The use of Ender nails in femoral shaft fractures: what are the remaining indications?

The use of Ender nails for the treatment of femoral shaft fractures has been described as technically easier and less time consuming than current intramedullary nailing techniques. We reviewed our results with unlocked Ender nails in 26 stable and 17 unstable fracture patterns an average of 3-4 years after injury. Because of continued instability, 42% of the stable and 76% of the unstable groups required adjunctive stabilization in the form of skeletal traction, a cast, or an external fixator. Additionally, nail migration and shortening and loss of motion at the knee were seen in 14 fractures in each group. Although two thirds of the patients with stable fracture patterns obtained good or excellent results, no outcome in the unstable group was rated excellent and only 19% were considered good. We therefore recommend that rigid locked intramedullary nails be used in femoral diaphyseal injuries. The use of Ender nails should be limited to stable fracture patterns and locked with screws or wires. They may be particularly useful for fractures in femora with small medullary canals (less than or equal to 8 mm), fractures below noncemented femoral prostheses, and fractures in young children requiring intramedullary stabilization without injuring the physeal plates.