Table of Contents
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 nail 5 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 nonambulatory 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.
The article is written by Jason P. Den Haese Jr. and under review by Dr. Michael J. Weaver.
- Weiss RJ, Montgomery SM, Al Dabbagh Z, Jansson KA. National data of 6409 Swedish inpatients with femoral shaft fractures: stable incidence between 1998 and 2004. Injury. 2009;40(3):304-308. https://doi.org/10.1016/j.injury.2008.07.017
- Abrahamsen B, Eiken P, Prieto-Alhambra D, Eastell R. Risk of hip, subtrochanteric, and femoral shaft fractures among mid and long term users of alendronate: nationwide cohort and nested case-control study. BMJ. 2016;353:i3365. https://doi.org/10.1136/bmj.i3365
- Lim SJ, Yeo I, Yoon PW, et al. Incidence, risk factors, and fracture healing of atypical femoral fractures: a multicenter case-control study. Osteoporos Int. 2018;29(11):2427-2435. https://doi.org/10.1007/s00198-018-4640-4
- Moed BR, Watson TJ. Retrograde Nailing of the Femoral Shaft. JAAOS - Journal of the American Academy of Orthopaedic Surgeons. 1999;7(4):209-216. https://doi.org/10.5435/00124635-199907000-00001
- Hussain N, Hussain FN, Sermer C, et al. Antegrade versus retrograde nailing techniques and trochanteric versus piriformis intramedullary nailing entry points for femoral shaft fractures: a systematic review and meta-analysis. Can J Surg. 2017;60(1):19-29. https://doi.org/10.1503/cjs.000616
- Chin KR, Altman DT, Altman GT, Mitchell TM, Tomford WW, Lhowe DW. Retrograde nailing of femur fractures in patients with myelopathy and who are nonambulatory. Clin Orthop Relat Res. 2000;(373):218-226. https://doi.org/10.1097/00003086-200004000-00026
- Sanders R, Koval KJ, DiPasquale T, Helfet DL, Frankle M. Retrograde reamed femoral nailing. J Orthop Trauma. 1993;7(4):293-302. https://doi.org/10.1097/00005131-199308000-00001
- Halvorson JJ, Barnett M, Jackson B, Birkedal JP. Risk of septic knee following retrograde intramedullary nailing of open and closed femur fractures. J Orthop Surg Res. 2012;7:7. Published 2012 Feb 17. https://doi.org/10.1186/1749-799X-7-7
- Mounasamy V, Mallu S, Khanna V, Sambandam S. Subtrochanteric fractures after retrograde femoral nailing. World J Orthop. 2015;6(9):738-743. Published 2015 Oct 18. https://doi.org/10.5312/wjo.v6.i9.738
- Prep and Drape, Surgical Timeout
- Enter Formal Canal with Guide
- Use Opening Reamer
- Pass Guidewire Across Fracture
- Measure for Length of Nail
- Reaming Femoral Canal
- Check Guidewire Under Fluoro
- Distal Locking Screw Placement
- Proximal Locking Screws
Okay. Blue marker.
So really want you just want to do is think - here’s midline. It’s variable. That should be plenty good since it’s right on the midline. With a tibby, you want to be up under here more. Here it’s almost - you want to go lower. Incision. You can use the whole thing up to the top here. You do? Okay, I thought that - No, no I just changed my mind. It’s like - just be bold. Cut right through that. There’s nothing bad here. Through that tendon - through that tendon. Yeah there we go. That’s it. Don’t go down. You don’t need to go down, right? Cuz you’re going straight that way. With tibia, you’re going down that way. This one - you’ll go straight that way.
Schnidt. That was really nice. See, you’re in the knee. Now feel right in there. You can feel the top of the notch. You want to be right on the top of the notch. Now the other thing to realize is that this is a midshaft femur fracture. They typically go apex posterior, okay? So you’re - you’re gonna aim a little like this - more down, okay? So you want to be right at the top of that notch - in the center, aiming a little bit down. If you put it in the notch when you ream, you’ll ream out the ACL. Okay. So don’t put it there. So like stay right on top? I want you to be like on the - like this is the notch - I want you to be like on the top of the notch. Look at your hand. I want your hand way up. Drop your hand a little bit. There you go. Good, good. Put it in. Don’t push that in - just push that in. Good. That looks pretty good.
Alright, so now let’s go to a lateral. Do we have a... I think it’s just maybe a millimeter too high. Yeah, so - so I like to keep that other pin in place because it’s your guide. X-ray. Alright, now you’ve gotta take out the top one. Now I want you to redirect that one. X-ray. Nice. Good. X-ray. Good. Making your incision in the right spot, so being careful and making it right in the center, then you’re gonna end up right where you want to be, so it just helps you. That looks good. Good. So save that.
