Given the significance of fracture morphology, it is of paramount importance to obtain adequate quality injury films of the affected bone prior to surgery. A minimum requirement is a radiograph of the whole bone in orthogonal (anteroposterior and lateral) plains including the proximal and distal joints of the fractured bone (Fig. 5.3). As placing the patient on the x-ray table is painful and positioning of the fractured extremity may be cumbersome, radiographs of broken legs of severely injured patients are often taken in a rush as more urgent issues are addressed first. Such compromises before entering the operation room may lead to inadequate understanding of the fractures and improper pre-operative planning, resulting in an unpredictable course during surgery. As a general rule, it is to be stated that if a patient’s condition is stable enough for a definitive intramedullary nailing procedure, there is no excuse for not taking high quality plain radiographs of the whole bone.

Even if good quality radiographs are taken, this is not always sufficient for optimal planning. For example, understanding of the exact morphology of a proximal femur fracture might be obscured by the deforming forces acting on the proximal fragment, yielding the injury films hardly readable at times. Adjuncts such as internal rotation-traction films may greatly assist in gaining more information regarding the precise fracture morphology [23].

Additional imaging may be needed in certain fractures. Distal tibia shaft fractures have been recently described to be in close association (25–40 %) with posterior malleolar fractures [24]. Therefore, a routine ankle film or an ankle CT is recommended prior to surgical stabilization. A similar, but less common association is the co-existence of occult femoral neck fractures with high energy femoral shaft fractures. A CT scan with fine-cuts through the femoral neck area is recommended to rule out these often-missed injuries [25].

Finally, a good quality film may enable preoperative templating using existing templates of implants, virtual fracture reduction and implantation of a nail prior to surgery. Unfortunately, this practice, taught and educated by many of us is not commonly practiced in reality. Digital films, that are most often produced nowadays, disable the use of paper templates, standard 15 % scaled radiographs and view boxes [26]. Magnification of films vary greatly and misinterpretation of the correct bone size may lead to complications when the choice of the implant’s length and diameter is solely based on the pre-operative data [27]. Some simple facts or tools help with image calibration: the existence of previous hardware of a known size, or using the interval of the splint as a calibration tool [28] (Fig. 5.3). Recently, imaging software including a standardized metal sphere placed in the vicinity of the affected limb as part of a digital implant template library has shown to be a promising, vivid, and useful tool for pre-operative planning. Several commercial companies offer now software products with very advanced templating, virtual reduction and implantation techniques. While very promising for education and teaching purposes, its practical implementation has still to be determined.

A major advantage of nails over plates is the smaller amount of tissue exposure needed for their application. Where soft tissue coverage is abundant (femur or humerus), extensive soft tissue injury is rarely a contraindication for nailing. Tibia soft tissue coverage is more tenuous and historically, high grade open fractures were considered to be a contraindication for nailing. More recent evidence including randomized control studies have ruled out this [9, 10]. However, it should be kept in mind that complications such as delayed union and infection rise as the soft tissues are disturbed. Therefore, the results of even a properly performed osteosynthesis may be compromised by soft-tissue destruction caused by the initial trauma. Historically, in grade IIIB open fractures, infection rate was estimated to be around 15–20 % while delayed union rates were described as high as 30–40 % [29, 30]. It is therefore advisable to perform meticulous soft tissue care including debridement, irrigation and coverage of exposed bone if necessary in order to minimize these complications. As a part of the preoperative planning, knowledge of the extent of soft tissue injury will facilitate the recruitment of adequate team members such as a plastic reconstructive surgeon; and the planning of additional procedures. The limb should be also checked for signs of compartment syndrome. Compartment decompression should be performed during the nailing procedure if necessary. It should be stressed that a compartment syndrome is not a contraindication for nailing if recognized early and treated adequately.

The availability of different nail types and designs can have a major impact on the decision whether to use an intramedullary nail for a certain fracture. The last generation nails allow a larger spectrum of fractures to be nailed. On the other hand, it is not necessary to nail a simple fracture with the most advanced implant type.

A femur fracture localized between the lesser trochanter and ending within 7 cm of the distal femur can be treated with a piriformis fossa entry, antegrade, reamed, statically locked intramedullary nail [13, 31]. This first generation slotted nail is still the workhorse for femoral shaft fractures. Considerations of using other types of nails are the following: a concomitant femoral neck fracture (most of them are nondisplaced) requires the use of a reconstruction type/cephalomedullary nail, or the use of a retrograde nail with an additional device for femoral neck fixation [32]. In case of an ipsilateral tibia shaft fracture [33], a bilateral femoral fracture; as well as in the morbidly obese patient [34], the femoral fracture may be more easily treated with a retrograde nail. If preoperative radiographs demonstrate a very narrow medullary canal or an exceptionally long or short bone, then a special sized nail should be ordered in advance. In patients with severely deformed femurs, nailing might be precluded in favor of other options [35]. In these cases, when nailing is still desirable in spite of the deformity, advanced measures such as a creation of CT-derived bone model [36] or corrective osteotomy should be considered.

Very distal or proximal fractures require special nail types, which allow multiple interlocking in the short fragment, obtaining adequate stability in all planes.

All mid-third tibia fractures can be nailed with simple, previous generation nails. More proximal and distal fractures pose a challenge especially in regard to maintaining reduction during and stable fixation after intramedullary nailing. Modern nail designs with multiple locking options and improved proximal curve allow easier nailing of these fractures [37]. If these nails are not available, it is strongly advised to consider other fixation methods.

It is recommended that implant templates are available as a transparency or as a computer image to be overlaid on the image of the reduced fracture (or the contralateral limb) in order to simulate the feasibility of nailing as well as to estimate the right length/diameter. An increasing number of commercially designed software modules for preoperative planning is available for individuals and institutions.

