Acta Scientific Orthopaedics (ISSN: 2581-8635)

Research Article Volume 6 Issue 7

Management of third fragment in femoral shaft fractures: a personal algorithm

Salvatore Bonfiglio1*, Giancarlo Salvo3, Giuseppe Caff2, Sebiano Pitronaci4 and Alessandro Famoso1

1Department of Othopedic Surgery, Garibaldi Nesima - Catania, Italy
2Department of Orthopedic Surgery, Garibaldi Centro - Catania, Italy
3Department of Orthopedic Surgery, Trauma Center, Cannizzaro Hospital, Catania, Italy
4Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, Azienda Ospedaliero Universitaria Policlinico G Rodolico-San Marco, Catania, Italy

*Corresponding Author: Salvatore Bonfiglio, Department of Othopedic Surgery, Garibaldi Nesima - Catania, Italy.

Received: April 26, 2023; Published: June 16, 2023


Background and Aim of the Work:Third fragment is often referred as cause of non-union or delayed healing in high-energy femoral shaft fractures. The purpose of this paper is to assess how third fragment features, such as fragment size, his angulation and displacement degree or a reverse fragment, can affect fracture healing, as well as the surgical technique applied, and to develop a decisional algorithm.

Research Design and Methods: From January 2005 to December 2022, the authors report their own experience above a total of 70 femoral shaft fractures with third fragment treated with both close and open reduction approach, analysing two cases with different approach and comparing it to literature.

Results: A total of 70 patients with presence of third fragment with a mean follow-up of 16.9 months (range 6–33 months) met the inclusion criteria. Patients were divided in four group (1A, 1B, 2A, 2B) according to dimension of third fragment and displacement and surgical approach.

The best fracture healing was recorded in fractures with fragment shorter than 5 cm and displaced less than 1 cm (group 1A-1B), while the poorest one was recorded in fracture with fragment longer than 5 cm and with displacement > 2 cm and/or reverse fragment (Group 2A-2B). Among Group 2’s patients the best outcome was in patients with open reduction approach.

Conclusion: Third fragment in femoral shaft fracture is still an unsolved challenge daily facing orthopaedic surgeon. Far from settling a specific approach, literature begins to define the usefulness of the open reduction for the third fragment management. Many Authors proved that in general management of a third fragment having specific characteristics performing an open reduction would improve the outcome in terms of fracture healing with a reduced risk of consolidation defects. However, currently there are still no univocal guidelines or appropriate decision-making algorithms. For that reason, we propose a new algorithm about management of femoral shaft fractures with a third fragment based on its characteristics.

