Intramedullary nailing seminar by dr ashwani panchal
DR ASHWANI PANCHAL
JSS MEDICAL COLLEGE
The intramedullary nail is commonly used for long-bone
fracture fixation and has become the standard treatment
of most long-bone diaphyseal and selected metaphyseal
To understand the intramedullary nail, knowledge of
evolution and biomechanics are helpful 2
In 16 th Century In Mexico Aztec physicians have placed
wooden sticks into the medullary canals of patients with long
In Mid 1800’s Ivory pegs were inserted into the medullary
canal for non-union. In1917 ‘s Hoglund of United States
reported the use of autogenous bone as a intramedulary
1930’s In the United States, Rush and Rush described the
use of Steinman pins placed in the medullary canal to treat
fractures of the proximal ulna and proximal femur.
1940 ‘s : The Evolution of Kűntscher Nailing
Gerhard Kűntscher was born in Germany in 1900
1931 : Smith-Petersen reported the success of stainless
steel nails for the treatment of NOF #s
Küntscher developed ‘V’
nail, Cloverleaf shaped and
the ‘Y’ nail.
His methods were based on
two principles: stable fixation
and closed nailing. .
Harvey C. Hansen and Dana
M. Street developed a diamond
shaped nail which is relied on
the holding power of cancellous
bone at both ends. He termed
the word ‘Bolt
Lottes designed three flanged
femur and tibial nails. Both nails
employed a screw-on driver-
Stryker designed a broach in
a cloverleaf and diamond
shaped pattern. It provided
maximum holding power to
resist torque and avoided
reaming the entire canal
Schneider designed his nail
which incorporated a double-
ended stud, self broaching and
fluted with a square cross
1950’s Interlocking Screws :
Modny and Bambara introduced
the transfixion intramedullary
nail in 1953
Nailing of tibia is introduced by
herzog in 1950.
Livingston bar,introduced a
short I-beam pattern pointed
nail at both ends,which had
short slots for cross-pinning with
Today any fracture is stabilized by one of the two
systems of fracture fixation .
1. compression system
2. splinting system
Intramedullary fixation belongs to internal splinting
Splintage may be defined as a construct in which
micromotion can occur between bone & implant,
providing only relative stability without interfragmentary
Depending on the anatomy the insertion can be ante
grade and retrograde.
The entry point depends on the anatomy of the bone but
is distant from the fracture site.
Intramedullary fixation techniques offer the advantages of
closed reduction and closed fixation.
A.CENTROMEDULLARY- K NAIL,FIRST GENERATION
B.CEPHALOMEDULLARY- GAMMA NAIL, RUSSELL
TAYLOR NAIL,UNIFLEX, PFN
C.CONDYLOCEPHALIC NAIL-ENDER NAIL,LOTTES
•Also known as elastic stable intramedullary nailing
(ESIN), is a primary definitvie fracture care (PDFC) in
paediatric orthopaedic practice.
•This method works by 3 – point fixation or bundle
•The elasticity of the construct allows for ideal
cirumstances of micro-motion for rapid fracture healing.
• Nonreamed nails are actually not nails but
pins. Their mechanical characteristics and
use are different from IM nails. They are of
smaller diameter and are more elastic.
• Their flexibility allows insertion through a
cortical window. There are many different
types of flexible nails, the best known are:-
Lottes nails - Tibia
Rush pins – for all the long bones of the body
Intramedullary nails to be
used as single without
A. Schneider nail [ solid,
four flutedcross section
and self broaching ends.
B. Harris condylocephalic
nail [curved in two
planes, and designed for
fixation of extra capsular
C. Lottes tibial nail
specially curved to fit the
tibia, and has triflanged
SOLID, CIRCULAR IN
SHARP BEVELLED TIPS
AND A HOOK AT THE
Ender Nails, which are
solid pins with an
oblique tip and an eye in
flange at the other end,
were originally designed
for percutaneous, closed
treatment of extra
capsular hip fractures
•Each nail is precurved to achieve 3-point fixation where the
required precurve should be approximately 3 times the
diameter of a long bone at its narrowest point.
•Part of the biomechanical
stability is provided by the intact
muscle envelope surrounding
the long bone.
•All currently available nails
have beaked or hooked ends to
allow satisfactory sliding down
on insertion along inner surface
of the diaphysis without
impacting the opposite cortex.
