The Incidence of Malrotation after Closed Reduction and Antegrade Intramedullary Nailing of Femoral Shaft Fractures

Background: Femoral shaft fractures are very common injuries, often secondary to high-energy trauma, occurring at age-specific peaks in young children, young adult men, and older women, and commonly with other injuries. Intramedullary nailing is the preferred treatment due to its minimally invasive method and predictable healing, though malrotation is a common complication.
Aim: The aim of this prospective study was to evaluate incidence of malrotation of the femur after closed reduction and internal fixation of femoral shaft fracture by antegrade intramedullary nail.
Patients and Methods: This was a prospective study that included 50 adult patients with isolated, closed femoral shaft fractures treated by antegrade intramedullary nailing at Menoufia University between April 2024 and February 2025.  
Results: This study found that 74% were males and 60% sustained their injuries in motor vehicle accidents. The comorbidities included diabetes (18%), hypertension (12%), and smoking (8%). Early operation (<6 hours) was experienced by half of them, and fracture patterns were more likely to be left-sided (58%), short spiral (46%), and transverse (44%). Most patients (86%) had neutral rotation. Group B (malrotation) had a significantly higher mean age and different fracture types but showed no significant differences in gender, side, BMI, or injury mechanism. Malrotation occurred more frequently in the lateral position but did not have a significant effect on functional outcomes.
Conclusion: Closed reduction and antegrade intramedullary nailing is an effective treatment for femoral shaft fractures, with a low incidence of clinically significant malrotation. Most patients (86%) maintained neutral rotation, and mild malrotation did not significantly affect functional outcomes. External rotation is more prevalent than internal, and using the supine position may help reduce malrotation risk.