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Review Article

Intramedullary Nailing of Femoral Shaft Fractures: Current Concepts

Ricci, William M. MD; Gallagher, Bethany MD; Haidukewych, George J. MD

Author Information
Journal of the American Academy of Orthopaedic Surgeons: May 2009 - Volume 17 - Issue 5 - p 296-305
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Abstract

Intramedullary (IM) nailing is an effective method of treating femoral shaft fracture and has become one of the preferred procedures in orthopaedics. In general, IM nailing is associated with high union rates and low complication rates. However, it is not necessarily a straightforward procedure. Multiple choices must be made, including the use of antegrade versus retrograde nailing, antegrade nailing through a piriformis fossa versus a trochanteric starting porthole, whether to position the patient supine or lateral with or without traction, and whether to use reaming. In determining the optimal combination of options, several factors must be taken into account, including the particular fracture characteristics, associated musculoskeletal and/or visceral injuries, patient body habitus, associated local soft-tissue injury, and the technical familiarity of the surgeon with each nailing method.

Insertion Portal

Antegrade Nailing

Piriformis Starting Point

Antegrade IM nailing through the piriformis fossa is associated with healing rates as high as 99% and with low complication rates.1 The piriformis fossa starting point has as its main advantage a colinear trajectory with the long axis of the femoral shaft (Figure 1). This reduces the risk of iatrogenic fracture comminution and varus malalignment compared with “offaxis” starting points, such as the trochanteric entry portal. Disadvantages of the piriformis starting point include the relative technical difficulty in obtaining such a starting point compared with retrograde and trochanteric portals, especially in obese patients.2 The piriformis starting point is also sensitive to anteroposterior translation, with anterior positioning being associated with extreme hoop stresses and increased risk of iatrogenic bursting of the proximal segment.3 The trochanteric portal, given its more cancellous nature, is more forgiving with regard to generation of hoop stress,3 such that a relatively anterior starting point in the trochanteric region is acceptable.

Figure 1
Figure 1:
Anteroposterior radiograph of the proximal femur in a patient treated for femoral shaft fracture with femoral nailing begun at the piriformis fossa. The insertion site is colinear with the long axis of the femur.

Trochanteric Starting Point

The tip of the greater trochanter was the original portal for nail insertion introduced by Küntscher.4 With the patient positioned supine, the subcutaneous location of the greater trochanter may provide a technically easier starting point for IM nailing than the piriformis fossa, especially in obese patients.2 However, the risk of varus malalignment and iatrogenic fracture comminution have limited the use of this starting point to nails designed for piriformis insertion (ie, without trochanteric proximal bend).1 Implants specifically designed for trochanteric insertion, with a proximal lateral bend, combined with modified insertion technique, have been shown to essentially eliminate varus malalignment and iatrogenic comminution.5,6 The lateral proximal bend of trochanteric nails reduces the risk of varus malalignment. However, it is critical that the starting point not be too lateral. In fact, the tip of the greater trochanter is not necessarily the proper landmark for the starting point. The alignment of the tip of the trochanter, relative to the long axis of the femoral shaft, varies significantly.7 Thus, the proper starting point for a trochanteric nail is just lateral to the long axis of the femur. Depending on the patient's anatomy, this can vary between just medial (Figure 2) and just lateral (Figure 3) to the tip of the greater trochanter. On the lateral view, the starting point is colinear with the long axis of the femur (Figures 2, C and 3, C).

Figure 2 A,
Figure 2 A,:
Anteroposterior view of the proximal femur in a patient with a trochanter tip that is lateral to the long axis of the femur. In such cases, the proper trochanteric starting point is just medial to the tip of the trochanter (B) and, on the lateral view, colinear with the long axis (C).
Figure 3 A,
Figure 3 A,:
Anteroposterior view of the proximal femur in a patient with a trochanter tip that is central to the long axis of the femur. In such cases, the proper trochanteric starting point is just lateral to the tip of the trochanter (B) and, on the lateral view, colinear with the long axis (C).

Iatrogenic comminution associated with trochanteric nailing is related to the medially directed insertion angle. The trochanteric bend does not help in avoiding this complication because the proximal portion of the nail has not yet engaged bone when the distal tip has come into contact with the medial femoral cortex. A starting point that is not too lateral is crucial to avoiding such iatrogenic comminution. A subtle, but important, modification of standard nailing technique can also help avoid iatrogenic comminution. This modification leverages the anterior bow of the nail. Rotation of the nail 90° upon insertion, such that the anterior bow is apex medial, directs the tip of the nail centrally. After the nail crosses the fracture, it is derotated gradually with successive mallet blows (Figure 4). Recent reports of trochanteric femoral nailing with modern implants and techniques have shown reduced complication rates5 and results similar to those seen with piriformis nailing.6

Figure 4 A,
Figure 4 A,:
Iatrogenic comminution can occur when intramedullary nails are inserted through a trochanteric starting point. B, Rotation of the nail 90°, such that the apex of the anterior bow is medial, points the tip of the nail centrally and helps to avoid iatrogenic comminution.

