Femoral Shaft Fracture Retrograde Intramedullary Nailing

Preoperative Patient Care


Outpatient Evaluation and Management


Obtains focused history and performs focused exam

  • document distal neurovascular status
  • concomitant and associated orthopaedic injuries


Interprets basic imaging studies

  • obtain biplanar radiographs of entire femur, hip, knee, and/or CT of femoral neck
  • 2-6% incidence of ipsilateral femoral neck fracture
  • often basicervical, vertical, and nondisplaced


Stabilized length of diaphyseal fracture (immobilzation vs. traction)

  • immobilization if time to surgery is acute
  • if potential delay in definitive fixation with intramedullary nail, place distal femoral or proximal tibia traction pin with ~25lb inline traction to reduce amount of shortening
  • no tibial traction pin if ipsilateral knee injury suspected
  • place in femoral traction if time to surgery will be delayed
  • definitive stabilization within 24 hours is associated with decreased pulmonary complications, thromboembolic events, and length of hospital stay


Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention


Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • diagnose and management of early complications
  • staples/sutures removed
  • continue physical therapy and range of motion exercises
  • repeat radiographs of femur
  • postop: ~ 3 month postoperative visit
  • diagnosis and management of late complications
  • repeat xrays of femur
  • postop: 1 year postoperative visit
  • obtain one year radiographs
  • document outcome with appropriate standardized scoring system

Advanced Evaluation and Management


Prioritizes the needs of the polytrauma patient

  • timing of long bone fixation
  • works with consulting


Complex wound management and debridement

  • understanding need for consultation for flap coverage


Capable of treating complications both intraoperatively and post-operatively

  • manages post operative infection

Preoperative History and Physical


Perform focused orthopedic exam

  • check ipsilateral femoral neck
  • check thigh compartments (anterior, posterior, adductor)
  • document distal neurovascular status


Order basic imaging studies

  • need AP and lateral radiographs of entire femur, hip, knee
  • CT of femoral neck


Perform operative consent

  • describe complications of surgery including
  • post-operative knee pain
  • heterotopic ossification
  • delayed union, nonunion
  • femoral nerve or artery injury (insertion of proximal interlocking screws)
  • increased risk if screws placed inferior to lesser trochanter
  • malrotation of femur
  • infection
  • hardware failure
  • missed femoral neck fracture
  • iatrogenic fracture (under-reaming, femoral neck fracture)
  • iatrogenic damage to cruciate ligaments

Operative Techniques


Preoperative Plan


Template fracture reduction

  • draw key fragments of fracture and plan forces required to obtain reductions


Template instrumentation

  • measure diameter intramedullary canal and approximate length


Execute surgical walkthrough

  • resident can describe the key steps of the procedure verbally to the attending prior to the start of the case
  • description of potential complications and steps to avoid them

Room Preparation


Surgical instrumentation

  • make sure retrograde intramedullary nailing system is present.


Room setup and equipment

  • radiolucent flat-top table
  • c-arm fluoroscopy
  • c-arm from contralateral side
  • perpendicular to the bed
  • take initial AP and lateral of hip to examine femoral neck


Patient positioning

  • patient supine with feet at the end of the bed
  • small bump under ipsilateral thigh
  • if traction pin in place, can remove prior to prep and drape
  • alternatively can leave in place to use for traction during case
  • prep and drape entire leg up to iliac crest

Anterior Knee Aproach


Position the knee and mark out the anatomy

  • place knee in ~30° flexion over radiolucent triangle
  • knee flexion also prevents distal fragment from being pulled into more flexion by gastrocnemius
  • mark out inferior pole of patella and borders of patella tendon


Expose the intercondylar notch

  • make incision, dissect through subcutaneous tissues, and perform arthrotomy
  • transtendinous approach
  • make 2cm incision from inferior pole of patella distal through tendon
  • perform tenotomy to develop paratenon layer, sharply dissect or cauterize through paratenon then patellar tendon
  • insert self-retainers and suction out synovial fluid
  • once in joint, remove small amount of fat pad to minimize guidepin deflection
  • parapatellar approach
  • 2 cm incision along medial third of patellar tendon
  • cut through subcutaneous tissue and retract tendon/paratenon laterally insert self retainer


Visualize intercondylar notch


Guidewire entry


Identify guidewire starting point

  • guidepin start point is in center of intercondylar notch, just superior to Blumensaat’s line


Use entry reamer with soft tissue protector


Insert guidepin to distal metaphysis

  • check C-arm image to ensure pin is in center of medullary canal


Place balltip guiewire

  • remove starting pin and reamer, and place balltip guidewire in canal with T-handle
  • place gentle bend at tip of balltip wire, manually push in to distal aspect of fracture site

