TIP OF THE MONTH: November/December 2005

The Origin, History and Use of the Intramedullary Nail
Timothy Witzigreuter, OTC

Through the years, many things have changed. I remember when you could rent your favorite movie on a “Beta Format,” make a phone call from a pay phone for a dime, and when someone said “mail” you automatically thought of the post office. Now movies are on compact discs, phone calls from pay phones now cost fifty cents, or are made with a prepaid card that has an allotted number of minutes. Now, instead of putting a stamp on an envelope, and taking it to the mailbox to wait on the postman, we go to the trusty computer, logon and, in a matter of seconds, send our letters, pictures, movies or cards to anyone in the world.

Changes in medicine have altered how patients are treated for particular problems. I remember as a Paramedic in the 1980’s, during a code situation some of the medications that I gave then are not given now. Was that the wrong treatment? No, that was the recommended treatment of choice at that time. The way we administer Cardio Pulmonary Resuscitation (CPR) and how we put our newborns in the crib has changed several times over the past three or four years. During CPR, the compression to breath ratios or when to stop and seek help has changed. Even how to put your newborn to bed has changed. Were you instructed to put your newborn on its side, stomach or back?

Other types of treatments were invented, challenged and changed many, many years ago, some of which are still practiced today. Some of these treatment changes were and are the way lower extremity fractures are treated. For instance: Hippocrates, in 400 BC, used traction to secure reduction and then used bandages and splints to hold a fracture of the femur. Some of today’s young orthopaedic surgeons have not seen or ever used traction as a treatment for fractures. Casting fractures dates back to 1740 when Cheselden had a fracture as a child treated by
a bonesetter with bandages dipped in egg white and starch. Later in his life, when he became a surgeon, he introduced casting as the method of fracture treatment for his patients. Unfortunately these casts took a day to harden.

Casting then progressed to manufactured plaster bandages, then fiberglass and to the new synthetic materials that we use today. Over the past 50-60 years, the treatment for lower extremity fractures has not changed very much. Usually one of three choices will be made:

-Casting of the extremity for six to eight weeks
-Insertion of pins distal to the fracture and placed supine in bed with the injured extremity in
balanced traction for up to twelve weeks
-Insertion of an intramedullary nail and be partial weight bearing very soon after insertion

The weight bearing status depends on the location and type of fracture, and the treating physician. These choices, or treatment avenues, are made by the orthopaedic surgeon depending on several factors. It is the age of the patient, location of the fracture, geographic location of the treatment facility, body morphology, severity of other injuries or underlying illnesses or combination of these that would contraindicate one or the other of these type of treatments. It may be that the treatment choice is made because the surgeon prefers one method to another.

Each of these treatment plans has the chance for complications. Casting an extremity has an increased chance of underlying skin issues, joint stiffness, nerve and circulatory compression. With any of these complications, it is important for the cast to be changed. Since these occur early after the initial injury, healing of the fracture is in very early stages.

Changing a cast before callus formation has started may allow an aligned fracture to become displaced while the cast is removed and reapplied. Swelling can cause pressure on the skin, musculature and vascularproblems which requires the cast to be uinvalved or bivalved. Once the cast is univalved or bivalved the integrity of the cast is violated which could allow too much movement of the fracture causing delayed healing as well as malunion or displacement. Traction can cause the patient to have sloughing of tissues at and around the pin sites; chances of pneumonia and emboli are increased from lack of mobility from being restricted to a supine position for an extended period. Pressure sores on the posterior pelvis area are also a concern from the prolonged supine position.

Intramedullary nailing of a bone also has its own chance of complications, as does any surgical procedure. The biggest factor is the recovery period of IM nailing versus casting or traction. In most cases, patients are up and ambulatory with crutches the day of surgery. This allows the patient to be mobile and the ability to move the extremity versus having the extremity held in one position for weeks. It makes the recovery and healing times easier for the patient to manage. Most importantly, reduction and fixation of the fracture is maintained while allowing the patient
to be self-sufficient.

The primary focus of this article is a discussion of the intramedullary nail (IM Nail), or IM rod as we sometimes hear it referred. The intramedullary nail was invented by Gerhard Kuntscher. His ideas, techniques, teaching and procedures changed the course of fracture treatment and healing and was the foundation for modern orthopedic traumatology. Kuntscher experimented with callus formation at the fracture site by inserted wires and other objects into the intramedullary canals of animal subjects. He then studied the formation of callus around these different objects that showed a certain amount of stability as well as a tiny amount of instability of the fracture. This showed that too much movement results in pseudoarthosis, and if almost no movement decreased the amount of callus or delayed healing.

The first human to have an intramedullary nail inserted was in 1939 by Kuntscher on a patient at the University of Hamburg’s Department of Surgery. This patient was a thirty-five year old shipbuilding engineer that fractured his femur from a fall on the docks. Kuntscher inserted an intramedullary nail and the shipbuilder was able to walk on his broken leg a few days after the operation. Complete bone healing was obtained within four months.

