Current Orthopaedics (1999) 13, 99 104

1999 Harcourt Brace & Co. Ltd

Mini-symposium: Tibial fractures

(iii) Intramedullary nailing: the case for reaming

H.S. Reid, C.M. Court-Brown

INTRODUCTION

the Rush brothers and Otto Lottes, who used

unreamed nails. In the last ten years, however, surgeons in Europe have become polarized into two
camps largely as a result of the introduction of the
AO unreamed nailing systems. These nails stimulated
a considerable amount of research, which was
designed to show the deleterious effect of reaming on
the endosteal vascular supply and intramedullary
pressure. These studies were generally undertaken
using animal models and the results were often contradictory. More recently, a number of clinical studies
have been undertaken to investigate the role of reaming. Reaming therefore remains somewhat controversial and surgeons continue to debate certain aspects
of the technique and its physiological effects.
Important questions include:

Intramedullary reaming was introduced by Gerhard

Kiintscher 1 to allow the insertion of large-diameter
intramedullary nails. His initial nails had no interlocking facility and it was only by reaming the endosteal
cortex into a tube that an intramedullary nail could
obtain purchase on a sufficient length of cortex to successfully stabilize a fracture. There is no doubt that
Kfintscher found reaming to be very useful, but he did
recognize that the technique had potential drawbacks
and he advised against nailing in the presence of fat
embolus. He also advocated care if intramedullary
nailing was used in the multiply injured patient or in
patients who had severe soft-tissue injuries.
Traditional unlocked Kiintscher nailing was found
to be a very useful technique in the management of
femoral fractures but was of less value in the tibia
because the morphological characteristics of many
tibial fractures meant that an unlocked nail could not
adequately stabilize the fracture. The introduction of
locked nails, however, following the work of Klemm
and Schellmann and Grosse and Kempf, meant that
virtually all femoral and tibial diaphyseal fractures
could be stabilized using intramedullary techniques
and the technique of interlocking nailing has become
routine in the management of these fractures.
It is interesting to note that initially the division
between reamed and unreamed 'nailers' was geographic. Europe tended to follow the teachings of
Kfintscher and therefore used reamed nails, whereas
surgeons in the USA were influenced by the work of

1. What is the effect of reaming on the endosteal

blood supply and intramedullary pressure?
Opponents of reaming suggest that its destruction
of the endosteal vasculature is deleterious to
fracture union and that the high intramedullary
pressure associated with its use may precipitate
compartment syndrome.
2. What are the clinical results of using reamed and
unreamed femoral and tibial nails? Are there any
physiological effects of reaming that might be
advantageous to bone union?
3. Does reaming and nailing cause fat embolus and
adult respiratory distress syndrome in multiply
injured patients? Opponents suggest that it does
and that unreamed nails cause less damage than
reamed nails.

Heather S. Reid FRCS, Orthopaedic Registrar; Charles M.

Court-Brown FRCSEd(Orth), Consultant Orthopaedic Surgeon,

Edinburgh OrthopaedicTrauma Unit, RoyalInfirmary of

Edinburgh NHS Trust, Lauriston Place, Edinburgh EH3 9YW,
UK. Tel: +44 (0)131 536 3721; Fax: +44 (0)131 660 4227
Correspondence to:

P H Y S I O L O G I C A L E F F E C T S OF R E A M I N G
Animal studies dealing with the effect of intramedullary reaming on fracture union show conflicting

Mr C.M. Court-Brown
99

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results. The original studies investigating the damage

