Intramedullary nailing: how a bone fracture is fixed with a rod

Intramedullary nailing is a way of fixing a broken long bone from the inside. Rather than a plate on the outside or a cast, a rod (the nail) is slid along the hollow channel in the middle of the bone so that it spans the break. The Northern Care Alliance NHS leaflet on tibial nailing describes the shin bone as a weight-bearing bone that needs to be fixed so you can walk on it, and explains that the surgeons consider the best way to hold the ends together is to insert a nail through the bone and allow proper bone healing.

The principle is the same for other long bones. This article draws on the detailed NHS leaflet for the tibia (shin bone), which is the clearest worked example available in UK patient information, and on the NHS broken leg page. If your operation is on a different bone, such as the thigh bone (femur), the exact approach, screws and recovery plan will differ, and your own surgical team and hospital leaflet should be your main guide.

The NHS broken leg page says treatment depends on the type of break and how bad it is, and lists rest and a boot or crutches for stress fractures, a cast, surgery with plates, rods or screws for serious breaks, and traction, which is often used for small children with a broken thigh bone. A rod is one form of the surgery option.

The Northern Care Alliance leaflet lays out the alternatives for a broken tibia. Not fixing the bone may result in non-healing, delayed union or malunion, which can cause quite significant disability and long-term problems. Other options include external fixation or plating, and there may be a non-operative option of a cast with regular X-rays, although the leaflet notes this means being non-weight-bearing, carries a very high risk of non-union in these fractures, and that a plaster cast is not appropriate for some fractures. It also reminds patients that they are entitled to a second opinion.

According to the leaflet, your surgeon will see you before the operation and mark the leg with a felt pen to make sure the correct leg is operated on. An anaesthetic is given, which can be general (asleep) or regional (a numbed area), or both.

In theatre the leg is cleaned with antiseptic and covered with sterile drapes. For the tibia, a small cut of around 3 to 5 cm is made just below the kneecap, and a surgical drill (reamer) can remove the marrow from the middle of the bone so that a nail can pass down across the break to the other side. X-rays are taken at regular intervals to check the nail position, and the surgeon may then pass interlocking screws into the nail from the side, on the inside of the shin at the top and above the ankle. The wounds are closed with stitches or skin staples, and the leaflet says both are equally successful.

When the anaesthetic wears off the leg will be sore, which the leaflet says is normal, and you will have a bandage across the lower leg. It advises that if the pain is excruciating you must tell someone. You will have repeat X-rays and a blood test the day after and be shown how to walk with crutches without putting weight through the leg. It also notes that a surgeon other than the consultant, with adequate training or supervision, may perform the operation.

All surgery carries risk, and the leaflet lists the possible complications with approximate frequencies. These are specific to this leaflet and operation, and your own surgeon can tell you how they apply to you.

The NHS says a broken leg usually takes 6 to 12 weeks to heal, though it can take longer, and you will usually have follow-up appointments to check healing. Physiotherapy for several months may be needed to reduce stiffness and help strengthen the leg, and it advises asking your doctor when you can return to contact sports or other activities that strain the leg.

The NHS recovery tips include resting and raising the leg when possible, taking paracetamol or the painkiller your doctor has given you, and gently moving your toes. The leaflet adds that you are advised not to put any weight on a nailed tibia for many weeks, and that starting to walk and keeping moving is one of the best ways to prevent blood clots, which is why you will be taught to use crutches. Your own team will give the weight-bearing plan, which can differ by bone and fracture type.

The leaflet also notes that metalwork may be removed if it becomes infected or painful or damages the skin, and sometimes the nail can be removed to allow greater movement once the bone has healed, so a nail is not always permanent.

The NHS says to call 999 or go to A&E after a leg injury if the leg is twisted or bent, a bone is sticking out, there is a bad cut or wound, or the skin is cold and sweaty, with a fast or weak pulse, breathing difficulty or blue, grey or pale skin.

While recovering, the NHS says to get help from NHS 111 if pain gets worse, you have a very high temperature or feel hot, cold or shivery, the leg, foot or toes feel numb or burning, they look swollen or turn blue or white, a cast feels too tight, or there is a bad smell or wetness under it. The Northern Care Alliance leaflet describes a red, swollen, painful wound with discharge as a possible infection and a red, painful, swollen leg as a possible blood clot. Severe breathlessness or chest pain after an operation is an emergency: call 999.

Most broken long bones are treated through the NHS, usually via A&E and a trauma and orthopaedic team, because the injury is acute and often needs operating on within days. Follow-up is in a fracture clinic with physiotherapy as needed.

Some people with private cover are treated by a private orthopaedic surgeon, though fractures are often urgent and the hospital needs to be equipped for trauma work. The leaflet notes that other surgical options and a second opinion are always something you can ask about. If you are treated outside the NHS, ask who will be responsible for follow-up and for any complications.