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How Is Intramedullary Nailing Done?

Intramedullary nailing is an operation performed by an orthopedic surgeon to stabilize fractures of the long bones, such as the hip, tibia (shin), femur (thigh) and humerus (upper arm), and even some smaller bones, such as the metacarpals (hand) and metatarsals (foot). It involves placing a rigid rod into the medullary, or marrow cavity, in the center of the bone. IM rodding/nailing helps fracture patients use the affected limb much sooner than does a cast or a plate with screws because the rod/nail actually bears part of the weight or stress on the limb, rather than merely supporting the bone.

  1. Preparation

    • With the patient in the operating room and under general anesthesia, the surgeon first reduces all fractures in the bone to be nailed -- and in any closely associated bones -- with the help of an assistant and using manual or mechanical traction or distraction. If the fracture is compound or comminuted (crushed), the surgeon uses fluoroscopy to assure that the IM canal is free of loose bone fragments.

    Opening the Canal

    • The surgeon makes an incision at the upper end of the bone and inserts a guide pin at the correct angle for entry. A cannulated cutter is passed over the pin and used to open the medullary canal. A ball-tip guide wire is passed down the canal under fluoroscopic guidance to the lower metaphysis (growth plate) and used to measure the length of nail needed.

    Reaming

    • If the medullary canal is narrow, the surgeon passes a reamer over the guide wire and uses it to enlarge the canal to accept a nail of sufficient diameter. This is done slowly and carefully to avoid over-reaming, heat buildup and increasing medullary pressure, which can lead to fat embolization.

    Nail Insertion

    • The surgeon inserts the nail into the canal until it reaches the desired end point in the distal metaphysis. Care is taken to maintain fracture reduction during this process.

    Nail Locking

    • The surgeon then turns attention to placing locking screws at each end of the IM rod/nail to hold it in position. The number and placement of locking screws depends type of nail used and the distribution, size and stability of the fracture fragments. Once screw placement is complete, the limb is cleaned and bandaged and the patient is transferred to the PACU (post anesthesia care unit) to recover.

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