to the endosteal circulation by reaming were undertaken by Danckwardt-Lillestrom.2 He showed that
reaming did interfere with the endosteal vascular supply but that, within a few weeks, the endosteal blood
vessels had returned. He also demonstrated that reaming enhanced the periosteal circulation. Recently, his
work has been repeated using more sophisticated
techniques, with similar results being found. Klein et
al. 3 have shown that there is a 70% reduction in
endosteal blood flow after reamed nailing compared
with a 30% reduction after unreamed nailing.
Schemitsch et al. 4 have demonstrated that cortical
revascularization occurs after six weeks using an
unreamed nail compared with after 12 weeks if a
reamed nail is used. ReikerSs 5 et al. found no difference in healing between reamed and unreamed
femoral osteotomies, whereas Grundes 6 et al. reported
modest reaming to be preferable to extensive reaming
in fracture union in rats.
Other researchers have examined the periosteal
stimulation associated with reaming. Reichert7 and
her co-workers investigated the vascular changes produced by reaming intact tibiae in sheep. Their experiments showed that, immediately after intramedullary
reaming, there was no significant difference in cortical
blood flow despite the fact that the dominant afferent
supply from the nutrient artery had been destroyed
and a proportion of the cortical bone had been
reamed out. They demonstrated that, within 30 min
there was a sixfold increase in blood flow in the
reamed tibia compared with the unreamed contralateral control and they concluded that the enhancement
of the periosteal circulation by reaming compensated
for any reduction in endosteal blood flow. They felt
that their results vindicated Trueta's belief that following trauma, or other pathological states, bone blood
flow can become centripetal? Most studies now agree
that periosteal blood flow dominates in the early
phase of bone-healing and that the repair process proceeds from the periphery until the medullary circulation is re-established.
In addition to demonstrating the effects of reaming
on bone blood flow, Danckwardt-Lillestrom2 also
showed that bone-marrow contents were forced subperiosteally during reaming and he noted that woven
bone was formed in these areas. In his animal studies,
he used the contralateral leg as a control and he
observed that, when the marrow contents were
removed by suction, the amount of subperiosteal
bone formation was considerably less. This suggested
that the reaming particles might well have a direct
osteoinductive effect. This effect was examined further by Tydings and his co-workers who examined
reaming products histologically. 9'1 They showed that
the initial reaming material comprised marrow contents with small amounts of bony trabeculae. As the
diameter of the reamers increased, the concentration
of bone increased. Some osteocytes and fibroblasts

were observed but no true osteoblasts. Small quantities of reaming products were injected into the gluteus
maximus muscle of rats who were given an intraperitoneal injection of tetracycline. Subsequent fluorescence studies indicated that the cellular component of
the bone reamings reamined viable. In a second experiment, reamings were compared with iliac crest bone
graft in dogs and it was noted that there was increased
new bone formation from the reamings.
The problem with much of the animal work is that
the experiments tended to concentrate on only one
facet of the fracture repair process. The results of the
experiments are unquestionably valid but are often
unreasonably extrapolated, making the clinical conclusions drawn from these animal experiments invalid.
Clinical studies are clearly required to investigate the
overall effect of the reduction in the endosteal vascular supply after reamed nailing.
One of the other criticisms that continues to be levelled against reaming is that, by raising the
intramedullary pressure, it causes compartment syndrome. Many surgeons diagnose compartment syndrome as being present if the intracompartmental
pressure rises above 30 mmHg and the belief that
reamed nailing causes compartment syndrome has
been reinforced by the observation that compartment
pressures are frequently above 30 mmHg immediately
after reamed nailing. Haas and his co-workers also
demonstrated that this was true for unreamed nailing,
however. 11 In their study, they undertook fasciotomy
whenever the intracompartmental pressure rose above
30 mmHg and as a result they had a 42% incidence of
fasciotomy. McQueen et al. have clearly shown that the
passage of any instrument down the medullary canal
of a long bone will increase intramedullary and therefore intracompartmental pressure. 12 Compartment
pressures may be high after intramedullary nailing but
they usually return to physiological levels fairly quickly
after the patient is removed from the nailing table.
McQueen and her co-workers demonstrated that
reaming and nailing were not associated with an
increased incidence of compartment syndrome. They
also dispelled the myth that surgeons should wait for
the intracompartmental pressure to settle before
undertaking intramedullary nailing of the tibia. Their
results showed no benefit from delaying surgery and
indeed delay is one of the factors that may well contribute to compartment syndrome. If a muscle compartment is shortened by the fracture ends overriding,
it is unlikely that there will be a compartment syndrome. It is the reduction of the fracture which elevates the compartment pressure and the longer the
delay the more difficult the reduction and the greater
the potential for compartment syndrome.
The other notorious cause of increased compartment pressure is fracture distraction. This concept
was well known to the fracture surgeons that perfected the techniques of cast and traction management of tibial fractures but seems to have been

Intramedullary nailing: the case for reaming

Table 1 The effects of reaming on blood flow and compartment
pressure
Reaming
1. damages the endosteal circulation, which returns in a
few weeks;
2. enhances the periosteal circulation;
3. does not cause an overall reduction in cortical blood flow;
4. causes sub-periosteal extrusion of marrow contents, which
form new bone;
5. transiently raises compartment pressures;
6. does not cause compartment syndrome.

