Intramedullary Nails

What is an Intramedullary Nail?

An intramedullary nail (also known as an intramedullary rod), is a metal nail that is surgically inserted into a bone that has been broken (fractured). Intramedullary nails are used to straigthen and hold fractures so that they can properly heal.

The thigh bone is known as the femur. It forms the hip joint at one end with the ball of the femur and the knee at the other end. The long section of bone in the middle of the femur is called the shaft of the femur.

If the thigh bone is fractured, it is generally very unstable and requires surgery to ensure proper healing. An intramedullary nail is surgically inserted through the centre of the thigh bone (running from the hip to the knee), in order to stabilise the two ends of the fracture.

Who is this operation for?

Intramedullary nailing may be used to treat fractures that require surgical fixation in order that the fracture will heal. Fractures that may require intramedullary nailing around the hip region include:

Complications

In general, intramedullary nailing is associated with high success rates and low complication rates. The following complications may however occur in association with intramedullary nailing:

  • Malunion: Malunion is defined as healing of a fracture in an abnormal position. In the case of a fracture of the femur, the fracture may cause a twist or a bend in the bone below the break. The aim of surgery is to correct the deformity created by the break but sometimes the correction is not perfect and some degree of deformity remains.
  • Nonunion: This means that the two ends of the break do not join and healing does not occur. This is a relatively rare complication associated with intramedullary nailing.
  • Implant failures: The intramedullary nail may bend or screws that hold it in place may fail. This is a rare complication but may result in the operation having to be performed again.
  • Leg Length Discrepancy: This means that one leg is longer than the other. If the fracture is bad enough to create bone fragments at the site of the break (known as a comminuted fracture), then a leg length discrepancy may occur following surgery.
  • Infection: Whilst infection is a risk of any operation, intramedullary nailing has a relatively low rate of infection.
  • Other Potential Complications:
    • Heterotopic bone – this is the process by which bone forms outside of the skeleton (usually in a muscle or fat). If the bone formation is large, it can cause pain and limit motion; in this case surgical removal may be necessary.
    • Nerve damage. Intramedullary nailing can directly or indirectly result in neurovascular injury (injury of nerves and blood vessels) leading to numbness in the affected leg. This damage may be permanent, or only short term with recovery occurring over a period of months.
    • Metal irritation. Irritation of soft tissues over the site of screws can occur.

General complications of any surgery include:

Before the operation

When you come in to the Emergency Department, the ED doctors will make sure you are stable, perhaps giving you some fluids and oxygen as well as pain relief, before sending you to get X-Rays of your leg.

The orthopaedic surgeons will need to see you to assess your injury and your general health before deciding if you can be taken straight to surgery. Some tests that may be ordered to check you’re fit for surgery include:

  • Blood tests
  • Chest X-Ray
  • ECG

If your fracture is complicated by breaks in the skin or infection you may need your wound cleaned in the emergency department.

You will be asked not to eat anything until the plan for surgery is confirmed. In the meantime, you will be kept comfortable and possibly taken up to the ward.

Make sure you tell your doctor if you:

  • Have heart, lung or blood conditions
  • Have ever taken prednisolone or other steroids
  • If you are taking warfarin or aspirin

About the Operation

Anaesthesia

The anaesthetic team will see you and decide the type of anaesthetic that’s best for you.

The different types of anaesthesia include:

  • General Anaesthetic. This type of anaesthetic puts you asleep during the whole procedure and a machine controls your breathing.
  • Spinal Anaesthetic. An injection is placed into your back to numb your hip and legs. You will be awake during the procedure, however a sedative can be given to you to help you doze off.
  • Nerve Blocks. This special injection is used to help with your pain after the operation and often used  in conjunction with a general anaesthetic.

The Operation

Once the anesthetic team have delivered the appropriate anesthesia (usually a general anesthetic), the fracture needs to be straightened. This involves re-aligning the two ends of the broken bone so that they match up again.

Once the bones are lined up properly, the intramedullary nail can be inserted.

This is usually done with just a few small holes in your skin. Sometimes, if your fracture is very severe, than a large incision must be created to re-align the bones properly.

Recovery Room

After the operation, you will be resting in the recovery room, where specially trained nurses will closely monitor to. This usually takes 1 to 2 hours. After which, you will be taken to your hospital room.

After the Operation

Your Stay in the Hospital

You will usually stay in the hospital for a few days. During that time, your thigh will be swollen and sore. Over the days, your swelling will improve and you will be encouraged to walk with crutches.

How much will it hurt?

After surgery, you will feel pain in your thigh.

If you have been given a spinal injection during your anaesthetic, your legs may be numb for the first 6-12 hours.

Pain medication, either tablets or injections, will be given to make you as comfortable as possible.

What exercises do I do whilst in hospital?

  • Breathing – To avoid lung problems after surgery, you will be asked to breathe deeply and cough frequently. This will help avoid pneumonia and lung collapse.
  • Physiotherapy – A physiotherapist will see you the day after your surgery and may show you some simple exercises to ensure your leg heals well
  • Walking – Walking and light activity are important to your recovery and will begin the day of or the day after your surgery. You may be required to walk with crutches.

Recovery and Rehabilitation

Wound Care | How do I look after my wound?

It is important to keep your wound as dry as possible.

Most patients are discharged home with a waterproof dressing, which can be left on for showering.

During the first 24 hours, it is normal to have some minor bleeding. After being discharded home, there should be no discharge, redness or bleeding around the wound.

If there is redness, discharge or a foul odor, please seek medical attention as soon as possible.

Wound Care | When will my stitches be removed?

There are a number of ways your wounds may be closed.

You may have either have

  • nonabsorbable stitches
  • absorbable stitches
  • surgical staples.

The stitches or staples are usually removed 10-14 days after surgery.

Diet | What should I eat and drink?

There are usually no specific diet or extra vitamins / nutrients needed to recover from a total hip operation.

It is important to have a normal healthy balanced diet and plenty of nonalcoholic fluids.

Activity | What exercises should I do at home?

Physiotherapy and the exercises that you perform at home are extremely important to achieve the best results after intramedullary nailing. It is important that you follow the advice of your physiotherapist following surgery in order to make a full recovery,.

Further investigations

You will need to have X-rays taken 6 weeks, 3 months and 6 months following your surgery to ensure the bone has healed well.

Does the nail ever get removed?

Usually the intramedullary nail does not require removal. The nail may be removed if there is irritation of soft tissues. Usually the nail will need to remain in place for at least a year before removal is considered.