Retrograde IMN can be used for gunshot wounds - Academy News at the 2007 AAOS Annual Meeting

Retrograde IMN can be used for gunshot wounds

By Mary Ann Porucznik

Researchers compared results to all blunt trauma femur fractures treated with IMN

Fractures secondary to gunshot wounds (GSW) are extremely common injuries encountered in urban emergency rooms across the United States. Although some physicians question the use of retrograde intramedullary nailing (retrograde IMN) for gunshot wounds to the femoral shaft, the research presented in poster exhibit P458 indicates that retrograde IMN can be an acceptable treatment option in this situation.

Antegrade intramedullary nails (antegrade IMN) are an accepted treatment for both closed and open fractures of the femur, including those secondary to GSW. Retrograde IMN were originally contraindicated in open fractures because of potential knee joint infection. Researchers wanted to evaluate the risk of infection in open femoral shaft fractures secondary to GSW treated with IMN (both retrograde and antegrade).

Between May 1994 and January 2005, 2,322 GSW were treated in a single emergency department. Among them were 121 femur fractures, which were included in this study. All fractures were immediately treated with irrigation and debridement andintramedullary nailing; retrograde IMN was used in 55 fractures; the other 66 fractures were treated with antegrade IMN.

(Left) Clinical picture of left femur with the entrance wounds from civilian gun shots. (Right) Preoperative radiograph of left femur in the same case (45mm caliber handgun).

To determine if the use of retrograde IMN for GSW resulted in a higher risk of infection, researchers compared results to all blunt trauma femur fractures treated with IMN during the same time period.

There were no cases of osteomyelitis or septic arthritis among patient in the GSW group who were treated with retrograde IMN. There were, however, three cases of osteomyelitis among patients with GSWs who were treated with antegrade IMN. There was no significant difference between patients with GSW who were treated with retrograde IMN and those treated with antegrade IMN with regard to infection or union.

Researchers then compared the results to those of patients treated for femur fractures caused by blunt trauma. Among patients treated with retrograde IMN, there was one case of osteomyelitis; among those treated with antegrade IMN, there were no cases of osteomyelitis. Furthermore, there was no significant difference with regard to infection or union in fractures caused by blunt trauma or GSW treated with retrograde IMN.

Because the results of this study showed no increased risk of bone or joint infection with acute insertion of retrograde IMN for open femur fractures due to gunshot wounds, researchers conclude it can be an acceptable treatment option. The research team is headed by Massimo “Max” Morandi, MD, and includes Jason Hurbanek, MD; Joseph Hoegler, MD; Robb Weir, MD; and Paul J. Dougherty, MD, all of Detroit. The authors report no conflicts of interest.


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