•Insertion points that do not lie
opposite to one another produce
differing internal tension and
imbalance of the fracture stability
•The apex of the curvature should
be at the level of the fracture site.
•The nail diameter should be 40%
of the narrowest medullary space
•Two nails of the same diameter
and similarly prebent to be
error is lack of internal support.
There are two basic methods of IM pinning, they are:
1. Three point compression.
2. Bundle nailing.
Most pins stabilize fracture by three point
These pins are C- or S – Shaped, they act like a
The equilibrium between the tensioned pin and the
bone with its attached soft tissues will hold the
The principle of bundle nailing was introduced by
He inserted many pins into the bone until they jammed
within the medullary cavity to provide compression
between the nails and the bone.
Both techniques should be seen more as IM splinting
than rigid fixation.
Bending movements are neutralized, but telescoping and
rotational torsion are not prevented with this technique
Flexible nail are usually simpler to use and can be
inserted more quickly.
If infection intervenes, the complication of likely less
severe. So can be used in tibia open fracture because of
its less blood supply and its subcutaneous location.
Because of small size of forearm bones reaming is
technically difficult, so unreamed nail have generally
•They are usually reamed nails in which interlocking is
its newer modification.
•The classic reamed nail is the hollow, open – section
nail of Küntscher.
•Most other reamed nails are variations of the
Küntscher nail such as the AO nail, and the various
interlocking nails, such as the Grosse – kempf, Klemm
Alta, Russell – Taylor, Uniflex, AO Universal and
Consecutive advancements of nails over years Can be
grouped under three generations
1 st generation:
primarily act as splints ,rotational stability is minimal , primarly
relies on close fit
Eg –K nail , V nail
2 nd generation :
Improved rotational stability due to locking screw
Eg-Russel taylor nail
3 rd generation:
Nails with various designs to fit anatomocally as much as
possible ,to aid the insertion and stability
Eg -Nails with multiple curves ,multiple fixation systems
Tibial nail with malleolar fixation
A. Kuntscher nail, designed for open
B. Kuntscher nail designed for closed
nailing which has a curved, tapered
tip, and is slotted throughout.
C.Grosse – Kempf nail
D.Alta intramedullary locking nail for
the femur. This is solid section,
cannulated nail with a hexagonal
cross section with smooth flutes to
Russell – Taylor nail:
This is a second generation nail.
Proximal locking into the
femoral head enhances its
stability in hip fractures
Brooker – Wills nail fixing a
fracture of the femur, an AP
roentgenogram. This nail has
flanges deployed through
slots in the tip of the nail for
Except for the Brooker – Wills nail with its flanges and
the expandable tip of the Seidel nail, which is used
exclusively for the humerus, all current designs use two
distal transverse cross – locking screws, as in the Alta
Proximal fixation includes inclined screws as in the
Grosse Kempf nail, two transverse screws, as in the Alta,
and specialized screws though the nail designed to
secure fixation in the femoral head, as in the Russell –
Gamma nail: This intramedullary
device is designed for proximal
intramedullary fixation of
intertrochanteric and some
When placed in a fractured long
bone, IM nails act as internal
splints with load-sharing
Various types of load act on an IM
nail: torsion, compression, tension
Physiologic loading is a
combination of all these forces
Bending moment = F x D
F = Force
F = Force
The bending moment for the plate
is greater due to the force being
applied over a larger distance.
IM Nail Plate
D = distance from force
• Nail cross section
is round resisting
loads equally in all
• Plate cross-section
loads in one plane
versus the other.
The amount of load borne by the nail depends on the
stability of the fracture/implant construct.
This stability is determined by
2.Number and orientation of locking screws
3.Distance of the locking screw from the fracture site
4.Reaming or non reaming
5.Quality of the bone
IM nails are assumed to bear most of the load initially, then
gradually transfer it to the bone as the fracture heals.
Several factors contribute to the overall biomechanical profile
and resulting structural stiffness of an IM nail.
Chief among them are
d)Length and working length
e)Extreme ends of the nail
f) Supplementary fixation devices
• Metallurgy less important
than other parameters for
stiffness of an IM Nail.
