Case Reports

Removal of the Distal Aspect of a Broken Tibial Nail

Am J Orthop. 2017 March;46(2):E112-E115

Nail breakage is a known complication of intramedullary nail (IMN) fixation of tibial fractures. Several case reports have described unique methods used to facilitate removal of broken IMNs. In this article, we describe an efficient technique for extracting broken tibial IMNs—a technique that can be used before attempting more invasive extraction methods.

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References

1. Bone LB, Kassman S, Stegemann P, France J. Prospective study of union rate of open tibial fractures treated with locked, unreamed intramedullary nails. J Orthop Trauma. 1994;8(1):45-49.

2. Blachut PA, O’Brien PJ, Meek RN, Broekhuyse HM. Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am. 1997;79(5):640-646.

3. Bonnevialle P, Savorit L, Combes JM, Rongières M, Bellumore Y, Mansat M. Value of intramedullary locked nailing in distal fractures of the tibia [in French]. Rev Chir Orthop Reparatrice Appar Mot. 1996;82(5):428-436.

4. Polat A, Kose O, Canbora K, Yanık S, Guler F. Intramedullary nailing versus minimally invasive plate osteosynthesis for distal extra-articular tibial fractures: a prospective randomized clinical trial. J Orthop Sci. 2015;20(4):695-701.

5. Bucholz RW, Ross SE, Lawrence KL. Fatigue fracture of the interlocking nail in the treatment of fractures of the distal part of the femoral shaft. J Bone Joint Surg Am. 1987;69(9):1391-1399.

6. Zimmerman KW, Klasen HJ. Mechanical failure of intramedullary nails after fracture union. J Bone Joint Surg Br. 1983;65(3):274-275.

7. Hahn D, Bradbury N, Hartley R, Radford PJ. Intramedullary nail breakage in distal fractures of the tibia. Injury. 1996;27(5):323-327.

8. Abdelgawad AA, Kanlic E. Removal of a broken cannulated intramedullary nail: review of the literature and a case report of a new technique. Case Rep Orthop. 2013;2013:461703.

9. Charnley GJ, Farrington WJ. Laparoscopic forceps removal of a broken tibial intramedullary nail. Injury. 1998;29(6):489-490.

10. Georgilas I, Mouzopoulos G, Neila C, Morakis E, Tzurbakis M. Removal of broken distal intramedullary nail with a simple method: a case report. Arch Orthop Trauma Surg. 2008;129(2):203-205.

11. Giannoudis PV, Matthews SJ, Smith RM. Removal of the retained fragment of broken solid nails by the intra-medullary route. Injury. 2001;32(5):407-410.

12. Gosling T, Allami M, Koenemann B, Hankemeier S, Krettek C. Minimally invasive exchange tibial nailing for a broken solid nail: case report and description of a new technique. J Orthop Trauma. 2005;19(10):744-747.

13. Hellemondt FJ, Haeff MJ. Removal of a broken solid intramedullary interlocking nail. A technical note. Acta Orthop Scand. 1996;67(5):512.

14. Levine JW, Georgiadis GM. Removal of a broken cannulated tibial nail: a simple intramedullary technique. J Orthop Trauma. 2004;18(4):247-249.

15. Schmidgen A, Naumann O, Wentzensen A. A simple and rapid method for removal of broken unreamed tibial nails [in German]. Unfallchirurg. 1999;102(12):975-978.

16. Steinberg EL, Luger E, Menahem A, Helfet DL. Removal of a broken distal closed section intramedullary nail: report of a case using a simple method. J Orthop Trauma. 2004;18(4):233-235.

17. Marwan M, Ibrahim M. Simple method for retrieval of distal segment of the broken interlocking intramedullary nail. Injury. 1999;30(5):333-335.

Take-Home Points

Nail breakage is a known complication of intramedullary nail (IMN) fixation of tibial fractures.
Several techniques have been described for broken IMN extraction.

Intramedullary nail (IMN) fixation is reliably used to manage tibial fractures and has become very popular for managing fractures of varying complexity.^1-4 An occasional complication of intramedullary nailing is nail breakage,^5-7 which can result from a fatigue fracture (from excessive fracture site instability caused by inadequate nail diameter, delayed fracture healing, or fracture nonunion) and direct traumatic impact.^5-7 Several case reports have described unique methods used to facilitate removal of broken hollow and solid IMNs from tibias and femurs.^4,8-16 In this article, we describe an efficient technique for extracting broken tibial IMNs—a technique that can be used before attempting more invasive extraction methods. The patient provided written informed consent for print and electronic publication of this case report.

