Intramedullary Nailing of
the Lower Extremity:
Matthew R. Bong, MD
Frederick J. Kummer, PhD
Kenneth J. Koval, MD
Kenneth A. Egol, MD
Dr. Bong is Trauma Fellow, Department
of Orthopaedic Surgery, Carolinas
Medical Center, Charlotte, NC. Dr.
Kummer is Associate Director,
Musculoskeletal Research Center,
Department of Orthopaedic Surgery,
NYU–Hospital for Joint Diseases, New
York, NY. Dr. Koval is Vice Chairman,
Department of Orthopaedic Surgery,
Dartmouth-Hitchcock Medical Center,
Lebanon, NH. Dr. Egol is Chief of
Fracture Service, Department of
Orthopaedic Surgery, NYU–Hospital for
Joint Diseases.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr. Bong, Dr. Kummer, Dr. Koval, and Dr.
Egol.
Reprint requests: Dr. Egol,
NYU–Hospital for Joint Diseases,
14th Floor, 301 East 17th Street,
New York, NY 10003.
J Am Acad Orthop Surg 2007;15:97-
106
Copyright 2007 by the American
Academy of Orthopaedic Surgeons.
Volume 15, Number 2, February 2007
Biomechanics and Biology
Abstract
The intramedullary nail or rod is commonly used for long-bone
fracture fixation and has become the standard treatment of most
long-bone diaphyseal and selected metaphyseal fractures. To best
understand use of the intramedullary nail, a general knowledge of
nail biomechanics and biology is helpful. These implants are
introduced into the bone remote to the fracture site and share
compressive, bending, and torsional loads with the surrounding
osseous structures. Intramedullary nails function as internal splints
that allow for secondary fracture healing. Like other metallic
fracture fixation implants, a nail is subject to fatigue and can
eventually break if bone healing does not occur. Intrinsic
characteristics that affect nail biomechanics include its material
properties, cross-sectional shape, anterior bow, and diameter.
Extrinsic factors, such as reaming of the medullary canal, fracture
stability (comminution), and the use and location of locking bolts
also affect fixation biomechanics. Although reaming and the
insertion of intramedullary nails can have early deleterious effects
on endosteal and cortical blood flow, canal reaming appears to have
several positive effects on the fracture site, such as increasing
extraosseous circulation, which is important for bone healing.
I ntramedullary (IM) nailing has be-
come the standard of care for the
treatment of many long-bone frac-
piriformis fossa starting points, was
used with retrograde femoral nails
as well as cephalomedullary nails
tures that require surgical stabiliza- (ie, nails with locking elements that
tion. However, this technique was traverse the femoral neck into the
initially met with a great deal of head). Expanding the canal diameter
skepticism in both Europe and with IM reamers was introduced to
North America during the first half enable placement of larger nails in
of the 1900s. closed diaphyseal long-bone frac-
During the second half of the tures. Reamed IM nailing indica-
1900s, advances in IM nailing cen- tions have been recently expanded
tered on improved designs as well as to include treatment of both open
modifications in technique, indica- fractures and very proximal and
tions, and postoperative protocol. distal metaphyseal fractures once
By the early 1990s, a trochanteric thought to be unsuitable for IM
starting point, rather than standard nails.
97
Intramedullary Nailing of the Lower Extremity: Biomechanics and Biology
Figure 1
The physiologic loading that acts on a nail involves torsion (A), compression of the
medial aspect of the nail (B), and tension on the lateral aspect of the nail (C).
Biomechanics of
Intramedullary Nails
When placed in a fractured long
bone, IM nails act as internal splints
with load-sharing characteristics.1
The amount of load borne by the
nail depends on the stability of the
fracture/implant construct. This sta-
bility is determined by several fac-
tors, including nail size, number of
locking screws or bolts, and distance
of the locking screw or bolt from the
fracture site. IM nails are assumed to
bear most of the load initially, then
gradually transfer it to the bone as
the fracture heals.
In current practice, with reaming
of the canal and the use of locking
screws, physiologic loads are trans-
98
mitted to the proximal and distal
ends of the nail through the screws.
When interlocking screws are ab-
sent, the implant acts to guide the
motion of the bone along the longi-
tudinal axis of the nail. The friction
of the nail within the medullary cav-
ity determines this resistance to mo-
tion. This friction between nail and
bone is affected by the amount of
bending of the nail (curvature), its
cross-sectional shape (particularly
the geometry of the surface of the
implant), and its diameter, as well as
the corresponding properties of the
canal (eg, size, shape, bone quality).
Fluting of the nail can increase its
torsional friction within the medul-
lary cavity. Some nails are designed
so that either a portion of or the en-
Journal of the American Academy of Orthopaedic Surgeons
Figure 2
Four-point loads (arrows) acting on a
distal interlocking screw. Under axial
load, and in the absence of cortical
contact, bending of the screw and
screw failure may occur.
tire nail is expandable under hydro-
static pressure, thereby allowing the
nail to contact the cortex and thus
increase its holding power.2
Three types of load act on an IM
nail: torsion, compression, and ten-
sion (Figure 1). Physiologic loading is
a combination of all three. Similar to
the intact femur, in which loading of
the offset femoral head causes a
bending moment in the femoral
shaft, bending of the nail under load-
ing creates compressive forces on
the concave side of the nail and ten-
sion forces on the convex side. When
cortical contact across the fracture
site is achieved postoperatively,
most of the compressive loads are
borne by the bony cortex; however,
in the absence of cortical contact,
compressive loads are transferred to
the interlocking screws, which re-
sults in four-point bending of the
screws (Figure 2).
