Abstract:
An intramedullary nail ( 20 ) and related method for fixing a fracture in a long bone. The nail ( 20 ) comprises an elongate member ( 22 ) having a longitudinal axis ( 54 ), a proximal end section ( 32 ), a distal end section ( 34 ) and a solid central section ( 24 ) extending between the proximal and distal end sections ( 32, 34 ). The proximal and distal end sections ( 32, 34 ) respectively include proximal and distal fastener receiving areas ( 28, 30 ) of greater cross sectional dimensions than the central section ( 24 ). Each fastener receiving area ( 28, 30 ) includes at least one hole ( 50, 52 ) extending transverse to the longitudinal axis for receiving a cross fastener ( 110 ) adapted to secure to the bone on opposite sides of the elongate member ( 22 ). The proximal and distal end sections ( 32, 34 ) thereby provide rigid anchoring locations relative to the central section ( 24 ) and the central section provides flexibility to promote healing of the fracture.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     The present application is a continuation of U.S. patent application Ser. No. 09/990,243 filed 21 Nov. 2001 now U.S. Pat. No. 7,008,425 which claims the benefit of U.S. Provisional Patent Application No. 60/252,536 filed 22 Nov. 2000, and is a continuation-in-part of International Patent Application No. PCT/US00/14840 filed 26 May 2000, which is a continuation-in-part of U.S. patent application Ser. No. 09/321,369 filed 27 May 1999, now abandoned all of which are each incorporated by reference herein. 
    
    
     BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     The present invention relates to devices and methods for repairing bone fractures, and, more particularly, to intramedullary nails and related internal fixation methods especially suitable for repairing long-bone fractures in children. 
     2. Description of Related Art 
     The use of intramedullary nails in the repair of long-bone fractures, such as in the femur, has been known in the orthopedic field. Exemplary devices include those known as the Rush and Enders and the Kuntschner nails, as well as those disclosed in U.S. Pat. No. 5,713,902 to Friedl; U.S. Pat. No. 5,697,930 to Itoman et al.; U.S. Pat. No. 5,573,536 to Grosse et al.; U.S. Pat. No. 5,562,666 to Brumfield; U.S. Pat. No. 5,374,235 to Ahrens; U.S. Pat. No. 5,312,406 and U.S. Pat. No. 5,167,663 to Brumfield; U.S. Pat. No. 5,122,141 to Simpson; U.S. Pat. No. 5,066,296, U.S. Pat. No. 5,041,114, and U.S. Pat. No. 4,776,330 to Chapman et al.; U.S. Pat. No. 4,976,258 to Richter et al.; U.S. Pat. No. 4,875,475 to Comte et al.; U.S. Pat. No. 4,846,162 to Moehring; U.S. Pat. No. 4,506,662 to Anapliotis; and U.S. Pat. No. 4,475,545 to Ender. 
     Referring to  FIG. 1 , a special problem in pediatric orthopedics exists in that reaming through the typical entry point in a femur  10 , i.e., the piriformis fossa  11 , can be too dangerous for the child. This is due to the presence of an artery  12  that supplies blood to the proximal femur. Specifically, this is the lateral epiphyseal artery  12  which is a branch of the femoral artery. If this artery  12  is damaged during the fixation procedure, such as while the intramedullary canal is being reamed to accept a nail, or possibly during insertion or after insertion of the nail, various complications can result. The lateral epiphyseal artery  12  supplies 75% of the blood to the growing femoral head  16 . If this artery  12  is damaged, then much of the femoral head  16  will die or necrose. The femoral head  16  will then heal with an irregular shape which inevitably leads to hip arthritis. 
