Intramedullary nail is the mainstay of treatment for femur shaft fracture. One of the potential complications of intramedullary nailing is nail breakage, which can occur due to trauma or nonunion at any part of the nail. Removal of the distal end of a solid nail, which is away from the fracture or nonunion site, is a difficult procedure that requires special extraction devices. 60-year-old male who sustained a road traffic injury 12 years back and was treated for a right floating knee injury (femur shaft fracture, patellar and tibial plateau fracture) managed with retrograde nail of femur, tension band wiring for patella, and plating for tibial plateau fracture. Currently presented with knee and distal thigh pain with decreased range of motion. Imaging shows right femur shaft nonunion with a broken intramedullary nail and interlocking screw at the level of the proximal dynamic hole. We removed the proximal part with a SIGN nail extraction system and the distal part of the solid nail was removed by pushing it upward to the piriformis using another broken nail after an entry hole was made over the piriformis. Broken nails far from the previous fracture or nonunion site are quite difficult to remove at the distal end. It is a technically demanding procedure that requires different techniques and special extraction tools. Several techniques have been described, mostly for cannulated nails, including widening the canal, development of bony windows, and pushing or pulling using various instruments. Our technique can be done without special extraction devices with decreased operative time and also obviates the need for a large cortical window and opening of fracture or nonunion site. The broken distal end of a solid retrograde nail in a resource-limited setup can be removed by pushing with the tip of another broken nail to the piriformis or from the piriformis to the knee after an entry hole was made in the proximal or distal femur, respectively. Nail removal should be performed with meticulous preoperative planning and preparation of different extraction devices.
Mengistu et al. (2026) studied this question.