Closed Reduction and Internal Fixation (CRIF) with Intramedullary Nailing for Mid-Shaft Femoral Fractures
For mid-shaft femoral fractures in healthy adults, perform closed reduction and intramedullary nail fixation within 24 hours using a fracture table or rapid reduction device, with the patient supine under spinal or general anesthesia, achieving anatomical alignment through traction and percutaneous manipulation before inserting a statically locked intramedullary nail.
Pre-Operative Preparation
Timing
- Perform surgery within 24 hours of admission 1. Early definitive fixation reduces local and systemic complications, particularly respiratory complications, ARDS, and fat embolism syndrome in femoral shaft fractures.
- Do NOT use preoperative traction 2 - it provides no benefit and delays definitive treatment.
Anesthesia Selection
- Either spinal or general anesthesia is appropriate 2.
- Spinal anesthesia may reduce postoperative confusion 3 and is preferred when not contraindicated.
- For spinal: use lower doses of bupivacaine (<10 mg) to reduce hypotension 3; add intrathecal fentanyl for prolonged analgesia.
- For general: reduce induction agent doses; provide peripheral nerve blockade for postoperative analgesia 3.
Patient Positioning and Setup
- Position patient supine on a fracture table 4, 5, 6.
- Apply skeletal traction through the distal femur or proximal tibia using the fracture table.
- Mount external supporting devices that can be controlled in both AP and lateral planes 6.
- Ensure adequate fluoroscopy access for both AP and lateral views.
Surgical Technique: Step-by-Step
1. Initial Reduction
- Apply longitudinal traction through the fracture table to restore limb length 4, 5.
- Use the traction to overcome the deforming forces of thigh muscles (quadriceps, hamstrings, adductors).
- Verify length restoration under fluoroscopy.
2. Fracture Alignment
For residual anterior-posterior or lateral displacement:
Alternative lever technique 4:
Maintain reduction with the fracture table and external supports while proceeding to nailing.
3. Entry Point and Reaming
- Make a 3-4 cm incision at the piriformis fossa or greater trochanter (depending on nail design).
- Establish the entry point under fluoroscopic guidance.
- Insert a guide wire across the fracture site while maintaining reduction.
- Ream the femoral canal carefully:
4. Nail Insertion
- Select appropriate nail length (measured from entry point to above the knee joint).
- Insert the intramedullary nail over the guide wire.
- Advance the nail across the fracture site under fluoroscopic control.
- Ensure the nail passes centrally through both fragments.
5. Proximal Locking
- Insert proximal interlocking screws through the targeting jig.
- Use at least 2 proximal screws for rotational stability.
- Verify screw position with fluoroscopy in both planes.
6. Distal Locking
- Static locking is mandatory for mid-shaft fractures 7.
- Use the freehand technique or distal targeting device.
- Insert 2 distal interlocking screws perpendicular to the nail.
- Confirm all screws engage both cortices.
- Average fluoroscopy time for entire procedure: 8-13 seconds 4, 5.
7. Final Verification
- Obtain AP and lateral fluoroscopic images.
- Verify:
- Anatomical alignment in both planes
- Appropriate nail length (tip 2-3 cm above knee joint)
- All screws properly positioned
- No intra-articular hardware
- Expected blood loss: 70-90 mL 4, 5.
Critical Technical Points
When Closed Reduction Fails
- If anatomical reduction cannot be achieved after 10-15 minutes of manipulation 4, 5:
- Consider limited open reduction through small incisions
- Use cerclage wires if needed, but recognize this increases complication risk 8
- Avoid extensive soft tissue stripping
Fracture-Specific Considerations
- Comminuted fractures (AO type C): May require additional cerclage wires or unicortical bridge plating before nailing 9, 8.
- Segmental fractures: Consider combined techniques (nail plus plate) for intermediate fragments 9.
- Subtrochanteric extension: Use cephalomedullary nail with proximal fixation 1.
Intraoperative Management
Monitoring
- Maintain systolic blood pressure within 20% of baseline 3.
- Ensure adequate hydration before and during surgery 3.
- Use cardiac output-guided fluid therapy to optimize outcomes 3.
Prophylaxis
- Administer antibiotics within 1 hour of skin incision 3.
- Apply intermittent compression devices intraoperatively 3.
- Maintain normothermia with active warming 3.
Common Pitfalls to Avoid
Excessive fluoroscopy: Use reduction devices to minimize radiation exposure (target <15 seconds total) 4, 5.
Inadequate reduction before nailing: Attempting to pass the nail through a malaligned fracture causes comminution and soft tissue damage.
Wrong entry point: Leads to malreduction and nail malpositioning; verify with fluoroscopy before reaming.
Insufficient distal locking: Single distal screw allows rotation; always use 2 screws for mid-shaft fractures 7.
Delayed surgery in stable patients: Increases risk of fat embolism, respiratory complications, and DVT 1.
Post-Operative Protocol
- Begin immediate knee range of motion exercises.
- Allow touch-down weight bearing initially.
- Progress to full weight bearing at 6-8 weeks based on callus formation.
- Expected union time: 4-6 months 4, 5, 10.
- Dynamization (removing proximal or distal screws) may be performed at 12-16 weeks if delayed union occurs 7.
This technique achieves anatomical reduction in >95% of cases without open surgery 4, 5, minimizes blood loss and operative time, and provides stable fixation allowing early mobilization and excellent functional outcomes.