So now we’re gonna use the opening reamer, and that’s going to create a hole in the top of the - or the end of the femur now to get access. Do you have a schnidt? Yep, good. Now take it out. We got good bone. Save that. Come proximal. Alright, we’re gonna trade. Okay, X-ray. Little more. Save that. Alright, let’s go to a lateral. Can you get your hand under there or something to lift like - X-ray. Good, come up to an AP. Good, alright.
So a lateral at the knee please. You really can’t tell the depth of the nail except at the lateral, so I think it’s important that you always check this. So that measures 300 exactly. So if we do 300, it would look like this. X-ray. That’s probably not enough room, so let’s do a 280. So 280 by 9, I think. So first reamer is an 8-5. Now this may - this reamer may be too big. I’m just - she’s got a very small canal. X-ray. Alright, that’s fine. Alright, hold on. Let’s switch for one second. I’m a just get - can I get - can I get some towels, please? Like 3 or 4 towels? So let’s - can we put this under the apex of the fracture there? Good - and then I’m going to pull like this. X-ray. X-ray. X-ray. Yeah, so we’re going to use a 9. Yep. Now just don’t lose that guidewire. So next will be 9-5 and then 10, and that’s our last reamer. So you gotta - you just gotta know your nail systems and know when they - the interlock screw sizes change cuz - you know, you gotta keep that in mind. So the - a lot of times they’ll go up, and you know, if you have a small interlock screw, that’s gonna fatigue and fail sooner than...
Now for this particular - did you say 9? I’m sorry. For the - for the femoral nail, 9s go to 5, yeah. And - and to be honest, for this fracture pattern, it doesn’t really matter. This is a length stable thing. The interlock screws aren’t going to do anything. Good. First - and this is one we’ll be able to impact after we lock it distally and compress the fracture and then lock it proximally. It - it matters what side we’re doing, and we’re doing a right. So we just - the way I always think of it is that the bow has got to go that way, and so it has to go this way. But keep in mind the bow… Here we’re doing a retrograde, and so we want to make sure the bow of the femur matches. If you go this way, you can kind of reverse the bow. You don’t want to do that. It’ll break the femur that way. Alright, good. So just slide that right on. Try not to touch the metal too much. And then - oh, one thing here. I’m gonna change this.
So I like to put this right on the end here. So there are two places, and this one is kind of colinear. So when you’re hitting it, you’re hitting it straight down. You’re not hitting any kind of side - cattywampus type thing. And there’s no twisting or anything with this one. This one goes straight in. Straight in, right? Cuz you’re colinear with the axis of the femur - so you just pound that in. Yep. Good. X-ray.
Alright, let’s come to a lateral please. So that’s your perfect lateral, okay? So save that, and that’s really what’s gonna show you… X-ray there. Good. So that’s really the one that’s showing you that you’re countersunk, and I really like this thing to be at least 5 millimeters or more underneath the chondral surface because that thing is prominent and really hurts with patella flexion. Alright, so come up to an AP. Do you have a blue magic marker? Kind of connect those dots, okay?
Just cut right through. Cut. Good. So the iliotibial band is right here, so you just gotta - it will still fit? It will. It will be fine. You just gotta pop through there. Rrrrrr. Good. X-ray there. Nice. Drill, and now this drill should be calibrated. 4-2 for a 5-0 locker. Go through the nail. Good. Now, stop a second. X-ray there. Watch your hand. That’s measuring 70, so probably a 65 cuz - cuz this is a little bit off the bone. Actually - really? Oh, 62. Yep, go ahead. So that’s about down. X-ray there. You want to be a little bit careful cuz this can drive into the bone, so. That’s a pretty good bite. X. So that’s about it there. Go a little bit more. Good. So that’s one where, if you just power through, it’ll go right through that lateral cortex. X-ray. You do that internal rotation view. That shows you if you’re long on the medial side cuz the distal femur is shaped like a trapezoid. So you’re gonna see through here. From the AP, you can’t see it - but then you internally rotate, and you can. Alright - same thing. Second burst same as the first.