Case Report and Surgical Technique

A 34-year-old male logger presented to our facility (Department of Orthopaedics, Warren Alpert School of Medicine, Brown University) with a new fracture of the left tibia and fibula with an associated broken IMN after a tree fell on his leg at work (Figures 1A, 1B).

The same leg had been injured under the same circumstances 1 year earlier; another facility placed the nail at that time. The earlier fracture had healed with an internal rotation deformity, but the patient had been able to return to work without pain or functional deficit. Operative management was recommended for the new fracture. The 2 sets of instruments required for the broken tibial nail removal technique described in this article are the standard T2 Tibial Nailing System (Stryker) and the Implant Extraction System (Stryker).

The original IMN had been placed through a paramedian incision, with lateral to medial distal locking screws. The tibial shaft fracture and broken nail were displaced in the coronal plane (Figures 1A, 1B). For restoration of the central canal of the nail, closed reduction was performed in the operating room (Figure 2A). Once the fracture was reduced, the more proximal of the 2 distal interlocking screws was partially backed out so the extraction hook could be passed antegrade into the distal segment of the nail (Figure 2A).

The distal interlocking screw was then partially backed out so the extraction hook could be advanced through the distal segment and engage the distal aspect of the nail (Figure 2B). Several unsuccessful attempts were made to hook the distal aspect of the nail, but neither the locking holes nor the distal end of the nail could be captured (Figure 2B). Bone ingrowth prevented capture of the distal nail segment. The hook was then rotated to point 180° away from the more distal of the 2 distal interlocking screws, and this screw was advanced against the extraction hook (Figure 2C), deflecting the hook enough to engage the distal aspect of the nail (Figure 2D). The broken nail tip became lodged after partial extraction (Figure 2E). The extraction hook was removed, and a conical extraction device was used to remove the proximal segment of the nail. A ball-tipped guide wire was then passed down the intramedullary canal and through the broken distal segment of the nail to allow a reamer to widen the canal above the incarcerated nail fragment (Figure 2F). Reaming was carried out to 12.5 mm (Figure 2F). The extraction hook was then passed down again, and it engaged the distal segment of the nail and extracted it (Figure 2G).

A ball-tipped guide wire was then passed down again, and reaming was carried out distally to 11.5 mm. A new tibial nail (10 mm × 315 mm) was placed down the intramedullary canal over the guide wire. The tibia was derotated to obtain better anatomical alignment using the fracture as an osteotomy, and 2 new distal interlocking screws were placed. The nail was then back-slapped to obtain impaction, and a single proximal dynamic interlocking screw was placed.

After surgery, the patient was allowed a gradual weight-bearing protocol.

At the last 3-month follow-up appointment, the patient reported no pain, was fully weight-bearing, and had improved rotational alignment. Radiographs showed evidence of interval healing (Figures 3A, 3B).

Discussion

IMN fixation of tibial fractures is reliable.^1-4An occasional complication of intramedullary nailing is nail breakage. Several case reports have described unique methods used to facilitate removal of broken hollow and solid IMNs from knees and femurs.^4,8-16

Our patient’s case involved a cannulated tibial IMN that broke secondary to an acute traumatic event. Several techniques have been used to remove the distal segment of broken cannulated tibial IMNs.^8,9,14,17 Abdelgawad and Kanlic⁸ described a technique in which a small distractor hook was introduced past the distal end of the broken distal piece, and a small (~2 in) piece of flexible nail was introduced into the slot of the distal interlocking screw hole. The hook was pulled back and became incarcerated in the nail by the flexible nail piece, allowing the hook to extract the distal segment of the nail.

Charnley and Farrington⁹used Petelin laparoscopic grasping forceps to extract the distal segment of a broken cannulated tibial IMN under fluoroscopic guidance. This tibial canal was initially reamed before inserting the instrument and removing the distal segment of the nail.

