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KEY FACTS
Terminology
Imaging
Clinical Issues
TERMINOLOGY
Definitions
- Nails and rods are intramedullary (IM) fixation devices for long bones that have varying definitions from different sources with no uniform definition
- IM nail (IMN): variably described as
- Rigid, straight, hollow IM device
- Has proximal and distal holes to allow locking into place
- Driven into position by specialized tool
- Requires reaming of marrow cavity to allow placement
- IM rods: variably described as
- Solid IM device; may be curved &/or flexible
- No interlocking function
- Does not require reaming or specific driver
- In general, wide-bore IM device that nearly fills marrow space at midportion = IMN; narrow device that is often used in multiples = rod
- Antegrade placement: placed from proximal end of bone to distal end of bone; most common direction of insertion
- Retrograde placement
- Placed in distal aspect of bone and directed proximally
- Indications for retrograde insertion in femur
- Distal femur fractures to achieve better control/reduction
- Obese patients in whom entry point in proximal femur will be difficult to reach
- Polytrauma patients to minimize surgical time
Concepts of Nail/Rod Placement and Use
- Used to treat long bone fractures
- Share load, allowing for early weight bearing
- Unlocked and dynamic locking allow micromotion, which stimulates healing
- Insertion with minimal soft tissue dissection compared to plates
- Antegrade vs. retrograde determined by site of fracture, ease of access to desired entry site
- Removed after healing achieved in children/young adults
- Static locking
- Rod locked at proximal end and distal ends
- Provides axial and rotational stability
- Allows immediate weight bearing
- Risk is overdistraction, which can lead to delayed healing
- Used for unstable fractures
- Prevents collapse at fracture, which could lead to limb-length discrepancy
- Dynamic locking
- Interlocking screw, locked at 1 end only
- To dynamize means to remove 1 set of screws of static (proximal and distal) locked rod
- Dynamizing allows natural compression across fracture to promote healing
- Used for transverse or shallow oblique fractures with minimal comminution
- Reaming: removing IM contents to allow passage of IMN, appropriate size of tunnel
- Reamed nails usually larger, provide greater stability
- May ↑ risk of fat embolism
- Provides degree of natural bone graft at fracture site
- Disrupts internal blood supply, ↑ infection risk
- Flexible rod: Ender, Lottes
- Used in immature skeleton to avoid growth plate
- Less rigid; may require additional stabilization, such as splint/cast
- Usually place multiple rods via multiple entry sites in metaphysis
- Usually leave small portion outside bone to enable subsequent retrieval
- Cephalomedullary nail (CMN)
- Femoral IMN coupled with fixed-angle device that extends up femoral neck into head
- Component for head: large screw, 2 smaller screws, or spiral blade
- Larger screw may function similar to dynamic hip screw
- Currently used for most peritrochanteric fractures
- "Gamma nail" was original CMN; no longer in use today
- Short and long versions exist
- Lengthening nail
- IMN devised to combine with osteotomy/corticotomy to lengthen bone
- Uses external magnets to elongate nail
- In setting of congenital or posttraumatic limb shortening
- Fusion nail
- Long version in use to fuse knee; extends from proximal femur to distal tibia
- Hindfoot nail: short IMN to fuse hindfoot and ankle, inserted retrograde
IMAGING
General Features
Radiographic Findings
CT Findings
MR Findings
CLINICAL ISSUES
Presentation
Selected References
- Hosny GA: Limb lengthening history, evolution, complications and current concepts. J Orthop Traumatol. 21(1):3, 2020
- Poutoglidou F et al: Flexible intramedullary nailing in the treatment of forearm fractures in children and adolescents, a systematic review. J Orthop. 20:125-30, 2020
- Gausden EB et al: Biomechanics of periprosthetic fixation: plates, nails, cables, and allografts. J Orthop Trauma. 33 Suppl 6:S1-4, 2019
- Hake ME et al: Modern implant options for the treatment of distal femur fractures. J Am Acad Orthop Surg. 27(19):e867-75, 2019
- Allen H et al: Orthopaedic fixation devices used in children: a radiologist's guide. Semin Musculoskelet Radiol. 22(1):12-24, 2018
- Virkus WW et al: Intramedullary nailing of periarticular fractures. J Am Acad Orthop Surg. 26(18):629-39, 2018
- Horwitz DS et al: Nail length in the management of intertrochanteric fracture of the femur. J Am Acad Orthop Surg. 24(6):e50-8, 2016
- Georgiannos D et al: Subtrochanteric femoral fractures treated with the long Gamma3 nail: a historical control case study versus long trochanteric Gamma nail. Orthop Traumatol Surg Res. 101(6):675-80, 2015
- Queally JM et al: Intramedullary nails for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 9:CD004961, 2014
- Study to prospectively evaluate reamed intramedullary nails in patients with tibial fractures investigators et al: randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am. 90(12):2567-78, 2008
- Gadegone WM et al: Proximal femoral nail - an analysis of 100 cases of proximal femoral fractures with an average follow up of 1 year. Int Orthop. 31(3):403-8, 2007
- Wood GW 2nd: Intramedullary nailing of femoral and tibial shaft fractures. J Orthop Sci. 11(6):657-69, 2006
