Closed intramedullary nailing of tibia without c-arm in a resource-deficient setup: nail-over-nail technique

Intramedullary nailing is a standard technique for the treatment of long bone fractures. This technique requires the use of on-table image intensifier in almost every step, of which the most important are guide-wire insertion and distal locking. Therefore, a c-arm is an important tool for closed intramedullary nailing. However, if a technique can be done without the use of a c-arm, intramedullary nailing could be done in setups with deficient resources and in poor countries. Thus, we developed the “nail-over-nail” technique, which can be done without using a c-arm for distal locking of the nail.