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Intramedullary nailing

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Intramedullary nailing

  1. 1. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT Dr. Bahaa Ali Kornah Prof.. Of Orthopedic Al-Azhar University Cairo - Egypt ‫وبركاته‬ ‫هللا‬ ‫ورحمة‬ ‫عليكم‬ ‫السالم‬
  2. 2. INTRAMEDULLARY NAILING biomechanics: Evolution and challenges Dr. Bahaa Ali Kornah M.D. Prof.. Of Orthopedic Al-Azhar University-Cairo - Egypt bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  3. 3. Objectives GOAL  Introduction  Evolution  Classification  Biomechanics  Applications  Special Circumstances  Recent Advances bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  4. 4. GOAL OF OPERATIVE FRACTURE FIXATION ❖ Full restoration of function ❖ Faster return to his preinjury status ❖ Minimize the risk and incidence of complications. ❖ Predictable alignment of fracture fragments bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  5. 5. The purpose of implants ❖ to provide a temporary support ❖ to maintain alignment during the fracture healing ❖ to allow for a functional rehabilitation bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  6. 6. fractured bone needs ➢ - A certain degree of immobilization (mechanical stability) ➢ -Optimally preserved blood supply ➢ -Biologic or hormonal stimuli in order to unite. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT Biology and Biomechanics on Fracture Healing
  7. 7. Stability Request for fx treatment Biology bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  8. 8. Mechanical stability, Elastic fixation provided by internal or external splinting of the bone Absolute stability rigid fixation that does not allow any micro motion bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  9. 9. HighRateof HealingHighRateof Healing Spectrum of Healing Absolute Stability = 10 Bone Healing Biology of Bone Healing THE SIMPLE VERSION... Relative Stability = 20 Bone Healing Fibrous Matrix > Cartilage > Calcified Cartilage > Woven Bone > Lamellar Bone Haversian Remodeling Minimal Callus Callus bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  10. 10. Fixation Stability Reality No callusCallus Relative – (Flexible) – Eg IM nailing - Bridge plating Absolute (Rigid) – eg Lag screw/ plate – Compression plate bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  11. 11. Introduction  Fracture stabilized by one of two systems  Compression  Splinting  Intramedullary fixation - internal splinting  Splintage -micro motion between bone & implant  Relative stability without interfragmentary compression.  Entry point - distant from fracture site – hematoma retained.  Closed reduction and fixation (biological) bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  12. 12. Intramedullary Nails • • • • • • Relative stability Intramedullary splint Less likely to break with repetitive loading than plate More likely to be load sharing . Secondary bone healing Diaphyseal and some metaphyseal fractures bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  13. 13. • 1. bending stability. • 2. axial stability. • 3. translational stability. • 4. rotational stability bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  14. 14. Intramedullary Fixation • Generally utilizes closed/indirect or minimally open reduction techniques • Greater preservation of soft tissues as compared to ORIF • IM reaming has been shown to stimulate fracture healing • Expanded indications i.e. Reamed IM nail is acceptable in many open fractures bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  15. 15. Intramedullary Fixation • • • Rotational and axial stability provided by interlocking bolts Reduction can be technically difficult in segmental and comminuted fractures Difficult to Maintain reduction of fractures in close proximity to metaphyseal flare bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  16. 16. Evolution of IMN 1st generation  Splints(1˚)  Rotational stability minimal  Closed fit  Longitudinal slot along entire length  Eg –K nail , V nail 2nd generation • Locking screw - improved rotational stability • Non- slotted. • Eg- russel taylor nail, delta nail 3rd generation • Fit anatomically as much as possible • Aid insertion and stability • Titanium alloy • Eg-trigen nail, universal femoral nail nails with multiple curves , multiple fixation systems • Tibial nail with malleolar fixation bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  17. 17. Classification IMN  Entry Portals : ❑ Centromedullary ❑ K nail ,1st generation IMN ❑ Cephalomedullary ❑ Gamma nail ❑ Russell taylor nail ❑ PFN ❑ Condylocephalic nail ❑ Ender nail Direction : ❑Antegrade ❑ Retrograde nailing bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  18. 18. Centromedullary Nails  First generation  Contained within medullary canal  Usually inserted from piriformis fossa  Proximal locking bolts - transverse or oblique in pertrochanter  Requires LT be attached to proximal fragment for adequate # stabilization bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  19. 19. Cephalomedullary Nails  second generation nails  More efficient load transfer than DHS  Shorter lever arm of IM device decreases tensile strain on implant - low risk of implant failure  screws/blade inserted cephald into femoral head and neck. ◼ Gamma nail ◼ Recon nail bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  20. 