Most of them are
fabricated from stainless
steel, with a small number
* 10 ⁸ psi
Titanium alloy has a modulus of elasticity closely
approximates that of cortical bone ( Modulus is ability to
resist deformation in tension
The material must be stiff . Titanium are 1.6 times stiffer and
elastic modulus is 50% lower than steel nail
The cross-sectional shape of the nail ,Diameter
determines its bending and torsional strengths( Resistance
of a structure to torsion or twisting force is called polar
movement of inertia )
Circular nail has polar movement of inertia proportional to
its diameter, in square nail its proportional to the edge
Nails with Sharp corners or fluted edges has more polar
Cloverleaf design resist bending most effectively .Presence
of slot reduces the torsional strength . It is more rigid when
slot is placed in tensile side
Nail diameter affects bending rigidity of nail.
For a solid circular nail, the bending rigidity is proportional to
the third power of nail diameter
Torsional rigidity is proportional to the fourth power of
Large diameter with same cross-section are both stiffer and
stronger than smaller ones.
•Some nails are designed in a such a way that stiffness
doesn’t vary with diameter.
•The diameter of a nail should always
be measured with a circular guage.
•In reamed nailing, the width of nail is
better determined by the feel of the
reamers than by radiographic
measurements, although the
approximate size to be used can be
determined from preoperative
(X 106 )
(X 106 )
10 40.0 20.0
11 52.0 26.0
12 69.0 34.5
13 88.8 44.4
14 112.1 56.4
15 139.1 69.6
16 170.1 75.1
17 241.4 120.7
Flexural rigidity (EI) of slotted cloverleaf
IM Nails (1mm wall thickness) (Nmm2)
Obtain preoperative radiographs of the
fractured long bone, including the proximal
and distal joints.
If there is any question, obtain an
anteroposterior radiograph of the opposite
normal limb at a tube distance of 1meter. A
nail of the appropriate size should be taped to
the side of the limb for reference, or a
radiographic ruler can be used, alternatively a
Kuntscher measuring device – the ossimeter
may be used to measure length and width.
The ossimeter has two scales, one of which
takes into account the magnification caused
by the X-ray at a 1 – m tube distance.
-In most cases, a nail reaching to within 1 to 2
cm of the subchondral bone distally is
Size – length
Longitudinal (Anterior) bow
•Governs how easily a nail can be inserted as well as bone/
nail mismatch, in turn influences the stability of fixation of the
nail in the bone.
•Complete congruency minimizes normal forces and hence
little frictional component to nail’s fixation.
•Conversely, gross mismatch increases frictional component of
fixation and inadequate fracture reduction.
Femoral nail designs have considerably less curve, with
radius ranging from 186 to 300 cm
Tibial nail also has a smooth 11
bend in the anterioposterior
direction at junction of upper one
third and lower two third .
Mismatch in the radius of
curvature between the nail and
the femur can lead to distal
anterior cortical perforation
When inserting nail , axial force is necessary as the nail
must bend to fit the curvature of the medularly canal .
The insertion force generates hoop stress in the bone (
Circumferential expansion stress )
Greater the insertion force higher the hoop stress. Larger
hoop stress can split the bone
Over reaming the entry hole by 0.5-
1mm ,selecting entry point
posterior to the central axis reduce
the hoop stress
Example :The ideal starting
point for insertion of an
antegrade femoral nail is in the
posterior portion of the piriformis
fossa . It reduces the hoop
Length and working length
A-Total nail length- total anatomical length
-Length of a nail spanning the fracture site
from its distal point of fixation in the proximal
fragment to proximal point of fixation in the
-Length between proximal and distal point of
firm fixation to the bone
-Un supported portion of the nail between
two major fragments
Working length is affected by various factors
Type of force (Bending ,Torsion )
Type of fracture
The bending stiffness of anail is inversely proportinal to
the square of its working
The torsional stiffness is inversely proportional to its
Shorter the working length stronger the fixation
Medullary reaming prepares a uniform canal and improves
nail- bone fixation
Towards the fracture,thus reducing the working length.
Interlocking screws are recommended for most cases of IM
The number of interlocks used is based on fracture location,
amount of fracture comminution , and the fit of the nail
within the canal.
Placing screws in multiple planes may lead to a reduction
of minor movement
The principle of interlocking nailing is different. The nail is
locked to the bone by inserting screws through the bone and
the screw holes. The resistance to axial and torsional forces
is mainly dependent on the screw – bone interface, and the
length of the bone is maintained even if there is a bone
when screws placed proximal and
distal to the fracture site. This restrict
translation and rotation at the fracture
Indications – communited ,
with bone loss lengthning or shortening
osteotomies , Atropic non union
•It achieves BRIDGING FIXATION
through which fracture is often held in
distraction , a favourable environment for
periosteal callus formation exists and
healing rather than nonunion is rule.
