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D'oh! Femoral reaming disaster

A simple femoral reaming goes off rails when an unsupervised trainee omits to first pass the ball-tipped guidewire.

Just a quick one while I finish the Ward Round...

A ST5 Trainee was asked to start the trauma list while consultant finished the ward round. The first case is an infected intramedullary nail, planned for a second debridement and vac change. It was discussed (briefly!) with the trainee who agrees it is with in their current skill set; the plan is to re-ream the canal and place antibiotic beads.

Simple, right?!

The Trainee reams the canal; the end of the reamer uncouples remaining in the femur!

"If you can imagine it, it can happen; even if you can't imagine it, it can happen!!"


The Consultant is contacted who advised using a pair of long urology forceps to retrieve it, which they are unable to do.

A long delay ensues. The Consultant scrubs, retrieves the reamer tip, asks for the ball tip wire back to ream again. Only then does the Trainee realise their error; they had not placed the ball tip guidewire before reaming!

Been there, done that...

This is an easy mistake to make if you are not overly familiar with the procedure and something which may not have even occured to the Trainee.... of supervising Consultant! The ball tip guide wire is not just a device to guide the reamer across a fracture but is also designed to prevent this complication occurring.

The bottom line

If you can imagine it, it can happen; even if you can't imagine it, it can happen!!

Be sure to check out our Error Log of similar bear traps which lie in wait for you when you least expect them...


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