Intramedullary nail fixation of the femur relies on successful navigation of the starting point and minimization of the flexion/abduction deformity. Compared to the supine position, the lateral decubitus position has the advantage of allowing gravity to displace the soft tissue around the piriformis start site to facilitate nail entry. Contraindications include polytrauma and spine instability. This video highlights the lateral decubitus position for an exchange nailing of a hypertrophic femoral shaft nonunion with associated varus deformity. In this particular case, blocking screws were used to guide the upsized nail into a more anatomic position to correct the varus deformity.