     Various nails, such as flexible Rush nails, are non-interlocked meaning that cross fasteners are not used to secure the nail to the bone. These nails are often small diameter rods, on the order of approximately 3-4 mm in diameter. In addition to being flexible to a significant degree prior to plastic deformation, non-interlocked solid nails or rods can be relatively easily bent with plastic deformation to a desired shape. A plurality of these nails or rods are typically driven into the intramedullary canal depending on the support necessitated by the fracture and bone characteristics of the patient. Other more rigid solid or hollow nails are interlocked to the bone using cross fasteners typically at the proximal and distal ends of the nail. Unlike non-interlocked nails, interlocked nails require sufficient cross-sectional dimensions to accommodate holes necessary for the cross fasteners. Currently available interlocked nails can be inserted away from the lateral epiphyseal artery  12  but are so rigid that they migrate during insertion dangerously close to the artery  12  and can endanger it. In addition, the large proximal size of small adult interlocked nails, which have typically been used in children, increases the potential for damage to the growth plate  17  at the proximal femur. 
     Among possible solutions, retrograde nailing avoids the proximal femur but also has at least one potential problem. The nails must be introduced close to the distal femoral growth plate or physis  19  ( FIG. 5 ) at an awkward angle, potentially causing growth arrest distally on the femur, i.e., adjacent the knee. An approach through the greater trochanter  18  is also well recognized, but usually only one small diameter non-interlocked nail or rod can be used because of the narrow safe entry zone of the greater trochanter. A second small diameter nail or rod needs to be inserted retrograde or through the opposite end of the femur in these situations. These small diameter, flexible nails allow flexure after insertion and the slightly added stress to the bone allowed by this flexure promotes faster bone healing. These non-interlocked nails work well for transverse fractures. However, spiral or comminuted fractures often need additional external support, such as with a cast or brace. This is due to the inability of the non-interlocked nail to effectively prevent rotation or length compromise at the fracture. 
     It would therefore be desirable to provide an interlocked intramedullary nail, especially suitable for pediatric use, which provides flexibility along a majority of the length of the nail to facilitate faster healing of a fracture, but which also provides for secure interlocking of the nail to the bone with cross fasteners to prevent compromising the fracture due to rotation or shortening at the fracture site. Ideally, such a nail and related methods of insertion would minimize trauma to the growth plates of the femur as well as the arteries that supply blood to the proximal end of the femur while still allowing easy insertion and fixation within the intramedullary canal. 
     SUMMARY OF THE INVENTION 
     In one general aspect, the present invention provides an intramedullary nail for insertion within an intramedullary canal of a long bone and fixing a fracture in the long bone. The nail is especially suitable for adolescent or preadolescent aged children, however, the nail may be useful in other orthopedic applications as well. The nail generally comprises an elongate member having a longitudinal axis, a proximal end section, a distal end section and a solid central section extending between the proximal and distal end sections. The proximal and distal end sections respectively have fastener receiving areas of greater cross sectional dimensions than the central section. The fastener receiving areas each include at least one hole extending transverse to the longitudinal axis of the elongate member for receiving a cross fastener adapted to secure to the bone on opposite sides of the elongate member. The proximal and distal end sections provide rigid anchoring locations relative to the central section and the central section provides flexibility to promote healing of the fracture. 
     In the preferred embodiment, the central section of the elongate member is curved in the sagital plane to generally follow the curvature of a femur. The proximal and distal end sections are bent out of this plane and form acute angles with respect to the sagital plane. The proximal and distal end sections are each bent laterally to one side of the central section. The side to which the proximal and distal end sections are bent depends on whether the nail will be used in a right or left femur and also allows easier insertions across the fracture. The bend of the distal end section allows for easier insertion of the nail from an insertion point extending through the greater trochanter of the femur. The bend of the proximal end section ensures that the proximal tip is presented directly at the insertion point after fixation so that it may be easily accessed for removal purposes upon healing of the bone. 
