Intramedullary Bone Fragment Obstructing Passage of Reaming Guide Wire With Iatrogenic Fractured Tibia

Reamed interlocking intramedullary fixation is the treatment of choice for displaced tibial shaft fractures in adults. In most cases it can be performed without difficulty; however, technical difficulties may be encountered during nailing in some cases. This article describes a case of closed nailing for a tibial shaft fracture in which intramedullary guide wire was obstructed by a small intramedullary bone fragment in the distal fracture segment. Forceful reaming and insertion of the nail led to a break in the cortex of the distal fragment and bending of guide wire. Finally, open reduction and intramedullary nailing was performed to retrieve the guide wire and intramedullary bone fragment and fix the tibia. A comminuted fracture with multiple close fragments in proximity to the fracture site should be preoperatively scrutinized to look for intramedullary bone fragment or a fragment that could be pushed in the intramedullary canal during the intramedullary nailing. The surgeon can then anticipate the potential operative difficulty that may be encountered during closed nailing of such a fracture; and the patient can be counseled, as open nailing is a safer and viable option. Finally it is pertinent that even if this fracture type is overlooked, catastrophe can be avoided by properly following all the steps of intramedullary nailing.