Intramedullary Nailing of Femoral Shaft Fractures

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SAMPLE EXCERPT
- Full procedure text, video and illustrations available with the full product
PRE-PROCEDURE
INDICATIONS
  • Femoral shaft fractures
  • Associated vascular injury
  • Associated tibial shaft fractures
  • Multiple trauma fractures
CONTRAINDICATIONS
  • Very proximal or distal femoral shaft fracture
  • Severely comminuted fracture
  • Hypovolemia
  • Hypothermia
  • Uncorrected coagulopathy
  • Preexisting deformity
  • Previously inserted fixation devices
EQUIPMENT
  • Fracture table
  • Traction unit or foot holder
  • Fluoroscopy unit
  • Perineal post
  • 3.2-mm tip threaded guide pin
  • Drill
  • Cannulated reamers, intramedullary and trochanteric
  • Curved awl
  • Guide rods and holders
  • Internal fracture alignment device
  • Intramedullary nail
  • Nail drivers and retractors
  • Interlocking screws
  • 4.8-mm twist drill
  • Red, blue, and green drill sleeves
  • 3/16-inch femoral hex driver
  • Ring forceps
  • Awl
  • Depth gauge
  • Radiolucent drill
  • Honeycomb insert
ANATOMY
  • The femur: largest bone, long tubular shaft
  • Femoral shaft: curved with convexity anterior, flares posteriorly at the linea aspera
  • Proximal femur: flares at subtrochanteric region, greater and lesser trochanters, femoral shaft, and head
  • Distal femur: flares to form medial and lateral condyles at the knee

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
TECHNIQUES
  • Post-Procedure: Interlocking Intramedullary (Russell-Taylor) Nailing
  • Post-Procedure: Antegrade Femoral Nailing (TriGen Nail)

Post-Procedure: Interlocking Intramedullary (Russell-Taylor) Nailing

POST-PROCEDURE CARE
  • Allow touch-down weight bearing on the first postoperative day using ambulatory aids such as crutches or a walker.
  • Encourage early hip and knee range of motion.
  • Begin quadriceps setting and straight leg raise exercises before discharge from the hospital.
  • Begin hip abduction exercises after wound healing.
  • Progress weight bearing as callus formation occurs.
  • Dynamization may be necessary later if union has not occurred by 6 months.
  • Nail removal should not be done before 12 months.
COMPLICATIONS
  • Infection
  • Delayed union or nonunion
  • Painful hardware
  • Heterotopic ossification
ANALYSIS OF RESULTS

Intramedullary nailing is the treatment of choice for most femoral shaft fractures and carries a low rate of nonunion and rotational malunion. Infection rates are low, with infection being most common in type IIIB open fractures.

OUTCOMES AND EVIDENCE
  • Kropfl et al: no nonunions, infections, or failures with unreamed statically locked AM nails (Ace Medical); 3 varus or valgus nonunions
  • Krettek et al: 0% nonunion, 3.5% screw failure, 1.7% nail failure, 1.7% loss of reduction, and 1.7% infection with unreamed AO nailing
  • Tornetta and Tiburzi: no differences in operative time, transfusion requirements, or pulmonary complication between reamed and unreamed nails; the unreamed group had two delayed unions and one broken interlocking screw; the reamed group had one angular malunion.
  • Winquist: 2.3% incidence of infection in type I and type II open femoral fractures treated with delayed nailing
  • Brumback et al: 0% infection in types I, II, or IIIA open fractures, but 11% infection in type IIIB open fractures
  • Hansen: 5% incidence of infection in types I, II, and III open femoral fractures treated with immediate reamed nailing
  • Moed and Watson: no cases of infection or hardware failure in unreamed retrograde nailing; 13.6% nonunion and 4.5% rotational malunion; knee motion was full in all patients.
  • Ricci et al: similar healing rates in retrograde and antegrade femoral nailing; 9% in antegrade group had hip pain and 36% in retrograde group had knee pain.
  • Ostrum et al: faster healing with antegrade nailing and more frequent need for dynamization of retrograde nailing; knee pain equal between groups, but more thigh pain in antegrade nailing
Procedure: Interlocking Intramedullary (Russell-Taylor) Nailing

Post-Procedure: Antegrade Femoral Nailing (TriGen Nail)

POST-PROCEDURE CARE
  • Allow touch-down weight bearing on the first postoperative day using ambulatory aids such as crutches or a walker.
  • Encourage early hip and knee range of motion.
  • Begin quadriceps setting and straight leg raise exercises before discharge from the hospital.
  • Begin hip abduction exercises after wound healing.
  • Progress weight bearing as callus formation occurs.
  • Dynamization may be necessary later if union has not occurred by 6 months.
  • Nail removal should not be done before 12 months.
COMPLICATIONS
  • Infection
  • Delayed union or nonunion
  • Painful hardware
  • Heterotopic ossification
ANALYSIS OF RESULTS

Intramedullary nailing is the treatment of choice for most femoral shaft fractures and carries a low rate of nonunion and rotational malunion. Infection rates are low, with infection being most common in type IIIB open fractures.

OUTCOMES AND EVIDENCE
  • Kropfl et al: no nonunions, infections, or failures with unreamed statically locked AM nails (Ace Medical); 3 varus or valgus nonunions
  • Krettek et al: 0% nonunion, 3.5% screw failure, 1.7% nail failure, 1.7% loss of reduction, and 1.7% infection with unreamed AO nailing
  • Tornetta and Tiburzi: no differences in operative time, transfusion requirements, or pulmonary complication between reamed and unreamed nails; the unreamed group had two delayed unions and one broken interlocking screw; the reamed group had one angular malunion.
  • Winquist: 2.3% incidence of infection in type I and type II open femoral fractures treated with delayed nailing
  • Brumback et al: 0% infection in types I, II, or IIIA open fractures, but 11% infection in type IIIB open fractures
  • Hansen: 5% incidence of infection in types I, II, and III open femoral fractures treated with immediate reamed nailing
  • Moed and Watson: no cases of infection or hardware failure in unreamed retrograde nailing; 13.6% nonunion and 4.5% rotational malunion; knee motion was full in all patients.
  • Ricci et al: similar healing rates in retrograde and antegrade femoral nailing; 9% in antegrade group had hip pain and 36% in retrograde group had knee pain.
  • Ostrum et al: faster healing with antegrade nailing and more frequent need for dynamization of retrograde nailing; knee pain equal between groups, but more thigh pain in antegrade nailing
Procedure: Antegrade Femoral Nailing (TriGen Nail)
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