X-ray. 52. Is there a - an instance where you want to lock proximally first? Right now - you could probably think of a situation, but most of the time not. And that’s because to compress you can hit it from this side. Yeah, and you don’t want the nails to be in the knee joint. Yeah, exactly, and if you’re back-slapping the nail, then you’re - you’re gonna get closer to the knee joint. So this - it’s safer to hit it this way. Just suck that down. Come up more proximal. So that looks pretty well reduced, so let’s go to a lateral and just see what it looks there. And then we’ll let you - so that looks pretty good. Very nice. So come up to an AP. X-ray there. Save that. X-ray. A little more. Good. X-ray. X-ray. X-ray. Try that - there you go. Tap, tap. X-ray. Get AP? Can I get the Acorn? The drill - the shorter drill. No?
Okay and now, with the handle out, you can extend the knee. So now this can go away. Yep. X-ray there. Alright, I can’t do better than that for you. Save that. It’s perfect. Yep. If you make every step go perfectly, then the whole thing goes nice and smoothly. So - perfect X-ray where that circle is really nice and centered in your frame. Incision right over it, so it’s not - you’re not fighting the skin to get your drill bit in the right spot. Drill bit really perfect. Now - and the other thing is I think a lot of people make a mistake in making their holes too small. I’d make it twice that. And hold - hold your knife like - no, I’m saying, when you hold it that - driver? But we do. It’s hard to get much better than that with a femoral shaft fracture cuz there’s a little plastic deformation, so it doesn’t key in quite perfectly. Yeah, I think the - the subtroc fracture is - X-ray - not quite as mobile as I thought. It's not too bad, I mean, it's pulling apart when I pull. Yeah, that’s - that’s all - want more proximal? Talk it out.
Like that? No, nope. So that’s too far towards the far side. This is ever so slightly towards you. That’s what I mean by being perfect - like a lot of people do that. That’s eclipsing it. You don’t want to eclipse it. You want it right on the center. X-ray. Tiny bit, tiny bit. X-ray. There you go. That’s perfect. And so - that’s the nail. And so - so we just pop this off. X-ray there. We’ll just adjust a little bit. Just tap it. X-ray. There you go. X-ray.
So for a lot of femur fractures, rotation is an issue, but for this particular one, you can see it interdigitates nicely. So I’m not too worried. And then just clinically, one of the advantages of being supine and doing a retrograde nail is you get to see both legs, and you can see that this - the - they’re fairly symmetric. Now obviously, she’s got a fracture here and a fracture in the subtroc region. So it kind of makes it a little more difficult, but things look pretty good. We were saying it was good that she does not have any comminution there. Absolutely.
30s. Like 36. 36? 36. 34? 36. Is it measuring exactly 36? It’s measuring 34. Exactly? Yep. 36. So if you look at these screws, they have a long tap area, so you want them to stick out. K - that’s not going to get much bite. This is a special kind of screwdriver. It grabs onto the screw so you don’t lose it. And then you just have to undo that. You unscrew that, and that pops it off. Yeah. Just be gentle with it. Like, it's possible to lose that screw, and then it really sucks. Like - just like that. Man, these are hard. Yeah - the first few you do by yourself are kind of scary too cuz you’re like “woo - it’s right-” but, you know, the vessels and everything are pretty medial actually - pretty medial.
So now if you think you’re down, what I want to do is actually check a lateral cuz once you - it’s really - it’s easy to lose this thing. Let’s come to a lateral, please. X-ray there. That looks pretty good, but you’ve got to go a little further. Here I’m going to put it down. Screwdriver. Mallet. X-ray there. Whoops - that’s a little on the long side. Do you have the - the blue one? So you were right. You were right.
You okay? Yeah, she has hard bone. Yeah. Yeah, I saw it. Even drilling, I was like - pushing. X-ray. You see some of that bleeding is probably - we’re getting into the fracture hematoma because we’re pretty close. Okay, so do the same thing. I think just take off two. I think 30 - either just - I think 34 I think like you said. I mean, you definitely want that thing to stick out, so. And that’s not going to bother her there. X-ray there. Yep, I like that. That’s good. Save that for us. Come up a little bit more proximal. That’s nice. Save that. Now come down to the knee please - south. And then come to a full lateral. Good. Sorry, maybe a little bit north from there. Save that.
So now you can see you’re countersunk, your starting point was really nice, and we’ve got a nice alignment. Alright, let’s come up to an AP. And her leg, you know, was really floppy before, and now it’s behaving like a femur, so. I don’t think she even needs traction. The proximal fracture is not really displaced, so. So no traction? No traction, no. Let’s come up proximal. I’ll take a picture of the hip, and I’ll see if I pull on it, if it helps the acetabulum, and if it does, we will. Save that. Little bit more proximal. X-ray there. Save that. Come up a little bit more proximal. Let’s get that out of the way. It didn’t really change the acetabulum, so. X-ray there. That’s reduced good. X-ray.