INTRAMEDULLARY

NAILING
DR ASHWANI PANCHAL
JSS MEDICAL COLLEGE
MYSORE

INTRAMEDULLARY NAILING
The intramedullary nail is commonly used for longbone fracture fixation and has become the
standard treatment of most long-bone diaphyseal
and selected metaphyseal fractures1
To understand the intramedullary nail, knowledge
of evolution and biomechanics are helpful 2

HISTORY
In 16 th Century In Mexico Aztec physicians have
placed wooden sticks into the medullary canals of
patients with long bone non-union.

In Mid 1800s Ivory pegs were inserted into the

medullary canal for non-union. In1917 s Hoglund of
United States reported the use of autogenous bone as
a intramedulary implant.

1930s In the United States, Rush and Rush described

the use of Steinman pins placed in the medullary
canal to treat fractures of the proximal ulna and
proximal femur.
1931 : Smith-Petersen reported the success of
stainless steel nails for the treatment of NOF #s
1940 s : The Evolution of Kntscher Nailing
Gerhard Kntscher was born in Germany in 1900

1940s:
Gerard
Kntscher
developed
V
nail,
Cloverleaf
shaped and the Y nail.
His methods were based
on two principles: stable
fixation
and
closed
nailing. .
.

Harvey C. Hansen and

Dana M. Street developed
a diamond shaped nail
which is relied on the
holding power of cancellous
bone at both ends. He
termed the word Bolt

Lottes designed three

flanged femur and tibial
nails. Both nails employed a
screw-on driver-extractor

1950s:
Stryker
designed
a
broach in a cloverleaf and
diamond shaped pattern.
It
provided
maximum
holding power to resist
torque
and
avoided
reaming the entire canal
circumference.

Schneider designed his

nail which incorporated a
double-ended stud, self
.
broaching and fluted with a
square cross section

1950s Interlocking Screws :

Modny and Bambara
introduced the transfixion
intramedullary nail in 1953
Nailing of tibia is introduced
by herzog in 1950.
Livingston bar,introduced
a short I-beam pattern
pointed nail at both
ends,which had short slots
for cross-pinning with
screws

INTRODUCTION

Today any fracture is stabilized by one of the

two systems of fracture fixation .
1. compression system
2. splinting system
Intramedullary fixation belongs to internal
splinting system.
Splintage may be defined as a
construct in which micromotion can occur
between bone & implant, providing only relative
stability without interfragmentary compression.

Depending on the anatomy the insertion can be

ante grade and retrograde.

The entry point depends on the anatomy of the

bone but is distant from the fracture site.

Intramedullary fixation techniques offer the

advantages of closed reduction and closed
fixation.

INTRAMEDULLARY DEVICES ARE

BROADLY CLASSIFIED INTO:

A.CENTROMEDULLARY- K NAIL,FIRST GENERATION

IM NAIL

B.CEPHALOMEDULLARY- GAMMA NAIL, RUSSELL

TAYLOR NAIL,UNIFLEX, PFN

C.CONDYLOCEPHALIC NAIL-ENDER NAIL,LOTTES

ETC

c o n d y l o c e p h a l i c fi x a t i o n
Also known as elastic stable intramedullary
nailing (ESIN), is a primary definitvie fracture
care (PDFC) in paediatric orthopaedic practice.
This method works by 3 point fixation or
bundle nailing.
The elasticity of the construct allows for ideal
cirumstances of micro-motion for rapid fracture
healing.

Nonreamed nails are actually not nails

but pins. Their mechanical
characteristics and use are different
from IM nails. They are of smaller
diameter and are more elastic.
Their flexibility allows insertion through
a cortical window. There are many
different types of flexible nails, the best
known are:-

Lottes nails - Tibia

Rush pins for all the long bones of the
body
Ender nails
Morote nails
Nancy nails
Prevot nails

Intramedullary nails to be
used as single without
reaming.
A. Schneider nail [ solid,
four flutedcross section
and self broaching ends.
B. Harris condylocephalic
nail [curved in two
planes, and designed for
percutaneous, retrograde
fixation of extra capsular
hip fractures.
C. Lottes tibial nail
specially curved to fit
the tibia, and has
triflanged cross section.

