Plating of femoral shaft fractures: open reduction and internal fixation versus submuscular fixation.

Background: The standard treatment for femoral shaft fractures is intramedullary nailing. However, there are indications for which plating can be performed either openly or in a submuscular manner.

Methods: Between June 1996 and May 2002, two fellowship-trained orthopedic trauma surgeons treated 40 acute diaphyseal femoral fractures in 37 patients with use of plating techniques. Traditional open plating with emphasis on preservation of soft tissue integrity was performed exclusively before February 1999 (n = 19). After that time point, in all but one case (n = 21) submuscular plating techniques were used. No bone grafting was used for either group. A comparison of reduction quality, union rates, secondary interventions, and infection rates between traditional open reduction and internal fixation and submuscular fixation was performed (retrospective cohort study/evidence-based medicine (EBM)-level III).

Results: In assessing reduction quality, there were no malreductions in the traditional plating group and six in the submuscular plating group. There was one infection and one nonunion in the open reduction or internal fixation group. One infection was noted in the submuscular group.

Conclusions: A 2.5% incidence of nonunion and a 5% incidence of infection (2 of 40; both in type III open fractures) were seen in this series of 40 femoral shaft fractures treated with plate application. Although the theoretical advantages of submuscular plating are well established, its utilization in the femoral shaft did not have a clear clinical advantage. In addition, its use appears to be more technically challenging, and is associated with a high rate of suboptimal reductions.