Locked Femoral Nailing.

Locked intramedullary nailing has become the standard of care for most femoral fractures. Originally designed to prevent rotation and shortening in comminuted fractures of the midshaft, its application has been extended proximally and distally to nearly all femoral fractures from the lesser trochanter to the supracondylar area. Achieving a closed reduction and selecting the proper starting point in the piriformis region are crucial to a successful result. Following the proper surgical technique for the specific nail used is more important than nail material or design. Large-diameter reamed nails provide greater strength than unreamed nails. Static locking has been shown to yield nearly the same high union rates as dynamic locking and is now the accepted standard. Distal targeting of the interlocking screw remains the most difficult aspect of the surgical technique; most surgeons prefer freehand targeting with a sharp trocar. Second-generation (reconstruction) nails, with screws directed toward the femoral head, has extended the indications for locked nailing proximally to subtrochanteric fractures and combined femoral neck-shaft fractures.