1. Introduction

2. Positioning

3. Marking and Incision

a. Obtain Starting Point for Guidewire

b. Drill Guidewire

c. Open Canal

d. Pass Wire Through Reduced Fracture

e. Measure and Ream

f. Insert Nail while Checking Placement

4. Insert Nail

a. Drill Guidewire for Locking Bolt

b. Puncture Iliotibial Band

c. Measure

d. Ream Across Femoral Neck

e. Place Locking Bolt

f. Engage Locking Mechanism

g. Check Reduction and Nail Placement

5. Proximal Locking

a. Drill for 1st Distal Locking Screw

b. Measure

c. Insert Screw

d. Drill and Insert 2nd Screw

e. Final X-ray Check

6. Distal Locking

7. Closing

Midshaft femur fractures have an annual incidence of 10 per 100,000 person-years. Femoral fractures typically occur in two major settings: high-energy mechanisms related to trauma and low-energy mechanisms in insufficiency fractures observed in elderly patients with osteopenia. Patients present with pain, swelling, and limited range of motion. Intramedullary nailing is the definitive surgical treatment for femoral fractures to allow secondary healing of bone. While retrograde nailing can be used for femoral shaft fractures, antegrade nailing is used for pathological fractures, including insufficiency fractures related to osteoporosis and long-term bisphosphonate use. In this case, closed cephalomedullary nailing of a diaphyseal femoral fracture is performed with the patient supine on a radiolucent fracture table for traction. 

Brigham and Women's Hospital