TECHNICAL TRICKS Removal of a Broken Distal Closed Section Intramedullary Nail Report of a Case Using a Simple Method Ely L. Steinberg,* Elhanan Luger,* Aharon Menahem,* and David L. Helfet† Summary: A simple method to remove a broken distal closed sec- tion intramedullary nail is presented. The surgical technique and a case report are described. This technique eliminates the need for an additional exposure, other than that required to insert the nail, or any specialized equipment. Key Words: broken nail, reaming, extraction devices (J Orthop Trauma 2004;18:233–235) M any methods have been published on the removal of the distal piece of a broken distal closed section intramed- ullary nail. 1–7 Some additional extraction devices also have been designed to remove a broken distal nail that is buried in- side the medullary canal and that cannot be accessed from the standard incision (Table 1). This article describes a simple method that can be used to remove a broken distal hollow nail remnant (closed or open) without using a special extraction device. MATERIALS AND METHODS The technique used is the same for broken intramedul- lary nails of either femur or tibia, with the exception of the approach to the bone. Femur The proximal part of the broken nail is accessed through a proximal incision over the greater trochanter. All locking screws and the proximal part of the broken nail are removed. A 3.5-mm Steinmann pin is inserted in one of the distal holes that previously contained a removed screw. A 3-mm guide is intro- duced in the distal nail, and the proximal medullary canal is reamed to a larger diameter, at least 2 mm greater than the diameter of the broken nail. It is recommended to begin the reaming with a 9-mm reamer that has end cutting reamer blades to remove the entrapped soft tissue inside the medullary canal and the pseudarthrotic tissue (Fig. 1A). To ensure that no soft tissue will interfere with nail removal, reaming should be performed to the proximal edge of the broken nail. An 8- to 10-mm Kuntscher nail (one that is rarely used any more) is tested for size and interference fit using the previously ex- tracted proximal nail portion; then only the Kuntscher nail is used to extract the distal piece (Fig. 1B). The 3-mm guide and the locking Steinmann pin are removed from the bone, and the nail is removed gently using rotatory movements. After nail removal, the medullary canal is reamed to the desired diameter for a new nail insertion. Tibia The same technique is applied as described for the fe- mur. The standard tibial approach is the access used, however. CASE PRESENTATION A 29-year-old man was injured in a motorcycle accident. His multiple injuries included a combined fracture of the neck and midshaft of the left femur and an open Gustilo type IIIA fracture of the left tibia. The midshaft femoral fracture was fixed with an AO unreamed intramedullary nail (400 mm × 9 mm), and three cannulated screws were used to secure the neck fracture. An external fixator was applied to the tibia. Three months after injury, the tibial fracture had healed, and the ex- ternal fixator was removed. One year after injury, a nonunion of the midshaft femoral fracture was noted, and the nail was changed to a larger reamed diameter (13 mm). Two years after the accident, a hypertrophic nonunion of the femur was treated with an iliac bone graft. One year later, the patient had a sen- sation of instability at the site of the fracture, and radiographs showed a broken nail and a hypertrophic nonunion of the left femur (Fig. 2). During the last year of follow-up, the patient Accepted for publication March 23, 2003. From the *Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel, and †Hospital for Special Surgery, New York, NY. No benefit in any form has been or will be received from a commercial party related directly or indirectly to the subject of this article. The devices that are the subject of this manuscript are FDA approved. Reprints: Ely L. Steinberg, MD, Department of Orthopaedic Surgery “B,” Tel- Aviv Sourasky Medical Center, 6 Weitzmann Street, Tel-Aviv 64239, Is- rael (e-mail: eli_st@netvison.net.il). Copyright © 2004 by Lippincott Williams & Wilkins J Orthop Trauma • Volume 18, Number 4, April 2004 233