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INTRAMEDULLARY NAILING

BASIC CONCEPTS

Dr.S.V.Hari krishnan
PGT , M.S .(Ortho)
Learning Objectives
 Introduction
 Evolution
 Classification
 Biomechanics
 Applications
 Special Circumstances
 Recent Advances
Introduction
 Fracture stabilized by one of two systems
 Compression
 Splinting

 Intramedullary fixation - internal splinting


 Splintage -micro motion between bone & implant
 Relative stability without interfragmentary compression.
 Entry point - distant from fracture site – hematoma retained.
 Closed reduction and fixation (biological)
Evolution
1st generation 2nd generation 3rd generation

 Splints(1˚) • Locking screw - • Fit anatomically as


 Rotational improved rotational much as possible
stability stability • Aid insertion and
minimal • Non- slotted. stability
 Closed fit • Titanium alloy
 Longitudinal slot • Eg-russel taylor nail, • Eg-trigen nail, universal
delta nail femoral nail nails with
along entire
multiple curves
length ,multiple fixation
systems
 Eg –K nail , V nail • Tibial nail with
malleolar fixation
Classification
 Entry Portals : Direction :

 Centromedullary Antegrade
 K nail Retrograde

 Cephalomedullary
 Gamma nail
 Russell taylor nail
 PFN

 Condylocephalic nail
 Ender nail
Centromedullary Nails
 First generation

 Contained within medullary canal

 Usually inserted from piriformis fossa

 Proximal locking bolts - transverse or


oblique in pertrochanter

 Requires LT be attached to proximal


fragment for adequate # stabilization
Cephalomedullary Nails
 second generation nails

 More efficient load transfer than SHS

 Shorter lever arm of IM device decreases


tensile strain on implant - low risk of implant
failure

 screws/blade inserted cephald into femoral


head and neck.
 Gamma nail
 Recon nail
Condylocephalic Fixation
 Elastic stable intramedullary nailing (ESIN) - primary definitive
paediatric fracture care .
 3 – point fixation or bundle nailing.
 Elastic and small - micro-motion for rapid fracture healing.
 Flexible -insertion through a cortical window.
 Examples :
 Lottes nails  Morote nails
 Rush pins  Nancy nails
 Ender nails  Prevot nails
 Bundle nails
Opposite  Apex of curvature - at level of fracture
site.

 Nail diameter - 40% of narrowest


medullary canal diameter

 Entry point - opposite to one another

 Used without reaming.

 Commonest biomechanical error is lack of


internal support.
 Schneider nail [ solid, four fluted cross section
and self broaching ends.

 Harris condylocephalic nail [curved in two


planes, and designed for percutaneous,
retrograde fixation of extra capsular hip
fractures.

 Lottes tibial nail specially curved to fit tibia,


and has triflanged cross section.
Ender Nails
 Solid pins with oblique tip and an eye
in flange at or end

 Designed for percutaneous, closed


treatment of extra capsular hip
fractures
Rush Nails
 Intended for fractures of diaphyseal
or metaphyseal fractures of long bones
like femur, tibia, febula, humerus,
radius and ulna.

 Pointed tip facilitates easy insertion.

 Curve at top prevents rotation and


stabilizes fracture.
Bundle Pinning
 C- or S – shaped, act like spring.
 Principle introduced by hackethal.
 Many pins are inserted in to bone until
jammed within medullary cavity to provide
compression between nails and bone.
 Bending movements neutralized, but
telescoping and rotational torsion not
prevented
Applications
 Diaphyseal fractures of long bones  Osteoporotic long bone fractures

 High proximal and low distal fractures of  Pathological fractures


long bones

 Floating hip, floating knee, floating elbow.  Open fractures up to grade IIIA

 Aseptic and septic non-union


Contraindications
 Narrow and anomalous medullary canal

 Open growth plates

 Prior malunion - prevents nail placement

 History of intramedullary infection

 Associated ipsilateral femoral neck or acetabular fracture (relative)


Mechanics (K Nail)
 Elastic deformation or “elastic
locking” of nail within medullary
canal

 Adequate friction of nail in both


fracture fragments

 To achieve elastic impingement-


 “V” profile or even better “clover-leaf”
design.
V Nail Clover Leaf Nail

 Compressible in only one  Compressible in two directions


direction  Directions right angles to each
other
Elastic Compressibility Of Clover – Leaf Nail
Solid Nail Elastic Nail

 Not occupy full width of  Nail with elastic cross section


medullary canal adjust to constrictions of
medullary canal.
Grosse – Kempf nail Russell – Taylor nail Brooker–Wills nail
Biomechanics of deforming forces
F = Force Bending moment = F x D

IM Nail Plate

D = distance from force


to implant.

