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Rare complication of segmental breakage of plastic medullary tube in closed intramedullary nailing
Injury, Int. J. Care Injured 32 (2001) 730– 731 www.elsevier.com/locate/injury
Case report
Rare complication of segmental breakage of plastic medullary tube in closed intramedullary nailing D. Ip *, W.C. Wu, S.H. Wong Pamela Youde Nethersole Eastern Hospital, Department of Orthopaedics & Traumatology, 3 Lok Man Road, Chai Wan, Hong Kong, China Accepted 9 April 2001
1. Introduction Treatment of closed fractures of the femoral shaft with intra-medullary nailing has become standard practice [1,2]. Breakage of plastic intramedullary tubes is rare, with only isolated case reports [3]. Segmental breakage is even rarer and has not been reported1. However, this rare intra-operative complication is difficult to deal with as it requires removal of translucent plastic fragment(s) not readily visualized by X-ray screening. This paper reports breakage of the plastic medullary tube in a patient with a fracture of the distal third of her femur. The two breaks of the tube occurred in the region of the distal fracture fragment.
2. Case report A 53-year-old lady suffered a closed fracture of the distal shaft of her left femur in a traffic crash as the only injury and it was decided to treat this by closed AO intramedullary nailing. After adequate reduction, the marrow cavity was reamed up to 12 mm, and, using a plastic tube; the bent tip reamer guide was replaced by the smooth tipped nail guide. On removing the plastic tube, it broke at two points some 3 and 6 cm distal to the fracture site.
* Corresponding author. Tel.: + 852-259-56415; fax: + 852-25956414. E-mail address: [email protected] (D. Ip). 1 No evidence of reported case of segmental plastic medullary tube on literature search at the time of writing.
Attempts to remove the fragments with broken-nail extractors failed. One segment was removed by the bent tip reamer guide successfully, while the remaining fragment had to be removed by opening the fracture site. The subsequent interlocking procedures and postoperative course were smooth. 3. Discussion Breakage of a plastic medullary tube during closed intramedullary nailing, albeit rare, poses treatment difficulties [3] especially if the break is segmental and occurs in the distal fracture segment (as in the present case). The situation is further worsened by the not infrequent need to open the fracture site for retrieving broken parts which turns the procedure from closed to open nailing. In the present case the plastic tube was found to be dirty brown in colour and this was also noted in previous case reports from UK hospitals. It will be obvious from the above discussion that prevention is important. The new AO intra-medullary reaming set which will be on the market soon addresses this problem by obviating the need to change from a reamer to a nail guide by interim insertion of a plastic intra-medullary tube. It is also recommended that plastic tubes which have become discoloured dirty brown by repeated autoclaving be used only with great caution or better discarded [4]. The practice of slightly bending the plastic tube to check its flexibility before insertion is also a prudent one. However, when this complication does occur, retrieval of plastic fragments by a bent-tip reamer guide rather than nail-extraction instruments is often more helpful.
0020-1383/01/$ - see front matter © 2001 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 1 ) 0 0 0 8 3 - 3
D. Ip et al. / Injury, Int. J. Care Injured 32 (2001) 730–731
Attempted visualization of broken multiple translucent plastic tube fragments by contrast injection is often made difficult by the presence of reamed materials in the medullary cavity. Also, injection of contrast is difficult if all the plastic fragments are located in the distal fracture fragment.
4. Conclusion We believe that this rare but difficult intraoperative complication of intra-medullary reaming is preventable.
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It is hoped that the newer AO reaming instrument set will make this complication a thing of the past. References [1] Christie J, Court-Brown C, et al. Intramedullary locking nails in the management of femoral shaft fractures. J Bone Joint Surg (Br) 1988;70B:206. [2] Browner B. The science and practice of intramedullary nailing, 2. Williams and Wilkins, 1996. [3] Godstiff SP, Heywood-Waddington MB. Closed intramedullary nailing complicated by breakage of plastic medullary tube. Injury 1993;24(2):136 – 7. [4] Texhamar R, Sequin F. AO/ASIF instrumentation manual of use and care. Berlin, Heidelberg: Springer-Verlag, 1981.
