlled axial micromovement on healing of tibial fractures. Lancet 1986 Nov. 22: 2(8517), 1195-1187. Klemm, K. W., Bomer, M. Interlocking nailing of fractures of the femur and tibia. Clin. Orthop. 1986: (212), 89-100. Kuntscher, G. Practice of intramedullary nailing (fans. H. H. Rinne). Springfield, n. Charles C. Thomas. 1976: pp. 85-96. Melis, G. c., Sotgiu, F., Lepori, M., Guido, P. Intramedullary nailing in segmental tibial fractures. J. Bone Joint Surg. (Am.) 1981: 63-A, 1310-1318. Merle, D'Aubigne, R., Maurer, P., Zucman, J., Masse, Y. Blind intramedullary nailing of tibial fractures. Oin. Orthop. 1974: (l05), 267-275. Nicoll, E. A. Fractures of the tibial shaft - A survey of 7905 cases. J. Bone Joint Surg. (Br.) 1964: 46-B, 373. Olerud, S., Karlstrom, G. The spectrum of intramedullary nailing of the tibia. Oin. Orthop. 1986: (212), 101-112. Puno, R. M., Teynor, 1. T., Nagano, J., Gustillo, R. B. Critical analysis of results of treatment of 201 tibial shaft fractures. Clin. Orthop. 1986: (212), 113-121. Rommens, P., Schmit-Neuerburg, K. P. Ten years of experience with the operative management of tibial shaft fractures. J. Trauma 1978: 27, 917-927. Sledge,S. L.,Johnson,K. D., Henley,M. B., Watson,J. T. Intramedullary nailing with reaming to treat non-union of the tibia. J. Bone Joint Surg. (Am.) 1989: 71-A, 1004-1019. Werry, D. G., Boyle, M. R., Meek, R: N., Loomer, R. L. Intramedullary fixation of tibial shaft fractures With AO and Gross-Kempf locking nails: A review of 70 consecutive fractures. J. Bone Joint Surg. (Br.) 1985: 67-B, 325. Wilson, J. N. In: Watson-Jones. Fractures and Joint Injuries - 6th Edition, Edinburgh, London, Melbourne, New York. Churchill Livingstone 1982. Zucman, J., Maurer, P. Two level fractures of the tibia - Results in thirty-six cases treated by blind nailing. J. Bone Joint Surg. (Br.) 1969: 51-B,686-693.
