Abstract
Intramedullary nailing is used to stabilize distal femoral, proximal tibial, and distal tibial periarticular fractures with short proximal or distal segments, as well as some intra-articular fractures in which a stable articular block can be created. Intramedullary nailing may be beneficial in complex fracture patterns with diaphyseal extension, segmental injuries, or patients who might benefit from a decreased incision burden. Step 1: Preoperative planning. Review imaging and make sure there is a nail with adequate interlocks. Consider the use of adjunctive techniques to obtain and maintain alignment, and how intra-articular fracture lines will be stabilized. Step 2: Position and prepare the patient. Step 3: Exposure for nailing via suprapatellar, infrapatellar, or knee arthrotomy approaches. Limited exposure of fracture planes may also be necessary for adjunctive techniques. Step 4: Convert an OTA/AO C-type fracture to an A-type fracture if needed. Step 5: Obtain appropriate starting point and trajectory with the nail starting wire and use the opening reamer. Step 6: Obtain reduction, if not yet done, and pass the ball-tipped reaming wire across the fracture. Step 7: Ream while holding reduction. Step 8: Pass nail. Step 9: Verify reduction is maintained and correct if needed. Step 10: Place interlocks, preferably multiplanar, in the short segment. Create a fixed angle construct if desired and convert adjunctive techniques/provisional fixation to definitive fixation as needed. Step 11: Perform final checks. Step 12: Closure. Step 13: Postoperative plan. For extra-articular fractures, one may expect healing with maintained alignment from what was present at the case end intraoperatively in the vast majority of cases. For intra-articular fractures, development of posttraumatic arthritis is an additional concern.
Footnotes
Published outcomes of this procedure can be found at: Injury. 2015;46(6):1097-101, Bone Joint J. 2016 Jun;98-B(6):846-50, and J Orthop Trauma. 2017 Apr;31(4):215-219.
Investigation performed at Indiana University Health Methodist Hospital, Indianapolis, Indiana
Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJSEST/A270).
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