Retrograde Nailing

Retrograde nailing is an alternative to antegrade nailing. Proper technique includes an insertion site in the intracondylar notch at the apex of the Blumensaat line, which is approximately 1 cm anterior to the posterior cruciate ligament origin. With this as the starting point, the trajectory for nail insertion should be colinear with the long axis of the femur in both the anteroposterior and lateral planes (Figure 5, A and B). The distal end of the nail must be buried beneath the subchondral bone (Figure 5, C) to avoid injury to the patella with the knee in flexion.8 At least two distal interlocks should be used to minimize the risk of secondary telescoping of the nail into the knee joint. This complication can occur after fracture of the distal interlocking screws associated with comminuted, axially unstable fracture patterns.9

Figure 5
Figure 5:
Anteroposterior (A) and lateral (B) views of the distal femur depicting the proper starting point and trajectory for retrograde nailing. C, Lateral radiograph demonstrating a nail that is properly countersunk.

A superficial analysis of union rates of antegrade nailing compared with retrograde nailing shows contradictory results. Early studies of retrograde nailing revealed nonunion rates greater than those typically reported in published series of antegrade nailing.10-12 The relatively low union rates seen in early series of retrograde nailing were likely related to the use of a nonreaming technique and small-diameter nails relative to the diameter of the femoral canal.13,14 Retrograde nailing using modern techniques that include reaming, snug-fitting nails, and interlocking screws is associated with union rates similar to those for antegrade nailing.9,13

More complications related to the knee have been seen after retrograde nailing, and more complications related to the hip have been seen after antegrade nailing.9 The relative importance of these problems on functional outcome is unknown. Knee stiffness and septic arthritis have not been shown to be significant problems after retrograde nailing. Retrograde nailing has the added benefit of helping to provide improved fracture alignment of distal shaft fractures,15 decreased operating room time, and decreased blood loss.2 Patient conditions that make proximal access to the femur for antegrade nailing either difficult (eg, obesity, bilateral femur fracture) or undesirable (eg, ipsilateral pelvic or hip fracture, ipsilateral tibia fracture, pregnancy) favor retrograde nailing.

Patient Positioning

One common setup for antegrade nailing involves positioning the patient supine on a fracture table. Skin traction is applied to the foot, which is secured in a boot. Skeletal traction is usually not required. The noninjured leg may be in the hemilithotomy position, widely abducted, or scissored; the choice largely depends on surgeon preference and the capabilities of the selected operating table. Elevated calf compartment pressures can be generated with the hemilithotomy position, especially when the limb in question has associated injuries or the femoral nailing procedure is prolonged.16 The well leg should be carefully monitored to avoid the development of compartment syndrome.

Antegrade nailing without traction on a radiolucent table can reduce surgical time and, because of ease of assessment of the contralateral limb, can reduce the incidence of rotational malalignment.16 The lateral decubitus position offers improved ease of access to the piriformis fossa but may cause difficulty in imaging the proximal fracture fragment. Regardless of the position selected, anteroposterior and lateral fluoroscopic views of the entire femur are required.

Reaming

Whether to use a reamed or an unreamed technique for the treatment of femur fractures with IM nails has been a persistent subject of debate. There has been concern about the systemic effects of reaming on multitrauma patients, especially those with pulmonary injury. In animal models, reaming has been shown to increase IM pressures, increase pulmonary artery pressures, and be associated with fat embolization.17,18 However, several studies have demonstrated only limited and transient effects of emboli on the development of adult respiratory distress syndrome and further systemic compromise.19,20 The degree of fat embolization associated with reamed nailing has been shown to be similar to or only marginally greater than that associated with unreamed nailing, with fat extravasation being greatest during nail insertion that is not dependent on a rise in IM pressure.21

Reaming has been shown to cause variable grades of endosteal thermal damage and disruption of the endosteal cortical blood flow in animal studies, effects that, in theory, would be detrimental to fracture healing. Thermal necrosis should be avoided. Excessive cortical reaming generates significant heat because of the relative hardness of the endosteal cortical bone. The disrupted endosteal blood supply reconstitutes rapidly, a characteristic that likely helps account for the lack of clinical evidence of any detrimental effect of reaming on healing.22

Modern reaming technique calls for minimal (0.5 to 1 mm) reaming beyond the occurrence of cortical chatter at the level of the isthmus. The proper nail diameter for a snug fit is therefore 1 to 1.5 mm smaller than the largest reamer used, a width that also correlates to the diameter of the isthmus. Such undersizing of the nail is required to avoid iatrogenic bursting of the femoral canal because of mismatch of femoral and nail bows.

