- 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.