Keywords

3.1 Indication

3.1.1 Femoral Shaft Fracture with Various Degrees of Comminution

Closed femoral nailing is a treatment of choice in femoral shaft fractures with various degrees of comminution (Fig. 3.1). The static interlocking method enables us to fix them without risk of collapse at the comminuted segment. It also offers stable fixation for immediate weight-bearing after IM nailing. IM nailing is possible in open fracture after careful, meticulous debridement of the open wound, usually in Gustilo-Anderson classification I and II, sometimes in IIIa (Fig. 3.2) [1,2,3,4,5,6,7,8].

Fig. 3.1
figure 1

Two cases of severely comminuted femoral shaft fracture. The positions and the situations of the butterfly fragment are different. Although the bone union was obtained in both cases, a large butterfly fragment that was displaced to the other side of the femur should have been reduced by the open technique in the second lower. Bone graft was necessary to fill up the defect before the nail removal in this case

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Fig. 3.2
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A 20-year-old female patient fell from the second floor through the window. The spear-shaped fence hit her thigh and fractured the femur (left). Sequential radiograms of this patient at the emergency room, operating room (immediate postoperative), and outpatient clinic (final follow-up, right)

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3.1.2 Segmental Fracture of the Femur

Segmental fracture of the femur is another best indication of IM nailing, although it requires high surgical skills (Fig. 3.3). Again, step by step procedure is necessary to overcome the problems encountered [9].

Fig. 3.3
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IM nailing is the treatment of choice for segmental femoral shaft fracture if the surgeons have good experiences and techniques to overcome the problems during the IM nailing procedures. Early callus formation is evident after this minimally invasive technique

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3.1.3 Delayed Union or Nonunion of Femoral Shaft Fracture

Nail conversion after failed plate fixation (Fig. 3.4) and exchange nailing is a popular method to overcome the compromised healing of femoral shaft fracture. For details, see Chap. 9–11 [10,11,12,13,14,15,16].

Fig. 3.4
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A 77-year-old lady fell from the standing height and sustained a spiral-type femoral shaft fracture. She underwent open reduction and internal fixation with a locking plate at the local hospital. The plate broke 4 months after surgery, and she was transferred to me. A broken plate was removed, and a femoral nail was inserted. Due to weakness of bone after several months of immobilization, three interlocking screws and two Poller screws were used to stabilize the distal fragment. The fracture was united 6 months after nail conversion [17]

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3.1.4 Pathologic Fracture

Certain metabolic bone diseases and tumorous conditions (osteomalacia, osteogenesis imperfect (Fig. 3.5), Paget’s disease (Fig. 3.6), hypophosphatemic rickets, fibrous dysplasia, etc.) weaken the femur and cause bowing and even fracture [18,19,20,21]. Therefore, prophylactic or therapeutic IM nailing is necessary to let the patients walk on weight-bearing. Deformity of the femur and medullary canal is a contraindication of IM nailing. However, it may be the final solution for a patient who suffers from repeated limb fractures due to osteogenesis imperfect. A metastatic bone tumor is another condition that IM nailing is required for the same purpose (Fig. 3.7).

Fig. 3.5
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This 30-year-old male patient suffered from 10 previous femur fractures and walked with the support of a long leg brace. He experienced another new fracture at the mid-shaft of the bowed femur after a fall (long white arrow). One of the previous fractures resulted in malunion (short white arrow). Deformity of the femur and associated obstruction of the medullary canal is a contraindication of the IM nailing. However, it could be the only solution in the treatment of osteogenesis imperfect. The Sofield technique is frequently applied to children, but rarely to adults. After osteotomy at the malunion site, IM nailing was performed to straighten the femur. The fracture healed uneventfully, but a proximal interlocking screw was removed due to pain 2 years postoperatively. The femur has been protected from the pathologic fracture for 16 years after the corrective osteotomy and IM nailing

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Fig. 3.6
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A 66-year-old female patient suffered from Paget’s disease on both femora and maxilla. Prophylactic femoral nailing was performed due to progressive bowing, pain, and impending fracture (white arrow). A femoral nail was inserted in external rotation to accommodate excessive anterolateral femoral bowing. Despite the slow healing process of the crack on the femoral bowing apex, the pain subsided 3 years after IM nailing [18, 22]

