INTRAMEDULLARY NAILING

WHAT IS INTRAMEDULLARY
NAILING?
An intramedullary rod, also known as an intramedullary nail
(IM nail) or inter-locking nail or Kntscher nail (without
proximal or distal fixation), is a metal rod forced into the
medullary cavity of a bone. IM nails have long been used to
treat fractures of long bones of the body. Gerhard Kntscher
is credited with the first use of this device in 1939.
WHAT IS IT USED FOR?
HOW?
TO ALIGN THE FRACTURED BONES AND PROVIDE OPTIMAL HEALING
SUPPORT, THE ORTHOPEDIC SURGEON MAKES A SMALL INCISION
THROUGH THE SKIN AND TISSUE CLOSEST TO ONE END OF THE BROKEN
BONES. THE SURGEON THEN INSERTS A SMALL ROD-LIKE NAIL DEVICE
INTO THE HOLLOW CENTER OF THE BONE, CALLED THE MEDULLARY
CAVITY. THE INTRAMEDULLARY NAIL FORMS A SELF-CONTAINED
INTERNAL SPLINT TO STABILIZE THE FRACTURE. THIS IS OFTEN DONE
FOR FRACTURES OF THE TIBIA, FEMUR (THIGH), AND HUMERUS
(SHOULDER).
WHAT IS IT USED FOR? HOW?

To align the fractured bones and provide optimal healing

support, the orthopedic surgeon makes a small incision
through the skin and tissue closest to one end of the broken
bones. The surgeon then inserts a small rod-like nail device
into the hollow center of the bone, called the medullary
cavity. The intramedullary nail forms a self-contained internal
splint to stabilize the fracture. This is often done for fractures
of the tibia, femur (thigh), and humerus (shoulder).
POTENTIAL ADVANTAGES OF
INTRAMEDULLARY NAILING
Provides durable, strong and flexible support.
Allows more exact alignment of the fractured bones for
faster healing and may lead to earlier weight bearing.
May lead to earlier joint motion for reduced stiffness.
Encourages more natural-like motion in uninjured muscles
and neighboring joints.
PREOPERATIVE PHASE
PRE-ADMISSION TESTING

Initiates initial preoperative assessment.

Initiates teaching appropriate to patients needs.
Verifies completion of preoperative testing.
Verifies understanding of surgeon-specific preoperative
orders (e.g. bowel preparation, preoperative shower)
Assess patients need for postoperative transportation and
care.
ADMISSION TO SURGICAL CENTER
OR UNIT
Completes preoperative assessment.
Assess for risk for postoperative complications.
Reports unexpected findings or any deviation from normal.
Verifies that operative consent has been signed.
Reinforce previous teaching.
Explain phase in perioperative period and expectation.
Develop a plan of care.
 IN HOLDING AREA
Assess patients status, baseline pain and nutritional status.
Review chart.
Identifies patient.
Verifies surgical site and marks site per institutional policy.
Establishes intravenous line.
Administers medication if prescribed.
Takes measures to ensure patients comfort.
Provides psychological support.
Communicates patients emotional status to other appropriate members of
the health care team.
INTRAOPERATIVE PHASE
 Maintenance of safety, aseptic and controlled environment.
Effectively manages human resources, equipment, and supplies
for individualized patient care.
Position the patient: function alignment, exposure of surgical
site.
Applies grounding device to patient.
Ensure that the sponge, needle, and instrument counts are
correct.
Completes intraoperative documentation.
 Physiologic Monitoring
Calculates effect on patient of excessive fluid loss or gain.
Distinguishes normal from abnormal cardiopulmonary data.
Reports changes in patients vital signs.
Transfer patient to operating room bed or table.
Interventions including insertion of a urinary catheter,
prophylactic administration of antibiotics and inflammation of
tourniquets.
POST-OPERATIVE PHASE
DIET

Begin with clear liquids and light foods (jellos, soups, etc.)
Progress to normal diet if the patient does not experience
nausea.
 WOUND CARE

Maintain operative dressing, loosen bandage if swelling

of the foot and ankle occurs, or wrap the patients foot
and ankle with an ACE wrap
It is normal for the knee to bleed and swell following
surgery if blood soaks through the ACE bandage, do
not become alarmed reinforce with additional dressing
Remove surgical dressing on the third post-operative
day.
 Note for increasing drainage on the gauze, increased
redness around the wound (spreading), or milky
drainage from the wound, call the doctor.
To avoid infection, keep surgical incisions clean and dry
the patient may shower by placing a large garbage bag
over the brace starting the day after surgery
If the patient is not using a brace, keep the incisions dry
for 3 days and when the patient shower on day 3, keep
the incisions covered with gauze to avoid direct impact
of water with the wound, and change this after the
shower
 ACTIVITY

Elevate the operative leg ABOVE chest level

whenever possible to decrease swelling. The first 48
hours is a balance between mobilization (which is
encourage) and elevation (to be done whenever
possible).
DO NOT PLACE A PILLOW UNDER THE BACK
OF the KNEE (i.e. do not maintain knee in a flexed
or bent position). Pillows should be under the ankle
which will keep the knee straight when elevating.
 Crutches are only for support the first 24-28 hours after
surgery, feel free to walk without crutches as soon as the
patient believe he can safely do so.
Do not engage in activities which increase knee
pain/swelling (prolonged periods of standing or walking)
over the first 7-10 days following surgery
Avoid long periods of sitting (without leg elevated) or long
distance traveling for 2 weeks
NO driving until instructed otherwise by physician and no
driving while taking narcotics
May return to sedentary work ONLY or school 3-4 days
after surgery, if pain is tolerable
PREVENTION OF COMPLICATIONS
Encourage early mobilization:
- Deep breathing and coughing
- Active daily exercise o Joint range of motion
- Muscular strengthening
- Make walking aids such as canes, crutches and walkers
available and provide instructions for their use
Ensure adequate nutrition
Prevent skin breakdown and pressure sores:
- Turn the patient frequently
- Keep urine and feces off skin
Provide adequate pain control
 EXERCISE
IMMEDIATELY AFTER SURGERY: Perform straight leg raise
and ankle pumps down into 10 sets of 10 reps
The patient cannot do too many ankle pumps (another
good reminder is to do them during commercials on TV)
Discomfort and knee stiffness is normal for a few days
following surgery
Formal physical therapy (PT) will begin after the first post-
operative visit and the script is provided to the patient on
the day of surgery
IF THE PATIENT IS RESTLESS,
SOMETHING IS WRONG.
Look out for the following in
recovery:

Airway obstruction
Postoperative pain
Hypoxia
Shivering, hypothermia
Haemorrhage: internal or
Vomiting, aspiration
external
Falling on the floor
Hypotension and/or
hypertension Residual narcosis
The recovering patient is fit for the ward when:
Awake, opens eyes
Extubated
Blood pressure and pulse are satisfactory
Can lift head on command
Not hypoxic
Breathing quietly and comfortably
Appropriate analgesia has been prescribed and is safely
established
 CALL THE DOCTOR IF ANY OF THE FF
ARE PRESENT:
Painful swelling or numbness
Unrelenting pain
Fever greater than 101.5 at least 48 hours after surgery surgery)
or chills
Redness that is spreading around incisions
Continuous drainage or bleeding from incision (a small amount of
drainage is expected)
Excessive nausea/vomiting
Difficulty breathing/chest pain - Consider going directly to the
emergency room if this is persistent
JE VOUS REMERCIE!!