As with all metallic implants,
there is a relative race between bone
healing and implant failure. Occa-
sionally, an implant will break when
fracture healing is delayed or when

nonunion occurs. IM nails usually
fail in predictable patterns. Un-
locked nails typically fail either at
the fracture site or through a screw
hole or slot. Locked nails fail by
screw breakage or fracturing of the
nail at locking hole sites, most com-
monly at the proximal hole of the
distal interlocks (Figure 2).3
Nail Characteristics
Several factors contribute to the
overall biomechanical profile and re-
sulting structural stiffness of an IM
nail. Chief among them are materi-
al properties, cross-sectional shape,
diameter, and degree of anterior bow
of the femoral nail.
The two most frequently used
materials in the construction of IM
nails are titanium alloy and 316L
stainless steel. Titanium alloy has a
modulus of elasticity that is about
half that of 316L stainless steel, but
it more closely approximates the
modulus of cortical bone. Modulus
is a material property. The stiffness
or rigidity of a nail depends both on
the material and its design. In bio-
mechanical testing of IM nails with
similar designs, Aitchison et al4
showed that although the stainless
steel nails had 25% more torsional
rigidity than did the titanium alloy
version, their ultimate strengths
were similar. Im and Shin5 found a
high breakage rate (8%) of titanium
locking screws in femoral shaft frac-
tures and recommended the use of
two distal screws. However, this
finding could be attributable to the
smaller diameter of the titanium
nails and higher loading of the
screws. Although there are measur-
able differences between titanium
alloy and 316L stainless steel in the
laboratory, the clinical results with
either material appear to be equiva-
lent.
The cross-sectional shape of the
nail affects its torsional rigidity and
the amount of contact within the
medullary canal. Because most nails
are similar in design, the cross-
Volume 15, Number 2, February 2007
Figure 3
Medial radiograph demonstrating that mismatch in the radius of curvature between
the nail and the femur can lead to distal anterior cortical perforation.
sectional shape has little effect on
the bending stiffness of the nail;
most nails are within 15% of each
other in this regard.6
The presence of a longitudinal slot
in the nail has a larger effect on its
torsional stability.6 The slot allows
increased radial compression of the
nail (depending on nail and cavity
size), which creates increased contact
stresses and friction between the nail
and inner cavity wall. This design
feature was of more importance be-
fore the development of interlocking
nails. Ultimately, the lowered tor-
sional stability of slotted nails led to
the abandonment of slotting.
Nail diameter affects nail bending
rigidity. For a solid circular nail, the
bending rigidity is proportional to
the nail diameter to the third power,
and the torsional rigidity is propor-
tional to the fourth power. Femoral
fractures fixed with interlocked nails
can withstand greater than four
times body weight before failure,
whereas biomechanical studies have
shown that femoral fractures fixed
with interlocked nails have 25% less
bending rigidity than do intact fe-
murs. Diameter also affects nail fit;
a well-fitting nail can help reduce
Matthew R. Bong, MD, et al
movement between the nail and
bone and maintain fracture reduc-
tion.
The anterior bow of femoral nails
affects the frictional fit within the ca-
nal of the femur and is an important
factor in nail insertion. Anthropo-
logic studies have shown that the av-
erage radius of curvature of the hu-
man femur is 120 (±36) cm.7 Current
femoral nail designs have consider-
ably less curve, with radii ranging
from 186 to 300 cm.7 Nails with a
smaller radius of curvature mis-
match are easier to insert but have
less frictional fixation. With a larger
mismatch, frictional fixation is in-
creased; however, insertion is more
difficult. Insertion of nails with a
large mismatch of curvature with the
bone can cause intraoperative femo-
ral fracture or can result in the need
to fix the fracture in an extension
malreduction. IM nails used for fem-
oral fractures proximal to the ante-
rior bow, such as basicervical or in-
tertrochanteric hip fracture, are at
higher risk for anterior cortical pen-
etration distally because of mismatch
in the radius of curvature between
the nail and the femur (Figure 3).
99
Intramedullary Nailing of the Lower Extremity: Biomechanics and Biology
Interlocking Screw/Bolt
Biomechanics
Interlocking screws or bolts are rec-
ommended for most cases of IM nail-
ing. The number of interlocks used is
based on fracture location, amount
of fracture comminution, and the fit
of the nail within the canal. Mid-
shaft transverse femoral fractures
have the greatest fixation stability
because of isthmic cortical contact.
Oblique and comminuted fractures
rely on interlocking screws for stabil-
ity, as do very proximal and very dis-
tal metaphyseal fractures, where the
medullary canal widens and is filled
with weaker cancellous bone.
Interlocking screws placed proxi-
mal and distal to the fracture site re-
strict translation and rotation at the
fracture site; however, minor move-
ments occur between the nail and
screws, allowing toggling of the
bone. Placing screws in multiple
planes may lead to a reduction of
this fragment toggle; however, this is
not always possible in certain loca-
tions because of the proximity of
neurovascular structures. At times,
the dynamization slots in the nail
are used to allow fracture compres-
sion while limiting rotation.
In a joint biomechanical and clin-
ical study of immediate weight bear-
ing after IM nailing of femoral frac-
tures, Brumback et al8 indicated that
stability depends on the locking
screw or bolt diameter for a given
nail diameter. Of course, there is a
limit to screw size in that too large a
hole in the nail will reduce its
strength. In general, this limit is 4 to
5 mm for humeral nails and 5 to 6
mm for tibial and femoral nails. As a
rule, however, nail hole size should
not exceed 50% of the nail diameter.
