Removing a bent femoral nail - man versus metal: A case report

Abstract

Introduction: Intramedullary nailing is the treatment of choice for femoral shaft fractures in adults with excellent clinical results and low complication rates reported in the literature. However, in situ bending of a femoral nail is a rare complication that merits special attention. While there are several extraction techniques and algorithms the scientific evidence to support these decision-making tools is unconvincing.

Presentation of case: A 26-year old man presented to the Accident and Emergency Department with a deformed thigh following a low-energy injury. Radiographs showed a bent femoral nail in situ and the patient disclosed that he had surgery four weeks earlier for a fractured femur sustained in a motor vehicle accident. A treatment algorithm was followed in planning the surgical strategy, but ultimately a simple hacksaw blade was used to cut and remove the nail. The fracture which was stabilised by exchange nailing went on to uncomplicated union and the patient recovered fully.

Discussion: Non-invasive methods of removing a bent femoral nail are often unsuccessful and may result in iatrogenic injuries. Surgeons should assess the available local resources and first consider using simple open methods when attempting to remove a bent femoral nail.

Conclusion: Open extraction methods often disregard the low-resource environment in which many surgeons work. We describe a simple and economical technique that uses a regular hacksaw blade to cut and remove a bent femoral nail.

Keywords: Bent; Case report; Femoral nail; Hacksaw; Intramedullary; Low-resource.

Fig. 1

A. Clinical photograph of the patient's thigh showing a significant varus deformity. B. Anteroposterior radiograph of the femur illustrating the bent intramedullary femoral nail in-situ.

Fig. 2

Immediate postoperative radiographs of the femur. Anteroposterior (A) and lateral (B) views showing a locked intramedullary femoral nail. Note the cerclage cable stabilising the segmental fracture.

Fig. 3

Anteroposterior (A) and lateral radiograph (B) of the femur two years after exchange nailing illustrating complete healing of the femoral fracture and extensive bone remodelling. Note: self-dynamization of the nail through the broken distal locking bolt and the missed proximal locking bolt.

Fig. 4

Algorithm for removal of bent intramedullary nails. Reprinted with permission from Springer Nature Customer Service Centre GmbH: Springer [Archives of Orthopaedic and Trauma Surgery] (Removal of a bent intramedullary nail in lower extremity: report of two cases and review of removal techniques, Ozkan Klose et al.) [CC-BY-NC-SA] (2015).