Retrograde Femoral Intramedullary Nail for a Midshaft Femoral Fracture with an Ipsilateral Subtrochanteric Fracture

This case illustrates a midshaft femoral fracture with an ipsilateral subtrochanteric fracture that is repaired with a retrograde femoral intramedullary nail technique. The annual incidence of midshaft femur fractures is approximately 10 per 100,000 person-years (most commonly low-energy falls in elderly females). Generally, these patients will present with pain, inflammation, and shortening of the leg. Retrograde femoral intramedullary nail placement is one of the most prevalent methods for treatment. It was initially discovered in 1970 and refined in 1995 to have improved surgery time, bleeding, and postoperative adverse outcomes. This procedure has proven to be particularly beneficial in obese and non-ambulatory patients, and those with multisystem injuries; it also has shown some benefit in pregnant women due to decreased pelvic radiation exposure. This case presents a woman with a femoral shaft fracture and an ipsilateral subtrochanteric fracture. Given this patient’s multiple ipsilateral femur fractures, it was favorable to intervene with a retrograde femoral intramedullary nail. The procedure was done in a supine position due to favorable imaging throughout the operation.

The annual incidence of midshaft femur fractures is approximately 10 per 100,000 person-years. This most commonly occurs in elderly women with an average age of 79.¹ Fractures of the femoral shaft in this population often involve low-energy falls. However, fractures of the femoral shaft in younger populations most commonly occur with high-energy trauma such as motor vehicle collisions. In rarer cases, atypical subtrochanteric and femoral shaft fractures can occur due to chronic use of bisphosphonates, osteopenia or osteoporosis, rheumatoid arthritis, increased femoral curvatures, and thicker femoral cortices.^2, 3 Retrograde femoral intramedullary nail placement can be used to repair these injuries.⁴ 

This patient is a 70-year-old female who arrived in the emergency room (ER) with a chief complaint of the right thigh and hip pain. The patient fell at home from a standing position, and her daughter found her in severe pain. Her pertinent medical history included osteopenia, obesity, and type 2 diabetes mellitus. Attempted weight bearing caused severe pain, and she was not ambulating upon arrival to the ER. 

The patient presented with physical findings of pain on palpation of the right thigh, inflammation, and shortening of the right leg. Diffuse ecchymoses were present on the anterior and lateral portions of the thigh. Distal pulses and sensation were intact with no signs and symptoms of neurovascular injury in either lower extremity. Due to pain, it was difficult to discern ipsilateral femoral neck and hip fractures; imaging was required to classify the injury and guide the treatment of this patient. 

Initial imaging should be done using anteroposterior (AP) and lateral x-rays of the entire femur. The proximal fragment is often abducted due to the gluteus medius and minimus and flexed due to the iliopsoas. The distal fragment is often in varus due to adductors in the medial aspect of the distal femur and extended due to the deforming forces of the gastrocnemius.

This patient received AP and lateral x-rays that showed a right-sided midshaft femur fracture and an ipsilateral subtrochanteric fracture. Computed tomography (CT) scan imaging was also used to rule out an ipsilateral femoral neck fracture. AP and lateral imaging of the ipsilateral knee and hip ruled out additional damage.

The natural history of femoral shaft fractures is highly variable. Most of these etiologies include low-energy trauma from falls and high-energy trauma (such as motor vehicle accidents, gunshots, falls from heights above 3 meters, etc.). These injuries occur most commonly in elderly females and younger males (respective to trauma patterns listed earlier).¹ The frequency of injury will vary based on the country’s automobile and gun laws. 

Operative treatment options for femoral shaft fractures include a retrograde femoral intramedullary nail and antegrade intramedullary nail⁵ with or without prior external fixation. A less common nonoperative option is long leg casting.

Treatment in patients with femoral shaft fractures can vary based on additional trauma but is mostly surgical. Retrograde femoral intramedullary nail was favorable here because of a concomitant ipsilateral subtrochanteric fracture. Long leg casting is only recommended in femoral shaft fractures that are nondisplaced.

Retrograde femoral intramedullary nail placement is advantageous in cases of multisystem injury, as well as ipsilateral femoral neck, subtrochanteric, and/or hip fractures. It also has an easier implant insertion in obese patients when compared with antegrade interlocked intramedullary nail procedures.⁴ This procedure has also been shown to be a safe and effective alternative to nonoperative treatments for the femoral shaft and supracondylar fractures in nonambulatory patients.⁶ 

This technique is relatively indicated in pregnant patients, as there is reduced pelvic exposure to radiation. It is recommended as a suitable alternative to antegrade intramedullary femoral nailing when proximal access is neither possible nor desirable.⁷  

This surgical procedure is contraindicated in patients with skeletal immaturity⁴ and those with a history knee joint sepsis.⁸  

Relative contraindications to this procedure include Type IIIB open fractures, severe soft-tissue injury, pre-existing limitations in knee flexion, and fractures located within 5 cm of the lesser trochanter.⁴ 

The operative approach to femoral shaft fractures can vary based on the location of the fracture and condition of the patient. Typically, antegrade intramedullary femoral fixation is the standard operative procedure. However, retrograde femoral intramedullary nail placement has been shown to be a viable alternative to antegrade approaches in certain instances, including when there are concomitant fractures on the femur, acetabulum, and/or hip. This procedure was also found to be beneficial in obese patients due to the ease of nail insertion.⁴ In patients with non-ambulatory status, a retrograde femoral intramedullary nail procedure was shown to be a suitable alternative.⁶ However, surgeons should be cautious in performing this procedure in patients with Type IIIB open fractures, severe soft-tissue injury, pre-existing limitations in knee flexion, and fractures within 5 cm of the lesser trochanter. Patients with significant skeletal immaturity⁴ and those with a history of knee joint sepsis should not receive this specific surgical intervention.⁸  

Intramedullary fixation can be dated back to the 1930s but had high rates of adverse effects (malunion, nonunion, knee joint issues, etc.). In 1970, retrograde nailing of the femur was first documented.⁹ It was not until 1995 that the retrograde femoral intramedullary nail fixation technique had been revised to decrease operative time, bleeding time, and postoperative complications. Due to these improvements, this procedure became more widely used.⁴ 

Outcomes for femoral shaft repair using the retrograde femoral intramedullary nail technique have an overall union rate of 94.6%. The mean time of the union rate is 3.2–3.75 months. 24.5% of patients have knee pain, which tends to improve within a year. The infection rate with this procedure is 1.1%.⁹ Operative time for nailing in these patients averaged 75 minutes with minimal blood loss. Fracture healing is visualized radiographically. Upon radiographic confirmation of fracture healing, follow-up for these patients typically ranges from 6–24 months with an average of 13 months.⁴ Average blood loss in this operation was shown to be within a range of 150–400 ml.⁶

This procedure was done with the patient supine because it allowed for the imaging of both lower extremities so that symmetry can be identified during the procedure. No traction was required during the procedure because the fragments were not severely displaced after implant placement.

• Portable fluoroscopy system
• Femoral interlocking nail - length: 280 mm, diameter: 9 mm
• Interlocking screws

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.