Interlocking screws undergo four-
point bending loads, with higher
screw stresses seen at the most
distal locking sites. Thus, screws
should be chosen with the largest
root diameter possible; this has led
to the use of partially threaded
screws, which have a solid body
100
with threads only on the end.
The number of locking screws is
determined based on fracture loca-
tion and stability. In general, one dis-
tal screw is sufficient for stable frac-
tures. The closer the fracture is to
the distal locking screws, the less
cortical contact the nail has, which
leads to increased stress on the lock-
ing screws.9 Additionally, the farther
the distal locking screw is from the
fracture site, the more rotationally
stable the fracture becomes because
of friction of the nail within the
medullary cavity.10
The location of the distal locking
screws affects the biomechanics of
the fracture, but the effect of the ori-
entation of the locking screws is less
clear. Oblique (ie, angled to nail axis,
not 90°) proximal locking screws ap-
pear to increase the stability of prox-
imal tibia fractures compared with
transverse (ie, 90° to nail axis) lock-
ing screws.11,12 However, oblique or
transverse orientation of the distal
screws in distal-third tibia fractures
has minimal effect on stability.13 Ori-
entation of the proximal femur lock-
ing screws has little effect on fixation
stability, with both oblique and
transverse proximal locking screws
showing equal axial load to failure.14
Two screws can be inserted at angles
to the cross-section of the nail to de-
crease motion between the screws
and the nail, but anatomic structures
must be taken into consideration
when performing this technique.
Biomechanics of
Intramedullary Reaming
IM reaming can act to increase the
contact area between the nail and cor-
tical bone by smoothing internal as-
perities. When the nail is the same
size as the reamer, 1 mm of reaming
can increase the contact area by
38%.15 Increased reaming allows in-
sertion of a larger-diameter nail,
which provides more rigidity in bend-
ing and torsion. Biomechanically,
reamed nails provide better fixation
stability than do unreamed nails.16
Journal of the American Academy of Orthopaedic Surgeons
Despite these advantages to
reaming, the process has some bio-
mechanically deleterious effects on
the bone itself. Depending on the
outer diameter of the bone and the
amount of bone removed, reaming of
the canal diminishes the cortical
wall thickness and can weaken the
bone. The effect of inner cortical
thinning can be mitigated with nail
insertion because the nail will carry
part of the load.
Other Factors Affecting
Nail Biomechanics
The starting point for insertion of
femoral nails can have significant
consequences on the ease of nail in-
sertion as well as the strength of the
resulting fixation. When the femoral
head is compressively loaded in ca-
daveric femurs, the load to failure is
affected more by nail starting point
malposition than by increased nail
size.17 Placing the starting point too
anterior from the piriformis fossa (≥6
mm) creates a major risk of proximal
femoral bursting with nail insertion
because of increased hoop stresses18
(Figure 4). The risk is lower for me-
dial and lateral malpositioning.
To maintain optimal alignment
in nondiaphyseal fractures, care
should be taken to direct the nail
into the center position of both frag-
ments. In addition, multiple locking
screws should be used in the meta-
physeal fragment. The placement of
blocking screws can aid in aligning
nondiaphyseal fractures of the femur
and tibia. Blocking screws also can
improve the primary stability of the
fixed fracture.19
Current nail designs are quite
similar across manufacturers; the
biggest differences are in the instru-
mentation and locking options.
Femoral nails can have standard
transverse locking screws (diaphy-
seal fractures) and angled locking
screws (subtrochanteric and inter-
trochanteric fractures); some nail
systems include both options. Tibi-
al nail designs can have very distal
 Matthew R. Bong, MD, et al

Figure 4 Figure 5

The ideal starting point for insertion of an antegrade femoral Cross-sectional view of a long bone. Fascial attachments are
nail is in the posterior portion of the piriformis fossa. Anterior the entry points of periosteal arterioles. These periosteal
placement of the starting hole places the proximal femur at arterioles provide the blood supply to the outer third of the
increased risk of intraoperative fracture. cortex and anastamose with medullary arterioles.

and proximal locking sites as well as
multiplanar locking options for the
fixation of proximal and distal meta-
physeal fractures. In addition, there
is variation in the proximal tibial
nail bend. Although the location of
the bend has little significance in the
treatment of diaphyseal and distal
metaphyseal fractures, its location
may affect the reduction of proximal
metaphyseal fractures. When the
nail bend is seated in the distal frag-
ment, it can lead to anterior dis-
placement of the proximal frag-
ment.11 This translation usually can
be remedied with modified nailing
techniques and the use of blocking
screws.
Weight Bearing After
Reamed Intramedullary
Nailing
Current recommendations regarding
weight bearing after IM nailing of di-
aphyseal femoral fractures are based
on the work of Brumback et al.8
These authors created a model of a
segmentally comminuted diaphy-
seal femoral fracture without bony
contact and found that nails with a
12-mm diameter and two distal
locking bolts could withstand the
typical biomechanical forces of
weight bearing. Their clinical results
supported this biomechanical find-
ing. In patients who retain diaphy-
seal bony contact after fracture fixa-
tion, nails with a diameter <12 mm
or nails with a single distal interlock
may provide adequate stability for
weight bearing because the bony
contact reduces the load encoun-
tered by the distal interlocking
screws.
