Intramedullary nailing

Intramedullary nailing is an internal fixation technique mainly used for the surgical management of long bone diaphyseal fractures and since more recently also in metaphyseal and periarticular fractures.

Bircher reported an intramedullary fixation with ivory pegs in 1886, HeyGroves used metallic nailing with unsatisfactory results in 1918 1.

Successful surgical management with intramedullary nailing or ‘marrow nailing’ was introduced in 1939 by Küntscher. The ‘interlocking nail’ was introduced in 1972 after its predecessor the ‘detensor nail’ in 1968 also by Küntscher, in the intention to solve problems with the treatment of comminuted fractures 1.

Indications of intramedullary nailing are the following 1,2:

  • femoral diaphyseal fractures and distal femur fractures
  • humeral shaft fractures
  • tibial shaft fractures, proximal and distal tibia fractures
  • metaphyseal fractures

Contraindications of intramedullary nailing include the following 2:

  • open epiphysis
  • small medullary canal
  • deformity e.g. prior malunion
  • grossly contaminated open or infected fractures
  • fracture in line of locking screws
  • an associated femoral neck fracture

The surgical technique encompasses several steps including the following 2,3:

  • appropriate insertion or entry point (e.g. piriformis fossa, trochanter, intercondylar notch)
  • determination of nail length and diameter
  • exact anatomic reduction and securing reduction during the following steps
  • reaming
  • nail insertion
  • interlocking

Complications of intramedullary nailing include the following 1-3:

general complications associated with surgery:

Nail position, fragment position and fracture healing can be assessed with anteroposterior and lateral views.

The radiological report should include a description of the following features:

The use of intramedullary nailing provides stability and is associated with preservation of the surrounding muscle and soft-tissues and involves only a small amount of soft-tissue dissection 1. Interlocking can provide control of length and rotation 2-4.

Advantages of intramedullary nailing include 1-4:

  • less-invasive implant insertion
  • long implants for spanning complex fractures
  • enhanced revascularization due to preserved soft-tissue sheathing
  • load sharing fixation with less requirement for additional support and earlier rehabilitation
  • lower risk for wound complications
  • can be combined with internal fixation methods as wire cerclage, buttress plates etc.

Disadvantages include technical and intraoperative complications such as reaming complications (destruction of the medullary contents, fat embolism) 1.

Article information

rID: 83015
Synonyms or Alternate Spellings:
  • Intramedullary nail fixation

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Cases and figures

  • Case 1: soft tissue irritation by the nail tip (wrist)
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