[Multifascicular intramedullary nailing of the forearm]

Purpose of the study was to present the advantages of intramedullary nailing of long bones for treatment of fractures of the forearm. These advantages are 1) preserving the fracture-hematoma and 2) non exposure of bone. This technique is based on the technique of bundle nailing developed by Hackethal (1959).

In a 16-year period we performed Hackethal bundle nailing in 94 patients with 159 fractures. Hackethal developed the nailing procedure named after him in 1959. The rationale of Hackethal nailing is based on elastic jamming, which can only be achieved by following four rules: jamming of the nails in the cortical window, jamming then in the waist of the medullary cavity, spreading the bundle of nails in the metaphysis and filling up the conus of the medullary cavity with short nails. We confined Hackethal nailing to closed and first-degree open fractures of the midshaft of the forearm. If closed reduction and nailing were impossible, we performed a plate fixation (AO). Second- or third-degree open fractures were treated with external fixators.

In 62.8 per cent patients surgery was performed within the first 8 hours following admission. We used two or three nails passing the fracture and one short nail. Except for 1 case, in which a cast was necessary, we achieved rotational stability. On average, the nails were removed after 11.5 months. The healing and complication rates were assessed by follow-up examination of 77 patients. The results were excellent and good in 75.3 per cent patients, satisfactory 14.3 per cent and poor in 10.4 per cent. Complications consisted of a 0.74 per cent infection rate (osteitis), 2.2 per cent non-union, 1.5 per cent with a synostosis, 0 per cent refracture and 2.2 per cent migration of nails, combined with tendon rupture. We have seen 1 case with metallosis.

There are four important benefits of this treatment. First with this principle bone healing is achieved after 2.6 month, but with the plate fixation it lasts 7.5 month. Second, the rate of non-union goes down from almost 6 per cent to 1.5 per cent. Third, the postoperative infection rate is reduced (0.74 per cent) and fourth joint motion is preserved. Our bad results are mainly caused by the polytraumatic conditions of some patients.

In conclusion with our confined spectrum of indications Hackenthal nailing is a low-risk method, which leads to rotational stability and early bone healing.