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Retrograde Nailing of Femoral Shaft Fracture

- Discussion:
- may be indicated for:
- combined fractures of the femoral neck and shaft and for distal femoral fractures;
- multi-trauma patient (procedure can be performed in supine position on regular flouro table);
- obese patients (starting hole is not a problem);
- advantages:
- avoids damage to the blood supply to the femoral head (ie avoids AVN);
- disadvantages:
- in case of open fractures, retrograde nailing thru the knee may provdie a conduit for infection to reach the knee joint;
- possible articular damage and injury to the PCL insertion;
- nail must be seated deeply below the level of the articular cartilage inorder to prevent impingement on patella during flexion;
- ref: Retrograde reamed femoral nailing.

- Intra-articular Nail Insertion:
- indicated for extra-articular supracondylar fractures, distal femur frxs, obese patients, or patients who have
sustained multi-trauma;

- Extra-articular Nail Insertion: (from Sanders, et al (1993))
- most indicated for femoral frx at the isthmus;
- inserts nail thru the extra-articular portion of the medial femoral condyle;
- best performed w/ Synthes Tibial IM Nail (11-13 mm diameter);
- contra-indicated w/ supracondylar frx (insertion of tibial nail may result in procurvatum deformity);
- absence of tibial bow may tend to straighten out the femur;
Retrograde reamed femoral nailing.
- entry site:
- a point 2 cm medial to the junction of the distal femoral articular cartilage and medial metaphyseal flare;
- obviously, the entry position needs to be made in line with the shaft of the femur on the lateral view;
- reduction:
- consider use of the universal femoral distractor;
- bicortical pin is placed proximally and distally a pin is inserted just proximal to the articular surface;
- reaming:
- over reaming by 0.5 to 1.0 cm is usually required;
- nail passage:
- initially keep the angled portion of the nail pointed upwards until the nail passes isthmus, at which time the angled portion is
rotated 45 deg posteriorly;

- Complications of IM Nails:
- compartment syndrome of thigh
- infected IM nails
- fat embolism syndrome
- Mortality after reamed intramedullary nailing of bilateral femur fractures.
- avascular necrosis from IM nailing:
- non union: (see general discussion of non union)
- in the report by Weresh MJ, et al, the authors noted that a significant number of patients undergoing reamed exchange nailing
of femoral shaft non unions required additional procedures to achieve fracture healing;
- they noted that exchange nailing by itself may not be sufficient for fracture healing;
- in the report by Bellabarba C, et al, the authors report on a consectutive series of 23 femoral non unions of femoral shaft
fractures treated by previous IM nailing;
- surgical treatment consisted of indirect fracture reduction techniques using 95 deg condylar blade plate;
- 21 of 23 non unions healed without further intervention (two other fractures had hardware failure);
- references
- Distal femoral nonunion treated with interlocking nailing.
- Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures.
- Results of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing.

Retrograde nailing of femoral shaft fractures.

Retrograde intramedullary nailing, without reaming, of fractures of the femoral shaft in multiply injured patients.

Retrograde Reamed Femoral Nailing.