There is less clinical evidence to
support immediate weight bearing
in patients with a tibial or meta-
physeal femoral fracture treated
with an IM nail. However, in our
opinion, weight bearing through a
locked IM nail could be allowed in
fractures in which 50% cortical con-
tact is present.
Biology of
Intramedullary Nails
Knowledge of the vascular anatomy
of long bones and the nature of the
vascular response to fracture are im-
portant in understanding the biolog-
ic response to IM nailing. The vascu-
lar supply to bone is comprised of
medullary arteries that supply the
inner two thirds of the cortex and of
periosteal arterioles that penetrate
the cortex at fascial attachments and
supply the outer one third (Figure 5).
The haversian system acts as a con-
duit between the endosteal and peri-
osteal circulation; normally, the
flow is centrifugal. In both the femur
and humerus, there can be numer-
ous diaphyseal nutrient arteries and
abundant periosteal arterioles. In

Volume 15, Number 2, February 2007 101

Intramedullary Nailing of the Lower Extremity: Biomechanics and Biology
>90% of patients, only a single prox-
imal diaphyseal nutrient artery is
seen in the tibia.20 Compared with
the metaphyseal regions, the tibial
diaphysis has relatively few ex-
traosseous vessels and a hypovascu-
lar posterior surface.21
There is a predictable local vascu-
lar response to fracture, composed of
five separate phases.22-24 In the first
phase, blood flow is temporarily in-
terrupted, usually as a result of di-
rect vessel injury. The second phase
is marked by vasoconstriction. In a
study of canine midshaft tibia os-
teotomies with radioisotope blood
flow analysis, a 50% reduction in
blood flow was seen at 10 minutes,
with only 29% of normal flow seen
4 hours later.22 The third phase is
marked by vascular recruitment;
this leads to an increase in local vas-
cular flow. This phase is initiated in
the first 1 to 3 days after injury and
can last for a total of 5 to 14 days.23
The fourth phase, neovasculariza-
tion, is modulated by local growth
factors. The fifth phase consists of
remodeling of the newly regenerated
vascular system.
Revascularization of the bone can
occur through four modes: en-
dosteal, periosteal, intracortical, and
extraosseous. Animal studies have
confirmed that the principle sources
of increased blood flow in healing di-
aphyseal fractures are the periosteal
and extraosseous tissues.24 However,
placement of an unreamed IM nail is
only destructive to the endosteal
blood supply in the diaphysis. Hupel
et al25 showed in a canine model that
the tighter the nail is only in the ca-
nal, the bigger the decrease in corti-
cal blood flow in a segmental frac-
ture stripped of soft tissue. Current
nail designs often contain grooves to
provide a path for endosteal recircu-
lation.
Local Biology of
Reaming
By definition, reaming of the canal
destroys the medullary contents and
102
the endosteal blood supply and has a
negative effect on cortical blood
flow. In a canine study, Hupel et al26
showed an 83% reduction in cortical
blood flow after IM nailing with pri-
or reaming of tibial fractures. Flow
returned to normal by 12 weeks.
Schemitsch et al27 also noted this
restoration of normal flow in a sheep
model. Although this effect may
seem to be counterproductive to
fracture healing, reaming provides
some biologic advantages. Multiple
animal studies have shown that, de-
spite its negative effect on the
endosteal circulation, reaming sig-
nificantly increases the vascular per-
fusion of surrounding muscles and
deep soft tissues.28,29 This effect can
last up to 12 weeks after reaming.
Reaming appears to have no delete-
rious effect on the vascularity of the
fracture callous compared with frac-
tures fixed with nails placed without
prior reaming.30
One local effect of reaming is the
deposition of autologous medullary
contents and osteoinductive factors
at the fracture site. In a study of
sheep femurs, Frolke et al31 showed
that 24% of reaming debris is depos-
ited at the fracture site, while 76% is
lost through the proximal starting
hole. Reaming also seems to affect
local bone quality. Although greater
bone porosity is seen with reaming,
reaming has no effect on the volume
of new bone formation or on the
mineral apposition rate.32
There has been concern about the
potential of reaming to increase in-
tracompartmental pressures. Com-
pared with nailing without prior ca-
nal reaming, reaming before nail
placement seems to have little effect
on local compartment pressures. In-
traoperatively placed compartment
pressure monitors showed no differ-
ence in peak compartment pressures
during insertion of IM nails with and
without prior reaming.33 Factors as-
sociated with elevated intracompart-
mental pressures during nailing are
related to fracture reduction itself
(ie, use of continuous skeletal trac-
Journal of the American Academy of Orthopaedic Surgeons
tion or manipulative fracture reduc-
tion) rather than to IM nail insertion
itself.33,34
Another proposed concern of IM
reaming is local infection, specifical-
ly in the setting of an open fracture.
It has been postulated that in the set-
ting of a fracture where local soft tis-
sues are traumatized and the ex-
traosseous blood supply has been
diminished, reaming would elimi-
nate the remaining blood supply,
thus predisposing the fracture to in-
fection. An increased infection rate
has been observed in a rabbit open
tibial fracture model, but recent hu-
man clinical studies have shown no
difference in the infection rate be-
tween nails placed with and without
prior reaming in open fractures.35
Systemic Effects of
Reaming
Most of the systemic effects that
have been attributed to medullary
reaming are thought to be caused by
the embolization of marrow con-
tents. These marrow contents can be
visualized intraoperatively by echo-
cardiography.36 In a sheep model,
Wozasek et al36 showed that both the
peak IM pressures and peak embo-
lization seen on echocardiography
occurred during nail insertion rather
than during the reaming process.
