Intramedullary nailing has become a standard procedure for treating fractures of long bones such as the femur, tibia and humerus. Over the past few decades, significant advances have been made in intramedullary nail technology and surgical techniques, making it a very effective treatment option. In this article, we will discuss the basics of intramedullary nailing, its benefits, and the latest developments in this field.

What is Intramedullary Nailing?

Intramedullary nailing, also known as IM nailing, involves the surgical insertion of a metal rod known as an intramedullary nail into the hollow centre (medullary cavity) of a broken long bone to aid healing. The nail acts as an internal splint, holding the bone fragments in proper alignment and position during the bone healing process.

A small incision is made near the proximal end of the bone, through which the specially designed intramedullary nail is inserted into the medullary canal. The nail may have holes at the ends through which screws or bolts are inserted to secure the nail in place and prevent it from moving. Depending on the severity of the fracture, additional fixation devices like plates or screws may also be used externally.

Benefits of Intramedullary Nailing

Intramedullary nailing offers several advantages over traditional skeletal traction and external fixation methods:

- Quick healing: IM nailing allows early weight bearing and mobilization as it provides rigid internal fixation and fracture stability. This facilitates a faster recovery.

- Minimal soft tissue damage: Unlike plate fixation that requires extensive soft tissue dissection, IM nailing causes minimal disruption to surrounding muscles, tendons and blood supply since it is inserted through a small incision. This reduces surgical trauma and complications.

- Cosmetic advantage: As the entire implant is contained within the bone, there are no protruding metal parts over the skin. This allows for an improved cosmetic outcome.

- Less chance of infection: By minimizing soft tissue trauma, intramedullary nailing lowers the risk of surgical site infections compared to plating.

- Preservation of bone blood supply: The minimal invasive nature of IM nailing prevents disruption to blood flow within the cortical bone and marrow cavity, an important factor for fracture healing.

- High union rates: When performed properly, IM nailing can achieve bone union rates of over 95% even for severe, complex fractures.

Advancements in Intramedullary Nail Design

Over the last few decades, improvements in intramedullary nail design and material have further enhanced the effectiveness of this technique:

- Latest nails are anatomically pre-bent to better match the curvature of individual bones like femur or tibia, enabling minimally invasive insertion techniques.

- Manufacturing advanced alloys like titanium allows for construction of thinner yet stronger nails that cause less irritation to tissues. Some nails even incorporate shock absorption properties.

- Expandable and telescoping nail designs have been introduced which can be gradually adjusted as the bone heals, avoiding repeated surgeries for nail exchange or adjustments.

- Nail interlocks with multiplanar screws and bolts provide superior multi-fragmentary fracture fixation compared to earlier nails relying on end screws alone.

- MRI-compatible nails are available now for long term post-operative imaging follow up without artifacts, aiding fracture assessment.

- Modular and customizable nails with side plates, modules and other accessories allow tailored fixation for complex injuries like blast fractures, periprosthetic fractures etc.

Special Considerations and Complications

While Intramedullary Nail is a low risk procedure, there are some special points to note:

- Nail placement must be accurate to avoid malreduction or malalignment during healing which can affect outcomes.

- Fracture hematoma needs to be preserved to maintain the bone's natural healing response. Excessive reaming should be avoided.

- Nail length must not protrude past the bone ends to prevent soft tissue irritation or failures at the fixation points.

- Protection of limited blood supply in certain bones like tibia is important to prevent medical non-unions.

Complications like infection, delayed or non-union, implant failure, fat embolism, compartment syndrome are still possible if the surgery is not performed meticulously by experienced surgeons.

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