Interlocking Nail

Introduction
These implants are introduced into the bone
remote to the fracture site and share
compressive, bending, and torsional loads with
the surrounding osseous structures

IM nails act as internal splints

with load-sharing characteristics.
HISTORY
Stimson in 1883 described the insertion of an ivory peg in
medullary canal.

Rush brothers described their IM pinning system in 1927.

 Gerhard Kuntschner
Femoral Nail-1939

Stable Osteosynthesis

Principle of fixation was based on compression between bone

and implant
Flexible Nails
Rush pins

Ender nails

Morote Nails

Nancy Nails
Mechanics
Act by stabilizing fractures with three or four point
compression

Equilibrium between the tensioned pin and the bone

with its soft attached tissues will hold the alignment.

Bending movements are neutralized but telescopining

and rotational torsion are not prevented.
Applications
Children- Mainly for forearm fractures
femur fracture.

Adults-Clavicle fracture
Proximal humerus fracture
Humeral shaft fracture
Forearm fracture
Disadvantages
Additional immobilization is often required.

Secondary loss of reduction

Shortening with loading

Intramedullary Nailing
Unlocked Nail

Interlocking Nail

Unreamed Nail

Reamed Nail
Unlocked Nail
Mechanics
Elastic Deformation is principle of nail stability
Nail insertion causes radially oriented force

Force is proportional to the contact area between the bone and

nail

Produced friction stops the nail from pulling out

“Elastic Locking”
Elastic Locking
Bending of the nail (curvature)

Cross-sectional shape (particularly the geometry of the

surface of the implant), and its diameter

The corresponding properties of the canal (eg, size, shape,

bone quality)
Interlocking Nailing
These nails have proximal and distal locking
screws.

The resistance to axial and torsional forces

is mainly dependant on screw bone
interphase.
Interlocking screws placed proximal and

distal to the fracture site restrict translation

and rotation at the fracture site; however,

minor movements occur between the nail

and screws, allowing toggling of the bone.

Nail Bio-Mechanics
Intrinsic

Extrinsic
Intrinsic Factors
Material properties

Cross-sectional shape

Anterior bow

Diameter
Extrinsic Factors
Reaming of the medullary canal

Fracture stability (comminution)

The use and location of locking bolts

Stability
Nail size

Number of locking screws or bolts, and

Distance of the locking screw or bolt from the

fracture site.
Nail Diameter
Bending rigidity is proportional to the nail diameter to the
third power,

The torsional rigidity is proportional to the fourth power

Working Length
It is the distance between proximal and distal locking screws

The working length influences nail stiffness in bending and

torsion.
Physiological loading of the Nail
Screw Breakage
With cortical bone contact
weight is transmitted through
bone also.

However in its absence four

point bending can occur
Implant Failures
Unlocked nails typically fail either at the fracture site or
through a screw hole or slot.

Locked nails fail by screw breakage or fracturing of the nail

at locking hole sites, most commonly at the proximal hole of
the distal interlocks
PATHOPHYSIOLOGY OF NAILING
Local effects

Systemic effects.

These effects are described with reamed nailing.

Local effects
Damage to endosteal blood supply
Heat necrosis
With intact soft tissue envelop reaming increases the
circulation in the surrounding muscles
Rate of non union is less with reamed nail as compared to
unreamed nail.
Systemic
Reaming causes transient raise of the pulmonary arterial pressure

IM instrumentation causes liberation of bone marrow contents to

blood stream

They undergo an increase in size due to platelet adhesions

Leads to a transient decrease in perfusion

Subsequent cascade reaction follows.

Unreamed nails
It is said that unreamed nailing is advantageous in treatment
of Gustilo IIIB open fractures.
It has got less amount of superficial infection and malunion as
compared to external fixation.
Disadvantages
Nonunion

Distal Screw breakage

Special Designs
Proximal Femoral Nails

Retrograde Nails

Distraction Nails

Knee Arthrodesis
Proximal Femoral Nail
Sub trochanteric fracture

Fracture NOF

Intertrochanteric Fractures
Retrograde Nails
Distal femur fractures

Humeral fractures

Periprosthetic fractures
IM SKELETAL KINETIC
DISTRACTOR
Principles
A motor with sub-cutaneous receiver for gradual lengthening

A mechanical function with one way cluches

Advantages over external
fixators
Limb lengthening by external fixators is associated with
problems such as
 Pain at the pin tracts
 Pin tract infections
 Reduced joint motion and
 Prolonged fixation time.
Coated Implants
Hydroxyapatite

Growth Factors

Antibiotics
Hydroxyapatite coated implants
The extraction torque of HAP coated
implants found to be higher.

Coating of the dynamic screw reduced

significantly rate of cutout
Growth Factors
Local application of the growth factors significantly
accelerates the fracture healing in early phase

The sustained release of growth factors doesn’t induce HO.

Antibiotics
Gentamycin coated implants have shown

reduced rate of infection in animal studies.