     In general, a method of fixing a fracture in a long bone of a patient, in accordance with the invention, includes providing an elongate member having a solid central section with a cross sectional dimension and having proximal and distal fastener receiving areas of increased cross sectional dimension relative to the cross sectional dimension of the central section. The fastener receiving areas each have at least one hole extending transverse to a longitudinal axis of the elongate member. The method involves inserting the elongate member into the intramedullary canal of the long bone through an insertion point and across the fracture and inserting cross fasteners through each of the holes and into the bone on opposite sides of the elongate member to fix the fracture of the long bone against rotational and lengthwise movements. 
     The bone nail and method of this invention allow the surgeon to better avoid the critical arterial blood supply to the femoral head which crosses at the piriformis fossa, i.e., the traditional point of entry for an adult nail. Instead, the entry point is on the greater trochanter, a location distinctly lateral of the critical region of the piriformis fossa. The very vulnerable growth plate between the greater trochanter and the femoral neck is also avoided using the nail and entry point in accordance with this invention. Another unique feature of the invention is the ability of the bone nail to be flexible, yet custom bent to match the exact geometry of the proximal femur, while also allowing interlocking with cross fasteners. In general, the preferred inventive nail provides interlockability, a relatively small solid cross section to provide flexure along at least the majority of the length of the nail, and malleability to allow custom bending especially at the proximal end. 
     The features that characterize the invention, both as to organization and method of operation, together with further objects, features and advantages thereof, will be better understood from the following written description taken in conjunction with the accompanying drawings. It is to be expressly understood that the drawings and detailed description thereof are for the purpose of illustration and description and is not intended as a definition of the limits of the invention. These and other objects attained, and advantages offered, by the present invention will become more fully apparent as the description that now follows is read in conjunction with the accompanying drawings. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is a perspective view of a portion of a femur including the femoral head and the greater and lesser trocantic regions. 
         FIG. 2  is a side elevational view of an intramedullary nail of the present invention shown in the anterior-posterior plane. 
         FIG. 3  is an elevational view of the nail shown in  FIG. 2 , but illustrating proximal and distal bends. 
         FIG. 4  is an elevational view of the nail shown in  FIG. 3 , but rotated 90°. 
         FIG. 5  is a schematic view of the step of initially inserting the bone nail of  FIGS. 3 and 4  into a femur. 
         FIG. 6  is a schematic view similar to  FIG. 5 , but illustrating the nail further inserted across the bone fracture. 
         FIG. 7  illustrates a drill rig and fastener inserting rig being used to cross fastened the nail after full insertion. 
         FIG. 8  is a schematic illustration of the fully inserted and cross fastened bone nail. 
         FIG. 8A  is a fragmented, partially sectioned view of the distal end section of the bone nail and the cross fastener of the present invention. 
         FIG. 9  is an elevational view showing one illustrative bending device being used to bend the proximal end section of the bone nail. 
         FIG. 10  is an elevational schematic view of another embodiment bone nail according to the present invention fully inserted in the femur. 
         FIG. 11  is an enlarged view of the distal end portion of the nail of  FIG. 10 . 
         FIG. 12  is a sectional view taken through line  12 - 12  of  FIG. 10 . 
         FIG. 13  is an elevational schematic view of a further embodiment bone nail according to the present invention fully inserted in the femur. 
         FIG. 14  is an elevational schematic view of yet another embodiment bone nail according to the present invention fully inserted in the femur. 
     
    
    
     DETAILED DESCRIPTION 
     An exemplary intramedullary nail  20 , as illustrated in  FIGS. 2-4 , comprises an elongate member  22 . In an embodiment intended for use in a femur of a child or adolescent, typically ages 6-14, for example, the nail  20  is formed from titanium and has a generally cylindrical shape with a diameter along a solid central section  24  of between 4 mm and 7 mm, although this is not intended as a limitation. Central section  24  should have a certain amount of elastic flexibility to permit accurate placement within the femoral canal as discussed below. Such elastic flexibility, which permits some flexure during movement and weight bearing activity, confers an additional benefit in that it has been found to stimulate bone healing. The nail  20  preferably ends in a rounded, smooth and tapered distal tip  26 . 
