♛VVIP Hyderabad Call Girls Chintalkunta🖕7001035870🖕Riya Kappor Top Call Girl ...
Intramedullary nailing
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
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. 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. 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
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. 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
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. 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
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. ❑ 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
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. Grosse – Kempf nail Russell – Taylor nail Brooker–Wills nail
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
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. 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. 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. 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. 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. 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
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. 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. 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. 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. 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. 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
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
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. 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. ❑ 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. 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. 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. 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. 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. 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