20. C o n d y l o c e p h a l i c F i x a t i o n  Morote nails  Nancy nails  Prevot nails  Bundle nails  Elastic stable intramedullary nailing (ESIN) -  primary definitive pediatric fracture care .  3 – point fixation or bundle nailing.  Elastic and small - micro-motion for rapid fracture healing.  Flexible -insertion through a cortical window.  Examples  Lottes nails  Rush pins  Ender nails : bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  21. 21. Opposite  Apex of curvature – at level of fracture site.  Nail diameter -40% of narrowest medullary canal diameter  Entry point -opposite to one another  Used without reaming.  Commonest biomechanical error is lack of internal support. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  22. 22.  Schneider nail [ solid, four fluted cross section and self broaching ends.  Harris condylocephalic nail [curved in two planes, and designed for percutaneous, retrograde fixation of extra capsular hip fractures.  Lottes tibial nail specially curved to fit tibia, and has triflanged cross section. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  23. 23. Ender Nails  Solid pins with oblique tip and an eye in flange at or end  Designed for percutaneous, closed treatment of extra capsular hip fractures bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  24. 24. Rush Nails ❑Intended for fractures of diaphyseal or metaphyseal fractures of long bones like femur, tibia, febula, humerus, radius and ulna. ❑Pointed tip facilitates easy insertion. ❑Curve at top prevents rotation and stabilizes fracture. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  25. 25. Bundle Pinning  C- or S – shaped, act like spring.  Principle introduced by hackethal.  Many pins are inserted in to bone until jammed within medullary cavity to provide compression between nails and bone.  Bending movements neutralized, but telescoping and rotational torsion not prevented bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  26. 26. Applications IMN ❑ Diaphyseal fractures of long bones ❑ High proximal and low distal fractures of long bones ❑ Floating hip, floating knee, floating elbow. ❑ Aseptic and septic non-union ❑ Osteoporotic long bone fractures ❑ Pathological fractures ❑ Open fractures up to grade IIIA bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  27. 27. Contraindications IMN  Narrow and anomalous medullary canal  Open growth plates  Prior malunion - prevents nail placement  History of intramedullary infection  Associated ipsilateral femoral neck or acetabular fracture (relative) bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  28. 28. Mechanics (K Nail)  Elastic deformation or “elastic locking” of nail within medullary canal  Adequate friction of nail in both fracture fragments  To achieve elastic impingement-  “V” profile or even better “clover-leaf” design. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  29. 29. ❑ Compressible in two directions ❑ Directions right angles to each other V Nail Clover Leaf Nail ❑ Compressible in only one direction bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  30. 30. Elastic Compressibility Of Clover – Leaf Nail bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  31. 31. Solid Nail Elastic Nail ❑Not occupy full width of medullary canal ❑Nail with elastic cross section adjust to constrictions of medullary canal. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  32. 32. Grosse – Kempf nail Russell – Taylor nail Brooker–Wills nail bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  33. 33. Biomechanics of deforming forces bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  34. 34. D F = Force Bending moment = F x D D PlateIM Nail Bending moment for plate greater due to force being applied over larger distance. D = distance from force to implant. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  35. 35. Comparision • Nail cross section round • Resisting loads equally in all directions. • Plate cross section • rectangular resisting greater loads in one plane versus the other bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  36. 36. Cortical contact  - compressive loads borne by bony cortex  compressive loads transferred to interlocking screws (“four-point bending of screws ”) + - - bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  37. 37. Ideal Intramedullary Nail  Strong and stable - maintain alignment and position  Prevent rotation - interlocking transfixing screws  Promote union - contact-compression forces at fracture surfaces  Accessible for easy removal bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  38. 38. Ideal Intramedullary Nail set ✓the number of instruments should be kept to a minimum simple to use. ✓minimise the number of implants necessary for a complete size inventory. ✓For a given size of implant, the strength should be as high as possible to guard implant failure. ✓it is desirable to maximise the flexibility of the implant ✓ to facilitate insertion without comninution; ✓ to transmit load to the bone to protect the implant while minimising stress protection resorbtion. ✓ To stimulate the natural fracture healing mechanisms by allowing adequate at the fracture interface. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  39. 