It achieves additional rotational
control of a fragment with large
medullary canal or short epi-
It is effective only when the contact
area between the major fragments is
atleast 50% of the cortical
With axial loading, working length in
bending and torsion is reduced as
nail bends and abuts against the
cortex near the fracture, improving
the nail-bone contact
•No longer std. practice to dynamize an interlocked
nail by removing the locked screws .
•It is indicated when there is a risk of development of
nonunion or established pseudoarthrosis.
•The screws are then removed from the longer
fragments, maintaining adequate control of shorter
fragment. Premature removal may cause shortening,
instability and nonunion.
•when malalignment develops during
nailinsertion,placement of blocking
screw, and nail reinsertion improves
•Most reliable in proximal and distal
shaft fractures of tibia.
•A posteriorly placed screw prevents
anterior angulation and laterally placed
screw prevents valgus angulation.
•Characterised by an outer
diameter, root diameter and
•Shape of the threads at their
base determines stress
concentration (sharp v/s
•Pullout strength is dependent on
the outer diameter.
•The largest diameter of the screw
which can be used is limited by the
diameter of the nail.
•Increasing the diameter of the
screws reduces the cross section
of the nail at its hole and their by
predisposes to failure.
Stability depends on the locking screw diameter for a given
nail diameter. In general, 4 to 5 mm for humeral nails and 5
to 6 mm for tibial and femoral nails.
Nail hole size should not exceed 50% of the nail diameter.
Interlocking screws undergo four-point bending loads, with
higher screw stresses seen at the most distal locking sites
The number of locking screws is determined based on
fracture location and stability.
In general, one proximal one distal screw is sufficient for
The location of the distal locking screws
affects the biomechanics of the fracture .
The closer the fracture to the distal locking
screws, the nail has less cortical contact ,
which leads to increased stress on the
More distal the locking screw is from
fracture site, the fracture becomes more
Orientation of the proximal femur locking screws has little
effect on fixation stability, with both oblique and transverse
proximal locking screws showing equal axial load to failure.
Oblique ( angled to nail axis, not 90°) proximal locking
screws appear to increase the stability of proximal tibia
fractures compared with transverse ( 90° to nail axis)
However, oblique or transverse orientation of the distal
screws in distal-third tibia fractures has minimal effect on
K-nail has slot/eye in the either ends for attachment of
extraction hook .one end is tapered to facilitate the insertion .
Present version of cannulated locking screw contains
cylinderical proximal end with internally threaded core to
allow firm attachment of driver and extracter.
Holes for interlocking screws present either ends .
Some nails have slots near the distal end for placement of
anti rotation screw
- Anterior slot - improved
- Posterior slot - increased
Non-slotted - increased
torsional stiffness, increased
strength in smaller sizes.
Unknown if its of any clinical
Closed nailing :
- Fluoroscopy is used to achieve fracture reduction .
- Medullary cavity is entered through one end of the bone “
eg-Piriformis fossa in femur .
Closed antegrade nailing is the method of choice .
Open nailing :
- Performed in lessthan ideal operation room conditions
- Antegrade nailing is prefered .
- In retrograde method nail is inserted in to the proximal
fragment through fracture site and brought out at one end of
the bone ,after reduction nail is driven in to the distal
- Infection and non union is six and ten times greater in open
F R A C T U R E R E D U C T I O N
The earlier a fracture is nailed,
easier is the reduction. Shortly
after injury, the hydraulic effects
of edematous fluid can cause
shortening and rigidity of the
limb segment, which may make
fracture reduction extremely
difficult. If nailing is not done
before this degree of edema,
gentle traction may be required
to regain length and alignment
In femur, the reduction is most easily achieved by placing
the distal fragment in neutral position, avoiding tightness of
the iliotibial band, which could otherwise result in shortening
and a fixed valgus deformity.
