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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.
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History and etymology
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, to solve problems with the treatment of comminuted fractures 1.
Indications of intramedullary nailing are the following 1,2:
extra-capsular proximal femur fractures, femoral diaphyseal fractures and distal femur fractures
humeral shaft fractures
tibial shaft fractures, proximal and distal tibia fractures
Contraindications of intramedullary nailing include the following 2:
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
Complications of intramedullary nailing include the following 1-3:
soft tissue irritation at the entry point
general complications associated with surgery:
Nail position, fragment position, and fracture healing can be assessed with anteroposterior and lateral radiographs.
The radiological report should include a description of the following features:
signs of fracture healing
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.
- 1. Vécsei V, Hajdu S, Negrin L. Intramedullary Nailing in Fracture Treatment: History, Science and Küntscher's Revolutionary Influence in Vienna, Austria. Injury. 2011;42:S1-5. doi:10.1016/s0020-1383(11)00419-0
- 2. Virkus W, Kempton L, Sorkin A, Gaski G. Intramedullary Nailing of Periarticular Fractures. J Am Acad Orthop Surg. 2018;26(18):629-39. doi:10.5435/jaaos-d-16-00849 - Pubmed
- 3. Ricci W, Gallagher B, Haidukewych G. Intramedullary Nailing of Femoral Shaft Fractures: Current Concepts. J Am Acad Orthop Surg. 2009;17(5):296-305. doi:10.5435/00124635-200905000-00004 - Pubmed
- 4. Rommens P, Küchle R, Hofmann A, Hessmann M. Intramedullary Nailing of Metaphyseal Fractures of the Lower Extremity. Acta Chir Orthop Traumatol Cech. 2017;84(5):330-40. - Pubmed