Reaming does not seem to alter the
peak IM pressure.37
Because of the concern for embo-
lization of marrow contents, most
early research into the systemic ef-
fects of IM nailing and reaming was
focused on the pulmonary effects.
Pape et al38 conducted a nonrandom-
ized study of 31 multiply injured pa-
tients undergoing nail placement ei-
ther with or without prior reaming for
femoral shaft fractures. Patients un-
dergoing reaming experienced ele-
vated pulmonary artery pressures and
decreased Pao2. One patient in the
reamed group developed adult respi-
ratory distress syndrome (ARDS).
Based on the results, the authors
stated that patients sustaining mul-

tiple trauma are at risk for ARDS and
should undergo nailing of femoral
shaft fractures without IM reaming.
However, subsequent animal and
clinical studies have not supported
this recommendation.
Heim et al39 found no difference
in pulmonary function in rabbits
that underwent femoral nailing with
and without prior canal reaming. In
a healthy sheep model, Wolinsky et
al40 observed embolization of mar-
row contents by echocardiography
during reaming; pulmonary function
was no different than in controls.
Similar results were noted in a
healthy pig model when reamed and
unreamed nailing groups were com-
pared with controls.41 Neudeck et
al42 compared reamed and unreamed
IM nailing with plating of femoral
fractures in sheep with blunt thorac-
ic trauma. Although increased IM
pressures and embolization were
seen in the two nail groups, no dif-
ference in pulmonary response was
seen compared with plating.
In a two-institution retrospective
study, Bosse et al43 studied patients
with femoral shaft fracture and tho-
racic injury who underwent reamed
IM nailing at one institution versus
open plating at the second institu-
tion. In patients without comorbid
disease, there was no difference in
the rate of ARDS, pulmonary embo-
lism, multiple organ failure, pneu-
monia, and death.43
Multiple studies have shown that
canal reaming leads to the release of
both proinflammatory mediators
(eg, interleukin-6) and suppressive
cytokines (eg, interleukin-10 [IL-
10]).44,45 IL-10 has been implicated in
the suppression of other cytokines in
the inflammatory cascade. Reaming
also seems to depress monocyte hu-
man leukocyte antigen–DR (HLA-
DR) expression.45 HLA-DR expres-
sion on monocytes is an important
component of antigen processing.
Reduction in this expression has
been shown to correlate well with
the development of sepsis in trauma
patients. It has been postulated that
Volume 15, Number 2, February 2007
Figure 6
This reamer design minimizes increases in intramedullary pressure. Note the narrow
reamer shaft, sharp cutting flutes, deep flutes, and conical shape.
IL-10 release may be involved in the
suppression of HLA-DR expression,
but a clear link has yet to be estab-
lished. It is possible that canal ream-
ing and nailing of fractures acutely
may lead to a so-called second hit
and a heightened systemic inflam-
matory response, while simulta-
neously leading to the release of
IL-10 and suppression of HLA-DR
expression. Although it is clear that
early stabilization of femoral frac-
tures in trauma patients leads to im-
proved morbidity and mortality, fur-
ther study is warranted of the
immune response generated through
reaming and nailing. Additional
study also is needed regarding the
role of damage control in patients
with an already heightened system-
ic inflammatory response.
Reamer Design
The design of the IM reamer can
markedly alter peak IM pressures
during reaming. In an attempt to
minimize peak pressures and subse-
quent embolization of marrow con-
tents, various reamer modifications
have been made. Reamer character-
istics that can lower peak IM pres-
sures include a narrow reamer shaft,
sharp cutting flutes, deep flutes, and
a conical shape46 (Figure 6). A single-
pass rinsing-suction reamer has been
developed that results in significant-
ly lower peak IM pressures (P < 0.05)
and marrow embolization (P < 0.05)
Matthew R. Bong, MD, et al
compared with a standard reamer in
a sheep model.47 Clinical applica-
tions of this new technology are cur-
rently being vetted.
Clinical Results of
Intramedullary Nailing
With and Without Prior
Reaming
In both closed and open femoral frac-
tures, there appear to be definite
clinical advantages to reamed IM
nailing. The Canadian Orthopaedic
Trauma Society conducted a mul-
ticenter randomized prospective
study comparing reamed and un-
reamed femoral nailing of both open
and closed femoral shaft fractures.48
They found a 4.5 times greater rela-
tive risk for the development of non-
union with unreamed nails. In a
meta-analysis of randomized and
pseudorandomized studies compar-
ing reamed and unreamed nailing of
femoral shaft fractures, Forster et
al49 found a significantly longer time
to union (P = 0.00001), higher non-
union rate (P = 0.002), higher delayed
union rate (P = 0.005), and higher re-
vision rate (P = 0.001) in the un-
reamed group.
Although multiple studies have
shown that reaming of closed tibial
shaft fractures can reduce both the
nonunion rate and time to healing,
the results in open fractures are less
clear.50 A recent study showed no dif-
103
Intramedullary Nailing of the Lower Extremity: Biomechanics and Biology
ference in clinical results for open
tibial fractures treated with nails re-
gardless of prior reaming.51 In current
practice, most IM nails are placed af-
ter canal reaming even in the pres-
ence of significant soft-tissue injury.
