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i Canis ISSN: 2398-2942

Fracture xation: interlocking nail

Synonym(s): Locking nail, locked nail
Contributor(s): Sorrel Langley-Hobbs, Prof Walter Renberg, Prof Mark Rochat

Introduction
 Interlocking nail (ILN) xation is a method of fracture repair that capitalizes on the inherent strengths of
intramedullary (IM) pin xation. From an overall biomechanical standpoint, a xation device is strongest when it
follows the central axis of the long bone. As the device is moved away from the central axis, the device is less able to
withstand cyclic bending loads and is more susceptible to fatigue failure. Bone plates  Fracture xation: plate and,
to a greater extent, external skeletal xators  Fracture xation: external skeletal xator , because they are distant to
the center of the bone, have increased loads placed on them and are therefore biomechanically less stable.
Obviously there are techniques that allow those devices to be used successfully but the weakness, nevertheless,
exists.
Intramedullary pin xation  Fracture xation: pin e ectively counters bending forces; however, rotational and
shear forces are not neutralized by IM pins, necessitating the use of supplemental devices such as cerclage
wires  Fracture xation: wire , or external skeletal xators. Cerclage wiring requires an open approach to the
fracture site and are applicable only to simple fracture con gurations that can be anatomically reconstructed.
External skeletal xators present their own set of problems including issues with pin placement and postoperative
maintenance. An ILN combines the inherent strength of a centrally located device with rotational and shear control
provided by locking screws or bolts placed transversely through holes in the proximal and distal ends of the nail.

Interlocking nails are indicated for fractures of the diaphysis of the humerus, tibia, and femur  Femur: head and
neck fracture xation. Simple and comminuted fractures can be repaired using ILN technology. Interlocking nails can
be used for treatment of fracture nonunions but attention must be given to other aspects of fracture nonunion
management such as debridement of brous tissue and cancellous bone grafting. The use of ILN xation for
treatment of open or infected fractures is somewhat controversial but if other aspects of open fracture management,
eg debridement, bacterial culturing, and antibiotic therapy are addressed, ILN xation can be used e ectively. On the
other hand, ILN xation should be avoided if a fracture is grossly infected and cannot be converted into a healthy
wound prior to fracture stabilization, if a segmental fracture pattern is present, or if there is signi cant vascular
and/or soft tissue injury. Such fractures are better treated with external xation as the de nitive method of
stabilization.
Numerous ILN systems have been developed for use in human beings. None of these systems are practically
applicable to dogs and cats due to size of nails and cost restraints. One commercially available system exists in the
United States that is speci cally designed for veterinary patients; more are o ered in other countries. The system
consists of the nail that is a modi ed Steinman pin, bolts, and instrumentation to implant the nail. The nail has a
trocar point on one end, a key-lock connection on the opposite end, and is made of surgical stainless steel  . One or
two transverse holes are present on each end of the nail to allow bolts or screws to pass through the bone and nail
to control rotation and shear. Nails with one hole are used when the fracture site is so close to the metaphysis that
two bolts cannot be placed without a bolt entering the fracture site. Interlocking nails are currently manufactured in
four diameters (4.0, 4.7, 6.0, and 8.0 mm) and varying lengths.

Instrumentation for placing the nail consists of reamers  , extensions  , alignment guides  , guide sleeves  ,
and instruments for placing bolts or screws. The use of bolts has largely replaced the use of screws in the nail, the
screws were prone to breaking or bending and as they do not form a tight t with the nail they allowed a signi cant
amount of rotation. The bolts form a much tighter t in the nail hole and in addition they have a larger core diameter
so they are signi cantly stronger and therefore less prone to complication. The reamers are used to prepare the
medullary canal for placement of the nail. Long and short extensions are made for coupling the nail to the alignment
guide and the guide is used to allow precise placement of the locking screws. Placement of the bolts is achieved using
a trocar; various guide sleeves; and a drill and screwdriver. Additionally a tap is provided if standard bone screws are
used in place of bolts.
It should be remembered that with closed approaches or open approaches where the fracture has been minimally
disturbed, anatomic reconstruction is not the goal but rather functional bone alignment. Some surgeons advocate
anatomic reconstruction of the fracture with supplemental xation devices such as cerclage wire prior placement of
the nail. In general, this approach defeats one advantage of ILN, minimal disruption of the fracture site. Additionally,
ILN are very strong and mechanically sound and the need for anatomic reconstruction is generally unnecessary.

Uses
 Interlocking nails are useful for diaphyseal fractures of the femur, tibia, and humerus.

Advantages
Biomechanically rigid xation:
Relatively inexpensive implant costs.

Can be placed through closed or limited open approaches.

Useful for some open fractures and nonunion fractures.

Disadvantages
Expensive instrumentation:
Use limited to diaphyseal fractures of the humerus, femur, and tibia.
Steep learning curve for use.

Requirements

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Preparation

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Procedure

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Aftercare

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Outcomes

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Prognosis
The prognosis for healing is generally very good and dictated primarily by the factors associated with the fracture.

Further Reading
Publications
Refereed papers
 Recent references from PubMed and VetMedResource.
Nanai B & Basinger R R (2005) Use of a new investigational interlocking nail supplement in the repair of comminuted
diaphyseal tibia fractures in two dogs. JAAHA 41 (3), 203-208 PubMed.
Basinger R R & Suber J T (2004) Two techniques for supplementing interlocking nail repair of fractures of the humerus,
femue, and tibia: results in 12 dogs and cats. Vet Surg 33 (6), 673-680 PubMed.
Duhautois B (2003) Use of veterinary interlocking nails for diaphyseal fractures in dogs and cats: 121 cases. Vet
Surg 32 (1), 8-20 PubMed.
Dueland R T, Johnson K A, Roe S C et al (1999) Interlocking nail treatment of diaphyseal long-bone fractures in dogs. J Am
Vet Med Assoc 214 (1), 59-66 PubMed.
Roush J K, McLaughlin R M (1999) Using interlocking nail xation to repair fractures in small animals. Vet Med 94 (1), 46-52
VetMedResource.

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