Nag Suman, Lall Hitesh, Jain Vijay Kumar, Bansal Pankaj, Khare Rahul, Mittal Deepak
Department of Orthopedics, Post Graduate Institute of Medical Education and Research, Dr Ram Manohar Lohia Hospital, New Delhi, India.
Orthopedics. 2010 Feb;33(2):119-21. doi: 10.3928/01477447-20100104-24.
Reamed interlocking intramedullary fixation is the treatment of choice for displaced tibial shaft fractures in adults. In most cases it can be performed without difficulty; however, technical difficulties may be encountered during nailing in some cases. This article describes a case of closed nailing for a tibial shaft fracture in which intramedullary guide wire was obstructed by a small intramedullary bone fragment in the distal fracture segment. Forceful reaming and insertion of the nail led to a break in the cortex of the distal fragment and bending of guide wire. Finally, open reduction and intramedullary nailing was performed to retrieve the guide wire and intramedullary bone fragment and fix the tibia.A comminuted fracture with multiple close fragments in proximity to the fracture site should be preoperatively scrutinized to look for intramedullary bone fragment or a fragment that could be pushed in the intramedullary canal during the intramedullary nailing. The surgeon can then anticipate the potential operative difficulty that may be encountered during closed nailing of such a fracture; and the patient can be counseled, as open nailing is a safer and viable option. Finally it is pertinent that even if this fracture type is overlooked, catastrophe can be avoided by properly following all the steps of intramedullary nailing.
扩髓带锁髓内固定是治疗成人胫骨干骨折的首选方法。在大多数情况下，该手术操作并不困难；然而，某些情况下在插入髓内钉时可能会遇到技术难题。本文描述了1例胫骨干骨折闭合穿钉病例，其远端骨折段内的一枚小髓内骨块阻碍了髓内导针。强行扩髓及插入髓内钉导致远端骨折块皮质骨断裂及导针弯曲。最后，通过切开复位及髓内钉固定取出导针及髓内骨块并固定胫骨。对于骨折部位附近有多个紧密骨块的粉碎性骨折，术前应仔细检查，以寻找髓内骨块或在髓内钉固定过程中可能被推入髓内管的骨块。这样外科医生就能预见此类骨折闭合穿钉时可能遇到的潜在手术困难；并且可以告知患者，切开穿钉是一种更安全可行的选择。最后，即便忽略了这种骨折类型，通过正确遵循髓内钉固定的所有步骤仍可避免灾难的发生，这一点至关重要。
