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Intramedullary Nailing of Femoral Shaft Frx

- See: 
       - Distal Femoral Shaft Fractures 
       - Infected IM nails 
       - Open Fractures 
       - Proximal Femoral Shaft Fractures 
       - Synthes IM Femoral Nail

- Discussion: Intramedullary Nailing:
    - closed IM nailing has supplanted other forms of treatment  for femur frx;
    - it affords predictable realignment of bone, rapid regeneration of bone and union of the fracture, and early functional use of the limb;
    - union can be expected in 28-29 weeks for reamed femoral nails and about 39 weeks for unreamed nails;
    - technique considerations:
           - in the report by Ostrum RF, et al (2000), the authors prospectively compared the results of antegrade vs retrograde IM nailing;
                  - the authors noted that the two techniques were essentially equally effective in treating shaft fractures;
                  - retrograde nails had a higher incidence of symptomatic distal interlocking screws;
                  - in the antegrade group, over 25% of patients had Trendelenburg gait pattern, weakness and or pain;
           - antegrade nailing technique:
                  - positioning for femoral shaft fractures 
                  - IM nail entry point 
                  - reaming and nailing maneuver 
           - retrograde nailing technique:
           - comminuted frx: - Winquiest Classification 
                  - in the past, major limitation of all nailing systems has been poor results in comminuted midshaft fractures & in fractures at proximal & distal aspects of the shaft;
                  - axial and rotatory loads are not neutralized by most nails, and postoperative shortening & malrotation are frequent complications;
    - locked nails:
           - locking nails has no deliterious effects on healing
           - may support 3x forces in axial loading;
           - usually unnecessary to reduce comminuted fragments
           - dynamic fixation:
                  - screws in just the proximal or distal holes
                  - indicated for fractures w/ no potential instability in rotation;
           - static fixation:
                  - w/ screws in both proximal and distal hole
                  - for frx w/ both shortening and malrotation are possible;
                  - increases stiffness of the nail in torsion;
                  - stress shielding is Not clinically significant;
                  - Wiss, et al. (1986);
                         - report 98% union rate, < 1% infection 
                         - Comminuted and rotationally unstable fractures of the femur treated with an interlocking nail.

    - Complications of IM Nails: 
           - compartment syndrome of thigh
           - femoral IM nail infection 
           - avascular necrosis from IM nailing 
           - femoral non union

Reamed versus unreamed femoral nails. A randomized prospective trial. 

Prospective Comparison of Retrograde and Antegrade Femoral Intramedullary Nailing