Future Directions
In addition to fine-tuning commer-
cially available implants and instru-
mentation, significant future ad-
vancements of IM implants likely
will involve three areas. Nails con-
structed of biodegradable polymers
will provide temporary stabilization
of fractures without the potential
long-term effects of a retained foreign
implant.52 Nickel-titanium shape-
memory alloys may enable the devel-
opment of implants that can change
shape as they warm to patient body
temperature. These implants can im-
prove stability as they change shape
or are bent to ease insertion and re-
cover curvature as they warm.53 Fi-
nally, so-called smart implants have
the potential to limit common post-
operative fracture complications. IM
nails coated with biologically active
agents, such as bone morphogenetic
proteins, could help diminish non-
union rates, while nails coated with
antibiotics could potentially limit
postoperative infection.54
Summary
Reamed IM nailing has become the
gold standard for the treatment of di-
aphyseal femoral fractures and is the
treatment of choice for tibia shaft
fractures requiring surgical stabiliza-
tion. The load-sharing nature of IM
nails allows for earlier mobilization
and weight bearing of the trauma pa-
tient. Factors affecting the biome-
chanical characteristics of the nail
include its material properties, di-
ameter, cross-sectional shape, ante-
rior bow, and the presence of locking
screws.
Although IM reaming has a nega-
tive effect on endosteal blood supply,
it allows for insertion of a larger,
104
stiffer nail with increased cortical
contact. In addition, reaming stimu-
lates local extraosseous and peri-
osteal blood flow, which is the most
important source of nutrient flow
during fracture healing. Although it
is clear that reaming causes embo-
lization of marrow contents and al-
ters levels of immune mediators, it
has not been shown in either animal
models or clinical human studies to
increase mortality or alter pulmo-
nary function.
Additional Resources
Instructional Course Lecture:
“Intramedullary Nailing of the
Femur,” by Robert J. Brumback,
MD, Clifford B. Jones, MD, Rob-
ert F. Ostrum, MD, David C.
Templeman, MD, and Robert A.
Winquist, MD. Scheduled for the
AAOS Annual Meeting in San
Diego, Thursday, February 15,
2007: http://www3.aaos.org/ed
ucation/anmeet/anmt2007/icl/
icl.cfm?Pevent=224
Related clinical topics articles
available on Orthopaedic Knowl-
edge Online: “Femoral Shaft
Fractures,” by Thomas A. De-
Coster, MD: http://www5.aaos.
org/oko/trauma/femoral_shaft_
fracture/pathophysiology/patho
physiology.cfm
“Intramedullary and Extramedul-
lary Splints: Relative Stability”
(slide lecture format), by Daniel S.
Horwitz, MD: http://www5.aaos
.org/OKO/partners/ota/fracturec
ourse/OTA002.cfm
References
Evidence-based Medicine: Level I/II
prospective randomized studies are
noted in references 33, 48, 50, and
51. The remaining references are
case-control series, case studies, sin-
gle and multiple comparison biome-
chanical and animal studies (level
IV) or expert opinion (level V).
Journal of the American Academy of Orthopaedic Surgeons
Citation numbers printed in bold
type indicate references published
within the past 5 years.
1. Cheung G, Zalzal P, Bhandari M,
Spelt JK, Papini M: Finite element
analysis of a femoral retrograde in-
tramedullary nail subject to gait load-
ing. Med Eng Phys 2004;26:93-108.
2. Steinberg EL, Blumberg N, Dekel S:
The fixion proximal femur nailing sys-
tem: Biomechanical properties of the
nail and a cadaveric study. J Biomech
2005;38:63-68.
3. Bucholz RW, Ross SE, Lawrence KL:
Fatigue fracture of the interlocking
nail in the treatment of fractures of
the distal part of the femoral shaft.
J Bone Joint Surg Am 1987;69:1391-
1399.
4. Aitchison GA, Johnstone AJ, Shep-
herd DE, Watson MA: A comparison
of the torsional performance of stain-
less steel and titanium alloy tibial in-
tramedullary nails: A clinically rele-
vant approach. Biomed Mater Eng
2004;14:235-240.
5. Im GI, Shin SR: Treatment of femoral
shaft fractures with a titanium in-
tramedullary nail. Clin Orthop Relat
Res 2002;401:223-229.
6. Russell TA, Taylor JC, LaVelle DG,
Beals NB, Brumfield DL, Durham AG:
Mechanical characterization of femo-
ral interlocking intramedullary nail-
ing systems. J Orthop Trauma 1991;
5:332-340.
7. Egol KA, Chang EY, Cvitkovic J,
Kummer FJ, Koval KJ: Mismatch of
current intramedullary nails with the
anterior bow of the femur. J Orthop
Trauma 2004;18:410-415.
8. Brumback RJ, Toal TR Jr, Murphy-Zane
MS, Novak VP, Belkoff SM: Immedi-
ate weight-bearing after treatment of a
comminuted fracture of the femoral
shaft with a statically locked intramed-
ullary nail. J Bone Joint Surg Am
1999;81:1538-1544.
9. Lin J, Lin SJ, Chen PQ, Yang SH: Stress
analysis of the distal locking screws
for femoral interlocking nailing.
J Orthop Res 2001;19:57-63.
10. George CJ, Lindsey RW, Noble PC, Al-
exander JW, Kamaric E: Optimal loca-
tion of a single distal interlocking
screw in intramedullary nailing of dis-
tal third femoral shaft fractures.
J Orthop Trauma 1998;12:267-272.
11. Henley MB, Meier M, Tencer AF: In-
fluences of some design parameters
on the biomechanics of the unreamed
tibial intramedullary nail. J Orthop
Trauma 1993;7:311-319.