39. Pre Requisites  Adequate preoperative planning  Patient tolerance to a major surgical procedure  Availability of nails of suitable length and diameter  Suitable instruments, trained assistants, and optimal hospital conditions  Closed nailing techniques - whenever possible bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  40. 40. INDICATIONS Standard intramedullary nail Non comminuted misdshaft fractures (A). for non-comminuted misdhaft bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  41. 41. Interlocking fixation Interlocking indications: •Comminuted shaft fractures (B). •Subtrochanteric fractures (C). •Distal third fractures (D). bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  42. 42. Reconstructive fixation Reconstructive indication: •Combination fracture of the shaft and neck (E). •Intertrochanteric fractures (F). •Combined intertrochanteric and subtrochanteric fractures (G). •Reconstruction following tumour resection. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  43. 43. Pre Operative Planning Biplaner Radiographic Images • Bone Morphology • Canal Dimensions • Fracture Personality • Comminution • Fracture Extensions Length Of Nail • Radiographs of contra lateral femur (magnified) • Traction radiographs (comminuted #) • Palpable greater trochanter to lateral epicondyle • TMD (tibial tubercle– medial malleolar distance) for tibial nail Diameter Of Nail • Narrowest portion of femoral canal at femoral isthmus – lateral radiograph • 1.0 to 1.5 mm greater in diameter than anticipated nail diameter. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  44. 44. Nail Length  Preoperative radiographs of fractured long bone with proximal and distal joints  AP radiograph of opposite normal limb at a tube distance of 1meter  Kuntscher measuring device :  Ossimeter used to measure length and width  Magnification is taken into account bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  45. 45. Biomechanics  Stability determined by fracture site 1. Nail design 2. Number and orientation of locking screws 3. Distance of locking screw from 4. Reaming or non reaming 5. Quality of bone  IM nails assumed to bear most of load initially, gradually transfer it to bone as fracture heals. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  46. 46. Nail Design  Factors contributing to biomechanical profile : I. Material properties II. Cross-sectional shape III. Diameter IV. Curves V. Length and working length VI. Ends of nail bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  47. 47. Nail design I- Material properties  Titanium alloy and 316l stainless steel.  Modulus of elasticity ◼ Titanium alloy – same as cortical bone ◼ SS – twice as cortical bone II- CROSS SECTIONAL SHAPE  Determines bending and torsional strengths  Polar moment of inertia ◼ Circular nail  diameter ◼ Square nail  edge length ◼ High in nails with sharp corners or fluted edges bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  48. 48. A-schneider B-diamond C-sampson fluted D-kuntscher E-rush F-ender G-mondy H-halloran i-huckstep J-AO/ASIF K-grosse –kempf L-russell-taylor J,k,l-now commonly used ‘intramedullary nails’ cross-sectional designs bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  49. 49. III. Nail diameter Nail diameter affects bending rigidity ❑solid circular nail,  Bending rigidity  third power of nail diameter (D3)  Torsional rigidity  fourth power of diameter (D4) Large diameter with same cross- section are both stiffer and stronger than smaller ones. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  50. 50. III. Nail diameter • assessing medullary canal diameter in AP and LV both site • pre-operative radiograph by using the templates provided. • The canal must be reamed to at least 1 mm to accept nail less than it bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  51. 51. IV. Nail curves  Long bones have curved medullary cavities  Nails contoured to accommodate curves of bone  Straight, curved or helical  Average radius of curvature of femur - 120(±36) cm.  Complete congruency minimizes normal forces and hence little frictional component to nail’s fixation.  Femoral nail designs have considerably less curve, with radius ranging from 150 to 300 cm  Im nails - straighter (larger radius) than femoral canal bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  52. 52. Nail curves  Angle of herzog :  11o bend in AP direction at junction of upper 1/3rd and lower 2/3rd of tibia nail  Mismatch in radius of curvature –  Distal anterior cortical perforation  more reaming required during insertion bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  53. 53. Hoop stress  Circumferential expansion stress during nail insertion  Larger hoop stress can split bone  Hoop stress reduction :  Use flexible nails  Over-ream entry hole by 0.5 to 1 cm  Selection of ideal entry point bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  54. 54. Posterior - loss of proximal fixation Ideal - posterior portion of piriformis fossa Anterior - generates huge forces, can lead to bursting of proximal bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  55. 55. V. Nail length A-Total nail length - Anatomical length tip of the greater trochanter to the intercondylar notch. length between proximal and distal point of firm fixation to bone B-working length - Working length Affected by various factors ➢ Type of force (Bending ,Torsion ) ➢ Type of fracture ➢ Interlocking and dynamization ➢ Reaming ➢ Weight bearing bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  56. 