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Injury Vol, 28, No. 9-10, pp. 693-694, 1997 © 1997 Elsevier Science Ltd. All rights reserved

Printed in Great Britain 0020-1383/97 $17.00 + 0.00

Pll: S0020-1383(97)00146-0

Removal of a broken intramedullary tibial nail using a hand reamer

M. Khan, P. J. Schranz and M. W. Ward Depar tmen t of Orthopaedics , Royal Hospital Haslar, Gosport , Hants, UK

Injury, Vol. 28, No. 9-10, 693-694, 1997

Introduction In t rameduUary tibial nailing is a popular operat ive procedure for diaphyseal fractures of the tibia. Broken nails are fortunately rare but w h e n they do occur, removal of the broken distal f ragments can be difficult and time consuming. We present a simple and effective me thod using a hand reamer for extri- cation of the broken distal fragment.

in t ramedul lary nails in the literature varies from 1 per cent to as high as 3.3 per cent 1 3. Although a relatively u n c o m m o n complication of in t ramedul lary nailing, b roken distal f ragments can be very difficult to remove.

Case report A 23-year-old male was routinely reviewed 3 weeks after tibial intramedullary nailing for an infected non-union of a distal tibial fracture, which had been nailed by using a size 13 by 345 mm AO tibial nail. Radiographs showed the fracture in the distal 1/3 of the tibia at the level of the upper distal locking screw hole. It was therefore decided to remove the tibial nail and insert a fresh intramedullary nail without direct exposure of the fracture site.

The patient was placed supine on a fracture table with image intensifier control. The proximal nail section was removed using a standard technique. Next a hand-held rigid hand reamer size 8mm was passed down the proximal medulla to reach the proximal end of the distal nail fragment making a tight fit as it was advanced into the nail. The proximal tibia was reamed increasing the space for removal of the distal fragment. A firm grip was achieved by the reamer on the inside of the distal nail fragment and the fragment easily removed. Reinsertion of a fresh intramedullary nail was then carried out in the standard way (Figures 1-3).

Discussion The dosed int ramedul lary nailing technique using interlocking nails has become a widely accepted form of operat ive t rea tment of diaphyseal fractures. It is increasingly being used because of improvemen t s in the technique and the availability of newer and more versatile types of nail. The incidence of breakage of Figure 1. An X-ray of the broken tibial nail.

694 Injury: International Journal of the Care of the Injured Vol. 28, No. 9-10, 1997

Although there have been m a n y reports of removal of broken int ramedul lary nail f ragments in the literature ~, none have suggested using a hand reamer. Standard methods using hooks may fail because of inadequate grip and mala l ignment of the fragments. Other methods of using multiple guide wires 5 may be successful but require the use of several pieces of equ ipment and large forces for removal. By using the appropr ia te sized hand

HAND REAMER PASSED INTO NAIL FRAGMENT MAKING A TIGHT FIT

Broken Nail Fragment

Figure2. Diagram of hand reamer passed into nail fragment.

reamers, the me thod described above allows extrica- tion of even the smallest f ragment of broken nail.

References 1 Bone L. B. and Johnson K. D. Treatment of tibial

fractures by reaming and intrameduilary nailing. ] Bone Joint Surg 1986; 68A: 877-877.

2 0 l e r u d S. and Karlstrom G. The spectrum of intra- medullary nailing of the tibia. Clin Orthop 1986; 212: 101-112.

3 Edeland H. G. and Errikson G. Fracture of the femoral shaft and the Kuntscher Nail. Suggestion for a method and device for the retraction of the distal nail fragment. Acta Orthop, Belgica 1979; 45: 429-433.

4 Levy O., Amit Y., Velkes S. and Horoszowski H. A simple method for removal of a fractured intramedullary nail. ] Bone and Joint Surg 1994; 761]: 502.

5 Middleton R. G., McNab I. S. H., Hasemi-Nejad A. and Nordeen M. H. H. Multiple guide wire technique for removal of the short distal fragment of a fractured intra- medullary nail. Injury 1995; 26: 531.

Paper accepted 26 August 1997.

Requests for reprints should be addressed to: Major Manawar Khan, Department of Orthopaedic Surgery, Royal Hospital Haslar, Gosport, Hants PO12 2AA.

Figure 3. Shows the extricated tibial nail with distal nail fragment.