forgotten by proponents of unreamed nailing of the

femur or tibia. An obvious consequence of attempting to hammer an 8-mm nail down an 8-mm
medullary canal is that the fracture will distract. This
tendency is often minimized by 'minimal reaming' or
by 'back-slapping' the nail, thereby leaving the proximal end of the nail in a prominent position. It is interesting to consider whether it is the actual distraction
or the associated high compartment pressure which
causes the high incidence of non-union associated
with fracture distraction. There is little doubt that
compartment syndrome is one cause of delayed
union ~3 and it is possible that raised compartment
pressure is one of the factors that causes the high rate
of non-union encountered with the use of unreamed
nails in clinical studies. The physiological effects of
reaming are summarized in Table 1.

CLINICAL STUDIES
When examining the clinical studies it is important to
separate the results of the management of closed fractures from those of severe open fractures. The effect of
the laboratory studies examining vascular changes
associated with reaming was to convince many surgeons that reaming would be particularly deleterious in
severe open fractures where the bone blood supply was
already damaged by the injury. This view seemed illogical to Court-Brown and his co-workers, as the nutrient
artery supplying the endosteal vasculature of the long
bone diaphyses was almost certainly destroyed in severe
open fractures and therefore reaming of the endosteum
could have minimal effect. They believed it likely that
the soft-tissue damage associated with severe open fractures was so great that it would dictate prognosis
regardless of the type of nail used to stabilize the fracture. They therefore undertook a prospective analysis
of closed fractures selecting only Tscherne C1 fractures,
these being the commonest closed tibial fractures presenting to orthopaedic surgeons. TM Fifty such fractures
were randomized to receive a reamed or unreamed nail
and followed for one year. There were no infections in
either group and in the reamed group there were no
non-unions or malunions and virtually no equipment
failure. However, the unreamed group showed a 20%
non-union rate and a 16% malunion rate with a 56%
incidence of screw breakage. All of the non-unions

101

united after exchange nailing using a reamed nail.

There was no difference in patient function at one year
but the 20% requirement for secondary surgery in the
unreamed group pointed to the clinical usefulness of
reaming.
Blachut et al. also undertook a prospective randomized trial comparing reamed and unreamed nailing in closed tibial fractures. 15 Unlike the series of
Court-Brown et al. they examined all closed fractures
regardless of the severity of the injury, although an
analysis of the fractures did not demonstrate significant differences between the two fracture groups.
Their results showed a statistical trend towards slower
union with unreamed nails and a statistically higher
incidence of screw breakage. It is interesting to note
that they had 3 (4.8%) compartment syndromes in the
unreamed group compared with none in the reamed
group. They noted the shorter surgical time associated
with the use of unreamed nails but concluded that the
use of reamed nails in closed tibial fractures was
preferable.
Recently, Sadowski et al. have demonstrated that
closed and grade 1 open diaphyseal fractures of the
tibia treated by unreamed nailing have a longer time
to union, a higher rate of complications and a greater
need for further surgery when compared to a similar
group of patients treated by reamed nailing. 16
Finkemeier et al. examined reamed and unreamed
nailing in both open and closed fracture, ~7In the open
group, they found no significant difference in the rates
of infection, compartment syndrome or secondary
procedures between the reamed and unreamed
groups. In the closed fracture group, reaming was
shown to have a significantly higher union rate,
although there was no difference in the rate of infection or compartment syndrome between the reamed
and unreamed groups in closed fractures. Keating et
al. also prospectively studied open tibial fractures
using reamed and unreamed nails and found that the
only statistically significant difference between the two
groups of patient was the higher rate of implant
breakage in the unreamed group. ~8 These results
appear to vindicate Court-Brown's initial view that it
would be closed fractures that would demonstrate the
advantages of reamed nailing, whereas the effects of
soft-tissue damage in severe open fractures would
obscure any positive effects from reaming.
The situation appears to be exactly the same in the
femur. The introduction of unreamed femoral nails
prompted a number of prospective clinical studies
examining the use of reaming in the femur. Four of
these were presented at the 1996 meeting of the
Orthopaedic Trauma Association t9 and each study
found that reamed nailing produced better clinical
results than unreamed nailing. Currently, the literature contains two full studies examining the use of
reaming in femoral diaphyseal fractures. Tornetta and
Tiburzi showed that reamed nailing led to faster healing of distal femoral fractures treated with statically

