Antegrade Intramedullary Nailing of Femoral Shaft Fractures

Overview

Reamed, locked antegrade intramedullary nailing is the standard treatment for most femoral shaft fractures (Campbell; AO; Rockwood). The nail is a load-sharing implant that gives relative stability and healing by callus; implant failure is rare and early weight bearing is encouraged (AO). Very few femoral shaft fractures cannot be treated with a nail (Rockwood). In Campbell's practice, most acute fractures are nailed antegrade through a trochanteric entry portal on a fracture table.

Femoral shaft fractures in healthy adults indicate high-energy trauma; associated injuries are common, and even an isolated closed fracture can lose up to 1.5 L of blood in the first 48 hours (AO).

Classification

Associated Injuries to Exclude

• Ipsilateral femoral neck fracture (about 2.5–6% of shaft fractures; usually undisplaced and more vertical than isolated neck fractures, and often missed) (AO). In a large cohort, 5.8% of patients with a femoral fracture had a femoral neck fracture (Rockwood).

• Distal femoral partial articular (Hoffa, 33B3.2) fractures, knee ligament and meniscal injuries, ipsilateral tibial shaft fracture (floating knee), and pelvic/acetabular fractures (AO; Rockwood).

• The neck and Hoffa fractures are the injuries most often missed. Improve detection with a 15° internal rotation view of the neck, a true lateral of the knee, careful review of the trauma CT, and intraoperative fluoroscopy (AO). A standardized CT protocol improves diagnosis of associated neck fractures (Rockwood).

Indications and Contraindications

Antegrade Nailing (Rockwood)

Campbell: Contraindications

Alternatives

• Nonoperative treatment (traction, cast-brace) has unacceptable results and is used only when surgery is not an option; traction is a temporizing measure (AO).

• Plating: For associated metaphyseal or articular fractures, periprosthetic fractures, a narrow or deformed canal, associated vascular repair, laparotomy, or severe pulmonary contusion (AO).

• Retrograde nailing: See the separate retrograde nailing guide for its relative indications.

Timing and Damage Control

• Early stabilization of long-bone fractures reduces morbidity and mortality, particularly in severely injured patients; it lowers the risk of remote organ injury, improves outcomes after severe head injury, and reduces immobilization-related complications (AO).

• There is no absolute rule, but fixation should be done at the earliest safe point after resuscitation, usually within 24 hours. A patient is considered resuscitated when there is no clinically significant metabolic acidosis (base excess better than −4 mmol/L and lactate < 2 mmol/L) (AO).

• The decision between early definitive fixation and damage control depends more on the patient's physiology than on the anatomic injury (AO).

• Temporary external fixation reduces blood loss and operative time and can be converted safely to a nail within 2 weeks (AO). Infection rates of 1.7–3.6% and union of 97% have been reported for conversion within 2 weeks (Rockwood). Inappropriate prolonged damage control increases ICU stay, ventilator days, infection and complications (AO).

• Rockwood authors' approach: In an unstable patient, use external fixation or skeletal traction until stable. Open fractures go to the operating room for irrigation and debridement and definitive reamed nailing unless the canal is grossly contaminated; then temporary external fixation and repeat debridement every 24–48 hours until clean.

Preoperative Planning

• Imaging: Two orthogonal views including the joint above and below (AO); evaluate femoral length, canal size and the anterior bow on the lateral view, because the nail's radius of curvature must match the femur (Rockwood).

• Canal size cannot be predicted from bone length (Campbell).

  • Young athletes with thick cortices often have a narrow isthmus.

  • The canal in elderly patients tends to be wide, sometimes too wide even for a 15 mm nail.

• Typically, the narrowest part of the canal is in the distal part of the proximal third. Fractures through the wider parts of the canal are held less securely by a standard nail (Campbell).

• Nail length: Determine it preoperatively on radiographs so that the right range of sizes is available (Campbell). A radiopaque ruler on the uninjured femur, measured from the greater trochanter to the physeal scar, can be used (Rockwood; AO).

• Nail diameter: Best determined at surgery, because uncalibrated digital measurements can be inaccurate (Campbell). Measure the canal at its narrowest point (Rockwood).

• Be familiar with the implant system, its locking options and its entry point, and confirm that all implants and instruments are in the room (Campbell; AO).

• Antibiotics: For open fractures start in the emergency department; for closed fractures give them in the operating room before the start (Rockwood).

Positioning and Table Selection

Surgeons should be familiar with at least two or three positioning options (AO).