56. V. Nail length  Shorter working length stronger fixation  Transverse fracture has a shorter working length than comminuted fracture  Torsional stiffness 1/ to l  Bending stiffness 1/ to l2  Surgeon’s techniques to modify “ l ”  Medullary reaming  Interlocking bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  57. 57. VI- Extreme ends  K-nail  Slot/eye in ends for extraction  One end tapered to facilitate insertion . ❑ Holes for interlocking screws  Some nails have slots near distal end for placement of anti rotation screw  Anterior slot- Improved flexibility  Posterior slot - Increased bending strength  Non-slotted - Increased torsional stiffness and strength in smaller sizes bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  58. 58. Interlocking of nail  Recommended for most cases of IM nailing.  Principle :  Resistance to axial and torsional forces depends on screw – bone interface  Length of bone maintained even in bone defect.  Number of interlocks :  Fracture location  Amount of fracture comminution  Fit of nail within canal.  Placing screws in multiple planes - reduction of minor movement bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  59. 59. Interlocking screw  Location of distal locking screws affects biomechanics of fracture  Distal locking screws  Closer to fracture site - less cortical contact -increased stress on locking screws  Distal from fracture site -fracture becomes more rotationally stable  Interlocking screws positioned at least 2 cm from fracture provides sufficient stability bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  60. 60. Poller /blocking screws  Corrects mal-alignment.  Centers IM nail.  Planned and inserted before IM nail insertion.  Saggital or coronal plane. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  61. 61. Poller screw • When malalignment develops during nail insertion, placement of blocking (Poller screws) screw, and nail reinsertion improves alignment. • Most reliable in proximal and distal shaft fractures of tibia. • A posteriorly placed screw prevents anterior angulation and laterally placed screw prevents valgus angulation.
  62. 62. Static locking  Screws placed proximal and distal to fracture site  Restrict translation and rotation at fracture site.  Acts as a “bridging fixation”  Indications :  Communited  Spiral  Pathological fractures  Fractures with bone loss  Atropic non union bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  63. 63. Dynamic locking ❑ Screws inserted only at one end (short fragment) ❑ Unlocked end stabilized by snug fit inside medullary cavity (long fragment) ❑ Prerequisite: at least 50% cortical circumferential contact ❑ Indications ❑ Fractures with good bone contact ❑ Non unions ❑ With axial loading , working length in bending and torsion is reduced - improving nail-bone contact bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  64. 64. Dynamisation ❑ “Weaken stability” ❑ Never done in progressive normal healing ❑ Indications ❑ Established nonnunion ❑ Pseudoarthrosis ❑ Caution: premature dynamization adds to shortening, instability and non-union. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  65. 65. Dynamisation  Primary Dynamisation  Dynamic locking of axially and rotationally stable fractures at time of initial fracture fixation  Secondary Dynamisation  Removing interlocking screw from longer fragment / moving proximal interlocking screw from static to dynamic slot in nail  Done in long bone delayed union and nonunion bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  66. 66. Reamed Versus Unreamed  Endosteal thermo-necrosis & endosteal cortical blood supply disruption ➢ Minimized by using sharp reamers with deep cutting flutes. ➢ Reaming - slow and smooth.  Endosteal blood supply regenerates rapidly - high healing rates in reamed nails.  No difference in infection rates  No overall difference in time to union bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  67. 67. Reamed Versus Unreamed ❑ Reamed nail : ❑ High chance of embolization of bone marrow fat to lungs but this phenomenon is limited & transient ❑ Fat extravasation greatest during insertion of nail in medullary cavity ❑ Not dependent upon increased intra medullary pressure  Reamed nailing generally report no statistical difference in pulmonary complications as compared to unreamed nailing bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  68. 68. Open intramedullary nailing (OIN) Primary indication :  Failure to do closed nailing  Nonunions  Fractures requiring intramedullary existing fixation in internal fixation device. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  69. 69.  Advantages (OIN) :  Less expensive equipment required than for closed nailing.  No special fracture table / preliminary traction  Absolute anatomical reduction  Direct observation of bone - undisplaced / undetected comminution  Improved rotational alignment and stability.  Prevents torquing and twisting in segmental fractures  In nonunions, opening of medullary canals of sclerotic bone is easier. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  70. 