Intra-Articular Penetration of the Knee Joint by a Fragment of Cortical Bone during Intramedullary Nailing of the Femur. A Report of Two Cases*

Abstract

The preferred treatment for comminuted fractures of the femur extending from the lesser trochanter to the adductor tubercle is fixation with an intramedullary locking nail5-7,11,12,15,24-31. The reported intraoperative complications of nailing have included an eccentric entry portal, problems with reaming, binding of the nail, iatrogenic comminution of the fracture, distraction of the fragments, extrusion of the nail into the soft tissues, injury of the femoral or popliteal artery, traction palsy of the sciatic or pudendal nerve, and penetration of the knee joint by the nail1-4,7-9,11-13,16-23. We report the cases of two patients in whom a fragment of cortical bone became trapped in the open tip of an intramedullary nail and was driven into the knee joint during nailing of the femur. CASE 1. A forty-five-year-old man was in a motorcycle accident and sustained a grade-II open, comminuted, supracondylar fracture of the femur10 and that extended into the intercondylar notch (Fig. 1-A). The fracture was irrigated and debrided, and two percutaneous cancellous-bone lag-screws, 6.5 millimeters in diameter, were inserted to stabilize the articular surface. After seven days of skeletal traction with use of a tibial pin, closed nailing of the femur with static locking was performed5. Before the operation, 1.5 centimeters of the distal end of a thirteen-millimeter-diameter intramedullary nail was cut off to ensure placement of two distal locking screws into the condylar fragments14. The 6.5-millimeter-diameter lag-screw that had been placed proximally at the …