     The nail  20  has two widened sections or fastener receiving areas  28 ,  30  in respective proximal and distal end sections  32 ,  34 . Each fastener receiving area  28 ,  30  is formed with an increased cross sectional dimension relative to central section  24 . Also, smooth, gradual transitions  36 ,  38  with the central section  24  avoid sharp edges along the length of nail  20 . The distal fastener receiving area  28  is positioned adjacent to but in spaced relation from distal tip  26 . The distal fastener receiving area  28  tapers on both proximal and distal sides thereof. The proximal fastener receiving area  30  extends to proximal tip  42 ; that is, there is a distal taper but no proximal taper, and the widened proximal fastener receiving area  30  instead continues to the proximal tip  42  and forms the entire proximal end section  32 . 
     Each fastener receiving area  28 ,  30  includes a generally cylindrical hole  50 ,  52  extending generally normal to the portion of the longitudinal axis  54  in which it is located for receiving a fastener (not shown). Holes  50 ,  52  preferably have diameters in a range of 3 mm to 4½ mm. 
     Proximal tip  42  includes attachment structure  58  for receiving a driver, described below, which may be a conventional driver used in the bone nail art. Preferably, attachment structure  58  comprises a threaded axial bore  60  extending along axis  54  and engageable with an externally threaded driver. A notch  62  extends across bore  60  and, as is known, aligns the driver for purposes of later drilling and cross fastening nail  20 , as will be discussed below. As further shown in  FIGS. 2 and 4 , nail  20  is curved in an anterior direction along a radius of curvature  70  to generally conform nail  20  to the typical femoral curvature. Preferably, this radius of curvature  70  is in the range of 30 inches to 60 inches. A proximal bend  72  and a distal bend  74  are formed, respectively, in central section  24  directly adjacent proximal and distal end sections  32 ,  34 . These bends  72 ,  74  are made in the same direction, i.e., laterally to one side of nail  20  or the other as shown best in  FIG. 3 . The solid lines in  FIG. 3  illustrate lateral bends  72 ,  74  out of the sagital plane and generally in the coronal plane at angles A, B for inserting nail  20  into a left femur. Angles A′, B′ corresponding to the respective lateral bends of proximal and distal end sections  32 ,  34 , shown in phantom, facilitate use of nail  20  in the right femur. As a unique feature of this invention, interlocking nail  20  may be custom bent by the surgeon just prior to use, not only to facilitate insertion in the right or left femur, but also to accommodate other particular shapes necessary for a particular patient. For example, some patients may have deformities necessitating one or more corrective osteotomies or fractures made by the surgeon. These osteotomies may also be fixed using nail  20 . 
     In the preferred embodiment, nail  20  is formed from titanium, although other materials such as those known in the art may be used as well. Central section  24  is of solid cross section and at least substantially constant diameter with a smooth outer surface to facilitate removal in 6-9 months. Proximal and distal end sections  32 ,  34  are also solid, except for holes  50 ,  52 , bore  60  and notch  62 . As appreciated from  FIG. 2 , the axes of holes  50 ,  52  are coplanar. In order to provide the desired flexibility of central section  24 , while retaining the cross fastening feature of the invention, fastener receiving areas  28 ,  30  have a cross sectional dimension greater than the cross sectional dimension of central section  24 . In general, central section  24  may be formed with a solid cylindrical cross section having a diameter of between 4 mm and 7 mm. Fastener receiving area  28  has a generally bulbous, rounded shape, while proximal fastener receiving area  30 , which is preferably continuous with distal end section  32 , has a cylindrical cross sectional shape. At the cross section taken along the axes of respective holes  50 ,  52 , the respective ratios of the cross sectional dimensions at these locations is at least about 1.3:1 relative to the cross sectional dimension of central section  24 . In exemplary embodiments of the invention, a nail  20  substantially as shown in  FIG. 2 , had a cross sectional dimension of 5.5 mm for central section  24 , an 8.5 mm cross sectional dimension for proximal end section  32 , and also a maximum 8.5 mm cross sectional dimension at the largest diameter portion of distal fastener receiving area  28 . This nail was used on children generally weighing less than 100 lbs. For children weighing more than 100 lbs., the 8.5 mm dimensions at the proximal and distal fastener receiving areas remained the same, while the cross sectional dimension for central section  24  was increased slightly to 6.5 mm to provide additional strength but still provide the desirable flexure. 