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locked intramedullary nails. 2 They found that the

blood loss was greater in the reamed group but this
did not translate into an increased requirement for
transfusion. They concluded that there was no advantage to unreamed femoral nailing. Giannoudis et al.
undertook a retrospective study of femoral nailing
but arrived at the same conclusions.21They noted that,
not only was the healing time after unreamed nailing
prolonged, but that there was more heterotopic bone
formation above the greater trochanter after reaming? 2 They concluded that both these observations
suggested that reaming was osteogenic.
Clinical studies clearly illustrate the value of
intramedullary reaming in the primary treatment of
closed femoral and tibial diaphyseal fractures. The
clinical usefulness of intramedullary reaming is also
demonstrated if the results of exchange nailing in the
management of aseptic tibial non-union are analysed.
This technique is widely utilized by surgeons who prefer primary unreamed nailing and consists of removal
of the intramedullary nail, reaming the medullary
canal by a further 1 mm and then inserting a larger
nail. This technique was analysed in detail by CourtBrown et al., who showed that exchange nailing promoted union in all closed fractures and in all open
fractures up to Gustilo IIIa in severity.23 While it is
accepted that the success of primary intramedullary
nailing relates to its enhancement of the periosteal circulation, the authors theorized that there were three
possible reasons for the success of secondary
exchange nailing given that reaming damages the
endosteal vasculature.
Firstly, they suggested that the increased stability
imparted by the larger intramedullary nail might stimulate union, although it was felt unlikely that this was
the case. They then theorized that the bone reaming
products might be osteogenic as suggested by Tydings
et al. 9,1and later demonstrated by Giannoudis et al. 21
They concluded that, while this might have an effect
on the fresh fracture, it was unlikely to play a role in
exchange nailing of non-unions where there was
fibrous tissue between the bone ends. Their third suggestion was that bone union was enhanced by stimulation of the periosteal circulation, as suggested earlier
by Danckwardt-Lillestrom,2 and later by Reichert et
al. 7 They postulated that this was the main reason for
the success of exchange nailing. The clinical effects of
reaming are summarized in Table 2.

REAMING AND PULMONARY

COMPLICATIONS
Kiintscher originally drew attention to the possible
embolic consequences of intramedullary reaming and
the effects that these emboli might have on the pulmonary circulation. However, it was Pape et al. 24 who
recently stimulated interest in the orthopaedic world
by undertaking a retrospective study which appeared

Table2 The effectof reamingas determinedby clinicaltrials

Reaming:
1. stimulatesfractureunionin closedfractures;
2. doesnot havethe sameeffectin severeopenfractures;
3. has an equivalenteffectin the femurand tibia;
4. promotesunionin asepticnon-unionfollowingprimary
reamedand unreamednailing.

to show that reamed nailing of fresh fractures in

patients with significant thoracic trauma was associated with a higher incidence of adult respiratory distress syndrome (ARDS). Pape and his co-workers
examined adult patients treated in the Hannover
Medical School who had femoral diaphyseal fractures
managed by reamed nailing and who did not die from
either head trauma or haemorrhagic shock. They identified four groups of patients: Group TI consisted of
patients who had significant thoracic trauma and who
had reamed femoral nailing performed within 24
hours of the injury; Group TII patients had thoracic
trauma but secondary nailing performed after 24 h;
Group NTI patients had no thoracic trauma but had
primary nailing; and the NTII group had no thoracic
trauma and secondary nailing. The incidence of
ARDS and mortality was much higher in the TI group.
This study caused considerable consternation, as
reamed intramedullary nailing had become the
method of choice for the treatment of femoral fractures and was popular for the management of tibial
fractures. Accordingly, a number of surgeons set out to
investigate the association between reaming and respiratory complications. The research followed three
main paths. Some workers examined pulmonary function in sheep and dogs while others used transoesophageal echocardiography to investigate the passage
of embolic material into the pulmonary and systemic
circulations of patients during intramedullary reaming. The third approach was to compare the physiological effects of nailing and other fixation methods in
polytraumatized patients.
Animal models have failed to show any association
between reamed nailing and significant respiratory
complications. Wolinsky et al. performed a study of
reamed femoral nailing in sheep in which an ARDSlike state had been induced using perilla ketone, a substance that increases pulmonary vascular resistance
without changing filling pressures. 25 They found that
the use of perilla ketone caused a significant pulmonary injury but that subsequent reamed
intramedullary femoral nailing caused no additional
significant effect on intrapulmonary shunts, mixed
venous oxygen saturation or dynamic compliance.
Their conclusion was that the fat embolization that
occurs during reamed intramedullary femoral nailing
in an appropriately resuscitated sheep does not have a
clinically significant effect on pulmonary function
even in the presence of severe pre-existing pulmonary
dysfunction. Duwelius et al., in a similar experiment,
showed that intramedullary nailing caused minimal