As the tibia is subcutaneous, direct
manipulation results in reduction in
- In upper extremity, reduction is
achieved by a combination of
manipulation of the proximal fragment
with the nail and direct manipulation
of the distal fragment and fracture site
- In open nailing, the key to reduction
is to angle the fracture. - The corners
of the cortices of the proximal and
distal fragments are approximated at
an acute angle, and the fracture is
then straightened into appropriate
With reamed rods, which are generally fairly rigid, the
entry site must be directly above the intramedullary
canal. Eccentric entry sites, particularly in the femur
and tibia, can result in incarceration of the nail or
For nonreamed, flexible nails, an eccentric entry site is
usually used to take advantage of three – point
fixation of the curved nail within the medullary canal.
Generally these nails are inserted distally through the
supracondylar flares of the long bones
The entry site for reamed
nails is in the thin cortex at
the base of the greater
trochanter at the site of its
junction with the superior
aspect of the femoral neck.
ANTEGRADE NAILING FOR FEMUR:
3 cm longitudinal incision
approximately 1 cm from
the medial border of
patella, beginning about 2
cm proximal to distal pole
of the patella
IM reaming can act to increase the contact area between the
nail and cortical bone by smoothing internal surfaces.
When the nail is the same size as the reamer, 1 mm of
reaming can increase the contact area by 38% .
Reaming reduces the working length and increase the
More reaming allows insertion of a larger-diameter nail,
which provides more rigidity in bending and torsion.
Biomechanically, reamed nails provide better fixation stability
than do unreamed nails
Medullary canal is more or less like an hour-glass than
a perfect cylinder. Reaming is an attempt to make the
canal of uniform size to adapt the bone to the nail. The
size of the canal limits the size of the nail.
Reamers must be sharp, and the
surgeon must consider the
relationship between the size of the
reamers and the nail.
A 12mm reamer is not necessary
equal in diameter to a 12mm nail.
Because flexible reamers follow a
curvilinear pathway, overreaming is
usually necessary for most nails.
Most nail require overreaming from
0.5 to 2mm over the size of the
nail, depending on the type of nail,
the configuration of the fracture,
and the canal of the bone.
Insert a ball-tipped reaming guide pin across the fracture
to the subchondral bone in the distal fragment begin with
an end – cutting reamer, generally 8.5 to 9.0 mm in
On the first pass of the reamer past the fracture site,
visualize it on the fluoroscope to ensure that reaming is
It is safest to ream progressively in 0.5 – 1mm
Both reamed and unreamed nails cause damage to
the endosteal blood supply.
Experimental data suggest that reamed nailing
deleteriously affects nutrient artery blood flow, but
cortical blood supply is significantly reduced after
reamed nailing compared with unreamed nailing.
Reaming is also associated with the potential risk of
Blunt reamers and the use of reamers larger in
diameter than the medullary canal Lead to increased
temperature , therefore it suggested that long bones
with very narrow canals should first be
reamed manually or an alternative treatment method
should be used.
Some surgeons believe that unreamed nailing is
advantageous in the treatment of Gustilo III B open
fractures, citing higher infection rates.
Clinical studies of both tibial and femoral fractures
show that reamed nailing of fractures with low – grade
soft tissue injuries significantly reduces the rates of
nonunion and implant failure in comparison with
unreamed nailing. In fractures with an intact soft
tissue envelope, reaming of the medullary cavity
increases significantly the circulation within the
surrounding muscles. This increased circulation may
improve fracture healing
Reaming does not increase the risk of compartment
Fat embolism due to IM reaming was described by
Kuntscher. Fat embolism due to passage of IM contents
into the bloodstream can occur only in the IM pressure
associated with instrumentation exceeds the physiologic
IM pressure and out weighs the effects of the normal
The incidence of fat embolism is more with femoral
reaming,. Reaming of the tibia does not lead to a
significant increase of IM pressure, and intraoperative
echocardiography does not show significant fat embolism
in reamed tibial fractures.
The use of a venting hole to reduce the IM pressure
increase during reaming is controversial.
• Allows insertion of larger-sized implants which helps in weight
bearing and joint function during the healing process.
- Improves nail-bone cortical contact across the working length of
the implant and directs fracture fragments into a more anatomical
- From a biologic standpoint, provides systemic factors to promote
mitosis of osteogenic stem cells and to stimulate osteogenesis.
Eccentric reaming may lead to malreduction of the fracture.
- Destroys all medullary vessels, resulting in a initial decrease in
endosteal blood flow and in turn decreased immune response and
delay in early healing of the involved cortices.