     The insertion and fixation techniques according to the preferred embodiment of the invention are best illustrated in  FIGS. 5-8 . In accordance with the invention, an insertion point  80  is created in the greater trochanter  18  of the femur  10  of a child, for example, at a distinctly lateral position relative to the piriformis fossa  11 . Intramedullary canal  10   a  of femur  10  is drilled and reamed in a known manner to accept bone nail  20 . A driver  82  is coupled with proximal tip  42 , also in a known manner, and the surgeon impacts the head  84  of the driver  82  while holding the handle portion  86 . Bend  74  facilitates better positioning of distal tip  26  upon insertion of nail  20  by allowing distal tip  26  to naturally follow the intramedullary canal  10   a  relative to the angle of the insertion point  80  in the greater trochanter  18 . As shown in  FIG. 6 , bone nail  20  may be rotated in either direction represented by arrow  90  as the distal tip  26  approaches and crosses the fracture  92 . This allows the surgeon, using fluoroscopy, to more easily locate and enter the intramedullary canal  10   a  of the distal bone segment  94 . After the bone nail  20  is fully inserted, as shown in  FIG. 7 , a drill rig  100  is attached to the proximal tip  42  through securement to handle portion  86 . The drill rig  100  aligns a drill guide  102  with the proximal fastener receiving hole  52  and a drill (not shown) is used to form a hole through femur  10  in line with hole  52 . A screw driving mechanism  104  is then used to insert a cross fastener  110  at this location. Using conventional fluoroscopy techniques, a second hole is drilled and a second cross fastener  112 , preferably of the same design as fastener  110 , is inserted through the distal hole  50 , as shown in  FIGS. 8 and 8A . More specifically, and as represented by distal fastener  112  in  FIG. 8A , fastener  112  comprises a drive head  150 , a proximal threaded portion  152 , a distal threaded portion  154 , and a central unthreaded portion  156  which is received within hole  50 . Threaded portions  152 ,  154  are securely engaged within cortical layer  10   b  of femur  10 . In this manner, bone nail  20  is interlocked to femur  10  at proximal and distal locations thereby preventing undesirable rotational and/or lengthwise bone movements at the fracture site. In this interlocked or fixed position, proximal tip  42  is presented directly at the insertion point  80  on the greater trochanter  18  so that, upon healing of the fracture, the cross fasteners  110 ,  112  may be removed and threaded bore  60  may be engaged to withdraw nail  20  from intramedullary canal  10   a.    
     Although bends  72 ,  74  may be pre-made by a manufacturer of nail  20 , for example, the present invention further contemplates a manual bending device as shown in  FIG. 9 . Using this device, nail  20  may be placed by the surgeon in a bending device  118  jaw structure comprising three rollers  120 ,  122 ,  124  with one roller  120  acting as a fulcrum and two opposite rollers  122 ,  124  applying forces in the direction of arrows  130 ,  132 . When the handles  134 ,  136  of the device are squeezed together in the direction of arrows  138 ,  140 , proximal end section  32  will be bent relative to central section  24  to form bend  72  as best illustrated in  FIG. 3  and as previously described. The same procedure may be used by the surgeon to bend distal end section  34  just prior to insertion within intramedullary canal  10   a . This aspect of the invention allows the surgeon to custom bend these or other portions of the nail  20  to suit the anatomy and/or needs of a particular patient prior to or during surgery. 
