Diagnosing segmental wedge fracture of the tibia before performing intramedullary nailing

Tibial shaft fractures with a wedge butterfly segment are often repaired with intramedullary fixation. At the time of presentation, the fragment may appear benign on radiographs as a portion of the cortical bone in an acceptable position. However, a segment that includes the entire circumference of the tibial cortex can be a problem during surgical stabilization. This ring effect will demand cannulation of the butterfly segment with the guide wire before rod insertion. Since computed tomography is not always necessary for minimally displaced fractures, this issue may not be discovered until surgery. Lack of cannulation may lead to painful nonunion. Preoperative recognition of this fracture pattern and intraoperative butterfly cannulation will improve the postoperative stability of this fracture.