D D
Bending moment for plate
greater due to force being applied
over larger distance.
Comparision
• Nail cross section round
• Resisting loads equally in all
directions.

• Plate cross section


rectangular resisting greater
loads in one plane versus the
other
Cortical contact


+ - compressive loads borne
by bony cortex

 - - compressive loads
transferred to interlocking
screws (“four-point bending
of screws ”)
Ideal Intramedullary Nail
 Strong and stable - maintain alignment and position

 Prevent rotation - interlocking transfixing screws

 Promote union - contact-compression forces at fracture


surfaces

 Accessible for easy removal


Pre Requisites
 Adequate preoperative planning

 Patient tolerance to a major surgical procedure

 Availability of nails of suitable length and diameter

 Suitable instruments, trained assistants, and optimal hospital


conditions

 Closed nailing techniques - whenever possible


Pre Operative Planning
Biplaner Radiographic
Length Of Nail Diameter Of Nail
Images

• Bone Morphology • Radiographs of contra lateral • Narrowest portion of


femur (magnified) femoral canal at femoral
isthmus – lateral
• Canal Dimensions • Traction radiographs radiograph
(comminuted #)
• Fracture Personality • Palpable greater trochanter to • 1.0 to 1.5 mm greater in
lateral epicondyle. diameter than anticipated
nail diameter.
• Comminution
• TMD (tibial tubercle–medial
malleolar distance) for tibial
• Fracture Extensions nail
Nail Length
 Preoperative radiographs of fractured long bone
with proximal and distal joints

 AP radiograph of opposite normal limb at a tube


distance of 1meter

 Kuntscher measuring device :


 Ossimeter used to measure length and width
 Magnification is taken in to account
Biomechanics
 Stability determined by
 Nail design
 Number and orientation of locking screws
 Distance of locking screw from fracture site
 Reaming or non reaming
 Quality of bone

 IM nails assumed to bear most of load initially,gradually


transfer it to bone as fracture heals.
Nail Design
 Factors contributing to biomechanical profile :
 Materialproperties
 Cross-sectional shape
 Diameter
 Curves
 Length and working length
 Ends of nail
Nail design
 Material properties  CROSS SECTIONAL
SHAPE
 Titanium alloy and 316l
stainless steel.  Determines bending and
torsional strengths
 Modulus of elasticity
 Titanium alloy – same as  Polar moment of inertia
cortical bone  Circular nail  diameter
 Square nail  edge length
 SS – twice as cortical bone
 High in nails with sharp
corners or fluted edges
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
J,k,l-now commonly used
Nail diameter
Nail diameter affects bending rigidity
 solid circular nail,

 Bending rigidity  third power of nail


diameter (D3)
 Torsional rigidity  fourth power of
diameter (D4)

 Large diameter with same cross-


section are both stiffer and stronger
than smaller ones.
Nail curves
 Long bones have curved medullary cavities

 Nails contoured to accommodate curves of bone


 Straight, curved or helical
 Average radius of curvature of femur - 120(±36) cm.

 Complete congruency minimizes normal forces and


hence little frictional component to nail’s fixation.