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References
Tables
Tables
KEY FACTS
Terminology
Imaging
Clinical Issues
TERMINOLOGY
Definitions
- Nails and rods are intramedullary (IM) fixation devices for long bones that have varying definitions from different sources with no uniform definition
- IM nail (IMN): variably described as
- Rigid, straight, hollow IM device
- Has proximal and distal holes to allow locking into place
- Driven into position by specialized tool
- Requires reaming of marrow cavity to allow placement
- IM rods: variably described as
- Solid IM device; may be curved &/or flexible
- No interlocking function
- Does not require reaming or specific driver
- In general, wide-bore IM device that nearly fills marrow space at midportion = IMN; narrow device that is often used in multiples = rod
- Antegrade placement: placed from proximal end of bone to distal end of bone; most common direction of insertion
- Retrograde placement
- Placed in distal aspect of bone and directed proximally
- Indications for retrograde insertion in femur
- Distal femur fractures to achieve better control/reduction
- Obese patients in whom entry point in proximal femur will be difficult to reach
- Polytrauma patients to minimize surgical time
Concepts of Nail/Rod Placement and Use
- Used to treat long bone fractures
- Share load, allowing for early weight bearing
- Unlocked and dynamic locking allow micromotion, which stimulates healing
- Insertion with minimal soft tissue dissection compared to plates
- Antegrade vs. retrograde determined by site of fracture, ease of access to desired entry site
- Removed after healing achieved in children/young adults
- Static locking
- Rod locked at proximal end and distal ends
- Provides axial and rotational stability
- Allows immediate weight bearing
- Risk is overdistraction, which can lead to delayed healing
- Used for unstable fractures
- Prevents collapse at fracture, which could lead to limb-length discrepancy
- Dynamic locking
- Interlocking screw, locked at 1 end only
- To dynamize means to remove 1 set of screws of static (proximal and distal) locked rod
- Dynamizing allows natural compression across fracture to promote healing
- Used for transverse or shallow oblique fractures with minimal comminution
- Reaming: removing IM contents to allow passage of IMN, appropriate size of tunnel
- Reamed nails usually larger, provide greater stability
- May ↑ risk of fat embolism
- Provides degree of natural bone graft at fracture site
- Disrupts internal blood supply, ↑ infection risk
- Flexible rod: Ender, Lottes
- Used in immature skeleton to avoid growth plate
- Less rigid; may require additional stabilization, such as splint/cast
- Usually place multiple rods via multiple entry sites in metaphysis
- Usually leave small portion outside bone to enable subsequent retrieval
- Cephalomedullary nail (CMN)
- Femoral IMN coupled with fixed-angle device that extends up femoral neck into head
- Component for head: large screw, 2 smaller screws, or spiral blade
- Larger screw may function similar to dynamic hip screw
- Currently used for most peritrochanteric fractures
- "Gamma nail" was original CMN; no longer in use today
- Short and long versions exist
- Lengthening nail
- IMN devised to combine with osteotomy/corticotomy to lengthen bone
- Uses external magnets to elongate nail
- In setting of congenital or posttraumatic limb shortening
- Fusion nail
- Long version in use to fuse knee; extends from proximal femur to distal tibia
- Hindfoot nail: short IMN to fuse hindfoot and ankle, inserted retrograde
IMAGING
General Features
Radiographic Findings
CT Findings
MR Findings
CLINICAL ISSUES
Presentation
Selected References
- Hosny GA: Limb lengthening history, evolution, complications and current concepts. J Orthop Traumatol. 21(1):3, 2020
- Poutoglidou F et al: Flexible intramedullary nailing in the treatment of forearm fractures in children and adolescents, a systematic review. J Orthop. 20:125-30, 2020
- Gausden EB et al: Biomechanics of periprosthetic fixation: plates, nails, cables, and allografts. J Orthop Trauma. 33 Suppl 6:S1-4, 2019
- Hake ME et al: Modern implant options for the treatment of distal femur fractures. J Am Acad Orthop Surg. 27(19):e867-75, 2019
- Allen H et al: Orthopaedic fixation devices used in children: a radiologist's guide. Semin Musculoskelet Radiol. 22(1):12-24, 2018
- Virkus WW et al: Intramedullary nailing of periarticular fractures. J Am Acad Orthop Surg. 26(18):629-39, 2018
- Horwitz DS et al: Nail length in the management of intertrochanteric fracture of the femur. J Am Acad Orthop Surg. 24(6):e50-8, 2016
- Georgiannos D et al: Subtrochanteric femoral fractures treated with the long Gamma3 nail: a historical control case study versus long trochanteric Gamma nail. Orthop Traumatol Surg Res. 101(6):675-80, 2015
- Queally JM et al: Intramedullary nails for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 9:CD004961, 2014
- Study to prospectively evaluate reamed intramedullary nails in patients with tibial fractures investigators et al: randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am. 90(12):2567-78, 2008
- Gadegone WM et al: Proximal femoral nail - an analysis of 100 cases of proximal femoral fractures with an average follow up of 1 year. Int Orthop. 31(3):403-8, 2007
- Wood GW 2nd: Intramedullary nailing of femoral and tibial shaft fractures. J Orthop Sci. 11(6):657-69, 2006