RUSH NAILS
SOLID,

CIRCULAR IN
CROSS SECTION,
STRAIGHT,WITH A
SHARP BEVELLED TIPS
AND A HOOK AT THE
DRIVING END.

Ender Nails, which are

solid pins with an
oblique tip and an eye in
flange at the other end,
were originally designed
for percutaneous, closed
treatment of extra
capsular hip fractures

BIOMECHANICS
Each nail is precurved to achieve 3-point fixation
where the required precurve should be approximately
3 times the diameter of a long bone at its narrowest
point.
Part of the biomechanical
stability is provided by the
intact
muscle
envelope
surrounding the long bone.
All currently available nails
have beaked or hooked
ends to allow satisfactory
sliding down on insertion
along inner surface of the
diaphysis without impacting
the opposite cortex.

Insertion points that do not

lie opposite to one another
produce
differing
internal
tension and imbalance of the
fracture stability and fixation.
The apex of the curvature
should be at the level of the
fracture site.
The nail diameter should be
40%
of
the
narrowest
medullary space diameter.
.

Two nails of the same

diameter
and
similarly
prebent to be used.

Commonest biomechanical
error is lack of internal
support.

There are two basic methods of IM pinning,

they are:
1. Three point compression.
2. Bundle nailing.

Most pins stabilize fracture by three point

compression.

These pins are C- or S Shaped, they act like a

spring.
The equilibrium between the tensioned pin and
the bone with its attached soft tissues will hold
the alignment.

The principle of bundle nailing was introduced by

Hackethal.
He inserted many pins into the bone until they
jammed within the medullary cavity to provide
compression between the nails and the bone.

Both techniques should be seen more as IM

splinting than rigid fixation.

Bending movements are neutralized, but

telescoping and rotational torsion are not
prevented with this technique

BUNDLE PINNING

Flexible nail are usually simpler to use and can be

inserted more quickly.

If infection intervenes, the complication of likely

less severe. So can be used in tibia open fracture
because of its less blood supply and its
subcutaneous location.

Because of small size of forearm bones reaming is

technically difficult, so unreamed nail have
generally been used.

INTRAMEDULLARY INTERLOCKING
NAILS:

They are usually reamed nails in

interlocking is its newer modification.

which

The classic reamed nail is the hollow, open

section nail of Kntscher.
Most other reamed nails are variations of the
Kntscher nail such as the AO nail, and the
various interlocking nails, such as the Grosse
kempf, Klemm Alta, Russell Taylor, Uniflex, AO
Universal and others.

VARIOUS GENERATIONS OF NAILS

Consecutive advancements of nails over years Can

be grouped under three generations

1 st generation:
primarily act as splints ,rotational stability is minimal ,
primarly relies on close fit
Eg K nail , V nail
2 nd generation :
Improved rotational stability due to locking screw
Eg-Russel taylor nail
3 rd generation:
Nails with various designs to fit anatomocally as
much as possible ,to aid the insertion and stability
Eg -Nails with multiple curves ,multiple fixation
systems Tibial nail with malleolar fixation

A. Kuntscher nail,
open nailing.

designed

for

B. Kuntscher nail designed for

closed nailing which has a
curved, tapered tip, and is
slotted throughout.
C.Grosse Kempf nail
D.Alta intramedullary locking nail
for the femur.
This is solid
.
section,
cannulated nail with a
hexagonal cross section with
smooth flutes to enhance
revascularization.

Russell Taylor nail:

This is a second generation
nail.
Proximal locking into the
femoral head enhances its
stability in hip fractures

Brooker Wills nail fixing a

fracture of the femur, an AP
roentgenogram. This nail has
flanges deployed through
slots in the tip of the nail for
distal stability.

LOCKING NAILS :

Except for the Brooker Wills nail with its flanges

and the expandable tip of the Seidel nail, which is
used exclusively for the humerus, all current
designs use two distal transverse cross locking
screws, as in the Alta intramedullary rod

Proximal fixation includes inclined screws as in the

Grosse Kempf nail, two transverse screws, as in
the Alta, and specialized screws though the nail
designed to secure fixation in the femoral head,
as in the Russell Taylor

Gamma

nail:

intramedullary
designed

This
device

for

intramedullary
intertrochanteric

is

proximal
fixation
and

subtrochanterc fractues.

of
some

BIOMECHANICS
When placed in a fractured
long bone, IM nails act as
internal splints with loadsharing characteristics.
Various types of load act on an
IM nail: torsion, compression,
tension and bending
Physiologic loading is a
combination of all these forces

F = Force

Bending moment = F x
D

F=
Force

IM Nail

Plate

D = distance from
force to implant.

