- Discussion:
    - see: Winquist Classification
    - sign of high energy trauma: more blood loss, systemic complications, and fat embolism syndrome;
    - all cortical contact is lost;
    - simple cloverleaf nails are contraindicated w/ type III and IV comminuted frxs because of risk of shortening of frx about nail;
    - small diameter nails fail to fill the canal, allowing even type I and type II comminuted frx to telescope about the nail;
    - even with IM nailing, there will be no cortical contact between the proximal and distal fragments;
    - static locking of the major fracture fragments prevents postoperative shortening and malrotation of the fracture;

- Reaming Considerations:
    - if there is a segmental bone loss or comminution in shaft, reamers should be pushed, not powered, across the defect
               to avoid damage to the soft tissues of the thigh;

- Leg Length Considerations::
    - clinical measurement of contralateral femur from tip of greater trochanter to the lateral aspect of the knee joint provides
              useful landsmarks for the correct leg length;
    - special varient of comminuted fractures, the segmental fracture, involves a double level fracture of the shaft;
    - preoperative measurements of femoral length and nail length are needed

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Secondary Union of a Critical Segmental Femoral Defect. A Case Report

Technical Problems Caused by Comminuted Cortical Free Fragments During Intramedullary Rodding: Case Reports.

Closed Interlocked Nailing in Comminuted and Segmental Femoral Shaft Fractures.

Global reconstruction of type IIIA open comminuted femoral shaft fracture with segmental bone loss in an 11-year-old girl.

Spontaneous healing of large femoral cortical bone defects: does genetic predisposition play a role?

Successful reimplantation of a large segment of femoral shaft in a type IIIA open femur fracture: a case report.

Grading system for gunshot injuries to the femoral diaphysis in civilians.

Double level fractures of the femur treated with closed intramedullary nailing.

Healing of 56 segmental femoral shaft fractures after locked nailing. Poor results of dynamization.

Closed locked intramedullary nailing. Its application to comminuted fractures of the femur. 

Comminuted and rotationally unstable fractures of the femur treated with an interlocking nail. 

Interlocked nailing for treatment of segmental fractures of the femur. 

Biomechanical characteristics of interlocking femoral nails in the treatment of complex femoral fractures.

Comminuted femoral-shaft fractures: treatment by roller traction, cerclage wires and an intramedullary nail, or an interlocking intramedullary nail. 

Comminuted femoral shaft fractures. 

Comminuted femoral shaft fractures treated by closed intramedullary nailing and functional cast bracing.

Femoral torsion after interlocked nailing of unstable femoral fractures. 

Assessing Leg Length After Fixation of Comminuted Femur Fractures