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.

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

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

• metaphyseal fractures

Contraindications

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

Procedure

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

Complications of intramedullary nailing include the following ^1-3:

• hematoma formation

• implant displacement

• infection

• fracture malunion

• fracture non-union

• periprosthetic fracture

• iatrogenic comminution

• implant malposition

• hardware failure

• length discrepancy

• heterotopic ossification

• soft tissue irritation at the entry point

general complications associated with surgery:

• cardiovascular complications

• pneumonia

• pulmonary edema

• pulmonary embolism/fat embolism

Radiographic features

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

Radiological report

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

• implant malposition

• fragment displacement

• malalignment/angulation

• implant loosening

• signs of fracture healing

• hardware failure

Outcomes

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

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

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

See also

• gamma nail

• proximal femoral nail

• titanium elastic nail system