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Intramedullary Femoral Nailing

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Intramedullary Femoral Nailing

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Intramedullary Femoral Nailing is now the gold standard option for treatment of femoral shaft fractures.

An intramedullary nail is a metal rod that is inserted into the medullary cavity of a bone and across the fracture in order to provide a solid support for the fractured bone.

Advantages of intramedullary femoral nailing include:

  1. Short hospital‐stay,
  2. Rapid union of the fracture
  3. Early functional use of the limb.

Intramedullary Femoral Nailing Procedure

Positioning and Preparation

  • Based on preoperative templating and surgical plan, decide on a radiolucent flat-topped or fracture table and patient position. We prefer the use of a fracture table.
  • We have used the lateral and supine positions extensively, and each has its relative indications. The supine position is more universal. It provides easier access for the anesthesiologist, especially in severely injured patients. The circulating and scrub nurses and the radiographic technicians also are more comfortable with the patient in this position. It is most useful for bilateral femoral fractures, fractures of the distal third of the femur, and femoral fractures with contralateral acetabular fractures.
  • If the patient is supine, adduct the trunk and affected extremity. Flex the affected hip 15 to 30 degrees.
  • Apply traction through a skeletal pin or to the foot with a well-padded traction boot. A well-padded perineal post is positioned, and the uninjured extremity is placed in a well-padded traction boot. The legs are positioned in a scissor configuration.
  • Estimate correct rotational alignment with respect to the normal anteversion of the hip as determined with the image intensifier.
  • Rotate the foot and distal fragment of the femur to match the proximal fragment by observing the image C-arm.
  • If the patient is in the lateral decubitus position with the perineal post, ensure that most of the trunk weight is on the trochanteric rest of the unaffected hip.
  • Place the fractured side in 15 to 30 degrees of hip flexion. The normal side is in neutral to slight hip extension.
  • Prepare the patient in the standard manner. Drape the buttocks and lateral thigh to the popliteal crease. Cover the image intensifier arm with a sterile isolation drape.

Preparation of Femur:

  • Make a short oblique skin incision starting 2 to 3 cm from the proximal tip of the greater trochanter, and continue it proximally and medially.
  • Incise the fascia of the gluteus maximus in line with its fibers.
  • Identify the subfascial plane of the gluteus maximus, and palpate the piriformis fossa or trochanteric portal.
  • Advance the threaded tip guidewire to the approximate level of the piriformis fossa.
  • Image the trochanteric region to adjust the position of the guidewire.
  • Check the pin position with anteroposterior and lateral imaging.
  • Rotate the foot and distal fragment of the femur to match the proximal fragment by observing the image C-arm.

Proximal Entry Portal Preparation:

  • Remove the honeycomb insert, leaving the guidewire and the entry portal tool in the wound.
  • Place the entry reamer assembly into the entry portal tool and over the guidewire.
  • Ream the assembly into the femur until it bottoms out on the entry portal tool.
  • Check the position of the reamer during the insertion with anteroposterior and lateral imaging.
  • Remove the entry reamer and guidewire, leaving the entry portal tube and the channel reamer in place.
See Also: Subtrochanteric Femur Fractures Deformity
Intramedullary Femoral Nailing entry point 2
Intramedullary Femoral Nailing entry point

Reduction and Guidewire Insertion:

  • Place the reduction tool consisting of the reducer and a T-handle into the channel reamer and connector in the femur.
  • Advance the reduction tool to the fracture site and use the tool to manipulate the proximal fragment and engage the distal fragment with the tool’s tip.
  • When the distal fragment is reached and engaged, advance the 3.0-mm ball-tipped guidewire across the fracture.
  • Confirm the reduction and position of the guidewire with anteroposterior and lateral images at multiple levels.