 Femoral nail designs have considerably less curve,


with radius ranging from 150 to 300 cm

 Im nails - straighter (larger radius) than femoral canal


Nail curves
 Angle of herzog :
 11o bend in AP direction at junction of upper
1/3rd and lower 2/3rd of tibia nail

 Mismatch in radius of curvature –


 Distal anterior cortical perforation
 more reaming required during insertion
Hoop stress
 Circumferential expansion stress
during nail insertion
 Larger hoop stress can split bone

 Hoop stress reduction :


 Use flexible nails
 Over-ream entry hole by 0.5 to 1 cm
 Selection of ideal entry point
Posterior - loss of Ideal - posterior portion Anterior - generates
proximal fixation of piriformis fossa huge forces, can lead to
bursting of proximal
Nail length
A-Total nail length - Anatomical length

B-working length - length between proximal and


distal point of firm fixation to
bone
Working length
Affected by various factors
Type of force (Bending ,Torsion )
Type of fracture
Interlocking and dynamization
Reaming
Weight bearing
Nail length
 Shorter working length stronger fixation

 Transverse fracture has a shorter working length than


comminuted fracture

 Torsional stiffness 1/ to l

 Bending stiffness 1/ to l2

 Surgeon’s techniques to modify “ l ”


 Medullary reaming
 Interlocking
Extreme ends
 K-nail  Anterior slot-
 Slot/eye in ends for extraction Improved flexibility
 One end tapered to facilitate insertion .
 Posterior slot -
 Holes for interlocking screws Increased bending
strength

 Some nails have slots near distal end


for placement of anti rotation screw  Non-slotted -
Increased torsional
stiffness and strength
in smaller sizes
Interlocking of nail
 Recommended for most cases of IM nailing.

 Principle :
 Resistance to axial and torsional forces depends on
screw – bone interface
 Length of bone maintained even in bone defect.

 Number of interlocks :
 Fracture location
 Amount of fracture comminution
 Fit of nail within canal.

 Placing screws in multiple planes - reduction of minor movement


Interlocking screw
 Location of distal locking screws affects
biomechanics of fracture

 Distal locking screws


 Closer to fracture site - less cortical contact -
increased stress on locking screws
 Distal from fracture site - fracture becomes
more rotationally stable

 Interlocking screws positioned at least 2 cm


from fracture provides sufficient stability
Poller /blocking screws

 Corrects mal-alignment.

 Centers IM nail.

 Planned and inserted before


IM nail insertion.

 Saggital or coronal plane.


Static locking
 Screws placed proximal and distal to fracture site

 Restrict translation and rotation at fracture site.

 Acts as a “bridging fixation”

 Indications :
 Communited
 Spiral
 Pathological fractures
 Fractures with bone loss
 Atropic non union
Dynamic locking
 Screws inserted only at one end (short fragment)

 Unlocked end stabilized by snug fit inside medullary cavity


(long fragment)

 Prerequisite: at least 50% cortical circumferential contact

 Indications
 Fractures with good bone contact
 Non unions

 With axial loading , working length in bending and torsion is


reduced - improving nail-bone contact
Dynamisation
 “Weaken stability”
 Never done in progressive normal healing

 Indications
 Established nonnunion
 Pseudoarthrosis

 Caution: premature dynamisation adds to


shortening, instability and non-union.
Dynamisation
 Primary Dynamisation
 Dynamic locking of axially and rotationally stable
fractures at time of initial fracture fixation

 Secondary Dynamisation
 Removing interlocking screw from longer fragment
/ moving proximal interlocking screw from static to
dynamic slot in nail

 Done in long bone delayed union and nonunion


Reamed Versus Unreamed
 Endosteal thermo-necrosis & endosteal cortical blood supply disruption
 Minimized by using sharp reamers with deep cutting flutes.
 Reaming - slow and smooth.

 Endosteal blood supply regenerates rapidly - high healing rates in reamed


nails.

 No difference in infection rates

 No overall difference in time to union


Reamed Versus Unreamed
 Reamed nail :

 High chance of embolization of bone marrow fat to lungs but this phenomenon is limited &
transient

 Fat extravasation greatest during insertion of nail in medullary cavity

 Not dependent upon increased intra medullary pressure

 Reamed nailing generally report no statistical difference in pulmonary complications


as compared to unreamed nailing
Open intramedullary nailing
Primary indication :
 Failure to do closed nailing
 Nonunions

 Fractures requiring intramedullary fixation in existing


internal fixation device.
 Advantages :
 Less expensive equipment required than for closed nailing.

 No special fracture table / preliminary traction

 Absolute anatomical reduction

 Direct observation of bone - undisplaced / undetected comminution

 Improved rotational alignment and stability.

