in february 2010 , a 39-year - old man fractured both bones of the forearm after his arm was caught in a conveyor belt ; he underwent a surgery at another hospital . an intramedullary forearm rod ( acumed , hillsboro , or , usa )
nineteen months after surgery , an attempt was made to remove the implant ; it failed because the threaded portion of the nail remover was broken while being connected to the nail ( fig .
two years after the failed surgery , the patient visited us with complaints of occurrence of left elbow pain , without having any new trauma .
a partial defect of the triceps tendon with severe pain and tenderness around the scar of nail insertion was noted .
ultrasonography revealed partial rupture of the triceps tendon , and bursitis around the tender area .
based on these observations , the authors planned to remove the nail and repair the tendon .
surgery was performed under general anesthesia , with the patient in the supine position ; a tourniquet applied to the affected area . the forearm was placed on the patient 's chest , with the shoulder joint and elbow joint each flexed at 90. a longitudinal skin incision exposed the hole of the nail insertion and the interlocking screws .
the inlet site of triceps brachii muscle was thinned not torn ; it was not possible to grip since it was already covered by the bone .
we removed the bone at the inlet site and created another bony window using an osteotome , to expose the interlocking screw holes .
we inserted an impactor in the middle interlocking hole , after which we tapped the impactor towards the proximal side .
the nail moved one inter - interlocking hole distance , and its end point passed through the triceps brachii tendon .
we gripped the end point of the nail by a vise grip and used a hammer to remove it ; however , the proximal part of the nail was damaged , and the vise grip and nail were separated ( fig .
finally , we hit the distal most part of the interlocking hole , and moved the nail to a two inter - interlocking hole distance .
based on the authors ' experience , we propose a surgical technique that can easily remove the nail , and minimize size of the bony window and damage to the triceps brachii .
the distal incision is approximately the size of 2 inter - interlocking holes , and the proximal incision is about 1 cm , big enough to pass the nail ( fig .
4 ) . only needs one inter - interlocking hole length of the bony window .
it needs to be placed on the proximal 2 interlocking holes , and not on the distal hole ( fig .
an impactor is inserted on the distal hole , and tapped proximally by the mallet ( fig .
6a ) . when the hole is moved to proximal part of the bony window ( fig .
6b ) , a new interlocking screw hole appears in the distal part of the window ( fig .
the impactor is then laid on the new distal interlocking hole and tapped again ( fig .
, the triceps brachii tendon can be carefully monitored , without being impacted by the nail in any way .
the nail is then exposed enough to be gripped firmly ( figs . 3 and 6e ) .
after the nail removal , the triceps brachii tendon is sutured and the bony window is covered , using the bone that was removed to make the window .
the distal incision is approximately the size of 2 inter - interlocking holes , and the proximal incision is about 1 cm , big enough to pass the nail ( fig .
it needs to be placed on the proximal 2 interlocking holes , and not on the distal hole ( fig .
in the bony window , an impactor is inserted on the distal hole , and tapped proximally by the mallet ( fig .
6a ) . when the hole is moved to proximal part of the bony window ( fig .
6b ) , a new interlocking screw hole appears in the distal part of the window ( fig .
6c ) . the impactor is then laid on the new distal interlocking hole and tapped again ( fig .
, the triceps brachii tendon can be carefully monitored , without being impacted by the nail in any way .
the nail is then exposed enough to be gripped firmly ( figs . 3 and 6e ) .
after the nail removal , the triceps brachii tendon is sutured and the bony window is covered , using the bone that was removed to make the window .
intramedullary nailing can be used to treat fractures with minimal skin incision . owing to its reliable biomechanical results
, it is widely used in cases of long bone fracture . however , its direct placement into the bone can sometimes cause difficulty in handling .
a hooked - shaped , modified guide pin was used when the nail 's middle portion had broken .
levy et al.2 ) reported a method of removing the distal piece of the broken nail , using another nail less than 1 mm .
georgiadis et al.3 ) reported on the management of failed proximal piece of the nail removal in the leg . despite reports of such related cases
, there were no case reports in the existing literature about failure of retrieval of an ulnar intramedullary nail .
when the extraction device is broken during removal of the ulna nail , only a bony window the size of 2 inter - interlocking holes at the most proximal part of the nail can be used to remove the nail with minimal damage of the triceps brachii tendon and soft tissue . in spite of the simplicity and usefulness of this method , care should be taken when making the bony window , because there is potential risk of a fracture around the olecranon , especially in osteoporotic old patients .
 methods about removal of intramedullary nail in complicated cases were reported in some literatures but there are no reports about nail removal in the ulna . 
 the authors would like to report such a case and the technique . 
 we removed bone of the inlet site and created another bony window using an osteotome to expose the interlocking screw holes . only a bony window the size of 2 inter - interlocking holes at the most proximal part of the nail can be used to remove the nail with minimal damage of the triceps brachii tendon and soft tissue . 