Campbell's preference: The extra setup time of a fracture table is acceptable, and easier imaging outweighs the disadvantages. Manual traction (no fracture table) saves setup time but needs a skilled assistant; uncomminuted fractures can be hard to reduce, while comminuted fractures reduce more easily but length and rotation are harder to judge (Campbell).

Supine

1. Adduct the trunk and the injured limb, and flex the injured hip 15–30° (Campbell).

2. Apply traction through a skeletal pin or a well-padded traction boot. Use a well-padded perineal post. Place the uninjured leg in a padded boot, with the legs in a scissor position (Campbell).

   • A distal femoral traction pin avoids traction across a possibly injured knee and allows the knee to be flexed to reduce sciatic nerve tension; insert it from medial to lateral and anterior so it does not block the nail (Rockwood).

   • Avoid the hemilithotomy (well-leg holder) position for the contralateral leg, or check it hourly: it raises compartment pressures in the well leg, especially in large patients (Rockwood).

3. Use only as much traction as reduction requires, to minimize traction neurapraxia (Campbell).

4. Adducting the leg around the post to reach the entry point can push the fracture into varus (Rockwood).

Lateral Decubitus

1. Rest most of the trunk weight on the trochanteric support of the uninjured hip (Campbell).

2. Flex the injured hip 15–30°, with the uninjured hip in neutral or slight extension (Campbell).

3. The leg tends to fall into adduction and internal rotation; keep internal rotation of the distal segment under 10–15° and minimize adduction (Rockwood). In a series of 988 patients, lateral positioning did not increase mortality or ICU admission (Rockwood).

Before Draping

• Image the hip and femur before preparing the patient, so that repositioning is possible if imaging is inadequate (Rockwood).

• Take and save fluoroscopic images of the uninjured hip and knee at a fixed C-arm rotation for later comparison (Campbell; Rockwood).

• Drape the buttock and lateral thigh down to the popliteal crease, and cover the C-arm (Campbell).

Entry Point Selection

• Piriformis (trochanteric) fossa: Directly in line with the femoral canal; used with straight nails. On cadaver specimens it lay at the medial edge of the greater trochanter in 88% and about 2.1 cm anterior to its posterior border (Rockwood). On the lateral view, the wire should be in line with the posterior third of the femur / the canal (AO).

• Trochanteric tip: For nails with a 4–6° proximal lateral bend (Rockwood). Many modern nails use this entry (AO). In about 70% of patients the correct trochanteric entry is just medial to the tip because of proximal femoral geometry, so templating is recommended (Rockwood). On the lateral view, about 5 mm posterior to the apex of the greater trochanter (Rockwood).

• Evidence: No functional difference has been shown between trochanteric and piriformis entry, or between antegrade and retrograde nailing; trochanteric entry has shorter operative and fluoroscopy times (Campbell; Rockwood).

• Piriformis entry is reserved by Campbell for selected subtrochanteric fractures, in which a trochanteric entry can worsen the deformity of the proximal fragment.

• Open physes: Avoid the piriformis entry because of the risk to the femoral head blood supply; enter at or lateral to the trochanteric tip (Rockwood).

• Errors (AO; Rockwood):

  • Too lateral → varus malalignment or lateral cortex fracture. The bone at the entry site is softer laterally and harder medially, so the portal tends to drift laterally; choose an entry medial to the tip even with a trochanteric nail.

  • Too anterior (piriformis) → high hoop stresses and iatrogenic femoral neck fracture or bursting of the proximal femur.

  • With a 10° extended lateral bend, an anterior entry more than doubled valgus malalignment and caused 13% iatrogenic fractures (Rockwood).

• Soft tissue injury: Hip pain is reported in 10–40% of patients. Trochanteric entry injures the piriformis tendon (80%), obturator internus and gluteus medius; moving the start just medial to the tip and using a 14 mm rather than 17 mm opening can spare the gluteus medius (Rockwood). Piriformis entry places the superior gluteal nerve and the medial femoral circumflex artery branches at greater risk (Rockwood).

Surgical Technique

Entry Point and Guidewire

1. Make a short oblique incision starting 4–6 cm proximal to the tip of the greater trochanter and continuing proximally and medially (Campbell); AO places it 2–4 cm proximal to the trochanter. With a percutaneous technique the incision is 1–4 cm and may lie 10–20 cm proximal to the tip in large patients (Rockwood).

2. Split the gluteus maximus fascia in line with its fibers (Campbell; Rockwood).

3. In the subfascial plane, palpate the piriformis fossa or the trochanteric entry point (Campbell).

4. Advance a threaded-tip guidewire. For trochanteric antegrade nailing, the entry is on the medial slope of the greater trochanter (Campbell).