     Other embodiments for an intramedullary nail for insertion in an intramedullary canal to repair fractures or osteotomies of a long bone are also contemplated. According to one aspect, the nail includes an elongate member having a longitudinal axis, a proximal end section, and a distal end section and a central solid section extending therebetween. The proximal end section includes a fastener receiving portion enlarged relative to the central section and having at least one hole extending therethrough normal to the longitudinal axis. The distal end section includes a fastener receiving portion enlarged relative to the central section. 
     In one form, the distal fastener receiving portion includes a first hole therethrough normal to the longitudinal axis and a second hole therethrough normal to the longitudinal axis and normal to the first hole. In another form, the distal fastener receiving portion includes a first upper hole therethrough normal to the longitudinal axis and a second lower hole therethrough normal to the longitudinal axis and parallel to the first hole. In yet another form, the distal fastener receiving portion includes at least one hole therethrough normal to the longitudinal axis, and there is at least one middle fastener receiving portion formed along the central solid section between the proximal end section and the distal end section. The middle fastener receiving portion is enlarged relative to the central solid section and has a hole therethrough normal to the longitudinal axis. 
     Referring now to  FIGS. 10-12 , there is illustrated another embodiment intramedullary nail  220 . Nail  220  has structural features and properties that are similar to nail  20  described above; however, nail  220  includes a distal end that allows placement of additional fasteners to provide added stability. While nail  220  has a length that makes it particularly suited for femur  10  having supracondylar fracture or osteotomy  92 , applications for other types of femoral fractures and osteotomies are also contemplated. 
     Nail  220  includes a central solid section  222  extending between a proximal end section  234  and a distal end section  232 . Except as otherwise provided herein, nail  220  generally has the structural, dimensional and elastic properties discussed above with respect to nail  20 . Nail  220  has two widened sections or fastener receiving areas  228 ,  230  in respective distal and proximal end sections  232 ,  234 . Smooth gradual transitions are provided between central section  222  and the fastener receiving areas  228 ,  230 . Distal fastener receiving area  228  is positioned adjacent to and in spaced relation from distal tip  226  with a distal taper therebetween. The proximal fastener receiving area  230  extends to proximal tip  242 , and can include a tool attachment structure as described above with respect to nail  20 . Nail  220  can be bent and installed into femur  10  in a manner similar to that described above with respect to nail  20 . 
     Proximal fastener receiving area includes a generally cylindrical hole  252  extending generally normal to the central longitudinal axis  254 . Proximal fastener  264  can be placed through hole  252 . Distal fastener receiving area  228  includes a lower generally cylindrical hole  250  extending normal to central axis  254 , and an upper generally cylindrical hole  251  extending normal to axis  254  and also generally normal to hole  250 , as shown in  FIGS. 11 and 12 . Upper distal fastener  260  can be placed through upper hole  251  and lower distal fastener  262  can be placed through lower hole  250 , providing added stability when distal end portion  232  of nail  220  is secured to femur  10 . 
     Referring now to  FIG. 13 , there is illustrated another embodiment bone nail  320  according to the present invention. Nail  320  preferably has a length that is particularly suited for a femur having an intertrochanteric osteotomy  94 , which allows de-rotation of a twisted femur. Nail  320  has an enlarged distal fastener portion for receiving multiple fasteners therethrough. It is also contemplated that nail  320  also has application with other types of femoral fractures and osteotomies. 
     Nail  320  includes a central solid section  322 , a proximal end section  334  and a distal end section  332 . Except as otherwise provided herein, nail  320  generally has the structural, dimensional and elastic properties discussed above with respect to nail  20 . Nail  320  has two widened sections or fastener receiving areas  328 ,  330  in respective distal and proximal end sections  332 ,  334 . Smooth gradual transitions are provided between central section  322  and the fastener receiving areas  328 ,  330 . Distal fastener receiving area  328  is positioned adjacent to and in spaced relation from distal tip  326  with a distal taper therebetween. The proximal fastener receiving area  330  extends to proximal tip  342 , and can include a tool attachment structure as described above with respect to nail  20 . Nail  320  can be bent and installed in a manner similar to that described above with respect to nail  20 . 
