Professional Documents
Culture Documents
Livingston bar,introduced a
short I-beam pattern pointed
nail at both ends,which had
short slots for cross-pinning with
screws
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.
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
•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.
•.
•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
Flexible nail are usually simpler to use and can be
inserted more quickly.
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, designed for open
nailing.
Physiologic loading is a
combination of all these forces
F = Force F = Force
Bending moment = F x D
IM Nail Plate
D 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 cross-section
is rectangular
resisting greater
loads in one plane
versus the other.
The amount of load borne by the nail depends on the
stability of the fracture/implant construct.
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
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
Metallurgy less important
•
Bone cortex
0
50
The material must be stiff . Titanium are 1.6 times stiffer and
elastic modulus is 50% lower than steel nail
Type of fracture
Interlocking
Reaming
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
Nail hole size should not exceed 50% of the nail diameter.
.
K-nail has slot/eye in the either ends for attachment of
extraction hook .one end is tapered to facilitate the insertion .
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 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.
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.
3 cm longitudinal incision
approximately 1 cm from
the medial border of
patella, beginning about 2
cm proximal to distal pole
of the patella
IM reaming can act to increase the contact area between the
nail and cortical bone by smoothing internal surfaces.
Disadvantages
Pathological fractures.
Malunions.