Intramedullary femoral nail fixation relies on successful navigation of the starting point and minimization of the flexion/abduction deformity. Compared with the supine position, the lateral decubitus position is advantageous because it allows gravity to displace the soft tissue around the piriformis starting point, facilitating nail entry. Contraindications to intramedullary femoral nail fixation via the lateral decubitus position include polytrauma and spinal instability. This video highlights the use of the lateral decubitus position in a patient who underwent exchange nailing of a hypertrophic femoral shaft nonunion with an associated varus deformity. In this particular patient, blocking screws were used to guide the upsized nail into a more anatomic position and correct the varus deformity.