The outbreak of World War II had Kuntscher serving as a medical officer in the German Army from 1941 to 1945. The German military initially disapproved of Kuntscher’s IM nailing technique, but he was allowed to continue. While in the Finnish Lapland from 1943 to 1944, he taught the Finish surgeons to do intramedullary nailings, which earned him recognition and respect, in the orthopedic community. The war also prevented the knowledge of Kuntscher’s use of the IM nail to exit Germany. The German military had the upper hand on treating soldiers with the IM nail and having them return to fighting status in just a few weeks. World wide knowledge was not established until the Prisoners of War (POW’s) returned to their home countries carrying Kuntscher’s legacy in the form of steel nails in their legs. Surgeons in the United States and France were surprised and puzzled by the huge nails seen in X-rays and by the descriptions of rapid healing by the POW’s themselves. Still, it took more than 20 years and the development of fluoroscopy before the method would receive worldwide acceptance.

Kuntscher continued working with his IM nails. The first of these nails were triangular or V-shaped. During the late 1940’s, he changed the nail to a cloverleaf shape that he decided controlled rotation much better than the V-shaped nail. During his desire to enlarge the use of the IM nail he designed the reamer, intramedullary saw and the interlocking nail which he called the “detensor”. Detensor nails were perforated at the ends for the insertion of bolts to prevent rotation and or telescoping of the fracture. These changes led to what we now refer to as the interlocking nail. Kuntscher’s intramedullary nail is still the most common treatment for lower extremity fractures by today’s orthopaedic surgeons. Many manufacturers of orthopaedic supplies have “their” IM Nail, but they all came from Kuntscher’s ingenious idea to stabilize the fracture with an internal device.

CASE STUDY

We are now going to follow a patient suffering a lower extremity fracture who was treated with an intramedullary nail. We will refer to this patient as “Patient T ”. Patient T sustained a fall on an ice-covered driveway that caused torque-type forces on the right lower extremity. These forces caused an oblique fracture to the distal third of the right tibia and the proximal fibula. The fracture of the tibia began approximately 5-6 centimeters proximal to the tibial-talar joint and spiraled proximally. The distal fragment was approximately one diaphysis width posterior in relation to the proximal fragment on lateral view (See Figure 1).The AP view showed a varus angulation with minimal to no offset of diaphysis (See Figure 2).

FIGURE 1 FIGURE 2
The fibular neck was also fractured with minimal displacement (See Figure 3 and 4). The extremity was initially splinted by emergency personnel with a posterior stirrup type splint.

FIGURE 3 FIGURE 4
The orthopaedic surgeon gave Patient T the choices of a long leg cast and non-weight bearing for 6-10 weeks or surgical insertion of an intramedullary nail the next morning with toe touch weight bearing soon post-operative. The right lower extremity had the IM nail in place with complete reduction of the fracture (See Figure 5 and 6). By late afternoon of the same day, Patient T was in the hallway ambulating on crutches with physical therapy instructing how to maneuver on crutches.

FIGURE 5 FIGURE 6
Patient T was released from the hospital on the second post-op day on crutches and in a posterior splint with instructions to keep the extremity elevated, dry, and to actively move the toes of the affected extremity. The toes of the injured extremity were unable to be actively flexed or extended due to a peroneal nerve injury. This was carefully watched for the return of sensory and motor function. The first scheduled recheck was at two weeks post-operative. X-rays were made and compared to the initial postoperative films, which showed a healing well-aligned fracture. The dressings were removed revealing benign incisions. The dressings were replaced and the splint discontinued. The sensory and motor functions in the foot were starting to return and Patient T was allowed to begin weight bearing as tolerated and scheduled for an EMG/NCV that same week and recheck scheduled for two more weeks.

At the fourth post-operative week visit, the extremity was again X-rayed which showed a well-aligned fracture and large callus formation at the fracture site.The EMG/NCV test confirmed a peroneal nerve palsy at the level of the fracture site. The increase in sensation and movement in the toes showed a possibility of full nerve recovery. Patient T was released to begin full weight bearing on the extremity. The next scheduled recheck was at the sixth postoperative week. X-rays were made again showing an aligned fracture with increased callus formation.

The fracture lines were barely visible. Patient T was released by the surgeon to full weight bearing status and to return if any problems. Patient T asked if the locking screws in the proximal and distal ends were to be removed, and was told only if they became symptomatic. Patient T, nine years after the injur and IM nail, is doing wonderfully well. The nail and locking screws are retained and Patient T has experienced no complications from this retained hardware. The only residual effect Patient T had is the peroneal nerve palsy that keeps ME from extending the toes on MY right foot as far as the ones on MY left foot.

EMAIL THE NAOT OFFICE TO REQUEST THE QUESTIONS FOR ON-LINE CEUS
(period to obtain CEUs on-line for this article expired January 6, 2006).

NAOT
8365 Keystone Crossing
Suite 107
Indianapolis, IN 46240
(317) 205-9484
(317) 205-9481 FAX
[email protected]
naot.org

Last Revised 2/28/06