Medial femoral condyle fracture as a complication of antegrade intramedullary nailing

Abstract

A 49-year-old man suffered a closed oblique fracture of the middle third of his left femur. Closed reduction and internal fixation by intramedullary (IM) nailing were performed. Per-operative fluoroscopic imaging and initial postoperative X-rays were judged normal and the patient followed the usual rehabilitation protocol. At 3-month follow-up the patient still demonstrated poor knee function and pain. A plain X-ray and a CT scan of the left knee revealed a displaced fracture of the medial femoral condyle. Analysis of the postoperative imaging suggests that the fracture occurred during the insertion of the IM nail. The nail possibly hit the Steinmann traction pin in the distal femur causing the medial condyle fracture. The patient was reoperated; open reduction and internal plate and screw fixation were performed with satisfactory clinical progress postoperatively. The description and illustration of this case is intended to make trauma surgeons aware of this rare but serious complication of IM femoral nailing.

Distal femoral complications following antegrade intramedullary nail placement

“…An additional cause of fracture at the distal end of femoral nails is a mismatch of the radius of curvature and anterior bow of the femur, resulting in anterior cortical perforation of the distal femur. 7 , 8 , 16 Using a starting point anterior to the midline and an implant with a smaller radius of curvature has been recommended in order to avoid this complication. 17 Despite the use of a modern nail with a smaller radius of curvature (150 cm), our case demonstrates that anterior cortical perforation may still occur, especially in patients with a radius of curvature that falls outside the normal range.…”

“…Additionally, distal femoral cortical breach is a rare but an important complication of antegrade femoral nailing. 7 , 8 Anatomic factors contributing to the occurrence of distal anterior cortical breach include fracture pattern and femoral radius of curvature in the sagittal plane. The anatomic average radius of curvature in the femur is 120 cm, while that of modern intramedullary nails range from 150 to 300 cm.…”

“… 7 , 9 Straighter implants are associated with higher rates of penetration of the anterior cortex. 8 Additionally, the medullary canal of the femur lies slightly anterior within the distal femur and the anterior femoral cortex undergoes significant thinning with age. 7 Surgeonrelated factors contributing to the occurrence of cortical breach include improper starting point or technical errors.…”

“… 10-12 Malunion, most frequently rotational, is seen in up to 28% of cases. 8 Rates of infection for closed femur fractures treated with antegrade intramedullary nailing range from 0.7% to 2.1%. 10 The rate of post-operative implant failure has been reported to be 6.7%, and is usually associated with the cephalomedullary or distal locking screw.…”