Expanding nail or expanding femur? An adverse event with the expandable intramedullary nail

The expandable intramedullary nail is self-locking and has the advantage of reducing operating time and exposure to ionizing radiation. The nail is recommended for simple diaphyseal fractures involving the middle third of long bones, where the nail can bypass the fracture site by at least 5 cm. We encountered a unique complication with the expandable nail in a simple transverse shaft fracture at the junction of the middle and distal third of the left femur in an otherwise healthy 57-year-old man. The fracture was reduced and a 12-mm expandable nail was inserted. Following full expansion, intraoperative radiographs were obtained prior to closure. After six postoperative weeks, it was noted that the nail expanded the femoral canal, converting a simple fracture to a distally progressing comminuted fracture with a butterfly fragment. A review of the intraoperative radiographs showed slight widening of the medullary canal at the level of the fracture. As the alignment was satisfactory and callus was present, no further surgical intervention was considered. The patient was advised not to bear weight and was provided with a locked knee brace in extension to wear for six weeks. Radiographs at 12 weeks demonstrated good progress of healing with adequate callus and the patient was permitted to bear weight as tolerated and commence knee flexion. The fracture united satisfactorily at four months. This adverse experience emphasizes that caution should be exercised when expanding the nail, with close observation of the medullary canal diameter during the later stages of expansion.