Retrograde improvisations and their iatrogenic complications: a case report of an antegrade femoral nail used as a retrograde construct.

Intramedullary nailing is the standard of care for femoral shaft fractures. Antegrade nails are designed for proximal insertion, while retrograde nails are for distal insertion, deviation from this pathway can result in mechanical failure. We report a 47-year-old female who presented with left thigh pain, swelling, and restricted mobility. Clinical examination revealed thigh deformity and ecchymosis, with preserved distal neurovascular status. Radiographs demonstrated an intramedullary nail with hypertrophic malunion at the distal femur with a proximal periprosthetic fracture. Computerized tomography imaging confirmed cortical breaches by screws, and an oblique fracture near the proximal screw. Images were suggestive of the use of an antegrade nail through a retrograde construct. The malpositioned nail was removed and replaced using the appropriate proximal entry site. Postoperative radiographs confirmed stable fixation. The patient reported improved mobility with radiographic healing. This case highlights the consequences of incorrect implant orientation and the importance of surgical verification.