   • The piriformis fossa is a posterior structure covered by the anterior cortex, so a well-placed wire tip appears to lie within bone before entering the cortex (AO).

5. Adjust the wire on fluoroscopy so that its trajectory leads to the center of the distal canal (Campbell).

6. If the wire is correct on one view but not the other, use a soft tissue guide with a multiple-pin parallel insert to fine-tune with a second pin (Campbell).

7. Once correctly placed, advance the wire to below the lesser trochanter (Campbell).

Proximal Entry Portal

1. Remove the honeycomb insert and leave the wire and portal tool in place. If no insert was used, place a soft tissue sleeve first to protect the abductor insertion (Campbell).

2. Pass the entry reamer assembly (14 mm channel reamer, connector and entry reamer) over the wire (Campbell). Large (15–17 mm) cannulated entry reamers that leave a tube in the opening ease reamer passage and prevent eccentric reaming (Rockwood).

3. Ream until the assembly bottoms out on the portal tool, checking AP and lateral images (Campbell).

4. Remove the entry reamer and the wire, leaving the portal tube and channel reamer (Campbell).

5. Alternative: Use the cannulated entry reamer over the wire without the channel reamer. The channel reamer is usually unnecessary in simple diaphyseal fractures but helps control the deformity of proximal (subtrochanteric) fractures (Campbell).

Reduction and Ball-Tipped Guidewire

1. Closed indirect reduction is preferred (AO). Adequate pharmacologic muscle relaxation is recommended (AO; Rockwood).

2. Reduction aids (AO; Rockwood): Bumps under the thigh, a femoral distractor, a radiolucent "F-tool", a crutch supporting the leg from the nonsterile field on a fracture table, an intramedullary reduction tool ("finger"), and percutaneous aids such as a bone hook, a ball-spike pusher or Schanz pins on T-handles used as joysticks.

   • Distractor pins: Proximally lateral to medial, usually posterior to the canal; distally anterior or distal to the nail tip, out of the path of the wire and nail (Rockwood).

   • Schanz pins near the fracture are usually unicortical; bicortical pins can align the fragments for wire passage but must be withdrawn before reaming (Rockwood).

3. Pass the reduction tool (reducer with T-handle) through the channel reamer to the fracture; manipulate the proximal fragment and engage the distal fragment with its tip (Campbell).

4. Pass the 3 mm ball-tipped guidewire across the fracture. A slight bend at its tip gives directional control (Rockwood).

5. Confirm reduction and wire position on AP and lateral views at several levels. Goal: A concentric, central wire reaching distally to the level of the physeal scar (Campbell). This is critical in distal fractures where the nail does not fill the canal; seat the wire tip in the dense physeal scar bone so it does not back out during reaming (Rockwood).

6. Open reduction may be needed if closed methods fail; a residual gap of more than 1 cm increases nonunion. Careful limited opening has not been shown to increase complications (Rockwood).

7. Distal fractures in the wide canal often need blocking (Poller) screws to keep the nail central and prevent malreduction (AO).

Canal Preparation

1. Reamed nailing is preferred. In the Canadian Orthopaedic Trauma Society trial (224 patients), nonunion was 1.7% with reaming vs 7.5% without, and the relative risk of nonunion was 4.5 times higher with unreamed small nails; reaming did not increase ARDS (Rockwood; AO). Reaming the femur took less than 7 minutes on average in one study (Rockwood).

2. Pulmonary dysfunction after nailing depends more on the severity of lung injury and quality of resuscitation than on the implant or technique (AO).

3. Ream in 0.5 mm steps until there is moderate "chatter", or until the reamer is 1–1.5 mm larger than the chosen nail (Campbell; Rockwood). Reamers should be sharp, deeply fluted and on narrow flexible shafts (AO; Rockwood). If a reamer jams, withdraw it and readvance gently at full speed (Rockwood).

4. Remove the channel reamer for reamers larger than 12.5 mm (Campbell).

5. Use an obturator with each reamer withdrawal so the ball-tipped wire is not pulled back. If it does come back, reposition it and confirm on fluoroscopy before reaming further (Campbell).

6. Reamer–irrigator–aspirator (RIA) is used mainly for bone graft harvest or reaming an infected canal (AO).

Nail Length

1. Place the wire at the desired distal nail position, usually between the superior pole of the patella and the distal physeal scar on the AP view (Campbell). AO states that antegrade nails should end at the level of the mid-patella.