Case report
Rare complication of segmental breakage of plastic medullary tube in closed intramedullary nailing D. Ip *, W.C. Wu, S.H. Wong Pamela Youde Nethersole Eastern Hospital, Department of Orthopaedics & Traumatology, 3 Lok Man Road, Chai Wan, Hong Kong, China Accepted 9 April 2001
1. Introduction Treatment of closed fractures of the femoral shaft with intra-medullary nailing has become standard practice [1,2]. Breakage of plastic intramedullary tubes is rare, with only isolated case reports [3]. Segmental breakage is even rarer and has not been reported1. However, this rare intra-operative complication is difficult to deal with as it requires removal of translucent plastic fragment(s) not readily visualized by X-ray screening. This paper reports breakage of the plastic medullary tube in a patient with a fracture of the distal third of her femur. The two breaks of the tube occurred in the region of the distal fracture fragment.
2. Case report A 53-year-old lady suffered a closed fracture of the distal shaft of her left femur in a traffic crash as the only injury and it was decided to treat this by closed AO intramedullary nailing. After adequate reduction, the marrow cavity was reamed up to 12 mm, and, using a plastic tube; the bent tip reamer guide was replaced by the smooth tipped nail guide. On removing the plastic tube, it broke at two points some 3 and 6 cm distal to the fracture site.
* Corresponding author. Tel.: + 852-259-56415; fax: + 852-25956414. E-mail address: [email protected] (D. Ip). 1 No evidence of reported case of segmental plastic medullary tube on literature search at the time of writing.
Attempts to remove the fragments with broken-nail extractors failed. One segment was removed by the bent tip reamer guide successfully, while the remaining fragment had to be removed by opening the fracture site. The subsequent interlocking procedures and postoperative course were smooth. 3. Discussion Breakage of a plastic medullary tube during closed intramedullary nailing, albeit rare, poses treatment difficulties [3] especially if the break is segmental and occurs in the distal fracture segment (as in the present case). The situation is further worsened by the not infrequent need to open the fracture site for retrieving broken parts which turns the procedure from closed to open nailing. In the present case the plastic tube was found to be dirty brown in colour and this was also noted in previous case reports from UK hospitals. It will be obvious from the above discussion that prevention is important. The new AO intra-medullary reaming set which will be on the market soon addresses this problem by obviating the need to change from a reamer to a nail guide by interim insertion of a plastic intra-medullary tube. It is also recommended that plastic tubes which have become discoloured dirty brown by repeated autoclaving be used only with great caution or better discarded [4]. The practice of slightly bending the plastic tube to check its flexibility before insertion is also a prudent one. However, when this complication does occur, retrieval of plastic fragments by a bent-tip reamer guide rather than nail-extraction instruments is often more helpful.
0020-1383/01/$ - see front matter © 2001 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 1 ) 0 0 0 8 3 - 3
D. Ip et al. / Injury, Int. J. Care Injured 32 (2001) 730–731
Attempted visualization of broken multiple translucent plastic tube fragments by contrast injection is often made difficult by the presence of reamed materials in the medullary cavity. Also, injection of contrast is difficult if all the plastic fragments are located in the distal fracture fragment.
4. Conclusion We believe that this rare but difficult intraoperative complication of intra-medullary reaming is preventable.
731
It is hoped that the newer AO reaming instrument set will make this complication a thing of the past. References [1] Christie J, Court-Brown C, et al. Intramedullary locking nails in the management of femoral shaft fractures. J Bone Joint Surg (Br) 1988;70B:206. [2] Browner B. The science and practice of intramedullary nailing, 2. Williams and Wilkins, 1996. [3] Godstiff SP, Heywood-Waddington MB. Closed intramedullary nailing complicated by breakage of plastic medullary tube. Injury 1993;24(2):136 – 7. [4] Texhamar R, Sequin F. AO/ASIF instrumentation manual of use and care. Berlin, Heidelberg: Springer-Verlag, 1981.