What are the advantages of treating a mid-shaft femoral shaft fracture with an intramedullary nail as compared to casting or traction?

(Also: what complications/patient morbidity may be seen despite this treatment?)

A mid-shaft femoral fracture in a skeletally mature individual is most commonly treated with an intramedullary (IM) nail (Figure 1). Other treatment options include casting and traction. Unless the patient is not stable enough for surgery, IM nail is the preferred treatment for two major reasons: a nail preserves bone alignment and maximizes patient mobility.

The goal of treatment in fracture is restoration of function, and for a femur fracture, that means (at the minimum) the limb’s original length and alignment must be restored.

By using an IM nail, the bone is fixed at its intended length, alignment and rotation. Without a nail, the pull of muscles still attached might tend to shorten, bend, or rotate the bone (Figure 2).

Figure 1: Left, Midshaft fracture of the femur (Image courtesy of Radiopedia.org rID: 22120); Right, Femur fixation with IM nail (Image courtesy of orthopaedicsone.com)
Figure 2: Without a nail, the fracture depicted in Figure 1 and again on the left of this image might heal in a short and bent position because of the pull of the adductor muscles, as shown here. (Image modified from Wikipedia.org)

Although traction can keep a fractured bone reasonably aligned and held at its normal length, traction is even more restrictive than casting. This is because the patient must remain in bed. Prolonged bed rest can produce complications such as bed sores, blood clots, and atelectasis.

While a common definitive treatment before the mid-1900s, traction is still used today, but primarily as a temporizing treatment: holding the bone in reasonable position for a short period as the patient is optimized for surgery.

While IM fixation is the preferred treatment for patients with mid-shaft femoral fractures, it is associated with complications of its own. For example, while inserting a femoral nail, the surgeon may create a fracture of the femoral neck. Also, the hardware is a foreign body that can get infected.

Another complication can occur when the nail is inserted in the medullary canal and bone marrow is pushed into the systemic circulation: namely, “fat embolism”. Fat emboli from the bone marrow travel to the lungs. In severe cases, they can cause adult respiratory distress syndrome (ARDS).

In sum, IM nail is a preferred method of treatment for mid-shaft femoral fractures because it allows for restoration of the normal skeletal anatomy and promotes mobility. Nailing, like all surgery, carries risks of complications that must be considered and mitigated by the surgical team.

Additional Points to Consider

As noted, a mid-shaft femoral fracture in a skeletally mature individual can also be treated with plate and screws. The question above addressed the advantages of nailing over casting or traction, but discuss playing. So ask yourself now: why might a nail be a better treatment than plates and screws? (In general, for a mid-shaft femoral fracture a nail is decidedly better.)

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