D
The bending moment for the
plate is greater due to the
force being applied over a
larger distance.

 Nail
cross
section is round
resisting
loads
equally in all
directions.

Plate
crosssection
is
rectangular
resisting greater
loads
in
one
plane versus the
other.

BIOMECHANICS
The amount of load borne by the nail depends on the
stability of the fracture/implant construct.
This stability is determined by
1.Nail Characteristics
2.Number and orientation of locking screws
3.Distance of the locking screw from the fracture site
4.Reaming or non reaming
5.Quality of the bone
IM nails are assumed to bear most of the load
initially, then gradually transfer it to the bone as the
fracture heals.

BIOMECHANICS
Several factors contribute to the overall
biomechanical profile and resulting structural stiffness
of an IM nail.
Chief among them are
a)Material properties
b)Cross-sectional shape
c)Diameter Curves
d)Length and working length
e)Extreme ends of the nail
f) Supplementary fixation devices

Material properties

Metallurgy less important than

other parameters for stiffness
of an IM Nail.

PMMA
Bone cortex
Titanium

* 10 psi

316L Stainless steel

Cobalt
0

20 40

Most of them are fabricated

from stainless steel, with a
small number from titanium.

The material must be stiff . Titanium are 1.6 times

stiffer and elastic modulus is 50% lower than steel
nail

Titanium alloy has a modulus of elasticity closely

approximates that of cortical bone ( Modulus is
ability to resist deformation in tension

The cross-sectional shape of the nail ,Diameter

determines its bending and torsional
strengths( Resistance of a structure to torsion or
twisting force is called polar movement of inertia )
Circular nail has polar movement of inertia
proportional to its diameter, in square nail its
proportional to the edge length
Nails with Sharp corners or fluted edges has more
polar movement inertia
Cloverleaf design resist bending most effectively
.Presence of slot reduces the torsional strength . It is
more rigid when slot is placed in tensile side

CROSS SECTIONAL SHAPES

A-Schneider
B-Diamond
C-Sampson fluted
D- Kuntscher
E-Rush
F-Ender
G- Mondy
H-Halloran
I- Huckstep
J-AO/ASIF
K-Grosse Kempf
L-Russell-Taylor

Diameter :
Nail diameter affects bending rigidity of nail.
For a solid circular nail, the bending rigidity is
proportional to the third power of nail diameter
Torsional rigidity is proportional to the fourth power
of diameter .
Large diameter with same cross-section are both
stiffer and stronger than smaller ones.
Some nails are designed in a such a way that
stiffness doesnt vary with diameter.

Nail
Diamet
er (mm)

Stainles
s Steel
(X 106 )

Titaniu
m
(X 106 )

10

40.0

20.0

11

52.0

26.0

12

69.0

34.5

13

88.8

44.4

14

112.1

56.4

15

139.1

69.6

16

170.1

75.1

17

241.4

120.7

Flexural rigidity (EI) of slotted cloverleaf

IM Nails (1mm wall thickness) (Nmm2)

The diameter of a nail should

always be measured with a
circular guage.
In reamed nailing, the width of
nail is better determined by the
feel of the reamers than by
radiographic
measurements,
although the approximate size to
be used can be determined from
preoperative radiographs.

Size length
Obtain preoperative radiographs of the
fractured long bone, including the
proximal and distal joints.
If there is any question, obtain an
anteroposterior
radiograph
of
the
opposite normal limb at a tube distance
of 1meter. A nail of the appropriate size
should be taped to the side of the limb
for reference, or a radiographic ruler can
be used, alternatively a Kuntscher
measuring device the ossimeter may
be used to measure length and width.
The ossimeter has two scales, one of
which
takes
into
account
the
magnification caused by the X-ray at a 1
m tube distance.
-In most cases, a nail reaching to within
1 to 2 cm of the subchondral bone

CURVES

Longitudinal (Anterior) bow

Governs how easily a nail can be inserted as well as
bone/ nail mismatch, in turn influences the stability of
fixation of the nail in the bone.
Complete congruency minimizes normal forces and
hence little frictional component to nails fixation.
Conversely, gross mismatch increases frictional
component of fixation and inadequate fracture
reduction.
Femoral nail designs have considerably less curve,
with radius ranging from 186 to 300 cm

Herzog bend
Tibial nail also has a smooth 11
bend in the anterioposterior
direction at junction of upper
one third and lower two third .

