[Intramedullary nailing of open fractures]

The goal of treatment of open fractures is to prevent infection, promote fracture healing, and restore normal limb alignment and function. The initial treatment of these fractures includes: debridement, soft tissue coverage, antibiotic therapy, and fracture stabilization. Four different techniques for intramedullary nailing for the fixation of open fractures have been employed: (1) unreamed, unlocked nails (i.e., Ender and Lottes, which have low infection rates, but are mechanically insufficient); (2) reamed unlocked nailing (which relies on overreaming to provide stability through bone-nail surface contact, but is associated with high infection rates); (3) reamed locked nailing (which may rely on limited reaming because of the interlocking screws); and (4) unreamed nailing (which always relies on interlocking screws and is associated with function better than and infection rates similar to those with external fixation, but has an increased incidence of screw breakage). In contrast to the biological problems in the tibia, those problems encountered in the femur are more predominantly mechanical in origin. For humeral shaft fractures, shoulder problems associated with the antegrade approach are frequent, and bypassing the rotator cuff with a retrograde approach appears advantageous.