All B and C type fractures, especially the non-reconstructible types, are amenable for internal fixation with an interlocking nail (ILN). The ILN can be used with an open approach but is an excellent minimally invasive device, since it can be placed through small incisions without disturbing the fracture site.
The ILN provides good relative stability to the fractured bone. They are highly effective in counteracting bending forces because of their large diameter and intramedullary location. Unlike intramedullary pins, they effectively counteract axial compression and torsion because of their interlocking mechanisms.
Illustrations of fracture types
Fracture types :
A) Comminuted, unreduced fracture B) Comminuted fracture aligned biologically C) Fracture aligned and biologically stabilized
Diameter, length and depth of ILN insertion are determined by preoperative planning using the radiograph of the opposite intact femur if available. The nail’s largest diameter should be approximately 75% of the medullary cavity at the femoral isthmus. The longest possible nail should be selected to optimize construct stability (Dejardin et al: Interlocking nail and minimally invasive osteosynthesis Vet Clin Small Anim 42 (2012) 935–962).
In the proximal femur, the only acceptable nail insertion technique is normograde. The medullary cavity is opened using an intramedullary pin or a dedicated awl inserted from the trochanteric fossa.
Depending on the type of nail used, reaming of the medullary canal in the distal fragment may be required.
The nail is coupled to an insertion handle via a nail extension. It is introduced along the anatomical axis of the femur and inserted into the medullary canal of the proximal segment by hand or gentle hammering. The fracture is aligned while the nail is further advanced into the distal segment. The nail is directed into the distal segment using fluoroscopic guidance, closed palpation, or visualization through an open-but-do-not-touch approach to the fracture site. A mallet is used to fully impact the nail into the intramedullary canal, until deeply seated in the distal metaphysis or epiphysis.
Validation of alignment and rotation
Reduction is confirmed using local landmarks and/or intraoperative fluoroscopy. Reduction is adjusted as necessary prior to locking the nail. Rotational alignment can be judged by palpation or by direct visualization of the greater trochanter and femoral trochlea or by examination of the adductor magnus muscle. The distal part of the femur is held in a true lateral position. The position of the greater trochanter is then inspected. If the femur is correctly aligned in the axial plane the greater trochanter should be slightly caudal to the long axis of the bone.
The alignment can also be checked by confirming the orientation of the femoral neck relative to the plane of the femur. This is done by inserting a small pin along side the femoral neck with the femur in a true lateral position. Orientation of the pin should be about 15°-25° in the cranial direction relative to the sagittal plane of the femur.
Final application of the nail
Once adequate alingment and proper nail insertion are confirmed, placement of the bolts or locking bolts is achieved through the use of an alignment guide coupled to the nail. The alignment guide and nail extension are removed at the end of the procedure.
6. Case example
4 year old 17 kg mixed breed male dog with a C3 femoral fracture.
The fracture has been repaired with an interlocking nail with bolts.
Alignment: fair/adequate Apposition : not attempted (indirect reduction)
Postoperative radiographs at 35 days. Activity: Appropriate healing
Postoperative radiographs at 60 days.
Phase 1: 1-3 day after surgery
Aim is to reduce the edema, inflammation and pain. Integrative medical therapies, anti-inflammatory and analgesics.
Phase 2: 4-10 days after surgery
Aim is to resolve the hematoma, edema and control pain, and prevent muscle contracture. Anti-inflammatory and analgesic medications may still be needed. Rehabilitation and integrative medical therapies can be used.
Special attention should be given to patients less than 1 year of age with a femoral fracture. Rehabilitation is strongly recommended to help prevent quadriceps muscle contracture.
If the dog is not starting to use the limb within few days after surgery, a careful evaluation is recommended.
10-14 days after surgery the sutures are removed.
Radiographic assessment is performed every 4-8 weeks until bone healing is confirmed.
~3-4 months after follow up radiographs surgery check bone healing.