Intramedullary Rods

Since their popularization during World War II, solid, single intramedullary rods have become the most common method of treating femoral and tibial fractures and, more recently, some humeral fractures (Fig 272-4). They have also been used to stabilize osteotomies or arthrodeses. Over the last decade their application to fractures has been extended by the addition of proximal and distal interlocking screws that add rotational stability. Over the past 5 years open fractures have been treated with intramedullary nails that are placed with minimal reaming of the bones. All these advances have led to the greater number of emergency patients who have intramedullary rods or nails.

Intramedullary rods are placed through an incision at the end of the bone, avoiding the joint surface. The intramedullary canal is then mechanically reamed to a slightly larger size than the nail. The nail is then inserted, and interlocking screws are added if needed for stability at the fracture or osteotomy. The immobilization of the fracture is less than that gained with plates and screws, and therefore the healing process involves visible callus formation at the fracture site ( Fig 2.7.2.-5). In open fractures, minimal or no reaming, which retains the maximum blood supply to the injury, may be performed and requires a smaller-diameter rod. Although less popular today than single, solid rods, multiple, small, flexible rods are still sometimes used to gain fracture stability (see F,ig .. 2.7.2,-§).

COMPLICATIONS As with all surgery, infection is the most worrisome early complication and still occurs with a 1 to 2 percent incidence in closed fractures despite the use of perioperative antibiotics. Unreamed nails are commonly used for open fractures and have up to a 25 percent infection rate. The number of emergency department encounters for postoperative infectious complications will increase. Due to their central location, rods have a greater mechanical strength than plates and screws. They, however, will also fail (usually after 1 year) by breaking at an unhealed facture site ( Fig... . .272-7). With weight bearing, the interlocking screws may break, often without loss of fracture stability. Any noninterlocked nail may work its way back out of the bone and irritate surrounding soft tissue. Femoral rods may then cause trochanteric bursitis. The multiple, small, flexible rods are notorious for this problem and often become palpable under the skin ( Fig 272:8). Nonunion of the fracture occurs more frequently with open fractures, and therefore the small unreamed nails used for these fractures are at risk for breakage.

FIG. 272-7. This distal femoral intramedullary nail broke before fracture union occurred.

FIG. 272-8. The Ender rods have "backed out" of the bone and were prominent just under the skin.

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