Mismatch in the radius of

curvature between the nail
and the femur can lead to
distal anterior cortical
perforation

When inserting nail , axial force is necessary as

the nail must bend to fit the curvature of the
medularly canal .
The insertion force generates hoop stress in the
bone ( Circumferential expansion stress )

Greater the insertion force higher the hoop stress.

Larger hoop stress can split the bone

Over reaming the entry hole by

0.5-1mm ,selecting entry point
posterior to the central axis
reduce the hoop stress

Example :The ideal starting

point for insertion of an
antegrade femoral nail is in
the posterior portion of the
piriformis fossa . It reduces
the hoop stress

Length and working length

A-Total nail length- total anatomical
length
B-Working length-Length of a nail spanning the fracture
site from its distal point of fixation in
the proximal fragment to proximal
point of fixation in the distal fragment
-Length between proximal and distal
point of firm fixation to the bone
-Un supported portion of the nail
between two major fragments

Working length is affected by various factors

Type of force (Bending ,Torsion )
Type of fracture
Interlocking
Reaming

Working length:
The bending stiffness of anail is inversely
proportinal to the square of its working
Length
The torsional stiffness is inversely proportional to
its working length.
Shorter the working length stronger the fixation
Medullary reaming prepares a uniform canal and
improves nail- bone fixation
Towards the fracture,thus reducing the working
length.

INTERLOCKING
Interlocking screws are recommended for most
cases of IM nailing.
The number of interlocks used is based on fracture
location, amount of fracture comminution , and the
fit of the nail within the canal.
Placing screws in multiple planes may lead to a
reduction of minor movement
The principle of interlocking nailing is different. The
nail is locked to the bone by inserting screws through
the bone and the screw holes. The resistance to
axial and torsional forces is mainly dependent on the
screw bone interface, and the length of the bone is
maintained even if there is a bone defect.

STATIC LOCKING

when screws placed proximal and

distal to the fracture site. This
restrict translation and rotation at
the fracture site.
Indications communited ,
spiral,pathologicalfractures
Fractures with bone loss
lengthning or shortening
osteotomies , Atropic non union
It achieves BRIDGING FIXATION
through which fracture is often held
in distraction , a favourable
environment for periosteal callus
formation exists and healing rather
than nonunion is rule.

DYNAMIC LOCKING
It achieves additional rotational
control of a fragment with large
medullary canal or short epimetaphyseal fragment.
It is effective only when the
contact area between the major
fragments is atleast 50% of the
cortical circumference.
With axial loading, working
length in bending and torsion is
reduced as nail bends and abuts
against the cortex near the
fracture, improving the nail-bone
contact

DYNAMISATION:
No longer std. practice to dynamize an
interlocked nail by removing the locked
screws .
It is indicated when there is a risk of
development of nonunion or established
pseudoarthrosis.
The screws are then removed from the longer
fragments, maintaining adequate control of
shorter fragment. Premature removal may
cause shortening, instability and nonunion.

Poller screw
when
malalignment
develops
during nailinsertion,placement of
blocking
screw,
and
nail
reinsertion improves alignment.
Most reliable in proximal
distal shaft fractures of tibia.

and

A
posteriorly
placed
screw
prevents anterior angulation and
laterally placed screw prevents
valgus angulation.

Screw
strength
Characterised
by
an
outer
diameter,
root
diameter and pitch.
Shape

of the threads at
their base determines
stress concentration
(sharp v/s rounded).

Pullout strength is dependent

on the outer diameter.
The largest diameter of the
screw which can be used is
limited by the diameter of the
nail.
Increasing the diameter of the
screws reduces the cross
section of the nail at its hole
and their by predisposes to
failure.

Stability depends on the locking screw diameter for a

given nail diameter. In general, 4 to 5 mm for
humeral nails and 5 to 6 mm for tibial and femoral
nails.
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
The number of locking screws is determined based
on fracture location and stability.
In general, one proximal one distal screw is
sufficient for stable fractures.