70. DISADVANTAGES (OIN) : ❑Skin scars ❑Fracture hematoma evacuated. ❑ Bone shavings created by reaming medullary canal often are lost. ❑Infection rate increased. ❑ Rate of union decreased. ❑ If a locking nail is used, locking is difficult without image intensification bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  71. 71. Nailing in open fractures  If initial debridement adequate and timely , definitive stabilization with reamed intramedullary nailing  with severe soft tissue injuries that require a second debridement, temporary external fixation reasonable  increased risk of infection after use of external fixation pins longer than 2 weeks followed by reamed intramedullary nailing.  Rapid initial management approach allows delayed conversion to a medullary implant at 5 to 10 days. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  72. 72. Nailing in openfractures ❖ Fractures with delay in initial debridement of more than 8 hours - staged nailing. ❖ Acceptable complication rate (11 % infection rate in type iii open fractures) ❖ No relationship between infection rate, non union with timing of nailing or associated soft tissue injury bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  73. 73. Aseptic non unions  Without bone defects-primary im nailing or exchange Nailing if well aligned  With bone defects -IM nailing with bone grafting  corticocancellous graft material - harvested with ria(little donor morbidity) bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  74. 74. Exchange nailing ➢ Biological effects :  Reaming of medullary canal – promotes union ➢ Mechanical effects :  Larger-diameter intramedullary nail – improved stability ❖ Exchage nail – at least 1mm larger than previous nail ❖ Canal reaming until osseous tissue observed in reaming flutes Removal of current intramedullary nail Reaming of medullary canal Placement of an larger intramedullary nail bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  75. 75. Septic non union  Main aim - eradicating infection  Osseous stability important in management of infected nonunion  Stabilization with antibiotic impregnated cement coated nail after serial debridement.  Cement nail elute high concentration of antibiotic in local sites for up to 36 weeks. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  76. 76. Antibiotic impregnated cement nail bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  77. 77. 40gms of bone cement is taken and mixed with 2 to 4 gms of powder when dough is semi solid. It is wrapped around K nail of size 6 to 7 mm and rolled between two palms.The rod is then passed through the holes of the nail major usually 8 to 9mm diameter to maintain uniformity of diameter.
  78. 78. In polytrauma , early femoral stabilization decreases incidence of severe fat embolism and pulmonary complications (ARDS). Nailing with reaming will not increase pulmonary complications Early intramedullary nailing may be deleterious and is associated with elevation of certain proinflammatory markers - (il)-6. Early external fixation of long bone fractures followed by delayed intramedullary nailing – high risk patients. Nailing in damage control orthopaedics (DCO) / early total care (ETC) bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  79. 79. ❑ 50% (↓)in mortality patients who underwent femoral shaft fracture stabilization beyond 12 hours This timing was hypothesized to allow for adequate resuscitation  Exact and optimal timing of femoral shaft fracture nailing remains unclear in polytrauma(esp. Chest injuries) Nailing in damage control orthopaedics (DCO)/early total care (ETC) bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  80. 80. Removal  Timing controversial  Indications :  Patient request(after union)  Pain, swelling secondary to backing out of implant.  Infected nailing  Full weight bearing immediately after removal  Femoral nail removed after 24-36 months ,  Tibial nail 18-24 months bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  81. 81. Failure IMN ❑ When fracture healing is delayed or nonunion occurs.  IM nails usually fail in predictable patterns.  Unlocked nails ◼ fail at fracture site or through a screw hole or slot.  Locked nails ◼ screw breakage or fracturing of nail at locking hole sites(proximal hole of distal interlocks ) bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  82. 82. Recent advances  Biodegradable polymers  Nickel-titanium shape-modifiable alloys  can improve stability as they change shape after insertion and recover curvature as they warm.  IM nails coated with bmp bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  83. 83. Conclusion ➢ IMN -Implant of choice in diaphyseal fractures ➢ Multiple factors determine final construct stiffness, should be understood and considered when choosing IM nail ➢ Ideal intramedullary nail is yet to be invented bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  84. 84. 1 • .CAMPBELL OPERATIVE ORTHOPAEDICS 11TH EDITION 2.The science and practice of Intramedullary Nailing – Bruce D. Brown 3.ROCKWOOD AND GREENS 4.INTERLOCKING NAILING-DD.TANNA 5.The elements of fracture fixation – Anand J Thakur 6.Prospective study of distal end radius fracture by an intramedullary nailing JBJS aug3 2011 Bibliography
  85. 85. Bahaa Ali Kornah bkornah@gmail.com ‫د‬/‫قرنة‬ ‫بهاء‬bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

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