Canal Preparation:

  • Remove the reducer and ream the canal sequentially at 0.5-mm intervals until there is moderate “chatter” or until the reaming exceeds the selected nail diameter by 1.0 to 1.5 mm.
  • Confirm the proper nail length by positioning the guidewire at the point of desired distal position.
  • Insert the ruler over the guidewire, and place it at the level of the femoral insertion.
  • Check this with the anteroposterior image. Read the measurement off the measurement device.
Intramedullary Femoral Nailing procedure

Nail Insertion:

  • Attach the drill guide assembly to the selected nail.
  • Remove the entry portal tube and channel reamer, leaving the guidewire in place.
  • Place the nail into the femur and advance it manually.
  • If there is significant resistance, remove the nail and ream the canal 0.5 mm larger.
  • Seat the nail completely as confirmed on multiplanar image intensification.

Interlocking of Nail:

  • For proximal and distal interlocking, use the 5-mm locking screws.
  • Place the gold drill sleeve into the proximal guide and dimple the skin.
  • Make a stab wound at that point and spread the tissue to the bone.
  • Insert the gold drill sleeve with the silver inner liner and use the long pilot drill to go to the inner cortex but not through it.
  • Measure the length on the calibrated drill bit at the silver guide top. Then penetrate the far cortex. Remove the drill and silver sleeve.
  • Insert the screw of the proper length and advance it manually until seated.
  • Check the position with an anteroposterior image.

Freehand Technique for Distal Targeting:

  • Place the image intensifier in the lateral position and scan the distal femoral metaphysis.
  • When the holes are completely circular, make a longitudinal stab incision through the skin, subcutaneous tissue, and iliotibial band centered over the interlocking hole in the nail.
  • Place a trocar-tip drill bit over the screw hole and make appropriate adjustments until the tip is centered over the desired hole.
  • Penetrate the lateral cortex. Remove the drill bit from the driver and confirm on the lateral image the drill bit placed within the interlocking hole.
  • Insert the screw of the proper length by hand, confirming satisfactory purchase.
  • Repeat if additional distal interlocking screws are desired.

Final Evaluation:

  • Before leaving the operative suite, evaluate femoral neck and confirm length and rotational reductions.
  • Evaluate the thigh compartments and examine the ligaments of the ipsilateral knee.
  • Obtain a postoperative anteroposterior pelvis radiograph with both hips internally rotated to check for occult femoral neck fractures.
See Also: Patellar Fractures | Broken Kneecap
Intramedullary Femoral Nailing antegrade
Intramedullary Femoral Nailing


Weight bearing depends on the stability of the fracture fixation. Weight bearing to tolerance is allowed immediately regardless of the nail size if satisfactory cortical contact is achieved.  In the rare circumstance that an adolescent nail is used in an adult, protected weight bearing should be initiated until early radiographic healing is noted.  Touch-down or partial weight bearing is allowed in comminuted injuries. Hip and knee range of motion are encouraged. 

Quadriceps setting and straight-leg raising exercises are begun before hospital discharge. Hip abduction exercises are begun after wound healing. Weight bearing is progressed as callus formation occurs. 

Ambulatory aids such as crutches or a walker are used for the first 6 weeks. Hip and knee range of motion and strengthening exercises are recommended during this time. 

Unassisted ambulation is permitted as strength recovery and radiographic healing progress.

References & More

  1. Rudloff MI, Smith WR. Intramedullary nailing of the femur: current concepts concerning reaming. Journal of Orthopaedic Trauma 2009;23(5 Suppl):S12‐7. [PUBMED: 19390369] [PubMed]
  2. Winquist RA, Hansen ST Jr, Clawson DK. Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases. Journal of Bone & Joint Surgery ‐ American Volume 1984;66(4):529‐39. [PUBMED: 6707031] [PubMed]
  3. Xiong R, Mai QG, Yang CL, Ye SX, Zhang X, Fan SC. Intramedullary nailing for femoral shaft fractures in adults. Cochrane Database Syst Rev. 2018 Feb 2;2018(2):CD010524. doi: 10.1002/14651858.CD010524.pub2. PMCID: PMC6491114. [PubMed]
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