Chronic tibial intramedullary nail migration with skin protrusion in a resource-limited setting: a limb salvage case report from rural Kenya

Introduction and importance: Chronic intramedullary nail (IMN) migration with hardware protrusion following tibial fracture fixation is an exceptionally rare complication, with only four previously reported cases. Management is complicated in low-resource settings where delayed presentation and limited access to specialized care are common. Case presentation: A 44-year-old man in rural Kenya presented with approximately 15 cm of the IMN protruding through the medial ankle skin, 9 years following SIGN nail fixation of a distal tibial fracture. Hardware protrusion occurred after an ankle eversion injury 4 years post-fixation, with progressive migration over the subsequent 5 years. Financial hardship and geographic barriers prevented timely care. Radiographs demonstrated distal tibial malunion with rotational malalignment. He underwent IMN removal, irrigation and debridement, corrective osteotomies, and external fixation. Anterolateral thigh free-flap reconstruction failed due to arterial and venous thromboses. Salvage used a saphenous artery-based cross-leg fasciocutaneous flap with antibiotic-impregnated cement beads and staged division and inset. He absconded postoperatively but returned 8 months later with healed tibial union and an intact external fixator. At follow-up, he was ambulatory without assistance and had resumed work. Clinical discussion: Chronic tibial IMN protrusion is associated with infection and instability. Successful management requires a staged approach using debridement, deformity correction, external fixation, and soft-tissue reconstruction. Limb salvage can be achieved despite infection, soft-tissue loss, and interruptions in care. Conclusion: This case illustrates the consequences of prolonged hardware exposure and the feasibility of limb salvage through staged reconstruction in resource-limited settings. Structured postoperative surveillance following IMN fixation is critical, particularly in low- and middle-income countries. Graphical abstract available at: https://links.lww.com/IJSCR/A217.