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The gold standard for treatment of long bone diaphyseal fractures is intramedullary nail fixation, leading to secondary bone healing. The biomechanical environment created by the construct can dictate whether or not the fracture goes on to unite. Biological factors such as fracture pattern, concomitant injuries, extent of the associated soft tissue injury, and patient comorbidities are not modifiable by the surgeon; however, the mechanical environment is. Modifiable factors include nail diameter, nail working length, number and position of interlocking bolts, and the use of a reamed or unreamed technique. In this chapter, several cases that illustrate the optimization of these modifiable factors are discussed, as well as cases where some changes had to be made in order to achieve fracture union. Surgeons have the responsibility to optimize the fracture biomechanical environment. This includes considering both modifiable and nonmodifiable factors and utilizing implants in a way that provides enough stability to induce healing.
KeywordsBiomechanics Intramedullary nail Nonunion Delayed union Strain Stabilization Secondary bone healing Exchange nailing Dynamization Reaming
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