The Hip: Preservation, Replacement and Revision

Intramedullary Nailing of Femoral Shaft Frx

- See: 
       - Distal Femoral Shaft Fractures 
       - Infected IM nails 
       - Open Fractures 
       - Proximal Femoral Shaft Fractures 
       - Synthes IM Femoral Nail

- Discussion: Intramedullary Nailing:
    - closed IM nailing has supplanted other forms of treatment  for femur frx;
    - it affords predictable realignment of bone, rapid regeneration of bone and union of the fracture, and early functional use of the limb;
    - union can be expected in 28-29 weeks for reamed femoral nails and about 39 weeks for unreamed nails;
    - technique considerations:
           - in the report by Ostrum RF, et al (2000), the authors prospectively compared the results of antegrade vs retrograde IM nailing;
                  - the authors noted that the two techniques were essentially equally effective in treating shaft fractures;
                  - retrograde nails had a higher incidence of symptomatic distal interlocking screws;
                  - in the antegrade group, over 25% of patients had Trendelenburg gait pattern, weakness and or pain;
           - antegrade nailing technique:
                  - positioning for femoral shaft fractures 
                  - IM nail entry point 
                  - reaming and nailing maneuver 
           - retrograde nailing technique:
           - comminuted frx: - Winquiest Classification 
                  - in the past, major limitation of all nailing systems has been poor results in comminuted midshaft fractures & in fractures at proximal & distal aspects of the shaft;
                  - axial and rotatory loads are not neutralized by most nails, and postoperative shortening & malrotation are frequent complications;
    - locked nails:
           - locking nails has no deliterious effects on healing
           - may support 3x forces in axial loading;
           - usually unnecessary to reduce comminuted fragments
           - dynamic fixation:
                  - screws in just the proximal or distal holes
                  - indicated for fractures w/ no potential instability in rotation;
           - static fixation:
                  - w/ screws in both proximal and distal hole
                  - for frx w/ both shortening and malrotation are possible;
                  - increases stiffness of the nail in torsion;
                  - stress shielding is Not clinically significant;
                  - Wiss, et al. (1986);
                         - report 98% union rate, < 1% infection 
                         - Comminuted and rotationally unstable fractures of the femur treated with an interlocking nail.

    - Complications of IM Nails: 
           - compartment syndrome of thigh
           - femoral IM nail infection 
           - avascular necrosis from IM nailing 
           - femoral non union

Reamed versus unreamed femoral nails. A randomized prospective trial. 

Prospective Comparison of Retrograde and Antegrade Femoral Intramedullary Nailing

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, August 6, 2012 1:02 pm