Tibial and fibular refracture with intramedullary nail bending – A surgical challenge

Abstract text (incl. references and figure legends)

Case History: Tibial and fibular shaft fractures are common lower limb injuries. Varied treatment strategies exist for different settings – open vs closed fractures; low vs high soft tissue injury; fracture location; concomitant injuries. However, some presentations are rarer and more challenging to treat. In this clinical case, a young male with prior history of right distal fibula and tibia shaft fractures presented in the ER, due to right leg trauma. Clinical history revealed that previous treatment was performed with tibial nailing and fibular plate with a reasonable clinical outcome. The last X ray showed good fracture alignment, albeit with delayed tibial shaft union. Clinical Findings: The patient presented with right leg deformity, swelling and pain. No wounds were present. New X rays showed refracture of distal fibula and tibia and bending of the tibial nail. Results: The patient was admitted to the hospital, and surgery was delayed to wait for soft tissue conditions and define a surgical plan. Therapy and Progressions: First, a tibial bone window was created, proximally to the nail bending site, and the nail was cut with a diamond high-speed drill. The nail was then removed, the proximal part using its extraction system, and the distal one using a clamp and hammer. Thorough endomedullary canal irrigation was performed to remove nail debris. Then, fibular osteotomy was performed to correct coronal alignment and new fixation was achieved with another tibial nail of higher diameter. After surgery, partial weightbearing and active mobilization was permitted. Excellent clinical outcome was achieved. 11 month post operative X rays showed bone consolidation with good alignment. Comments: New fractures over previously operated sites always constitute greater challenges for a trauma surgeon. This case imposed various challenges, the main one being the removal of a damaged tibial nail. Using a diamond drill to facilitate extraction constituted a viable solution.

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