Levine and Georgiadis¹⁴ used a 4.5-mm bit to drill a hole in the distal aspect of the medial malleolus. A smooth Steinmann pin was used to engage the tip of the IMN. The nail was hammered several centimeters up the medullary canal of the tibia. A 3.0-mm ball-tipped guide wire was inserted in the hole in the medial malleolus and advanced through the distal aspect of the nail under fluoroscopic guidance. The guide wire was advanced through the extent of the nail proximally until it emerged through the knee incision. The distal segment of the broken nail was extracted with the guide wire; the end of the guide wire with the ball engaged the distal aspect of the nail.

Our technique allowed us to use a nail extraction device to extract the distal segment of a broken tibial IMN. This device is usually on hand for routine nail extraction. We used the more distal of the 2 distal interlocking screws to push the extraction hook over the distal lip of the nail, allowing for extraction without additional incisions or additional drill holes in bone. Our technique was efficient in this particular situation and avoided more time-consuming extraction methods. In cases in which the extraction hook does not engage the distal aspect of the nail secondary to bone ingrowth, our technique should be used before attempting other extraction methods.

References

1. Bone LB, Kassman S, Stegemann P, France J. Prospective study of union rate of open tibial fractures treated with locked, unreamed intramedullary nails. J Orthop Trauma. 1994;8(1):45-49.

2. Blachut PA, O’Brien PJ, Meek RN, Broekhuyse HM. Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am. 1997;79(5):640-646.

3. Bonnevialle P, Savorit L, Combes JM, Rongières M, Bellumore Y, Mansat M. Value of intramedullary locked nailing in distal fractures of the tibia [in French]. Rev Chir Orthop Reparatrice Appar Mot. 1996;82(5):428-436.

4. Polat A, Kose O, Canbora K, Yanık S, Guler F. Intramedullary nailing versus minimally invasive plate osteosynthesis for distal extra-articular tibial fractures: a prospective randomized clinical trial. J Orthop Sci. 2015;20(4):695-701.

5. Bucholz RW, Ross SE, Lawrence KL. Fatigue fracture of the interlocking nail in the treatment of fractures of the distal part of the femoral shaft. J Bone Joint Surg Am. 1987;69(9):1391-1399.

6. Zimmerman KW, Klasen HJ. Mechanical failure of intramedullary nails after fracture union. J Bone Joint Surg Br. 1983;65(3):274-275.

7. Hahn D, Bradbury N, Hartley R, Radford PJ. Intramedullary nail breakage in distal fractures of the tibia. Injury. 1996;27(5):323-327.

8. Abdelgawad AA, Kanlic E. Removal of a broken cannulated intramedullary nail: review of the literature and a case report of a new technique. Case Rep Orthop. 2013;2013:461703.

9. Charnley GJ, Farrington WJ. Laparoscopic forceps removal of a broken tibial intramedullary nail. Injury. 1998;29(6):489-490.

10. Georgilas I, Mouzopoulos G, Neila C, Morakis E, Tzurbakis M. Removal of broken distal intramedullary nail with a simple method: a case report. Arch Orthop Trauma Surg. 2008;129(2):203-205.

11. Giannoudis PV, Matthews SJ, Smith RM. Removal of the retained fragment of broken solid nails by the intra-medullary route. Injury. 2001;32(5):407-410.

12. Gosling T, Allami M, Koenemann B, Hankemeier S, Krettek C. Minimally invasive exchange tibial nailing for a broken solid nail: case report and description of a new technique. J Orthop Trauma. 2005;19(10):744-747.

13. Hellemondt FJ, Haeff MJ. Removal of a broken solid intramedullary interlocking nail. A technical note. Acta Orthop Scand. 1996;67(5):512.

14. Levine JW, Georgiadis GM. Removal of a broken cannulated tibial nail: a simple intramedullary technique. J Orthop Trauma. 2004;18(4):247-249.

15. Schmidgen A, Naumann O, Wentzensen A. A simple and rapid method for removal of broken unreamed tibial nails [in German]. Unfallchirurg. 1999;102(12):975-978.

16. Steinberg EL, Luger E, Menahem A, Helfet DL. Removal of a broken distal closed section intramedullary nail: report of a case using a simple method. J Orthop Trauma. 2004;18(4):233-235.

17. Marwan M, Ibrahim M. Simple method for retrieval of distal segment of the broken interlocking intramedullary nail. Injury. 1999;30(5):333-335.

Removal of the Distal Aspect of a Broken Tibial Nail

References

Take-Home Points

Case Report and Surgical Technique

Discussion

Recommended Reading