Other strategies to avoid thermal necrosis and excessive fat embolization include use of modern fluted reamer designs and use of sharp reamers. The optimal revolution speed for reaming has not been definitively determined. Slower reaming, which remains the de facto standard, generates less heat but more emboli than does faster reaming.23

Despite the theoretic detriments of reaming on fracture healing, multiple clinical studies have demonstrated beneficial effects of this technique on union rates.19,24 This finding is thought to be primarily because of increased cortical support for the nail and, thus, greater fracture stability; a beneficial inflammatory response caused by reaming; and the deposition of local bone graft at the fracture site.

Special Situations

Multitrauma Patient

The timing of IM nailing and the safety of reaming in the multitrauma patient have been closely scrutinized in recent years. Several detrimental effects of acute femoral nailing in patients with multiple trauma, especially those with pulmonary compromise, have been theorized and have led to the current practice of damage control orthopaedics.25 The additional trauma induced by IM nailing can tip a borderline stable patient toward decompensation. Release of inflammatory mediators, surgical blood loss, hypothermia, and the effects of reaming associated with IM nailing procedures are among the factors implicated in systemic decompensation.25,26

Current damage control principles include provisional surgical stabilization methods that minimize surgical time, blood loss, and additional trauma. Most commonly, these are practiced with monolateral external fixation that, in the absence of pinsite infection, can be safely converted to IM nailing once the patient is optimally stabilized.27 Retrograde unreamed nailing with or without proximal locking has recently been advocated as an alternative to external fixation.28

Open Fractures

Open fractures of the femur are much less common than those of the tibia. Because of the presence of a large protective soft-tissue envelope about the femur, open fractures are often associated with significant soft-tissue trauma. Small skin wounds can disguise significant deep muscle and periosteal injury. All open fractures of the femoral shaft should be treated in a timely fashion, as directed by the patient's medical status and the availability of appropriate resources.

Several studies have shown that the timing to initial débridement of open fractures does not significantly affect infection risk; rather, the severity of the open injury is the most significant factor determining the risk of deep infection.29,30 Wounds should be extended for evaluation of the deep soft tissues, and all nonviable soft tissues and bone should be débrided. Serial débridement at 24- to 48-hour intervals is typically recommended with higher-grade or highly contaminated open injuries. Although closure of contaminated wounds should be avoided, whether clean wounds should be left open or closed between serial débridements is controversial. Concerns about nosocomial infection provide a theoretic basis for closure between surgical débridements.

Immediate IM nailing of open femoral shaft fractures is indicated in all but the most severe cases, most notably those involving grossly contaminated canals. Provisional external fixation for open fractures is useful when repeat irrigation and débridement of a contaminated IM canal is necessary. IM nailing can be performed once the canal has been sufficiently cleansed. Intravenous antibiotics should be initiated at presentation and continued until definitive wound closure. Routine wound culture is not indicated.

Fractures of the femur caused by gunshot wound are technically open fractures; however, they can usually be treated as closed injuries.31 The entry and exit wounds should be débrided locally at the level of skin and subcutaneous tissue. The deeper tissues do not require formal irrigation and débridement. Fracture stabilization can thereafter follow standard treatment of closed fractures.32 The exceptions to this method are wounds from shotgun blasts at close range and high-velocity gunshot wounds with severe soft-tissue compromise. In these instances, treatment should be as for other highgrade open injuries.

Vascular and Neurologic Injury

Femoral shaft fractures associated with either vascular or neurologic injury are rare and are usually associated with penetrating trauma. The algorithm for management of fractures with associated vascular injury traditionally consists of bony stabilization, either definitive or provisional, followed by neurovascular repair with attention to obtaining proper length.33 The most expeditious stabilization method is usually external fixation, which, in the absence of infected pin sites, can be safely converted to definitive IM nailing within 2 weeks without increased risk of deep infection.27 Another expeditious alternative is retrograde nailing with interlocking deferred until after neurovascular repair.28 Deferring any skeletal stabilization until after vascular repair can reduce ischemic time as well as the need for fasciotomy.34 Recent clinical evidence indicates that this sequence can be applied safely without disruption of the vascular repair during definitive fracture treatment.34