Intramedullary nailing: the case for reaming

pulmonary dysfunction and that there was no difference between reamed and unreamed nailing?6
Schemitsch et al. used a canine model and compared
the use of plates and intramedullary nails in femoral
osteotomies in dogs in which fat embolism had been
induced57 They showed no differences and concluded
that the method of fixation had little influence on the
outcome of treatment. As with all animal work, these
researchers found it difficult to reproduce the exact
clinical conditions seen in patients and their methodology can therefore be criticized. However, the uniformity of opinion is impressive.
A number of workers undertook transoesophageal
echocardiography to directly assess the amount of
embolic material produced by reaming and
intramedullary nailing. When this is combined with
assessment of the patient's respiratory and cardiac
function, it is possible to make an assessment of the
dangers of nailing. Christie and his co-workers in
Edinburgh have undertaken much of this work. 28They
have shown that 92% of patients have evidence of fat
and marrow embolization during intramedullary procedures. They classified the embolic events into three
types according to their extent: Type 1 events showed
emboli associated with clots of at least 8 cm in length;
Type 2 embolic showers showed smaller coagulative
masses while type 3 showers did not show evidence of
any coagulative events and were characterized by the
appearance of mild non-coagulative embolic showers
of fine consistency in the right atrium.
Christie did not encounter anything more than
mild type 3 embolic showers during tibial nailing. All
of the severe embolic events were associated with
femoral surgery with the most serious problems
occurring during nailing of femurs with pathological
deposits or in patients undergoing cemented hip
arthroplasty. The only fatalities occurred in patients
with pathological femoral deposits. Christie noted
that about 10% of patients who had femoral reaming
undertaken because of fracture showed moderate or
severe embolic events. However, the incidence of such
events did not appear to increase in bilateral reamed
femoral nailing or in patients with multiple injuries.
He also pointed out that about 30% of the normal
population can be shown to have a patent foramen
ovale and these patients may develop major systemic
embolic events leading to sudden death.
It is obvious that it would be virtually impossible to
carry out a prospective study investigating the role of
reaming in polytraumatized patients and some of the
most impressive data come from a retrospective study
undertaken in Switzerland by Trentz and his associates. 29 They analysed 55 patients who presented with
Injury Severity Scores (ISSs) of more than 15 who
had femoral or tibial diaphyseal fractures. In 32
patients, the fractures were nailed within four days of
injury, the remaining 23 patients being treated by primary external fixation and secondary intramedullary
nailing. The mean ISS in the group that was primarily

103

nailed was 21.8 but there was a 25% mortality and a

25% incidence of ARDS. In the group treated with
sequential external fixation and later nailing, the
mean ISS was 41.8 but there were no deaths and no
cases of ARDS. The conclusions of this study were
that primary nailing is safe if the patient's ISS is below
25 but if the ISS is greater than 40, primary external
fixation and secondary nailing should be used. This
study suggests that the degree of injury is important
in determining a patient's susceptibility to ARDS and
this conclusion is also supported by Wolinsky et al. 25
Carlson et al. also undertook a retrospective study
of patients with femoral fractures treated by reamed
intramedullary nailing. 3 They examined four groups
of patients. The first group had significant chest
injuries but no femoral or tibial fractures. The second
group consisted of patients who had chest injuries and
had a femoral fracture treated by reamed
intramedullary nailing, while the third group of
patients had chest injuries and femoral fractures
treated by a method that did not involve
intramedullary reaming. The fourth group consisted
of patients who did not have chest injuries in whom
the femoral fracture was treated by reamed nailing.
Their results showed that Groups I and II had a very
similar incidence of ARDS, pneumonia and number
of ventilator days. Group III patients had a significantly higher incidence of ARDS and number of days
on a ventilator than Groups I and II, although the
degree of chest injury was no worse. Group II patients
had significantly more ARDS and more ventilator
days than Group IV patients when the raw data were
analysed but, when the results were adjusted for the
ISS, there were no significant differences in pulmonary function. The conclusion of this study was
that reamed femoral nailing did not increase pulmonary morbidity in chest-injured patients.
Bosse et al. undertook a retrospective analysis of
multiply injured patients in two level 1 trauma centres
in the USA. 31 One centre favoured intramedullary
femoral nailing, while the other preferred femoral
plating. The patient populations were similar and the
conclusion was that the use of reamed intramedullary
nailing in multiply injured patients who had a thoracic
injury did not appear to increase the incidence of
ARDS, pulmonary embolism, multiple organ failure,
pneumonia or death.
The conclusion of these experimental studies must
be that, under most circumstances, intramedullary
femoral nailing will not cause significant respiratory
problems. However, it must be stressed that Trentz's
group 29 and Wolinsky and his co-workers 25 have both
pointed to the significance of the severity of injury.
Other researchers have strived to ensure that their
patients had equivalent ISSs but, in most studies, the
mean ISS of a patient population is only about 25 and
it may well be that reaming does become more problematic in more severely injured patients when the ISS
is above 40.