The location of the distal locking

screws affects the biomechanics of
the fracture .
The closer the fracture to the distal
locking screws, the nail has less
.
cortical
contact , which leads to
increased stress on the locking
screws.
More distal the locking screw is from
fracture site, the fracture becomes
more rotationally stable

Oblique ( angled to nail axis, not 90) proximal

- locking screws appear to increase the stability of
proximal tibia fractures compared with transverse
( 90 to nail axis) locking screws.

However, oblique or transverse orientation of the

distal screws in distal-third tibia fractures has
minimal effect on stability

Orientation of the proximal femur locking screws has

little effect on fixation stability, with both oblique and
transverse proximal locking screws showing equal
axial load to failure.

EXTREME ENDS OF NAILS

K-nail has slot/eye in the either ends for attachment
of extraction hook .one end is tapered to facilitate
the insertion .
Present version of cannulated locking screw contains
cylinderical proximal end with internally threaded
core to allow firm attachment of driver and extracter.
Holes for interlocking screws present either ends .
Some nails have slots near the distal end for
placement of anti rotation screw

Slot
- Anterior slot - improved
flexibility
- Posterior slot - increased
bending strength
Non-slotted
increased
torsional stiffness, increased
strength in smaller sizes.
Unknown if its of any clinical
advantage.

CLOSED AND OPEN NAILING

Closed nailing :
- Fluoroscopy is used to achieve fracture reduction .
- Medullary cavity is entered through one end of the
bone antegrade .
eg-Piriformis fossa in femur .
Closed antegrade nailing is the method of choice .

Open nailing :
- Performed in lessthan ideal operation room
conditions
- Antegrade nailing is prefered .
- In retrograde method nail is inserted in to the
proximal fragment through fracture site and brought
out at one end of the bone ,after reduction nail is
driven in to the distal fragment
- Infection and non union is six and ten times greater
in open nailing

FRACTURE REDUCTION
The earlier a fracture is
nailed,
easier
is
the
reduction.
Shortly after
injury, the hydraulic effects
of edematous fluid can
cause shortening and rigidity
of the limb segment, which
may make fracture reduction
extremely difficult. If nailing
is not done before this
degree of edema, gentle
traction may be required to
regain length and alignment
gradually.

In femur, the reduction is most easily achieved by

placing the distal fragment in neutral position,
avoiding tightness of the iliotibial band, which could
otherwise result in shortening and a fixed valgus
deformity.

As the tibia is subcutaneous,

direct manipulation results in
reduction in most cases.
- In upper extremity, reduction is
achieved by a combination of
manipulation of the proximal
fragment with the nail and direct
manipulation
of
the
distal
fragment and fracture site .
- In open nailing, the key to
reduction is to angle the fracture.
- The corners of the cortices of
the
proximal
and
distal
fragments are approximated at
an acute angle, and the fracture
is
then
straightened
into
appropriate alignment.

ENTRY SITES:
With reamed rods, which are generally fairly
rigid, the entry site must be directly above the
intramedullary canal. Eccentric entry sites,
particularly in the femur and tibia, can result in
incarceration of the nail or comminution.
For nonreamed, flexible nails, an eccentric entry
site is usually used to take advantage of three
point fixation of the curved nail within the
medullary canal. Generally these nails are
inserted distally through the supracondylar
flares of the long bones

ENTRY SITES

ANTEGRADE NAILING FOR FEMUR:

The entry site for
reamed nails is in the
thin cortex at the base
of the greater
trochanter at the site of
its junction with the
superior aspect of the
femoral neck.