- In open fractures, avascular and nonviable fragments causes
increased susceptibility to infections.
- Heat: a rise in temperature upto 44.6⁰ C had
a negative effect on fracture healing.
•Cell enzymes get damaged and cannot fullfill
•The threshold value of heat induced
osteonecrosis is 47⁰C.
- Pressure: hydraulic pressure builds up in the
cavity which far exceeds that of blood
pressure and is independent of the size of the
•It acts as a piston in sleeve which is filled
with a mixture of medullary fat, blood, blood
clots and bone debris.
•High intramedullary pressure forces contents
into the cortical bone and systemic circulation.
A long, very sharp awl, mounted on a T – handle, must
be used to pinpoint the area of penetration of the bone to
avoid exposing the surgeon’s hands to the direct beam of
Bring the awl into the fluoroscope image, placing it
directly over the screw hole image. Mark the location for
the skin incisions.
Make a 1 cm longitudinal incision directly over the screw
hole. Insert the awl percutaneously to the cortex of the
Again, bring the tip of the awl into the fluoroscopic image
at an angle to the fluoroscope beam and locate the tip of
the awl directly in the middle of the screw hole, make a
hole in cortex.
Once this hole is made, insert the appropriately sized
drill point and, while maintaining alignment with
fluoroscope head, drill the hole through the rod and
Verify its position on the anteroposterior view, and then
insert the appropriately sized screw.
view of the distal
screws in Grosse –
The hole, which is to
be cross – locked is
in the center of the
screen and is
Segmentally comminuted diaphyseal fracture without bony
contact and nails with a 12-mm diameter and two distal
locking bolts could with stand the typical biomechanical
forces of weight bearing.
In patients who retain diaphyseal bony contact after fracture
fixation, nails with a diameter <12 mm or nails with a single
distal interlock may provide adequate stability for weight
bearing because the bony contact reduces the load
encountered by the distal interlocking screws.
Weight bearing through a locked IM nail could be allowed in
fractures in which 50% cortical contact is present
It is not necessary to remove a nail in a weight bearing limb
unlike a plate.
If needed can be removed after 18 months.
Indications for removal-
- Patient request, pain swelling secondary to backing out of
- Nail removal should not be undertaken lightly ,specialized
extraction equipment fitting the nail must be available.
- Full weight bearing can commence immediately after the
removal of nail
Z-Effect is an unfortunate by-product of most intramedually
nails that utilize two screws placed up into the femoral neck
and head. Typically, the superior screw is of smaller diameter
than the inferior and bears a disproportionate amount of load
during weight bearing. Excessive varus forces placed on the
smaller screw at the lateral cortex cause it to toggle and either
back out or migrate through the femoral head into the
acetabulum. The larger inferior screw is neither keyed in
rotation nor locked in place, and it too will either back out or
migrate medially. The resultant Z-Effect where the two screws
move in opposite directions is one mode of failure for the
conventional two screw reconstruction device.
With all metallic implants, there is a relative race between
bone healing and implant failure.
Occasionally, an implant will break when fracture healing is
delayed or when nonunion occurs.
IM nails usually fail in predictable patterns. Unlocked nails
typically fail either at the fracture site or through a screw hole
Locked nails fail by screw breakage or fracturing of the nail at
locking hole sites, most commonly at the proximal hole of the
applications of im nailing
Anatomic alignment, early weight bearing, early unrestricted joint &
muscle rehabilitation are of advantage to the patient.
ARDS can be prevented in multiple injuries by stabilizing and mobilizing
the patient immediately.
Floating hip, floating knee, floating elbow.
To protect the vascular repair following injuries by a fracture.
Aseptic and septic non-union.
High proximal and low distal fractures of long bones
Open tibial and femoral grade I and II fractures
40gms of bone cement is
taken and mixed with 2 to 4
gms of powder when dough
is semi solid.
It is wrapped around K nail
of size 6 to 7 mm and rolled
between two palms.The rod
is then passed through the
holes of the nail major
usually 8 to 9mm diameter
to maintain uniformity of
1.CAMPBELL OPERATIVE ORTHOPAEDICS
2.The science and practice of Intramedullary
Nailing – Bruce D. Brown
3.ROCKWOOD AND GREENS
5. The elements of fracture fixation – Anand J
6.Prospective study of distal end radius fracture by an
intramedullary nailing JBJS aug3 2011