Obese Patients

Obtaining a proper starting point for antegrade nailing in obese patients can be difficult. A higher number of complications have been reported when the entry site for nailing is through the piriformis fossa.35 Better results for antegrade technique have been obtained with nailing through the tip of the greater trochanter, especially with newer implants that have a proximal lateral bend designed for this insertion site.2 Retrograde nailing in this setting provides advantages of reduced radiation exposure and surgical time.2

Ipsilateral Proximal Femur and Femoral Shaft Fractures

Femoral shaft fractures with associated femoral neck or intertrochanteric fractures are challenging injuries to treat. Such associated injuries occur in up to 9% of all femoral shaft fractures.36 These proximal fractures are often minimally displaced (25% to 60%) and are easily missed (20% to 50%).36 Evaluation of the femoral neck with fine-cut computed tomography (CT) imaging and dedicated internal rotation hip radiographs can improve the physician's ability to diagnose an associated femoral neck fracture.36 The femoral neck component of such injuries is the highest priority for optimal, but not necessarily initial, stabilization. A variety of fixation techniques can be used to address both femoral neck and femoral shaft fractures. These include separate implant placements, such as retrograde nailing or plating of the shaft combined with standard fixation of the proximal fracture using cannulated screws or a sliding hip screw.37 Alternatively, simultaneous treatment of the proximal and shaft fractures using a single IM device in a reconstruction model has been advocated.38

Because of the high-energy nature of these combined injuries, femoral neck fractures, when associated with shaft fractures, are often vertically oriented midcervical fractures with little inherent stability.39 In these situations, a sliding hip screw construct with a derotation screw may provide better biomechanics than would cannulated lag screws. A formal open reduction of displaced femoral neck fractures is indicated when anatomic reduction cannot be achieved by closed means. Antegrade IM nailing can cause displacement of occult nondisplaced fractures of the femoral neck. Thus, intraoperative anteroposterior and lateral radiographs of the femoral neck should be obtained after the nailing procedure. These practices can reduce the risk of delayed diagnosis of a femoral neck fracture and potentially prevent the devastating sequelae of osteonecrosis and nonunion associated with missed fractures of the femoral neck.

Complications of Femoral Nailing

Malunion

Angular malunion of femoral shaft fractures after IM nailing is most common in proximal (30%) and distal (10%) fractures, in which the surgeon cannot rely on the interference fit of the nail to align the fracture.15 Blocking screws can be used to assist in aligning more proximal and distal fractures, but these are unnecessary in the diaphysis. Reaming until osseous chatter is heard, then selecting a nail approximately 1 mm smaller, will provide excellent interference fit and will neatly align most diaphyseal fractures. Diaphyseal angular malunion is of greater concern in elderly patients with capacious canals, in which poor diaphyseal contact is likely.

Rotational malunion remains a concern even with modern nailing techniques. The patient may “sag” on the fracture table, resulting in relative external rotation of the hemipelvis. Alignment of the anterior superior iliac spine, the patella, and the second toe can assist the surgeon in obtaining correct rotation. Additionally, fluoroscopic evaluation of cortical widths,40 any key fragments, or femoral anteversion41 can assist in obtaining proper rotation. Both legs should be examined for rotational symmetry before exit from the operating suite. Rotational malalignment, if noted at this time, can be easily treated by removing interlocking screws, manually correcting the rotation, and reinserting interlocking screws. Rotational malalignment can be evaluated by clinical examination; however, a CT scan can be more accurate.42 Symptomatic rotational malunion after union is achieved requires osteotomy, either open or with an IM saw.

Nonunion

The rate of nonunion after nailing of femoral shaft fractures, regardless of starting point, is low, usually <10%.1,5,9 In the event of nonunion, deep infection should be considered and ruled out before surgical repair is undertaken. The treatment of nonunion may involve dynamization, exchange nailing, or plate fixation with bone grafting. Dynamization can be useful for distracted fractures; however, no large series have evaluated the efficacy of this strategy, and success rates vary from 54% to 92.3%.43,44

Fractures with bony defects, atrophic characteristics, or failed dynamization may benefit from reaming and exchange nailing or open grafting and repair. Results for exchange nailing of femoral shaft fractures show good but not outstanding union rates, ranging from 53% to 96%.45,46 Recalcitrant nonunions may warrant an evaluation for underlying metabolic disturbances47 and can be successfully managed with bone grafting and plating.48

Leg Length Discrepancy

Obtaining equal leg lengths after nailing of comminuted fractures is a challenge, with discrepancy noted in up to 43% of cases.49,50 Immediately after nailing, leg lengths should be compared and any discrepancy corrected at the same setting. A modified scanogram taken with the use of a sterile Bovie cord (Bovie Medical, N. St. Petersburg, FL) or radiopaque ruler can be used intraoperatively to compare the length of the fractured extremity with the uninjured side. If there is any residual doubt, postoperative clinical examination or CT scanogram can be used to define discrepancies.49 The treatment protocol for a problematic discrepancy is to return to the operating room and relock the nail at the correct length.