     Proximal fastener receiving area includes a generally cylindrical hole  352  extending generally normal to the central longitudinal axis  354 . Proximal fastener  364  can be placed through hole  352 . Distal fastener receiving area  328  includes a lower generally cylindrical hole  350  extending normal to central axis  354 , and an upper generally cylindrical hole  351  extending normal to axis  354  and also generally parallel to hole  350 . Upper distal fastener  360  can be placed through upper hole  351  and lower distal fastener  362  can be placed through lower hole  350 , providing added stability to distal end portion  332  of nail  320  secured to femur  10 . 
     Referring now to  FIG. 14 , there is illustrated another embodiment bone nail  420  according to the present invention. Nail  420  is particularly suited for multiple level osteotomies  93   a ,  93   b  for correction of femoral deformity, or for multiple fractures of the femur. It is also contemplated that nail  420  has application with other types of femoral fractures and osteotomies. 
     Nail  420  includes a pair of central solid sections  422 ,  423  extending from a middle fastener receiving section  429  towards a proximal end section  434  and a distal end section  432 , respectively. Except as otherwise provided herein, nail  420  generally has the structural, dimensional and elastic properties discussed above with respect to nail  20 . Nail  420  has widened sections or fastener receiving areas  428 ,  430  in respective distal and proximal end sections  432 ,  434 . Nail  420  further has a middle widened fastener receiving area  429  between central sections  422 ,  423 . Preferably, central sections  422 ,  423  have respective lengths that position middle receiving area  429  between upper osteotomy  93   a  and lower osteotomy  93   b . Although the embodiment of  FIG. 14  has one middle receiving area  429 , it is contemplated that two or more middle receiving areas could be provided for use in multiple level fractures or osteotomies so that each section of bone has a fastener associated therewith. Smooth gradual transitions are provided between central section  422 ,  423  and the fastener receiving areas  428 ,  429 ,  430 . Distal fastener receiving area  428  is positioned adjacent to and in spaced relation from distal tip  426  with a distal taper therebetween. The proximal fastener receiving area  430  extends to proximal tip  442 , and can include an attachment structure as described above with respect to nail  20 . Nail  420  can be bent and installed in a manner similar to that described above with respect to nail  20 . 
     Proximal fastener receiving area  430  includes a generally cylindrical hole  452  extending generally normal to the central longitudinal axis  454 . Proximal fastener  464  can be placed through hole  452 . Distal fastener receiving area  428  includes a generally cylindrical hole  450  extending normal to central axis  454 . Middle fastener receiving area  429  includes a generally cylindrical hole  451  extending normal to axis  254 . Middle fastener  460  can be placed through hole  451  and distal fastener  462  can be placed through hole  450 , securing nail  420  to each of the fractured sections of femur  10 . 
     It may be appreciated by one skilled in the art that additional embodiments may be contemplated, including combinations of the above described embodiments. For example, the dual hole distal end portion of nail  220 ,  320  could be used with nail  20  or nail  420 . It is also contemplated that additional embodiment may be similarly designed for nails used to fix fractures in long bones other than the femur in child and adolescent patients. It is also contemplated that similar nails could be used in repair of animal long-bone fractures. 
     In the foregoing description, certain terms have been used for brevity, clarity and understanding, but no unnecessary limitations are to be implied therefrom beyond the requirements of the prior art, because such words are used for description purposes herein and are intended to be broadly construed. Moreover, the embodiment of the apparatus illustrated and described herein are by way of example, and the scope of the invention is not limited to the exact details of construction illustrated herein. 
     While the invention has been illustrated and described in detail in the drawings and foregoing description, the same is to be considered as illustrative and not restrictive in character, it being understood that only the preferred embodiments have been shown and described and that all changes and modifications the come within the spirit of the invention are desired to be protected.