Intramedullary nailing of femoral shaft fractures. Part I: Decision-making errors with interlocking fixation.

Author summary

Of 133 dynamic femoral intramedullary nailing (IM) procedures performed after locking techniques became available:

• 10.5% (n = 14) were complicated by loss of postoperative fixation and reduction.

• 13 of the 14 femora shortened an average of 2.0 cm and one shortened slightly with clinical loss of rotational stability.

• Errors in surgical judgment were attributed to (alone or in combination):

• Inadequate preoperative analysis of fracture patterns

• Undetected comminution during reaming or nail insertion

• Failure to recognize postoperatively increased comminution

• Fracture instability

Authors suggest:

• Use of high-quality preoperative x-rays to detect nondisplaced comminution of major fracture fragments.

• Intraoperative fluoroscopic assessment: increase in comminution secondary to reaming or nail insertion is an indication for static locked fixation.

• Analysis of radiographs taken immediately postoperatively while patient is still under anesthesia to evaluate previously undetected instability that should be treated by static locked fixation.

• Dynamic IM stabilization should be reserved for transverse or short oblique fractures at the femoral isthmus that have type I or type II comminution.