Penetration injury of the hindfoot following intramedullary nail fixation of a tibial fracture.

Technical errors during intramedullary nail insertion are not uncommon. We report a case of tibial guide wire penetration into the distal tibial articular surface, the talus and the calcaneus during insertion of the nail with the ankle dorsiflexed. This has not been reported in the past. Computerized tomogram was a useful tool in the diagnosis. This complication was associated with long-standing ankle pain, which however eventually settled. We advise frequent use of biplanar C-arm image during the insertion of the guide wire, the reamer and tibial nail into the medullary canal of the tibia or other long bones. None of these instruments should be forced through. Once the knobbed guide wire is exchanged to a straight guide wire, the wire should not be forced through or reamed over, and the nail should be introduced over the guide wire with caution. Early intraoperative identification and recording of this iatrogenic accident is necessary in order to explain the situation to the patient and modify treatment accordingly.