Intramedullary bone pedestal formation contributing to femoral shaft fracture nonunion: A case report and review of the literature

Figure 1 Post-operative radiographs of the left femur from outside hospital. A: Anterior-posterior radiograph showing transverse mid-shaft femur fracture with some comminution and Russell-Taylor Delta II 9 x 380 mm antegrade nail with single distal interlocking screw; B: Lateral radiograph showing the same.

Figure 2 Radiographs of the left femur from outside hospital obtained 4 mo post-operatively. A: Anterior-posterior radiograph showing broken distal interlocking screw and poor fracture healing; B: Lateral radiograph showing the same.

Figure 3 Radiographs of the left femur obtained 8 mo post-operatively. A: Anterior-posterior radiograph showing continued poor evidence of fracture healing despite prior distal interlocking screw removal; B: Lateral radiograph showing the same.

Figure 4 Illustration and radiograph of left femur obtained intra-operatively. A: Illustration of bone pedestal at tip of intramedullary nail blocking guide rod passage; B: Radiograph showing guide rod tip (inside intramedullary nail) unable to pass intramedullary bone pedestal (outlined).

Figure 5 Illustration of left femur intra-operatively. A: Showing femur after intramedullary nail removal. Guide rod tip still unable to pass distally in canal due to intramedullary bone pedestal; B: Showing starting reamer used to breach intramedullary bone pedestal; C: Showing new nail (solid lines) at area of wider, more distal meta-diaphyseal bone compared to old nail (dotted lines) at area of more proximal, narrow diaphyseal bone.

Figure 6 Illustration and fluoroscopic radiographs of left femur obtained intra-operatively. A: Illustration showing intramedullary nail placed past bone pedestal; B: Anterior-posterior radiograph showing new, larger diameter intramedullary nail placed past bone pedestal; C: Lateral radiograph showing the same.

Figure 7 Fluoroscopic radiographs of left femur obtained intra-operatively. A: Anterior-posterior radiograph one year post-operatively showing early callous formation but incomplete fracture healing; B: Lateral radiograph showing the same but at increased magnification.

Figure 8 Radiographs of the left femur obtained 18 mo post-operatively. A: Anterior-posterior radiograph showing evidence of good fracture healing; B: Lateral radiograph showing the same.