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NAILING
DR ASHWANI PANCHAL
JSS MEDICAL COLLEGE
MYSORE
INTRAMEDULLARY NAILING
The intramedullary nail is commonly used for longbone fracture fixation and has become the
standard treatment of most long-bone diaphyseal
and selected metaphyseal fractures1
To understand the intramedullary nail, knowledge
of evolution and biomechanics are helpful 2
HISTORY
In 16 th Century In Mexico Aztec physicians have
placed wooden sticks into the medullary canals of
patients with long bone non-union.
1940s:
Gerard
Kntscher
developed
V
nail,
Cloverleaf
shaped and the Y nail.
His methods were based
on two principles: stable
fixation
and
closed
nailing. .
.
1950s:
Stryker
designed
a
broach in a cloverleaf and
diamond shaped pattern.
It
provided
maximum
holding power to resist
torque
and
avoided
reaming the entire canal
circumference.
INTRODUCTION
c o n d y l o c e p h a l i c fi x a t i o n
Also known as elastic stable intramedullary
nailing (ESIN), is a primary definitvie fracture
care (PDFC) in paediatric orthopaedic practice.
This method works by 3 point fixation or
bundle nailing.
The elasticity of the construct allows for ideal
cirumstances of micro-motion for rapid fracture
healing.
Intramedullary nails to be
used as single without
reaming.
A. Schneider nail [ solid,
four flutedcross section
and self broaching ends.
B. Harris condylocephalic
nail [curved in two
planes, and designed for
percutaneous, retrograde
fixation of extra capsular
hip fractures.
C. Lottes tibial nail
specially curved to fit
the tibia, and has
triflanged cross section.
RUSH NAILS
SOLID,
CIRCULAR IN
CROSS SECTION,
STRAIGHT,WITH A
SHARP BEVELLED TIPS
AND A HOOK AT THE
DRIVING END.
BIOMECHANICS
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.
All currently available nails
have beaked or hooked
ends to allow satisfactory
sliding down on insertion
along inner surface of the
diaphysis without impacting
the opposite cortex.
Commonest biomechanical
error is lack of internal
support.
BUNDLE PINNING
INTRAMEDULLARY INTERLOCKING
NAILS:
which
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,
open nailing.
designed
for
LOCKING NAILS :
Gamma
nail:
intramedullary
designed
This
device
for
intramedullary
intertrochanteric
is
proximal
fixation
and
subtrochanterc fractues.
of
some
BIOMECHANICS
When placed in a fractured
long bone, IM nails act as
internal splints with loadsharing characteristics.
Various types of load act on an
IM nail: torsion, compression,
tension and bending
Physiologic loading is a
combination of all these forces
F = Force
Bending moment = F x
D
F=
Force
IM Nail
Plate
D = distance from
force to implant.
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
crosssection
is
rectangular
resisting greater
loads
in
one
plane versus the
other.
BIOMECHANICS
The amount of load borne by the nail depends on the
stability of the fracture/implant construct.
This stability is determined by
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
IM nails are assumed to bear most of the load
initially, then gradually transfer it to the bone as the
fracture heals.
BIOMECHANICS
Several factors contribute to the overall
biomechanical profile and resulting structural stiffness
of an IM nail.
Chief among them are
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
Material properties
PMMA
Bone cortex
Titanium
* 10 psi
20 40
Diameter :
Nail diameter affects bending rigidity of nail.
For a solid circular nail, the bending rigidity is
proportional to the third power of nail diameter
Torsional rigidity is proportional to the fourth power
of diameter .
Large diameter with same cross-section are both
stiffer and stronger than smaller ones.
Some nails are designed in a such a way that
stiffness doesnt vary with diameter.
Nail
Diamet
er (mm)
Stainles
s Steel
(X 106 )
Titaniu
m
(X 106 )
10
40.0
20.0
11
52.0
26.0
12
69.0
34.5
13
88.8
44.4
14
112.1
56.4
15
139.1
69.6
16
170.1
75.1
17
241.4
120.7
Size length
Obtain preoperative radiographs of the
fractured long bone, including the
proximal and distal joints.
If there is any question, obtain an
anteroposterior
radiograph
of
the
opposite normal limb at a tube distance
of 1meter. A nail of the appropriate size
should be taped to the side of the limb
for reference, or a radiographic ruler can
be used, alternatively a Kuntscher
measuring device the ossimeter may
be used to measure length and width.
The ossimeter has two scales, one of
which
takes
into
account
the
magnification caused by the X-ray at a 1
m tube distance.
-In most cases, a nail reaching to within
1 to 2 cm of the subchondral bone
CURVES
Herzog bend
Tibial nail also has a smooth 11
bend in the anterioposterior
direction at junction of upper
one third and lower two third .
Working length:
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
Medullary reaming prepares a uniform canal and
improves nail- bone fixation
Towards the fracture,thus reducing the working
length.
INTERLOCKING
Interlocking screws are recommended for most
cases of IM nailing.
The number of interlocks used is based on fracture
location, amount of fracture comminution , and the
fit of the nail within the canal.
Placing screws in multiple planes may lead to a
reduction of minor movement
The principle of interlocking nailing is different. The
nail is locked to the bone by inserting screws through
the bone and the screw holes. The resistance to
axial and torsional forces is mainly dependent on the
screw bone interface, and the length of the bone is
maintained even if there is a bone defect.
STATIC LOCKING
DYNAMIC LOCKING
It achieves additional rotational
control of a fragment with large
medullary canal or short epimetaphyseal fragment.
It is effective only when the
contact area between the major
fragments is atleast 50% of the
cortical circumference.