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Fig. 3.7
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A 60-year-old lady sustained a pathologic subtrochanteric fracture that was caused by a metastatic bone tumor from lung cancer. Intraoperative fluoroscopic image showed a significant void in the subtrochanteric area (white arrow). Because the IM canal was small, it could only accommodate an 8.3 mm diameter femoral nail. In addition, jamming of the transitional part of the nail (black arrow) interfered with proper insertion of the proximal interlocking screws into the femoral head. Further destruction of the trochanter was noted 6 weeks after IM nailing

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3.1.5 Reconstruction of Segmental Defect

The IM nail and external fixator combination enables us to correct the leg length discrepancy in a severely injured patient. After correction of the femoral length, a defect can be filled with a simple autogenous bone graft (Fig. 3.8) [23,24,25,26] or Masquelet technique [27]. For details, see Chap. 7.

Fig. 3.8
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A 19-year-old boy sustained an open femur shaft fracture after a motorcycle accident. Segments of bone were missing through the open wound. An external fixator was applied after debridement at first. Due to the shortening of the femur, primary closure of the open wound was possible after debridement (lower column). Two weeks after injury, the femur was fixed with IM nail and augmented with a Monorail type of Orthofix external fixator. The gradual lengthening of the femur was performed until the length of the injured femur matched with an intact side. Then, distal interlocking of the femoral nail and autoiliac bone graft was performed. Augmentative lateral plate fixation was an operating surgeon’s discretion. Bone union is evident at postoperative 4 months

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3.1.6 Lengthening of Femur

Shortening of the femur after the injury is a serious complication that results in limping and back pain due to scoliosis. Specially designed nails with rachets inside can increase the length of the nail and interlock the femur to correct leg length discrepancy (Fig. 3.9). The outcomes of motorized intramedullary lengthening nail are good with acceptable complication rates [28, 29]. For details, see Chap. 12.

Fig. 3.9
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Fixation of femoral shaft fracture with the Ender nail resulted in bony union with shortening of 6 cm. The shortened femur was osteotomized using the IM saw and fixed with an Albizzia nail. Gradual lengthening was performed after 2 weeks, and early callus formation was evident at postoperative 1.5 months. The lengthened part was completely remodeled at postoperative 2 years

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3.2 Contraindication

  1. 1.

    Active infection: Active infection is a contraindication of osteosynthesis with an internal implant, such as nail and plate.

  2. 2.

    Narrow medullary canal; Obliteration or excessive narrowing of the medullary canal is a contraindication of IM nailing (Figs. 3.10 and 3.11).

  3. 3.

    Deformity of the medullary canal due to previous injury.

    Severe deformity of the long bone precludes IM nailing unless correctional osteotomy is performed before the nailing (Fig. 3.12). For IM nailing in deformed femur, see Chap. 11 [33].

  4. 4.

    Severe lung injury in a multiple injured patient [34,35,36,37,38].

    The reamer head acts as a piston within a syringe. So, the rapid advancement of the reamer head causes high IM pressure and pulmonary embolism of the medullary contents, which is critical in severe lung injury (Fig. 3.13).

Fig. 3.10
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An extremely narrow medullary canal in the middle segment of the segmental femoral shaft fracture precluded IM nailing because of the fear of spinning the middle segment, heat necrosis, and fat embolism during IM reaming. Therefore, osteosynthesis was performed using MIPO technique instead

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Fig. 3.11
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A case of osteopetrosis with an extremely narrow medullary canal. It is wise to avoid IM nailing if the medullary canal is not traceable [30,31,32]

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Fig. 3.12
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The locking plate for the complex deformity in the femoral shaft. The patient had complex deformity at the femoral shaft and sustained an insufficiency fracture at the distal zone of the deformity. We aligned the straight portions of both proximal and distal fragments and attached the locking plate and screws from the lateral aspect of the femoral shaft. It mimicked as if we performed a correctional opening osteotomy. The fracture site and posterior opening gap (white arrow) were healed 6 months after plate osteosynthesis. A locking plate is a useful tool in fixing the irregular surfaces of the femoral shaft. Otherwise, tightening of the conventional screw pulls the cortex to the undersurface of the plate, interfering with open osteotomy effect

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Fig. 3.13
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IM nailing in a multiply injured patient with severe lung injury may aggravate the lung function due to embolization of the marrow contents. The chest tubes were inserted in both sides of the pleural cavities to treat the flail chest. MIPO technique was used to treat the severely comminuted femoral shaft fracture. Union was obtained 12 months after the operation

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