Infection

Infection rates noted in large series of femoral shaft fractures treated with IM nails are low, ranging from 1% to 3.8%.51 Infections can be categorized as early (<3 months) or chronic; both are generally associated with ununited fractures. Early infections, such as those associated with open fracture wounds, can typically be treated with nail retention, serial débridement, and organism-specific intravenous antibiotics. Nail removal is indicated when the early infections cannot be controlled. External fixation or antibiotic cement nails, created over a metal wire or other substrate, can provide stability during the treatment period.52 The cement nail offers more limited mechanical support but fills the dead space in the medullary canal and delivers high concentrations of local antibiotics.

Chronic infections and infected nonunions are treated based on the principles of osteomyelitis management. Generally, the nail is removed, the canal is reamed for débridement purposes, and nonviable bone from the fracture margin is resected. Intravenous and potentially local antibiotics in the form of cement beads or a cement spacer are typically administered for at least 6 weeks. Definitive reconstruction is delayed until the infection is controlled. The progress of the infection is monitored through close clinical observation and routine laboratory values (ie, complete blood count, erythrocyte sedimentation rate, C-reactive protein level). Host factors, such as smoking or malnutrition, should be addressed. Finally, if there is still concern for infection at the time of reconstruction, frozen tissue sections can be obtained intraoperatively. White blood cell count per high-powered field of >10,000/μL is suggestive of persistent infection.

Other Potential Complications

A patient may develop heterotopic bone at the site of antegrade nail insertion. Although present radiographically, heterotopic bone islands often have little functional significance.53 A mass that becomes large can cause pain and limit motion; thus, excision should be considered. No protocol exists for prevention of heterotopic bone formation with antegrade femoral nailing.

IM nailing can directly or indirectly result in neurovascular injury. Positioning on the fracture table with excessive traction may cause pudendal nerve compression. Fortunately, this neurapraxia often resolves without sequelae. Insertion of the proximal locking screws during retrograde nailing can cause injury to branches of the femoral nerve; risk of this outcome can be minimized by locking the nail proximal to the lesser trochanter.54 Overzealous drilling for interlocking screw placement can cause vascular injury and pseudoaneurysms.55

A patient may have pain and other symptoms related to prominent hardware. This is most commonly seen around the distal interlocking screws of the retrograde nail. In addition, some patients may report knee pain secondary to inadequately countersunk retrograde nails. This complication warrants revision to prevent further articular damage to the patella.

Functional Outcome

Although IM nailing of diaphyseal femur fracture is the standard treatment for this injury, patients may experience residual functional deficits following fracture fixation. Reduced strength of the hip abductors and hip extensors as well as altered gait pattern have recently been demonstrated following antegrade femoral nailing.56,57 Functional outcome scores have been found to be persistently reduced relative to baseline at 1 year after antegrade nailing.6 These findings support the need for prolonged muscle- strengthening therapy protocols.

Summary

IM nailing is an effective method for the treatment of fractures of the femoral shaft, providing generally high union rates and low complication rates. With the use of modern techniques and implants, good results can be obtained for femoral nailing with any pairing of starting point (ie, piriformis, greater trochanter, retrograde), the choice of which depends on several factors. These include fracture characteristics, associated injuries, body habitus, and surgeon familiarity with each nailing method. Other important technical decisions concern body position, use of traction, and reaming. Of paramount importance to outcome is adherence to meticulous surgical technique, with each combination of starting point and positioning method requiring specific attention to detail.

References

Evidence-based Medicine: References 13, 14, 19, 24, and 43 are level I/II randomized controlled trials or meta-analysis. References 36, 41, and 49 are level II diagnostic studies. References 2, 5, 6, 9, 15, 17, 26, 27, and 42 are level III cohort studies, and references 29, 30, 51, and 53 are level III case-control studies. References 1, 10-12, 16, 33, 37, 39, 44-48, 50, 52, 56, and 57 are level IV case series. References 3, 28, and 55 are level V case reports.

Citation numbers printed in bold type indicate references published within the past 5 years.

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