2. Preferred method: A cannulated depth gauge over the 3 mm wire, positioned at the entry point (Campbell).

3. Alternative: The overlapping guidewire method, or a ruler on the contralateral femur under fluoroscopy, or the nail in its packaging held over the opposite femur (Campbell; AO; Rockwood).

Nail Insertion

1. Attach the drill guide to the nail (Campbell).

2. Remove the portal tube and channel reamer, leaving the guidewire (Campbell).

3. Insert the nail by hand; gentle impaction may be needed. Manipulating the fracture is often required to let the nail pass smoothly across it (Campbell; Rockwood).

4. If there is significant resistance, remove the nail and ream 0.5 mm larger (Campbell).

5. Confirm full seating on biplanar fluoroscopy (Campbell).

Proximal Locking

1. Use 5 mm locking screws. Standard static locking goes from the greater trochanter obliquely toward the lesser trochanter; options include oblique, transverse or cephalomedullary screws (Campbell; Rockwood).

2. Place the drill sleeve in the guide, mark the skin, make a stab incision and spread down to bone (Campbell).

3. Drill with the long pilot drill up to, but not through, the far cortex; read the length off the calibrated drill, then drill the far cortex (Campbell).

4. Insert the screw by hand and check on the AP view (Campbell).

5. Confirm that length and rotation are correct before distal locking (Campbell; Rockwood).

Distal Locking (Freehand)

1. Acute femoral nailing should always be statically locked; dynamic modes are reserved for delayed union or nonunion where length and rotation are stable. Most femoral nails are locked with two screws above and below (AO). Brumback reported 98% healing with statically locked reamed nails and found no need for routine dynamization (Rockwood).

2. Scan the distal metaphysis with a lateral view. The holes must appear as perfect circles; oval or double-density holes mean the view is not true (Campbell; Rockwood).

3. If the fracture is length-stable, release traction before distal locking to avoid distraction and improve cortical contact (Campbell). For a transverse fracture that may be distracted, lock distally first and back-slap the nail to compress, confirming on fluoroscopy (Rockwood).

4. Center a ring forceps or scalpel tip over the chosen hole and make a stab incision through skin and iliotibial band (Campbell; Rockwood).

5. Hold a trocar-tip drill at about 45° so it can be seen, and adjust it until it is centered; then bring it in line with the beam (Campbell). Oscillating mode reduces "walking" of the bit (Rockwood).

6. Drill the lateral cortex, confirm that the bit is in the hole, then drill the medial cortex (Campbell; Rockwood).

7. Measure, insert the screw by hand, and add further distal screws as needed. A second screw is advantageous in comminuted fractures with little bone contact (Rockwood). Electromagnetic targeting can reduce radiation and errors (Rockwood).

8. Irrigate and close in layers (Campbell).

Length and Rotation Control

• Typical errors: Overdistraction with excessive traction on a fracture table, and shortening with inadequate manual traction (AO).

• Methods (AO; Rockwood; Campbell):

  • Contralateral radiograph with a ruler; matching the nail length to the opposite side.

  • Lesser trochanter profile: Obtain a true lateral of the knee, rotate the C-arm 90° and image the proximal femur; compare the size and shape of the lesser trochanter with the saved image of the intact side. A smaller lesser trochanter indicates internal rotation of the proximal segment; a larger one indicates external rotation (Rockwood).

  • Cortical step sign: Mismatched cortical thickness on either side of the fracture indicates malrotation; more useful on the lateral view (Rockwood).

  • Oblique patterns: Rotation can often be corrected by keying the fragments together like a puzzle (Rockwood).

  • Anteversion matching: The angle difference between true lateral views of the knee and hip equals femoral anteversion (Campbell; Rockwood).

  • Rotation can also be estimated from the built-in anteversion of a cephalomedullary nail (Campbell).

• Rotate the distal segment to adjust rotation before distal locking (Rockwood).

• Clinical examination is simple but imprecise: in a CT study of 76 femurs, almost half had a 20° deformity missed clinically. A difference of more than 15° warrants revision of the locking screws (Rockwood). In a CT series, 28% of patients had more than 15° of malrotation (AO).

• Bilateral fractures: Fix the simpler side first and match the more difficult side to it (Rockwood; Campbell).

Final Evaluation (Before Leaving the Operating Room)

1. Occult femoral neck fracture: Examine the neck with multiplanar fluoroscopy; dynamic stress fluoroscopy detects occult fractures better than static images (Campbell).