12. Laflamme GY, Heimlich D, Stephen

D, Kreder HJ, Whyne CM: Proximal
tibial fracture stability with in-
tramedullary nail fixation using ob-
lique interlocking screws. J Orthop
Trauma 2003;17:496-502.
13. Chen AL, Tejwani NC, Joseph TN,
Kummer FJ, Koval KJ: The effect of
distal screw orientation on the intrin-
sic stability of a tibial intramedullary
nail. Bull Hosp Jt Dis 2001;60:80-83.
14. Aboulafia AJ, Price MM, Kennon RE,
Hutton WC: A comparison of me-
chanical strength of the femoral neck
following locked intramedullary nail-
ing using oblique versus transverse
proximal screws. J Orthop Trauma
1999;13:160-163.
15. Bechtold JE, Kyle RF, Perren SM: Bio-
mechanics of intramedullary nailing,
in Browner B, Edwards C (eds): The
Science and Practice of Intramedul-
lary Nailing. Philadelphia, PA: Lip-
pincott Williams and Wilkins, 1987,
pp 89-101.
16. Fairbank AC, Thomas D, Cunning-
ham B, Curtis M, Jinnah RH: Stability
of reamed and unreamed intramedul-
lary tibial nails: A biomechanical
study. Injury 1995;26:483-485.
17. Miller SD, Burkart B, Damson E,
Shrive N, Bray RC: The effect of the
entry hole for an intramedullary nail
on the strength of the proximal femur.
J Bone Joint Surg Br 1993;75:202-206.
18. Johnson KD, Tencer AF, Sherman
MC: Biomechanical factors affecting
fracture stability and femoral bursting
in closed intramedullary nailing of
femoral shaft fractures, with illustra-
tive case presentations. J Orthop
Trauma 1987;1:1-11.
19. Krettek C, Miclau T, Schandelmaier
P, Stephan C, Mohlmann U, Tscherne
H: The mechanical effect of blocking
screws (“Poller screws”) in stabilizing
tibia fractures with short proximal or
distal fragments after insertion of
small-diameter intramedullary nails.
J Orthop Trauma 1999;13:550-553.
20. Kirschner MH, Menck J, Henner-
bichler A, Gaber O, Hofmann GO: Im-
portance of arterial blood supply to
the femur and tibia for transplanta-
tion of vascularized femoral diaphy-
ses and knee joints. World J Surg
1998;22:845-852.
21. Borrelli J Jr, Prickett W, Song E, Becker
D, Ricci W: Extraosseous blood sup-
ply of the tibia and the effects of differ-
ent plating techniques: A human ca-
daveric study. J Orthop Trauma
2002;16:691-695.
22. Smith SR, Bronk JT, Kelly PJ: Effect of
fracture fixation on cortical bone
Volume 15, Number 2, February 2007
blood flow. J Orthop Res 1990;8:471-
478.
23. Hughes S, Khan R, Davies R, Lavender
P: The uptake by the canine tibia of
the bone-scanning agent 99mTc-MDP
before and after an osteotomy. J Bone
Joint Surg Br 1978;60:579-582.
24. Triffitt PD, Cieslak CA, Gregg PJ: A
quantitative study of the routes of
blood flow to the tibial diaphysis after
an osteotomy. J Orthop Res 1993;11:
49-57.
25. Hupel TM, Aksenov SA, Schemitsch
EH: Cortical bone blood flow in loose
and tight fitting locked unreamed in-
tramedullary nailing: A canine seg-
mental tibia fracture model. J Orthop
Trauma 1998;12:127-135.
26. Hupel TM, Aksenov SA, Schemitsch
EH: Effect of limited and standard
reaming on cortical bone blood flow
and early strength of union following
segmental fracture. J Orthop Trauma
1998;12:400-406.
27. Schemitsch EH, Kowalski MJ,
Swiontkowski MF, Senft D: Cortical
bone blood flow in reamed and un-
reamed locked intramedullary nail-
ing: A fractured tibia model in sheep.
J Orthop Trauma 1994;8:373-382.
28. Hupel TM, Aksenov SA, Schemitsch
EH: Muscle perfusion after intramed-
ullary nailing of the canine tibia.
J Trauma 1998;45:256-262.
29. Schemitsch EH, Kowalski MJ,
Swiontkowski MF: Soft-tissue blood
flow following reamed versus un-
reamed locked intramedullary nail-
ing: A fractured sheep tibia model.
Ann Plast Surg 1996;36:70-75.
30. Schemitsch EH, Kowalski MJ,
Swiontkowski MF, Harrington RM:
Comparison of the effect of reamed
and unreamed locked intramedullary
nailing on blood flow in the callus and
strength of union following fracture of
the sheep tibia. J Orthop Res 1995;
13:382-389.
31. Frolke JP, Van de Krol H, Bakker FC,
Patka P, Haarman HJ: Destination of
debris during intramedullary ream-
ing: An experimental study on sheep
femurs. Acta Orthop Belg 2000;66:
337-340.
32. Hupel TM, Weinberg JA, Aksenov SA,
Schemitsch EH: Effect of unreamed,
limited reamed, and standard reamed
intramedullary nailing on cortical
bone porosity and new bone forma-
tion. J Orthop Trauma 2001;15:18-
27.
33. Nassif JM, Gorczyca JT, Cole JK, Pugh
KJ, Pienkowski D: Effect of acute
reamed versus unreamed intramedul-
lary nailing on compartment pressure
Matthew R. Bong, MD, et al
when treating closed tibial shaft frac-
tures: A randomized prospective study.