When newer, modern types of nails are chosen, it is of utmost importance that ancillary equipment for the use of these nails is available. Despite being a mere technical issue, a mismatch between guide wires, reamers, as well as interlocking screws all of which may be available in separate from the main nail system, may result in a catastrophe, especially at time when least prepared, i.e., at nights and weekends. The surgeon and his/her team must make sure that all of the necessary equipment is readily available at all times – prior to surgery (Box 5.1).

The choice of patient’s position prior to nailing can be crucial to the success of the procedure and should be an integral part of the plan. Patient factors, operation room factors and surgeon factors all might play a role in the choice of patient positioning and preparation. Most femur fractures can be successfully treated with a fracture table. However, in certain cases, some patient factors prevent its use: polytrauma, the need for other skeletal and non-skeletal surgeries to take place, or morbid obesity. The advantages of having a traction table as compared to manual traction must be outweighted due to potential complications such as pudendal nerve palsy [38], contralateral (healthy) leg compartment syndrome [39] and increased prevalence of malrotation [40]. Others advocate using manual traction in either supine or lateral decubitus position, allowing easier entry point access [41] and better alignment control. It is to the surgeon’s discretion, based on the available evidence, equipment and experience, to determine the desirable patient positioning. Whatever it may be, the operation room set-up including the surgeon, the surgical assistants, the operation room nurses and the radiograph technician should be familiar and clear to the entire team prior to the procedure, and be part of the plan (Box 5.1).

One of the most critical aspects of intramedullary nailing in all bones is the correct choice and meticulous performance of the entry point. Whatever the entry point for the nail should be, the familiarity of the surgeon with the bony and soft tissue anatomy is of paramount importance to ensure an optimal position of the implant in the bone and to prevent complications that likely occur when the perfect entry point is not chosen. The two main issues which must be addressed when planning an entry point are potential damage of critical soft tissues structures around the entry point, and the influence of a correct entry point on fracture alignment.

Soft tissues can be severely compromised due to non-careful and non-meticulous handling during the entry point preparation. Each entry point has its hazards, which have to be known to the surgeon. Cadaveric studies have shown the most typical damages. At the proximal femur, the abductors, external rotators, and the blood supply of the femoral head can be damaged by using a standard piriformis fossa entry point [42, 43]. At the tibia, the patellar tendon, intermeniscal ligament and the Hoffa fat pad can be damaged [44, 45]. There still is an ongoing debate on the reasons for and how to avoid anterior knee pain after tibia nailing. At the humerus, a proximal entry point is a potential source for shoulder pain [46]. Whatever entry point for nailing is chosen, careful and meticulous soft tissue care and dissection is mandatory for reducing the frequency and extent of these potential complications.

The choice of the correct entry portal is of paramount importance for fracture alignment. It has been shown that the shape of the greater trochanter may vary between different patients. As a consequence, the spatial relation between the trochanter tip entry point and the intramedullary canal is variable and affects alignment of the fracture [47]. When inserting a trochanteric nail too lateral in a proximal fracture, a varus malreduction will occur. At the proximal tibia, due to its triangular shape, the medullary canal is located more laterally at its proximal part. Therefore, a slightly more lateral and proximal entry point is crucial for avoiding a valgus malalignment in proximal tibia fractures [48]. In proximal humerus fractures, a too lateral entry point may also adversely affect fracture alignment [5]. The correct entry portal is dependent of whether the nail has a lateral bent or is straight. The surgeon must profoundly understand the influence of the entry point on fracture alignment as dictated both by the bony anatomy and nail design. A very good advice, when the soft tissue envelope is thick, is to use a metal object and a marking pen on two orthogonal fluoroscopic views to ensure that a proper entry point is made (Figs. 5.4 and 5.5). A surgeon should not attempt to perform a nailing procedure unless he/she is totally familiar with the surgical approaches and potential pitfalls and hazards of entry point selection. The choices of an adequate nail design and the related correct entry point therefore must be the ones that the surgeon feels most familiar and skilled with. Hands on courses, cadaveric dissection and visiting fellowships are encouraged to obtain the necessary knowledge and experience.

The reduction might be the most technically demanding part of the nailing procedure. In midshaft fractures, especially in the femur, where the soft tissue envelope is the thickest, it can be hard to obtain a good reduction and alignment in muscular or obese heavy individuals. Other difficulties in reduction occur in fractures near to the metaphyseal area. In these zones, there is no real medullary canal. Precise reduction and maintenance of reduction must be guaranteed before and during nail insertion. In the next chapter, reduction aids and tips for correct nail placement will be described.

A few tools and general concepts, however, should be dealt with and considered prior to surgery. A fracture table can serve as a reduction tool, but often cannot provide a precise alignment. Adjuncts such as an external fixator or the AO femoral distractor can and should be used. The type, position and insertion of the distractor will differ according to the fracture type and localization [21, 49–51]

Bone clamps for percutaneous reduction should also be considered [52]. Numerous authors have suggested the use of “poller” or blocking screws used for nailing of metaphyseal fractures [53, 54]. These are intended for narrowing the medullary canal, therefore forcing the nail into a specified path useful for obtaining and maintaining reduction. The rationale for the use of poller screws is dictated by fracture localization and morphology. The exact placement of each screw should be planned in advance [55]. Careful inspection of the preoperative films should is mandatory in order to plan the proper position of each such screw, avoiding entering occult or overt fracture lines and creating additional damage with such screw insertion. Understanding common deformities dictated by the fracture morphologies will allow the correct placement of poller screws.