Most usual entry point is just lateral to the to articular surface

of the humeral head and just medial to the greater tuberosity

Tibia nailing direct route is through the patellar

tendon into the bone just proximal to the tibial
tubercle , but to avoid injury to the patellar tendon,
most surgeons now enter just medial to the patellar
tendon

RETROGRADE IM
NAILING

3 cm longitudinal
incision approximately
1 cm from the medial
border of patella,
beginning about 2 cm
proximal to distal pole
of the patella

A cortical window was made at tip of radial styloid and

MICRONAIL was inserted with help of jig.
3 distal locking screws inserted

BIOMECHANICS OF IM
REAMING
IM reaming can act to increase the contact area
between the nail and cortical bone by smoothing
internal surfaces.
When the nail is the same size as the reamer, 1 mm
of reaming can increase the contact area by 38% .
Reaming reduces the working length and increase
the stability.
More reaming allows insertion of a larger-diameter
nail, which provides more rigidity in bending and
torsion.
Biomechanically, reamed nails provide better fixation
stability than do unreamed nails

Medullary canal is more or less like an hourglass than a perfect cylinder. Reaming is an
attempt to make the canal of uniform size to
adapt the bone to the nail. The size of the canal
limits the size of the nail.

Reamers

must be sharp, and

the surgeon must consider the
relationship between the size
of the reamers and the nail.
A 12mm reamer is not
necessary equal in diameter
to a 12mm nail. Because
flexible reamers follow a
curvilinear pathway,
overreaming is usually
necessary for most nails.
Most nail require overreaming
from 0.5 to 2mm over the size
of the nail, depending on the
type of nail, the configuration
of the fracture, and the canal
of the bone.

REAMING TECHNIQUE:

Insert a ball-tipped reaming guide pin across the

fracture to the subchondral bone in the distal
fragment begin with an end cutting reamer,
generally 8.5 to 9.0 mm in diameter.

On the first pass of the reamer past the fracture

site, visualize it on the fluoroscope to ensure that
reaming is progressing appropriately.

It is safest to ream progressively in 0.5 1mm

increments.

REAMING TECHNIQUE

LOCAL CHANGES:

Both reamed and unreamed nails cause damage

to the endosteal blood supply.
Experimental data suggest that reamed nailing
deleteriously affects nutrient artery blood flow, but
cortical blood supply is significantly reduced after
reamed nailing compared with unreamed nailing.
Reaming is also associated with the potential risk
of fat necrosis
Blunt reamers and the use of reamers larger in
diameter than the medullary canal Lead to
increased temperature , therefore it suggested
that long bones with very narrow
canals
should first be reamed manually or an alternative
treatment method should be used.

LOCAL CHANGES:

Some surgeons believe that unreamed nailing is

advantageous in the treatment of Gustilo III B
open fractures, citing higher infection rates.
Clinical studies of both tibial and femoral fractures
show that reamed nailing of fractures with low
grade soft tissue injuries significantly reduces the
rates of nonunion and implant failure in
comparison with unreamed nailing. In fractures
with an intact soft tissue envelope, reaming of the
medullary cavity increases significantly the
circulation within the surrounding muscles. This
increased circulation may improve fracture
healing
Reaming does not increase the risk of
compartment syndrome.

SYSTEMIC CHANGES

Fat embolism due to IM reaming was described by

Kuntscher. Fat embolism due to passage of IM
contents into the bloodstream can occur only in
the IM pressure associated with instrumentation
exceeds the physiologic IM pressure and out
weighs the effects of the normal blood flow.

The incidence of fat embolism is more with

femoral reaming,. Reaming of the tibia does not
lead to a significant increase of IM pressure, and
intraoperative echocardiography does not show
significant fat embolism in reamed tibial fractures.

The use of a venting hole to reduce the IM

pressure increase during reaming is controversial.

Advantages
Allows insertion of larger-sized implants which helps in
weight bearing and joint function during the healing
process.
- Improves nail-bone cortical contact across the working
length of the implant and directs fracture fragments into a
more anatomical position.
- From a biologic standpoint, provides systemic factors to
promote mitosis of osteogenic stem cells and to stimulate
osteogenesis.
Disadvantages
Eccentric reaming may lead to malreduction of the
fracture.
- Destroys all medullary vessels, resulting in a initial
decrease in endosteal blood flow and in turn decreased
immune response and delay in early healing of the
involved cortices.

Side effects
- Heat: a rise in temperature upto 44.6
C had a negative effect on fracture
healing.
Cell enzymes get damaged and cannot
fullfill their function.
The threshold value of heat induced
osteonecrosis is 47C.
- Pressure: hydraulic pressure builds up
in the cavity which far exceeds that of
blood pressure and is independent of
the size of the reamer.
It acts as a piston in sleeve which is
filled with a mixture of medullary fat,
blood, blood clots and bone debris.
High intramedullary pressure forces
contents into the cortical bone and
systemic circulation.

