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Intramedullary Nail/Rod
Kirkland W. Davis, MD, FACR; Jonelle M. Petscavage-Thomas, MD, MPH
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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

                  1. Hosny GA: Limb lengthening history, evolution, complications and current concepts. J Orthop Traumatol. 21(1):3, 2020
                  2. 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
                  3. Gausden EB et al: Biomechanics of periprosthetic fixation: plates, nails, cables, and allografts. J Orthop Trauma. 33 Suppl 6:S1-4, 2019
                  4. Hake ME et al: Modern implant options for the treatment of distal femur fractures. J Am Acad Orthop Surg. 27(19):e867-75, 2019
                  5. Allen H et al: Orthopaedic fixation devices used in children: a radiologist's guide. Semin Musculoskelet Radiol. 22(1):12-24, 2018
                  6. Virkus WW et al: Intramedullary nailing of periarticular fractures. J Am Acad Orthop Surg. 26(18):629-39, 2018
                  7. 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
                  8. 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
                  9. Queally JM et al: Intramedullary nails for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 9:CD004961, 2014
                  10. 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
                  11. 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
                  12. Wood GW 2nd: Intramedullary nailing of femoral and tibial shaft fractures. J Orthop Sci. 11(6):657-69, 2006
                  Related Anatomy
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                  Related Differential Diagnoses
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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

                                  1. Hosny GA: Limb lengthening history, evolution, complications and current concepts. J Orthop Traumatol. 21(1):3, 2020
                                  2. 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
                                  3. Gausden EB et al: Biomechanics of periprosthetic fixation: plates, nails, cables, and allografts. J Orthop Trauma. 33 Suppl 6:S1-4, 2019
                                  4. Hake ME et al: Modern implant options for the treatment of distal femur fractures. J Am Acad Orthop Surg. 27(19):e867-75, 2019
                                  5. Allen H et al: Orthopaedic fixation devices used in children: a radiologist's guide. Semin Musculoskelet Radiol. 22(1):12-24, 2018
                                  6. Virkus WW et al: Intramedullary nailing of periarticular fractures. J Am Acad Orthop Surg. 26(18):629-39, 2018
                                  7. 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
                                  8. 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
                                  9. Queally JM et al: Intramedullary nails for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 9:CD004961, 2014
                                  10. 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
                                  11. 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
                                  12. Wood GW 2nd: Intramedullary nailing of femoral and tibial shaft fractures. J Orthop Sci. 11(6):657-69, 2006