Fracture Reduction and Reaming


Reduce fracture by pulling traction

  • can use small blue towel bump to add flexion to distal segment
  • if pulling straight inline traction on foot you will cause more flexion deformity of the distal segment due to pull of the gastrocnemius
  • need to pull traction at 30° angle over triangle


Advance guidewire

  • manually push guidewire past fracture site and up to lesser trochanter
  • insert guidewire past lesser trochanter by 3-4cm


Check placement of wire with AP and lateral radiographs


Measure nail length

  • use radiolucent ruler to measure appropriate nail length
  • use ruler on contralateral side to measure intact femur if segmental comminution exists


Ream intramedullary canal

  • start with 9mm reamer, then ream up 0.5-1.0mm with consecutive reamer
  • ream 1.5mm above size of final nail (i.e. size 12.5mm reamer head for size 11mm nail)
  • don’t stop reamer in canal (avoids reamer head from becoming incarcerated)
  • if eccentric reaming/wire position is seen, can place blocking screws

Nail Insertion


Assemble femoral nail

  • attach jig to nail on backtable and check that targeting guide lines up with holes in nail


Insert nail over guidewire

  • cover holes closest to nail handle with hand to make sure blood doesn't pressurize out of nail during insertion
  • insert nail with jig lateral to thigh
  • hold nail by handle, not the targeting guide, mallet or manually advance to fracture site


Advance the nail

  • manually advance nail past the fracture site to avoid iatrogenic comminution or development of new fracture lines
  • possible with use of the mallet
  • seat nail fully


Confirm nail depth

  • lateral radiograph of the knee is the appropriate view to assess nail insertion depth


Remove guidewire before placing interlocking screws


Distal Interlocking Screws


Place trocar onto bone

  • use targeting guide to place most distal interlock first
  • mark skin with sleeve, incise through skin, spread down to bone with hemostat, and place trochar on bone


Place interlocking screw

  • drill bicortically through the nail
  • leave drill bit in until screw arrives to hold nail/bone position
  • remove drill bit then quickly place the screw
  • repeat process above for placement of other interlocking screws if indicated


Remove jig

  • use attachment to remove nail jig, then take out triangle to lay leg flat


Check femoral neck again on C-arm


Proximal Interlocking Screws


Obtain perfect circles

  • ensure no rotation of the distal femur is done while getting these views
  • move the C-arm, not the leg
  • magnification of the fluoroscopic view can be used if desired


Identify placement of interlocking screws

  • incise through skin, careful blunt spreading down to bone, especially if distal to lesser trochanter
  • start with most proximal interlocking hole (screw will be longer than the more distal screw)


Drill holes for interlocking screws

  • ensure drill bit placed over center of hole, parallel to C-arm beam to measure
  • can use a second drill bit or depth gauge
  • alternatively use a 34 or 36mm screw


Insert interlocking screws

  • remove drill quickly and insert screw when available
  • use locking screwdriver or place silk suture around screw head so it doesn’t get lost in soft tissues


Repeat above process for 2nd proximal interlocking screw


Take final radiographs

  • raise leg up off of bed, 90° bend in knee, then take final AP and lateral radiograph of proximal, middle, and distal aspects of femur


Take hip through a range of motion to assess for fracture

  • fluoroscopic evaluation is key, whether static or dynamic at the end of the procedure


Check limb lengths and rotation


Perform a knee examination under anesthesia


Wound Closure


Irrigation, hemostasis, and drain

  • place knee under triangle and strongly flush out reamings with saline bulb irrigation
  • irrigate until backflow is clear
  • cauterize peripheral bleeding vessels


Fascia closure

  • transtendinous
  • close patellar tendon and paratenon layers with 0-vicryl
  • subcutaneous and skin closure
  • parapatellar
  • close peripatellar arthrotomy
  • subcutaneous and skin closure



  • Soft dressings over knee, distal, and proximal femur

Postoperative Patient Care


Perioperative Inpatient Management


Write comprehensive admission orders

  • advance diet as tolerated
  • pain control
  • wound management
  • remove dressings POD2
  • foley out when ambulating
  • check appropriate labs
  • antibiotics
  • prescribe DVT Prophylaxis


Appropriately orders and interprets basic imaging studies

  • obtain radiographs of the femur and knee in postop


Initiate physical therapy POD 1

  • weight bear as tolerated
  • immediate range of motion exercises to hip and knee


Appropriate medical management and medical consultation


Discharges patient appropriately

  • pain meds
  • outpatient PT
  • schedule follow up visit
  • weightbearing as tolerated

Complex Patient Care


Develops unique, complex post-operative management plans


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