Physiotherapy Role in Intramedullary Nailing Surgery

INTRODUCTION[edit | edit source]

Intramedullary nailing(IMN) is a world wide method for fracture stabilization for long bones [1] IMN was introduced by Kuntscher and this procedure has has an advantage of preventing infections, managment of the non-union of fractures, shortenings and angulations, thereby improving patient  outcomes postoperatively[2]. It is a metal rod placed across the fracture and into the medullary cavity of a bone to give the fractured bone a strong support. The "gold standard" for treating femoral shaft fractures is intramedullary nailing[3]. It is a preferred method for the fixing of femoral shaft fractures [4]

The goals of intramedullary nailing are to maintain the anatomical integrity of fracture sites and to offer a suitable environment for fracture healing. In turn, this ought to enhance functionality and lessen long-term effects like arthritis pain. Additionally, nailing helps to preserve the blood flow during surgery, limiting injury to the soft tissues close to the bone and promoting fracture healing and satisfactory functional recovery[5]. It is also used to align the fractured bones and provide optimal healing support; the orthopaedic surgeon makes a small incision through the skin and tissue closest to one end of the broken bones.. This is often done for fractures of the tibia, femur (thigh), and humerus (shoulder). There are several team that involves in intramedullary nailing surgery, pre and post-surgical. Post surgically, the pain management in terms of medication include using steroids, glucocorticoids and nerve blocking. IMN is also associated with insertional pain as a result of insertional which is located primarily near the area of insertion[6].

Pre-operatively, therapeutic nerve blocking is one of the procedures that occur during the intramedullary nailing surgery. The anaesthetic agent impact on the sensory and the motor system of the nerve supply of the extremity where the intramedullary nail occurs. Thus therapeutic nerve blocking and the intramedullary nailing surgery procedure leave patients with sensory and motor residual deficit/impairment. Therefore, physiotherapy intervention is essential to improve the symptoms such as the temporary loss in the sensory and motor functions. Post-operatively, continuous peripheral nerve blocking is used alternative method for pain modulation[7]

Physiotherapy Role[edit | edit source]

Physiotherapists play an important role in the post-operative management for Intramedullary Nailing Surgery as rehabiitatation focuses on weight bearing exercises, muscle strengthening and exercise conditioning[8]. Following an Intramedullary nailing, the aim of physiotherapy treatment is to improve function and prevent disability in patients who have undergone intramedullary nailing surgery. Physiotherapists also educate patients on proper postures and positions to attain in order to increase comfort and reduce to risk of development of bed sores or pressure ulcers. The summary of physiotherapy role the post-operative are:

  1. Prevention of complications: The complications from intramedularry nailing includes pressure ulcers, compartment syndrome, disorders of the arterial and venous system such as thromboembolism, neurological deficits like muscle weakness and fat embolism.[9]
  2. Early mobilization post surgery reduces the risk of post surgical complications, brings about faster recovery and reverses the physiological effects of surgery on the body [10] Examples of early mobilization exercises include passive and active range of motion active side-to-side turning, postural changes, passive movements and bed exercises.
  3. Weight bearing Exercises: this should begin at the early stages of management.
  4. Strengthening exercises to prevent hypotrophy of thigh muscles[11]. This surgery is often associated with weakness in the knee extensors and this alters the kinematics of the knee[12]
  5. Pain Management: Patients who have the intramedullary nailing of the tibia usually have complaints about chronic anterior knee pain or functional impairments[13] and this is due to the dissection of the patellar tendon and its sheath [14]
  6. The use of Cryotherapy using the method of cryo and cyclic compression for fracture healing has been effective[15]
  7. Range of Motion exercises to prevent stiffness particalary in the knee, hip and ankle joints post Tibial intramedullary surgery which alteres the kinematics of the knee joint[12]
  8. Gait and transfer training is a vital part in the rehabilitation of patients who have had intramedullary nailign surgery.


  1. Rommens PM, Küchle R, Hofmann A, Hessmann MH. Intramedullary Nailing of Metaphyseal Fractures of the Lower Extremity. Acta Chir Orthop Traumatol Cech. 2017;84(5):330-340. English. PMID: 29351533.
  2. Brudnicki, Jaroslaw & Kubicz-Chachurska, Małgorzata. (2011). Rehabilitation in lower extremities fractures treated with intramedullary nailing. 15. 21-27.
  3. Rudloff MI, Smith WR. Intramedullary nailing of the femur: current concepts concerning reaming. J Orthop Trauma. 2009 May-Jun;23(5 Suppl):S12-7. doi: 10.1097/BOT.0b013e31819f258a. PMID: 19390369.
  4. Ricci WM, Gallagher B, Haidukewych GJ. Intramedullary nailing of femoral shaft fractures: current concepts. J Am Acad Orthop Surg. 2009 May;17(5):296-305. doi: 10.5435/00124635-200905000-00004. PMID: 19411641.
  5. Xiong R, Mai QG, Yang CL, Ye SX, Zhang X, Fan SC. Intramedullary nailing for femoral shaft fractures in adults. Cochrane Database Syst Rev. 2018 Feb 2;2018(2):CD010524. doi: 10.1002/14651858.CD010524.pub2. PMCID: PMC6491114.
  6. Yohan Jang, Laurence B. Kempton, Todd O. Mckinley, Anthony T. Sorkin, Insertion-related pain with intramedullary nailing, Injury, Volume 48, Supplement 1,2017, Pages S18-S21,ISSN 0020-1383,
  7. Imbelloni LE, Rava C, Gouveia MA. A new, lateral, continuous, combined, femoral-sciatic nerve approach via a single skin puncture for postoperative analgesia in intramedullary tibial nail insertion. Local Reg Anesth. 2013 Feb 15;6:9-12. doi: 10.2147/LRA.S37261. PMID: 23630433; PMCID: PMC3633185
  8. Sarah L. Mitchell, David J. Stott et al.Randomized controlled trial of quadriceps training after proximal femoral fracture Clinical Rehabilitation, 15, 3, 2001
  9. Lies A, Josten C, Muhr G. Komplikationen der Verriegelungsnagelung und deren Vermeidung [Complications of intramedullary nailing and their prevention]. Zentralbl Chir. 1993;118(6):342-50. German. PMID: 8342342.
  10. Tazreean R, Nelson G, Twomey R. Early mobilization in enhanced recovery after surgery pathways: current evidence and recent advancements. J Comp Eff Res. 2022 Feb;11(2):121-129. doi: 10.2217/cer-2021-0258. Epub 2022 Jan 20. PMID: 35045757.
  12. 12.0 12.1 Inga Kröger, Janina Müßig et al. Gait & Posture, 91, 1 2022. Recovery of gait and function during the first six months after tibial shaft fractures
  13. Olli Väistö, Jarmo Toivanenet al. The Journal of trauma, 64, 6, 6 2008Anterior knee pain after intramedullary nailing of fractures of the tibial shaft: an eight-year follow-up of a prospective, randomized study comparing two different nail-insertion techniques
  14. Olli Väistö,Jarmo Toivanen et al.Anterior knee pain after intramedullary nailing of fractures of the tibial shaft: an eight-year follow-up of a prospective, randomized study comparing two different nail-insertion techniques The Journal of trauma, 64, 6, 6 2008
  15. Nick C. Leegwater,Peter A. Nolte et al. BMC musculoskeletal disorders, 17, 1, 4 2016 The efficacy of continuous-flow cryo and cyclic compression therapy after hip fracture surgery on postoperative pain: design of a prospective, open-label, parallel, multicenter, randomized controlled, clinical trial