Keywords:Third Fragment; Non-Union; Femoral Shaft Fracture; New Algorithm


  1. Singer BR., et al. “Epidemiology of fractures in 15,000 adults: the influence of age and gender”. Journal of Bone and Joint Surgery Br2 (1998): 243-248.
  2. Ricci WM., et al. “Intramedullary nailing of femoral shaft fractures: current concepts”. Journal of the American Academy of Orthopaedic Surgeons5 (2009): 296-305.
  3. Nicola R. “Early Total Care versus Damage Control: Current Concepts in the Orthopedic Care of Polytrauma Patients”. ISRN Orthopaedics (2013): 329452.
  4. Metsemakers WJ., et al. “Risk factors for nonunion after intramedullary nailing of femoral shaft fractures: Remaining controversies”. Injury8 (2015): 1601-1607.
  5. Hamahashi K., et al. “Clinical outcomes of intramedullary nailing of femoral shaft fractures with third fragments: a retrospective analysis of risk factors for delayed union”. Trauma Surgery Acute Care Open1 (2019): e000203.
  6. Watanabe Y., et al. “Infra-isthmal fracture is a risk factor for nonunion after femoral nailing: a case-control study”. Journal of Orthopaedic Science1 (2013): 76-80.
  7. Salminen ST., et al. “Population based epidemiologic and morphologic study of femoral shaft fractures”. Clinical Orthopaedics and Related Research 372 (2000): 241-249.
  8. Jaarsma RL., et al. “Avoiding rotational malalignment after fractures of the femur by using the profile of the lesser trochanter: an in vitro study”. Archives of Orthopaedic and Trauma Surgery 3 (2005): 184-187.
  9. Somford MP., et al. “Operative treatment for femoral shaft nonunions, a systematic review of the literature”. Strategies in Trauma and Limb Reconstruction 8 (2013): 77–88.
  10. Vicenti G., et al. “The impact of the third fragment features on the healing of femoral shaft fractures managed with intramedullary nailing: a radiological study”. International Orthopaedics1 (2019): 193-200.
  11. An K-C., et al. “The fate of butterfly fragmentsin extremity shaft comminuted fractures treated with closed interlocking intramedullary nailing”. Journal of the Korean Fracture Society 25 (2012): 46.
  12. Lee JR., et al. “Effects of third fragment size and displacement on non-union of femoral shaft fractures after locking for intramedullary nailing”. Orthopaedics and Traumatology: Surgery and Research2 (2016): 175-81.
  13. Lin SJ., et al. “Effect of fragmentary displacement and morphology in the treatment of comminuted femoral shaft fractures with an intramedullary nail”. Injury4 (2014): 752-756.
  14. Yang S., et al. “Effect of the degree of displacement of the third fragment on healing of femoral shaft fracture treated by intramedullary nailing”. Journal of Orthopaedic Surgery and Research1 (2022): 380.
  15. Burç H., et al. “The Intramedullary Nailing of Adult Femoral Shaft Fracture by the Way of Open Reduction is a Disadvantage or Not?” Indian Journal of Surgery 77 (2015): 583-588.
  16. Fitzgerald JA and Southgate GW. “Cerclage wiring in the management of comminuted fractures of the femoral shaft”. Injury 2 (1987): 111-116.
  17. Devendra A., et al. “Vascular injuries due to cerclage passer: Relevant anatomy and note of caution”. Journal of Orthopaedic Surgery (Hong Kong)1 (2018): 2309499018762616.
  18. Pazzaglia UE., et al. “Anatomy of the intracortical canal system: scanning electron microscopy study in rabbit femur”. Clinical Orthopaedics and Related Research9 (2009): 2446-2456.
  19. Wang TH., et al. “Role of open cerclage wiring in patients with comminuted fractures of the femoral shaft treated with intramedullary nails”. Journal of Orthopaedic Surgery Research1 (2021): 480.
  20. Stübig T., et al. “Comparison of early total care (ETC) and damage control orthopedics (DCO) in the treatment of multiple traumas with femoral shaft fractures: benefit and costs”. Unfallchirurg11 (2010): 923-930.
  21. Quattrini F., et al. “Static vs dinamic short nail in pertrochanteric fractures: experience of two center in Northern Italy”. Acta BiomedS3 (2021): e2021021.


Citation: Salvatore Bonfiglio., et al. “Management of Third Fragment in Femoral Shaft Fractures: A Personal Algorithm”.Acta Scientific Orthopaedics 6.7 (2023): 23-29.


Copyright: © 2023 Salvatore Bonfiglio., et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Acceptance rate33%
Acceptance to publication20-30 days

Indexed In

News and Events

  • Certification for Review
    Acta Scientific certifies the Editors/reviewers for their review done towards the assigned articles of the respective journals.
  • Submission Timeline for Upcoming Issue
    The last date for submission of articles for regular Issues is May 30, 2024.
  • Publication Certificate
    Authors will be issued a "Publication Certificate" as a mark of appreciation for publishing their work.
  • Best Article of the Issue
    The Editors will elect one Best Article after each issue release. The authors of this article will be provided with a certificate of "Best Article of the Issue"
  • Welcoming Article Submission
    Acta Scientific delightfully welcomes active researchers for submission of articles towards the upcoming issue of respective journals.

Contact US