TECHNIQUE FOR
INTERLOCKING:

A long, very sharp awl, mounted on a T handle,

must be used to pinpoint the area of penetration
of the bone to avoid exposing the surgeons hands
to the direct beam of the fluoroscope.

Bring the awl into the fluoroscope image, placing

it directly over the screw hole image. Mark the
location for the skin incisions.

Make a 1 cm longitudinal incision directly over

the screw hole. Insert the awl percutaneously to
the cortex of the bone.

Again, bring the tip of the awl into the

fluoroscopic image at an angle to the fluoroscope
beam and locate the tip of the awl directly in the
middle of the screw hole, make a hole in cortex.

Once this hole is made, insert the appropriately

sized drill point and, while maintaining alignment
with fluoroscope head, drill the hole through the
rod and medial cortex.

Verify its position on the anteroposterior view, and

then insert the appropriately sized screw.

Lateral
fluoroscopic view
of the distal
screws in Grosse
Kempf nail:
The hole, which is
to be cross
locked is in the
center of the
screen and is
perfectly
superimposed

WEIGHT BEARING AFTER IM NAILING

Segmentally comminuted diaphyseal fracture without
bony contact and nails with a 12-mm diameter and
two distal locking bolts could with stand the typical
biomechanical forces of weight bearing.
In patients who retain diaphyseal bony contact after
fracture fixation, 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 encountered by the
distal interlocking screws.
Weight bearing through a locked IM nail could be
allowed in fractures in which 50% cortical contact is
present

IM NAIL REMOVAL
It is not necessary to remove a nail in a weight
bearing limb unlike a plate.
If needed can be removed after 18 months.
Indications for removal- Patient request, pain swelling secondary to backing
out of the implant.
- Nail removal should not be undertaken lightly
,specialized extraction equipment fitting the nail
must be available.
- Full weight bearing can commence immediately
after the removal of nail

Z-effect of im nails
Z-Effect is an unfortunate by-product of most
intramedually nails that utilize two screws placed up
into the femoral neck and head. Typically, the superior
screw is of smaller diameter than the inferior and
bears a disproportionate amount of load during weight
bearing. Excessive varus forces placed on the smaller
screw at the lateral cortex cause it to toggle and either
back out or migrate through the femoral head into the
acetabulum. The larger inferior screw is neither keyed
in rotation nor locked in place, and it too will either
back out or migrate medially. The resultant Z-Effect
where the two screws move in opposite directions is
one mode of failure for the conventional two screw
reconstruction device.

IM NAIL FAILURE
With all metallic implants, there is a relative race
between bone healing and implant failure.
Occasionally, an implant will break when fracture
healing is delayed or when nonunion occurs.
IM nails usually fail in predictable patterns. Unlocked
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 commonly at the
proximal hole of the distal interlocks

a pp l icat i on s of im na il in g
Anatomic alignment, early weight bearing, early unrestricted
joint & muscle rehabilitation are of advantage to the patient.
ARDS can be prevented in multiple injuries by stabilizing and
mobilizing the patient immediately.
Floating hip, floating knee, floating elbow.
To protect the vascular repair following injuries by a fracture.
Aseptic and septic non-union.
Pathological fractures.
Malunions.
High proximal and low distal fractures of long bones
Open tibial and femoral grade I and II fractures

Technique for preparing antibiotic

impregnated nail:

40gms of bone cement is

taken and mixed with 2
to 4 gms of powder when
dough is semi solid.
It is wrapped around K
nail of size 6 to 7 mm
and rolled between two
palms.The rod is then
passed through the holes
of the nail major usually
8 to 9mm diameter to
maintain uniformity of
diameter.

REFERENCES:
1.CAMPBELL OPERATIVE ORTHOPAEDICS 11TH
EDITION
2.The science and practice of Intramedullary Nailing
Bruce D. Brown
3.ROCKWOOD AND GREENS
4.INTERLOCKING NAILING-DD.TANNA
5. The elements of fracture fixation Anand J Thakur
6.Prospective study of distal end radius fracture by an
intramedullary nailing JBJS aug3 2011

7.Textbook of orthopaedics and trauma GS

KULKARNI

THANK YOU