256 Injury: the British Journal of Accident Surgery Vol. 11/No. 3

for six weeks (Fig. 4). The patient lay free in bed in comfort after fixation (Fig. 5) and started to get up one week before the removal o f the coat hanger. Later radiographs showed good reduction of the fracture.

DISCUSSION Fixation of the unstable fracture of the pelvis is indicated by age alone in the elderly patient and by failure of satisfactory reduction or of its maintenance in the young. Firm external fixa- tion allows the patient to be nursed with much less pain and unencumbered by slings, traction apparatus or plaster to the consequent benefit of patient and nurses. Movements in bed and early walking can be more easily achieved. Fixation can be removed after three weeks in the elderly, but it should be left for longer in the younger and more active patient. At present the apparatus is made in the Hastings Orthopaedic Workshop.

Acknowledgements I am extremely grateful to Mr Devas for

allowing me to describe the coat hanger which he originally designed and also for his help in writing this paper. I am also grateful to Mrs A. Caswell for typing it.

REFERENCES Carabalona P., Rabichong P., Bonnel F. et al. (1973)

Apports du fixateur extreme dans les disjonctions du pubis et de I'articulation sacro-iliaque. Montpel/ier Chir. 19, 61.

Connes H. (1973) Hoffmann's Double Frame External Anchorage. Paris, Gead.

Devas M. (ed.) (I 977) Geriatric Orthopaedics. London, Academic Press, p. 138.

Dommisse G. F. (1960) Diametric fractures of the pelvis. J. Bone Joint Surg. 42B, 432.

Holdsworth F. W. (1948) Dislocation and fracture- dislocation of the pelvis. J. Bone Joint Surg. 30B, 461.

Sl~tis P. and Karaharju E. O. (1975) External fixation of the pelvic girdle with a trapezoid compression frame. Injury7, 53.

Watson-Jones R. (1938) Dislocations and fracture- dislocations of the pelvis. Br. J. Surg. 25, 773.

Requests for reprints should be addressed to: Mr G. N. Boobbyer, Senior Orthopaedic Registrar, Guy's Hospital, St Thomas Street, London, SEI 9RT.

KLintscher nailing of the tibia a n e w tibial jig

R i c h a r d K i n g

Senior Registrar, St Mary's Hospital, London

Summary This paper illustrates the use of a new tibial jig which facilitates closed Kiintscher nailing of the tibia. A brief history of medullary nailing is given, followed by a description of the jig.

INTRODUCTION THE first advocate of medullary nailing was Hey Groves in 1916. His methods fell into disrepute because it was thought then that a medullary nail was incapable of providing sufficiently rigid internal fixation without external splintage. Kiintscher (1958) then described his technique of reaming the medullary cavity and inserting a nail which would provide sufficient fixation without external splintage. Alms (1962) then introduced Kiintscher nailing of the tibia to Great Britain with the aid of a jig which he designed.

PREOPERATIVE PREPARATION On admission, the leg is elevated on a Braun frame with 8-10 Ib of traction applied to either a calcaneal or a low tibial pin. A tourniquet is not essential for the operation, but it is useful to apply one to the thigh, should closed nailing fail. The leg is then placed on the jig (Fig. l), which allows varying degrees of knee flexion and the use of the image intensifier in the antero- posterior and lateral planes. The bottom end of the operating table is first removed, and the metal bar on the jig is then secured to the runners on the side rails of the operating table. The distal upright rests on the floor, and up to l l0" of flexion can be achieved, by sliding the table down or by extending the distal upright (Fig. 2). The position is then secured by the locks. The top of the table is contoured to the shape of the calf and curved at its proximal end

Wrinkle Corner 257

Fig. 1. The leg to be nailed is in position on the jig; the other leg rests on the tray.

to prevent pressure at the popliteal fossa; the surface is covered with a layer of gamgee or sorbo rubber. A traction rod, which telescopes and locks, pulls out from the distal end. There is also a tray support for the other leg which slots into the table (Fig. l); alternatively, the other leg may be flexed out of the way onto a lithotomy pole and stirrup so that the image intensifier may be positioned between the patient's legs, while the surgeon operates on the other side. This is the best position for the operation and requires very little adjustment once it has been set up correctly. When the leg is flexed, the axis of the image intensifier must be tilted so that the arc remains perpendicular to the fracture site. If there is any lateral shift and/or displacement of the fracture, it is useful to distract the fracture fragments as this enables the assistant to re-align the fracture before the guide wire is passed.

C O N C L U S I O N The results of Ki.intscher nailing are good, provided that the indications are observed.

Fig. 2. The attachment of the jig at the end of the operating table. Flexion may be increased by extending the distal upright.

Closed nailing is less likely to become infected than open nailing. The use of the tibial jig which allows flexion at the knee and direct vision with an image intensifier in the anteroposterior and lateral planes, facilitates closed Kiintscher nailing of the tibia.

A c k n o w l e d g e m e n t s I would like to thank Mr Derek Wilson, FRCS, consultant orthopaedic surgeon at the Royal Free Hospital, London, for his encouragement, and Mr Tom O'Brien, carpenter, for con- structing the jig. The photographs were taken by the Photographic Department at the Royal Free Hospital, London.

REFERENCES Alms M. (1962) Medullary nailing for fractures of the

shaft of the tibia. J. Bone Joint Surg. 44B, 328. KiJntscher G. B. G. (1958) The Kiintscher method of

intramedullary fixation. J. Bone Joint Surg. 40A, 17.

Requests for reprints should be addressed to: M r Richard King, Senior Registrar, St Mary's Hospital, London.