Wedge fragments: no significant impact on bone healing in femoral shaft fractures treated with intramedullary nailing.

Abstract

Introduction: Intramedullary nailing (IMN) is the treatment of choice for femoral shaft fractures with wedge-shaped fragments. However, the management of wedged fragments remains controversial. This study investigated whether wedged fragments affect bone union rates in patients treated with IMN. The primary hypothesis was that wedged fragments would not significantly affect bone union when proper IMN principles were followed.

Materials and methods: Between March 2014 and June 2023, 162 patients were diagnosed with femoral shaft fractures (AO/OTA 32-B type) accompanied by wedge fractures. The surgeries involved the use of a reconstruction antegrade nail with a greater trochanteric entry point. Closed reduction was performed, and recon-type screws were used for proximal fixation of the femoral neck and head and at least two screws distally. The wedged fragments were not manipulated further. We analyzed the characteristics of the wedged fragments, including size, displacement, angle, and reversal morphology, and assessed the main fracture gap size in relation to bone union outcomes.

Results: The study included 95 of the 162 patients, of whom 82 (86.3%) achieved bone union and 13 (13.7%) experienced nonunion. Demographic and preoperative variables showed no significant differences between the union and nonunion groups. Postoperative radiographic analysis of the wedged fragments revealed no significant differences in fragment size, angle, displacement, or presence of reversed fragments. However, the main fracture gap size significantly differed, averaging 5.2 mm in the union group and 15.6 mm in the nonunion group(p = 0.01). Complications included superficial infections in four patients and malrotation in three, which were managed conservatively.

Conclusions: Wedge fragments in femoral shaft fractures do not significantly affect bone union with IMN. Instead, the size of the main fracture gap is critical for healing. Surgery should focus on stable fixation and minimization of the main fracture gap rather than manipulating the wedged fragments.