Introduction

There is a wealth of published literature on intra-medullary nailing. With current locking designs, intramedullary nailing indications have been expanded to include a large number of diaphyseal and even metaphyseal fractures in adult patients. Küntscher was the one who pioneered the concept [1], but extensive work had been previously carried out on nailing or pinning techniques in which the nails/pins did not fill the entire transverse section of the diaphysis. The so called alignment nailing technique was widely used by Rush [2] after World War II. These bulky devices were used in forearm fractures, where they allowed maintaining a precarious reduction without any control of the rotatory stability, which made it necessary to use external immobilization. Furthermore, they were associated with postoperative complications such as skin ulceration at the insertion site. Bundle nailing for metaphyseal fractures using two, three, four, or even more thin elastic nails was widely used by Hackethal for treatment of fractures of the upper end of the humerus [3], and by Ender for femoral neck fractures in the elderly [4]. Ender nailing almost completely disappeared from the therapeutic armamentarium due to the incidence of rotational malunion of the femur and nail migration, in favor of more advanced devices. But the notion of “elastic” osteosynthesis was retained, and was used for fixation of certain types of fractures like tibial fractures [5]. Actually, it was even incorporated into the concept of the Ilizarov external fixator, as Ilizarov had fully demonstrated that when traction-compression forces are applied to bone with intact periosteum and blood vessels, healing occurs regardless of the circumstances [6].