2. Length and rotation: Compare with the uninjured side, combining several methods in comminuted fractures; a postoperative CT can confirm if there is doubt (Campbell; Rockwood).

3. Thigh compartments: Measure pressures if clinically concerned (Campbell).

4. Ipsilateral knee: Examine the ligaments after locking (Campbell; Rockwood).

5. AP pelvis radiograph with both hips internally rotated for the best profile of the femoral neck; review it before anesthesia ends (Campbell).

Rockwood Authors' Algorithm (Femoral Shaft)

• Unstable patient: External fixation or skeletal traction (distal femoral pin if a knee injury is suspected) until stable.

• Associated femoral neck fracture: Neck first (sliding hip screw plus derotation screw), then reamed retrograde nailing; two devices are preferred even for undisplaced neck fractures.

• Canal obstructed (deformity, retained implant, prosthesis, narrow canal): Plate fixation.

• Elderly patient with poor bone: Reamed cephalomedullary nail to protect the neck.

• Morbid obesity or pregnancy: Statically locked reamed retrograde nail.

• Location: Proximal third to distal fifth → antegrade; distal third to distal fifth → retrograde. At least two locking screws on the side closer to the fracture.

• Standard choice: Reamed antegrade nail through the greater trochanteric entry, using a percutaneous guide pin; fracture table with boot traction for isolated fractures, lateral position on a fracture table for morbid obesity, radiolucent table for polytrauma.

Postoperative Care

• Weight bearing (Campbell; AO; Rockwood):

  • With a statically locked nail and proximal and distal screws, patients may bear weight as tolerated immediately, even with comminution (AO). With modern nails and 5.0 mm or larger locking screws, immediate weight bearing is allowed regardless of comminution (Rockwood).

  • In a matched cohort of 154 patients, non–weight bearing delayed radiographic healing (122 vs 85 days) compared with weight bearing as tolerated (Rockwood).

  • If an adolescent nail has been used in an adult (rare), protect weight bearing until early healing (Campbell).

  • In comminuted fractures, Campbell allows touch-down or partial weight bearing.

• Encourage hip and knee motion; quadriceps setting and straight-leg raises before discharge; hip abduction exercises once the wound has healed (Campbell). Target abductors, external rotators, hip and knee flexors and extensors, balance and gait (Rockwood).

• Consider DVT prophylaxis (AO).

• Radiographs at 6 and 12 weeks, then every 6–8 weeks until union. Significant groin pain at any time should prompt hip radiographs for a missed femoral neck fracture (Rockwood).

Complications

• Nonunion: Union after reamed antegrade nailing is about 95% (AO). Options include reamed exchange nailing (if there is a small gap without malalignment) or augmentation plating (AO). Always consider infection (AO).

• Malunion: Most common in the proximal and distal thirds (AO). Early recognized malrotation: remove the locking screws at one end, derotate and relock; after healing, osteotomy is needed (AO; Rockwood).

• Infection: Debride, identify the organism, keep a stable implant until union; RIA is ideal for canal debridement; with implant loosening, remove it and use an external fixator (AO).

• Hip pain and abductor weakness: Common; attributed to gluteus medius/minimus or superior gluteal nerve injury during portal creation, or inadequate rehabilitation (Campbell). Heterotopic ossification and nail prominence are frequent causes of hip pain after antegrade nailing (Rockwood; AO).

• Pudendal nerve palsy: Hip adduction and traction on a fracture table increase pressure on the nerve; minimize traction and its duration and use a well-padded post (Campbell).

• Residual symptoms: Many patients still report weather-related pain, limp, difficulty with stairs and standing, and trochanteric or thigh pain more than a year after injury (Campbell).

• Implant removal is eventually needed in about 30% (AO).

References

1. Rudloff MI. Fractures of the lower extremity. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 59, Technique 59.26.

2. Balogh ZJ. Femur, shaft (including subtrochanteric fractures). In: Buckley RE, Moran CG, Apivatthakakul T, eds. AO Principles of Fracture Management. 3rd ed. Stuttgart: Thieme; 2017. Chapter 6.6.2. (Turkish edition: AO Kırık Tedavisinin Prensipleri.)

3. Adams JD Jr, Jeray KJ. Femoral shaft fractures. In: Tornetta P III, Ricci WM, Ostrum RF, McKee MD, Ollivere BJ, de Ridder VA, eds. Rockwood and Green's Fractures in Adults. 10th ed. Philadelphia: Wolters Kluwer; 2024. Chapter 57. (Turkish edition: Erişkin Kırıkları.)