Background: Intramedullary nailing is the method of choice in the treatment of acute femoral shaft fractures in adults. It is associated with a high fracture union rate and a low complication rate. Nonunion as well as its other rare complications are treated by exchange femoral nailing. Objective: To look at the use of the Kuntscher nail in the management of femoral shaft fracture and to look at complications of Kuntscher nailing that require intramedullary nailing. Design: This was a ten year observational study. Setting: Ward 6D, Kenyatta National Hospital, Nairobi, Kenya. Patients and methods: All patients admitted to ward 6D, Kenyatta National Hospital with fracture shaft of femur and treated by Kuntscher nailing between 1 st January 2001 and 30th April 2011 were followed up. Those who developed a complication requiring exchange femoral had the exchange femoral nailing performed by the authors. Results: Over the study period, four patients underwent exchange femoral nailing.The indications for the exchange nailings were infection,two cases, malrotation, bent nail, and long Kuntscher nails. Infection coexisted with malrotation and a long Kuntscher nail. Exchange involved using both the conventional Kuntscher nail and a Russel-Taylor interlocking nail. Conclusions: Exchange femoral nailing was undertaken in only 0.24% of Kuntscher nailings over this ten year’s study period.