 Prevents torquing and twisting in segmental fractures

 In nonunions, opening of medullary canals of sclerotic bone is easier.


DISADVANTAGES :

Skin scars

Fracture hematoma evacuated.

 Bone shavings created by reaming medullary canal often are lost.

Infection rate increased.

 Rate of union decreased.

 If a locking nail is used, locking is difficult without image intensification


Nailing in open fractures
 If initial debridement adequate and timely , definitive stabilization with
reamed intramedullary nailing

 with severe soft tissue injuries that require a second debridement,


temporary external fixation reasonable

 increased risk of infection after use of external fixation pins longer than 2
weeks followed by reamed intramedullary nailing.

 Rapid initial management approach allows delayed conversion to a


medullary implant at 5 to 10 days.
Nailing in open fractures
 Fractures with delay in initial debridement of more than
8 hours - staged nailing.

 Acceptable complication rate (11 % infection rate in type


iii open fractures)

 No relationship between infection rate, non union with


timing of nailing or associated soft tissue injury
Aseptic non unions

 Without bone defects - primary im nailing or exchange


nailing if well aligned

 With bone defects - im nailing with bone grafting

 corticocancellous graft material - harvested with


ria(little donor morbidity)
Exchange nailing
 Biological effects :
 Reaming of medullary canal – promotes union Removal of current
intramedullary nail
 Mechanical effects :
 Larger-diameter intramedullary nail – improved
stability
Reaming of medullary
canal
 Exchage nail – atleast 1mm larger than
previous nail
Placement of an larger
 Canal reaming until osseous tissue observed intramedullary nail
in reaming flutes
Septic non union
 Main aim - eradicating infection

 Osseous stability important in management of infected nonunion

 Stabilization with antibiotic impregnated cement coated nail after serial


debridement.

 Cement nail elute high concentration of antibiotic in local sites for up to 36 weeks.
Antibiotic impregnated cement nail
Nailing in damage control orthopaedics (DCO)/early total care (ETC)

 In polytrauma , early femoral stabilization decreases incidence of


severe fat embolism and pulmonary complications (ARDS).

 Nailing with reaming will not increase pulmonary complications

 Early intramedullary nailing may be deleterious and is associated with


elevation of certain proinflammatory markers - (il)-6.

 Early external fixation of long bone fractures followed by delayed


intramedullary nailing – high risk patients.
Nailing in damage control orthopaedics (DCO)/early total care (ETC)

 50% (↓) in mortality patients who underwent femoral shaft


fracture stabilization beyond 12 hours

 This timing was hypothesized to allow for adequate


resuscitation

 Exact and optimal timing of femoral shaft fracture nailing


remains unclear in polytrauma(esp. Chest injuries)
Removal
 Timing controversial

 Indications :
 Patient request(after union)
 Pain, swelling secondary to backing out of implant.
 Infected nailing

 Full weight bearing immediately after removal

 Femoral nail removed after 24-36 months , tibial nail 18-24 months
Failure
 When fracture healing is delayed or nonunion occurs.

 IM nails usually fail in predictable patterns.


 Unlocked nails
 fail at fracture site or through a screw hole or slot.
 Locked nails
 screw breakage or fracturing of nail at locking hole sites(proximal
hole of distal interlocks )
Recent advances
 Biodegradable polymers

 Nickel-titanium shape-modifiable alloys


 can improve stability as they change shape after
insertion and recover curvature as they warm.

 IM nails coated with bmp


Conclusion
 Implant of choice in diaphyseal fractures

 Multiple factors determine final construct stiffness,


should be understood and considered when
choosing IM nail

 Ideal intramedullary nail is yet to be invented


Bibliography
 Campbell operative orthopaedics 12th edition

 Rockwood and green – fractures in adults 8th edition

 Elements of fracture fracture fixation – anand J.Thakur(3rd edition)

 History of intramedullary nailing ,matw R. Bong, M.D., Kenneth J.


Koval,m.D., And kenneth A. Egol, M.D., Bulletin of NYU hospital for
joint diseases • volume 64, numbers 3 & 4, 2006