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Intramedullary nailing is an internal fixation technique mainly used for the surgical management of long bone diaphyseal fractures and since more recently also in metaphyseal and periarticular fractures.

History and etymology

Bircher reported an intramedullary fixation with ivory pegs in 1886, HeyGroves used metallic nailing with unsatisfactory results in 1918 .

Successful surgical management with intramedullary nailing or ‘marrow nailing’ was introduced in 1939 by Küntscher. The ‘interlocking nail’ was introduced in 1972 after its predecessor the ‘detensor nail’ in 1968 also by Küntscher, in the intention to solve problems with the treatment of comminuted fractures .

Indications

Indications of intramedullary nailing are the following :

femoral diaphyseal fractures and distal femur fractures
humeral shaft fractures
tibial shaft fractures, proximal and distal tibia fractures
metaphyseal fractures

Contraindications

Contraindications of intramedullary nailing include the following :

open epiphysis
small medullary canal
deformity e.g. prior malunion
grossly contaminated open or infected fractures
fracture in line of locking screws
an associated femoral neck fracture

Procedure

The surgical technique encompasses several steps including the following :

appropriate insertion or entry point (e.g. piriformis fossa, trochanter, intercondylar notch)
determination of nail length and diameter
exact anatomic reduction and securing reduction during the following steps
reaming
nail insertion
interlocking

Complications

Complications of intramedullary nailing include the following :

hematoma formation
secondary displacement
infection
fracture malunion
fracture non-union
periprosthetic fracture
iatrogenic comminution
implant malposition
hardware failure
length discrepancy
heterotopic ossification
soft tissue irritation at the entry point

general complications associated with surgery:

Radiographic features

Nail position, fragment position and fracture healing can be assessed with anteroposterior and lateral views.

Radiological report

The radiological report should include a description of the following features:

implant malposition
fragment displacement
malalignment/angulation
implant loosening
signs of fracture healing
hardware failure

Outcomes

The use of intramedullary nailing provides stability and is associated with preservation of the surrounding muscle and soft-tissues and involves only a small amount of soft-tissue dissection . Interlocking can provide control of length and rotation .

Advantages

Advantages of intramedullary nailing include :

less-invasive implant insertion
long implants for spanning complex fractures
enhanced revascularization due to preserved soft-tissue sheathing
load sharing fixation with less requirement for additional support and earlier rehabilitation
lower risk for wound complications
can be combined with internal fixation methods as wire cerclage, buttress plates etc.

Disadvantages

Disadvantages include technical and intraoperative complications such as reaming complications (destruction of the medullary contents, fat embolism) .