With axial loading, working
length in bending and torsion is
reduced as nail bends and abuts
against the cortex near the
fracture, improving the nail-bone
contact
DYNAMISATION:
No longer std. practice to dynamize an
interlocked nail by removing the locked
screws .
It is indicated when there is a risk of
development of nonunion or established
pseudoarthrosis.
The screws are then removed from the longer
fragments, maintaining adequate control of
shorter fragment. Premature removal may
cause shortening, instability and nonunion.
Poller screw
when
malalignment
develops
during nailinsertion,placement of
blocking
screw,
and
nail
reinsertion improves alignment.
Most reliable in proximal
distal shaft fractures of tibia.
and
A
posteriorly
placed
screw
prevents anterior angulation and
laterally placed screw prevents
valgus angulation.
Screw
strength
Characterised
by
an
outer
diameter,
root
diameter and pitch.
Shape
of the threads at
their base determines
stress concentration
(sharp v/s rounded).
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.
ENTRY SITES:
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.
For nonreamed, flexible nails, an eccentric entry
site is usually used to take advantage of three
point fixation of the curved nail within the
medullary canal. Generally these nails are
inserted distally through the supracondylar
flares of the long bones
ENTRY SITES
RETROGRADE IM
NAILING
3 cm longitudinal
incision approximately
1 cm from the medial
border of patella,
beginning about 2 cm
proximal to distal pole
of the patella
BIOMECHANICS OF IM
REAMING
IM reaming can act to increase the contact area
between the nail and cortical bone by smoothing
internal surfaces.
When the nail is the same size as the reamer, 1 mm
of reaming can increase the contact area by 38% .
Reaming reduces the working length and increase
the stability.
More reaming allows insertion of a larger-diameter
nail, which provides more rigidity in bending and
torsion.
Biomechanically, reamed nails provide better fixation
stability than do unreamed nails
Medullary canal is more or less like an hourglass than a perfect cylinder. Reaming is an
attempt to make the canal of uniform size to
adapt the bone to the nail. The size of the canal
limits the size of the nail.
Reamers
REAMING TECHNIQUE:
REAMING TECHNIQUE
LOCAL CHANGES:
LOCAL CHANGES:
SYSTEMIC CHANGES
Advantages
Allows insertion of larger-sized implants which helps in
weight bearing and joint function during the healing
process.
- Improves nail-bone cortical contact across the working
length of the implant and directs fracture fragments into a
more anatomical position.
- From a biologic standpoint, provides systemic factors to
promote mitosis of osteogenic stem cells and to stimulate
osteogenesis.
Disadvantages
Eccentric reaming may lead to malreduction of the
fracture.
- Destroys all medullary vessels, resulting in a initial
decrease in endosteal blood flow and in turn decreased
immune response and delay in early healing of the
involved cortices.
Side effects
- Heat: a rise in temperature upto 44.6
C had a negative effect on fracture
healing.
Cell enzymes get damaged and cannot
fullfill their function.
The threshold value of heat induced
osteonecrosis is 47C.
- Pressure: hydraulic pressure builds up
in the cavity which far exceeds that of
blood pressure and is independent of
the size of the reamer.
It acts as a piston in sleeve which is
filled with a mixture of medullary fat,
blood, blood clots and bone debris.
High intramedullary pressure forces
contents into the cortical bone and
systemic circulation.
TECHNIQUE FOR
INTERLOCKING:
Lateral
fluoroscopic view
of the distal
screws in Grosse
Kempf nail:
The hole, which is
to be cross
locked is in the
center of the
screen and is
perfectly
superimposed
IM NAIL REMOVAL
It is not necessary to remove a nail in a weight
bearing limb unlike a plate.
If needed can be removed after 18 months.
Indications for removal- Patient request, pain swelling secondary to backing
out of the implant.
- Nail removal should not be undertaken lightly
,specialized extraction equipment fitting the nail
must be available.
- Full weight bearing can commence immediately
after the removal of nail
Z-effect of im nails
Z-Effect is an unfortunate by-product of most
intramedually nails that utilize two screws placed up
into the femoral neck and head. Typically, the superior
screw is of smaller diameter than the inferior and
bears a disproportionate amount of load during weight
bearing. Excessive varus forces placed on the smaller
screw at the lateral cortex cause it to toggle and either
back out or migrate through the femoral head into the
acetabulum. The larger inferior screw is neither keyed
in rotation nor locked in place, and it too will either
back out or migrate medially. The resultant Z-Effect
where the two screws move in opposite directions is
one mode of failure for the conventional two screw
reconstruction device.
IM NAIL FAILURE
With all metallic implants, there is a relative race
between bone healing and implant failure.
Occasionally, an implant will break when fracture
healing is delayed or when nonunion occurs.
IM nails usually fail in predictable patterns. 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
a pp l icat i on s of im na il in g
Anatomic alignment, early weight bearing, early unrestricted
joint & muscle rehabilitation are of advantage to the patient.
ARDS can be prevented in multiple injuries by stabilizing and
mobilizing the patient immediately.
Floating hip, floating knee, floating elbow.
To protect the vascular repair following injuries by a fracture.
Aseptic and septic non-union.
Pathological fractures.
Malunions.
High proximal and low distal fractures of long bones
Open tibial and femoral grade I and II fractures
REFERENCES:
1.CAMPBELL OPERATIVE ORTHOPAEDICS 11TH
EDITION
2.The science and practice of Intramedullary Nailing
Bruce D. Brown
3.ROCKWOOD AND GREENS
4.INTERLOCKING NAILING-DD.TANNA
5. The elements of fracture fixation Anand J Thakur
6.Prospective study of distal end radius fracture by an
intramedullary nailing JBJS aug3 2011
THANK YOU