Intramedullary Fixation

By Dr. Mohamed Hegazy

History
The first description of IM fixation may have been from Stimson in 1883, who described the insertion of an ivory peg into the medullary canal. Hey-Groves used different types of IM devices for the treatment of fractures of the femur. The Rush brothers described their IM pinning system in 1927 in femoral shaft.

 Probably the most important work in the field of IM fixation was done by the German surgeon Gerhard Kuntscher, who perfected the technique of IM nailing in 1939. Nailing of the tibia was introduced in 1950 by Herzog, who bent the proximal end of the nail.

Why .intramedullary fixation

Closed intramedullary nails negated all the draw backs of open osteosynthesis using plates and screws, which are namely: 1. Extensive soft tissue and periosteal injury through surgical dissection. 2. Intruption of the fracture hematoma, which was later acknowledged not only as a scaffold but essentially the perfect environment for tissue differentiation and subsequent bone formation.

3. stress shielding resulting in underlying osteoporosis and stress rissers at both ends of the plates 4. Eccentric surface positioning has greater bending moments, being away from the mechanical axis of the loading. 5. High risk of surgical complicatins associated with open surgical procedures.

Types of intrameduallry fixation.

Flexible nails, better called pins. Intramedullary nailing using rigid nails

Flexible intramedullary pinning

Smaller diameter, more elastic Low cost implants Can be inserted through a cortical window Mechanics: 1. Three or four point intramedullary compression. 2. Large number of them to jam the medulla (bundle nailing).

 Most stability in three or four point compression nails is gained if the vertex of the rod (either one or two) is located at the level of the fracture. The stability of the rod depends on its stiffness, which is dependent on its diameter, material, and length.

 bundle nailing was introduced by Hackethal. He inserted many pins into the bone until they jammed within the medullary cavity to provide compression between the nails and the bone

disadvantages
additional immobilization is often required and that the torsional and bending stiffness is much less than that of intact bone and of an IM nail. Secondary loss of reduction is a problem, especially in comminuted fractures, which are not sufficiently immobilized by IM threepoint stabilization and tend to shorten with loading

Rigid Intramedullary Nailing

Mechanics (non-locked, non-reamed )
Elastic deformation is the principle of nail stability. Nail insertion induces strain>>>> radially orientated force. (proportional to the contact area between the bone and the nail and produces friction that stops the nail from pulling out.> (Elastic locking). unlocked nails attain stability also by a curvature mismatch between the bone and the nail, inducing a longitudinal interference fit. To increase the elasticity, the hollow nail has a cloverleaf cross-section with a longitudinal slot). Due to the shape of the medullary cavity of the femur, only a small part of the bone is in contact compression with the nail. Thus, with the initial technique of IM nailing, only fractures close to the isthmus could be adequately stabilized.

Mechanics (non locked, reamed nails)

Reaming increases the diameter of the IM canal.. Leading to 1. first, the contact area between the bone and the nail is increased.fracture stabilization to include most of the diaphysis. 2. Second, reaming of the IM canal facilitates the insertion of a nail with a larger diameter, with higher bending and torsional stiffness. The weak point is the resistance to axial forces, as the stability depends on the friction between the bone and the nail. This is a minor problem in simple oblique or transverse fractures, as the contact of the two main fragments provides adequate stability. With comminuted fractures, this is not the case

Mechanics: locked nails

The principle of interlocking nailing is different. These nails have proximal and distal screw holes. The nail is locked to the bone by inserting screws through the bone and the screw holes. The resistance to axial and torsional forces is mainly dependent on the screw bone interface, and the length of the bone is maintained even if there is a bone defect. The weak points of the construct are the screws themselves and the hold they have in the bone.

Mechanics: working length of a nail

It is that portion of the nail that spans the fracture site between areas of fixation in the proximal and distal fragments. 1. In unlocked nails this can vary due to the size of the fracture gap, and in comminuted fractures it can measure several centimeters. 2. In interlocking nails, the working length is the distance between the proximal and distal locking screws.

Working length
The working length influences nail stiffness in both bending and torsion. In bending, the stiffness is inversely proportional to the square of the working length. In torsion, the stiffness is inversely proportional to the working length. Bending stiffness is related to the outer diameter of the nail. Hollow nails, slotted nails, and solid nails do not differ significantly in bending stiffness. Solid nails are, however, significantly stiffer in torsion than hollow and slotted nails

Pathophysiology of Intramedullary Nailing Local changes

Are all related to reaming which are 1. Deleterious effect on endosteal circulation and cortical hypoperfusion persisting up to 12 weeks after surgery 2. Heat necrosis specially in bones of narrow diameter and with the use of motorized rather than manual reamers 3. Spiky increase in compartment pressure that rapidly falls to normal postoperative. 4. Provides an autologus bone graft at the fracture site.

 Fat embolism: related to reamed femoral nails more than the tibial ones. It is due to the passage of IM contents into the bloodstream can occur only if the IM pressure associated with instrumentation exceeds the physiologic IM pressure and outweighs the effects of the normal blood flow. The highest pressure increase occurs during the passage of the first reamer, when the main distal fragment is entered. Raised IM pressure causes an elevation of the pulmonary artery pressure, and an increase in intracerebral pressure has also been reported

Systemic Effects

Locking techniques
Nails can be locked in either dynamic or static modes. Transverse,short oblique, and some fractures with butterfly fragments that are axially stable can be dynamically locked. This allows compressive loading of the fracture, which promotes healing (Winquist type A& some B). However, fractures lacking axial stability or those with segmental loss (Winquist type C& some B cases) must undergo static locking for the benefit of increasing the working length and increasing the bending and torsional stability of the nail .

Thank u