J Orthop Trauma 2000;14:554-558.
34. Tornetta P III, French BG: Compart-
ment pressures during nonreamed tib-
ial nailing without traction. J Orthop
Trauma 1997;11:24-27.
35. Melcher GA, Metzdorf A, Schlegel U,
Ziegler WJ, Perren SM, Printzen G: In-
fluence of reaming versus nonream-
ing in intramedullary nailing on local
infection rate: Experimental investi-
gation in rabbits. J Trauma 1995;39:
1123-1128.
36. Wozasek GE, Simon P, Redl H, Schlag
G: Intramedullary pressure changes
and fat intravasation during in-
tramedullary nailing: An experimen-
tal study in sheep. J Trauma 1994;36:
202-207.
37. Heim D, Schlegel U, Perren SM: In-
tramedullary pressure in reamed and
unreamed nailing of the femur and
tibia: An in vitro study in intact, hu-
man bones. Injury 1993;24(suppl 3):
S56-S63.
38. Pape HC, Regel G, Dwenger A, et al:
Influences of different methods of in-
tramedullary femoral nailing on lung
function in patients with multiple
trauma. J Trauma 1993;35:709-716.
39. Heim D, Regazzoni P, Tsakiris DA, et
al: Intramedullary nailing and pulmo-
nary embolism: Does unreamed nail-
ing prevent embolization? An in vivo
study in rabbits. J Trauma 1995;38:
899-906.
40. Wolinsky PR, Sciadini MF, Parker RE,
et al: Effects on pulmonary physiology
of reamed femoral intramedullary
nailing in an open-chest sheep model.
J Orthop Trauma 1996;10:75-80.
41. Buttaro M, Mocetti E, Alfie V, Paniego
G, Pineiro L: Fat embolism and relat-
ed effects during reamed and un-
reamed intramedullary nailing in a
pig model. J Orthop Trauma 2002;16:
239-244.
42. Neudeck F, Wozasek GE, Obertacke U,
Thurnher M, Schlag G: Nailing versus
plating in thoracic trauma: An exper-
imental study in sheep. J Trauma
1996;40:980-984.
43. Bosse MJ, MacKenzie EJ, Riemer BL,
et al: Adult respiratory distress syn-
drome, pneumonia, and mortality fol-
lowing thoracic injury and a femoral
fracture treated either with intramed-
ullary nailing with reaming or with a
plate: A comparative study. J Bone
Joint Surg Am 1997;79:799-809.
44. Giannoudis PV, Smith RM, Bellamy
MC, Morrison JF, Dickson RA, Guil-
lou PJ: Stimulation of the inflamma-
tory system by reamed and unreamed
105
Intramedullary Nailing of the Lower Extremity: Biomechanics and Biology
nailing of femoral fractures: An anal-
ysis of the second hit. J Bone Joint
Surg Br 1999;81:356-361.
45. Smith RM, Giannoudis PV, Bellamy
MC, Perry SL, Dickson RA, Guillou
PJ: Interleukin-10 release and mono-
cyte human leukocyte antigen-DR ex-
pression during femoral nailing. Clin
Orthop Relat Res 2000;373:233-240.
46. Muller C, McIff T, Rahn BA, Pfister U,
Weller S: Intramedullary pressure,
strain on the diaphysis and increase in
cortical temperature when reaming
the femoral medullary cavity: A com-
parison of blunt and sharp reamers.
Injury 1993;24(suppl 3):S22-S30.
47. Joist A, Schult M, Ortmann C, et al:
Rinsing-suction reamer attenuates in-
tramedullary pressure increase and fat
intravasation in a sheep model.
J Trauma 2004;57:146-151.
48. Canadian Orthopaedic Trauma Soci-
ety: Nonunion following intramedul-
106
lary nailing of the femur with and
without reaming: Results of a multi-
center randomized clinical trial.
J Bone Joint Surg Am 2003;85:2093-
2096.
49. Forster MC, Aster AS, Ahmed S:
Reaming during anterograde femoral
nailing: Is it worth it? Injury 2005;
36:445-449.
50. Blachut PA, O’Brien PJ, Meek RN,
Broekhuyse HM: Interlocking in-
tramedullary nailing with and with-
out reaming for the treatment of
closed fractures of the tibial shaft: A
prospective, randomized study.
J Bone Joint Surg Am 1997;79:640-
646.
51. Keating JF, O’Brien PJ, Blachut PA,
Meek RN, Broekhuyse HM: Locking
intramedullary nailing with and with-
out reaming for open fractures of the
tibial shaft: A prospective, random-
ized study. J Bone Joint Surg Am
Journal of the American Academy of Orthopaedic Surgeons
1997;79:334-341.
52. van der Elst M, Bramer JA, Klein CP,
de Lange ES, Patka P, Haarman HJ:
Biodegradable interlocking nails for
fracture fixation. Clin Orthop Relat
Res 1998;357:192-204.
53. Kujala S, Tuukkanen J, Jamsa T, Da-
nilov A, Pramila A, Ryhanen J: Com-
parison of the bone modeling effects
caused by curved and straight
nickel-titanium intramedullary nails.
J Mater Sci Mater Med 2002;13:1157-
1161.
54. Schmidmaier G, Wildemann B,
Cromme F, Kandziora F, Haas NP,
Raschke M: Bone morphogenetic
protein-2 coating of titanium implants
increases biomechanical strength and
accelerates bone remodeling in frac-
ture treatment: A biomechanical and
histological study in rats. Bone 2002;
30:816-822.