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Table 3 The effect of reaming on pulmonary complications

Reaming:
1. does not appear to cause significantpulmonary complications
in animal experiments;
2. can be shown by echocardiography to cause fat and marrow
embolization in 92% of patients;
3. of unilateral or bilateral femur does not cause significant
embolization;
4. of femur with metastatic deposits can cause fatal embolization
in 10% of patients;
5. has not been shown to have an increased morbidity in
clinical trials;
6. may be harmful in the very seriously injured patient.

A n analysis o f the data currently available does n o t

s u p p o r t the view that the endosteal damage caused by
r e a m i n g is sufficiently severe to discard the technique.
O n the contrary, it has become clear from b o t h a n i m a l
a n d clinical studies that i n t r a m e d u l l a r y r e a m i n g is
associated with stimulation of the periosteal circulation
a n d improved union. This p h e n o m e n o n has been
d e m o n s t r a t e d in closed fractures a n d it is likely to occur
in less severe open fractures as well. I n severe open fractures, any advantage from r e a m i n g is more t h a n outweighed by the considerable soft-tissue problems. There
would appear to be n o disadvantage to the use of nailing or r e a m i n g in m o s t multiply injured patients.
However, the results produced by Trentz 29 are impressive a n d it would seem unnecessarily foolhardy to use
i n t r a m e d u l l a r y techniques in patients who present with
extensive injuries associated with severe thoracic
trauma. I f the surgeon wishes to use a n i n t r a m e d u l l a r y
nail for these patients he or she should be aware of the
potential problems a n d carefully m o n i t o r the patient
peroperatively. If there is any suggestion of p u l m o n a r y
problems, i n t r a m e d u l l a r y nailing should be a b a n d o n e d
in favour of other fixation techniques. I n most surgeons' practice, this will only be necessary in a very
small n u m b e r of patients. The effects of reaming o n
p u l m o n a r y complications are s u m m a r i z e d in Table 3.
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2. Danckwardt-Lillestrom G. Reaming of the medullary cavity
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3. Klein MPM, Rahn BA, Frigg R, Kessler S, Perren SM.
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4. Schemitsch EH, Kowalski MJ, SwiontkowskiMF, Senft D.
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9. TydingsJD, Martino LJ, Kircher M, Alfred R, Lozman J. The

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13. Court-Brown CM, McQueen MM, Compartment syndrome
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study in Tscherne C1 fracture. J Bone Joint Surg 1996; 78B:
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15. Blachut Pa, O'Brien PJ, Meek RN, Broekhuyse HM.
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for the treatment of closed fractures of the tibial shaft. J Bone
Joint Surg [Am] 1997; 79A: 640-646.
16. Sadowski C, Schopfer A, Le Coultre B, Peter R. Reamed or
unreamed intramedullary for closed and open grade 1 tibial
shaft fractures. Louisnille: Orthopaedic Trauma Association,
1997.
17. Finkemeier CG, Kyle RF, Schmidt AM, Templeman DC,
Verecka TE Surgeon randomised, prospective study
comparing reamed versus unreamed intramedullary nailing
for the treatment of unstable closed and open tibial diaphyseal
fractures. Louisville:Orthopaedic Trauma Association, 1997.
18. Keating JF, O'Brien PJ, Blachut PA, Meek RN, Broekhuyse
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