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Intramedullary Nailing of Femoral Shaft Fractures: Current Concepts

Dr. Ricci is Associate Professor, Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO. Dr. Gallagher is Resident, Department of Orthopaedic Surgery, Washington University School of Medicine. Dr. Haidukewych is Attending Orthopaedic Surgeon, Florida Orthopaedic Institute, Temple Terrace, FL.

Reprint requests: Dr. Ricci, Department of Orthopaedic Surgery, Washington University School of Medicine, 1 Barnes Hospital Plaza, Suite 11300, St. Louis, MO 63110. ricci@wustl.edu

Dr. Ricci or a member of his immediate family serves as a board member, owner, officer, or committee member of the Orthopaedic Trauma Association; is affiliated with the publications Journal of Bone and Joint Surgery American and British, and Journal of Orthopaedic Trauma; has received royalties from Smith & Nephew; is a member of a speakers’ bureau or has made paid presentations on behalf of AO, Wright Medical Technology, Synthes, and Smith & Nephew; serves as a paid consultant to or is an employee of Wright Medical Technology and Smith & Nephew; and has received research or institutional support from AONA, Synthes, Smith & Nephew, and Wright Medical Technology. Dr. Haidukewych or a member of his immediate family serves as a board member, owner, officer, or committee member of The Florida Orthopaedic Institute; is affiliated with the publication Journal of Orthopaedic Trauma; has received royalties from DePuy and Zimmer; is a member of a speakers’ bureau or has made paid presentations on behalf of DePuy; serves as a paid consultant to or is an employee of DePuy; has received research or institutional support from DuPuy; and has stock or stock options held in SurModics. Neither Dr. Gallagher nor a member of her immediate family has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article.

Intramedullary nailing is the preferred method for treating fractures of the femoral shaft. The piriformis fossa and greater trochanter are viable starting points for antegrade nailing. Alternatively, retrograde nailing may be performed. Each option has relative advantages, disadvantages, and indications. Patient positioning can affect the relative ease of intramedullary nailing and the incidence of malalignment. The timing of femoral intramedullary nailing as well as the use of reaming must be tailored to each patient to avoid systemic complications. Associated comorbidities, the body habitus, and associated injuries should be considered when determining the starting point, optimal patient positioning for nailing, whether to use reduction aids as well as which to use, and any modifications of standard technique. Intramedullary nailing of diaphyseal femur fractures provides a stable fixation construct that can be applied using indirect reduction techniques. This method yields high union rates and low complication rates when vigilance is maintained during preoperative planning, the surgical procedure, and the postoperative period.