Ball tip guide wire: The purpose of the ball tip is to allow you to pull the reamer head (which won’t slip over the ball) out by pulling out the guide wire (if your reamer shaft breaks). Do not be tempted to use non ball tip wires for reaming.
Reversing the reamer: Most flexible reamer systems use a spiral wound spring shaft, which only remains intact when twisted in a clockwise direction. If you accidentally reverse the reamer driver while reaming, it can unwind that spiral wound spring into an incredible snarl of tangled wire within the intramedullary canal, which can be impossible to remove. Do not reverse the reamer!!
Preventing guide wire back out: If the ball tip guide wire is tapped down into the cancellous bone of the distal metaphysis, it often wedges in firmly enough that it does not come out when the reamers are backed out after each pass. This can prevent loss of reduction.
When backing the reamer out: Don’t hold the guide wire with your gloved hand, as the wire can spin, wrapping up your glove and tearing it. This will contaminate the wire and reamer. If you do contaminate the wire cut off the contaminated part—they are not nearly as expensive to replace as the wasted OR time getting a new guide wire, and reamer system (if it was over the wire when you contaminated the wire you can’t get it off the wire without contaminating the reamer driver, reamer and reamer shaft).
Exchanging the guide wire: This is done so that the ball tip will not hang up in the end of the nail and make removal of the guide wire impossible. It may not be necessary when your nail has a large cannulation, but is probably always a good idea.
Incarcerated nails: The reason you must ream to a larger diameter than the nail you insert is because the flexible reamers do not follow the same smooth arc of curvature that the nail itself does. Thus, the irregular curvature of the reamed medullary canal must be larger than the nail inserted for the nail to pass through. Sometimes even though you have reamed larger, the nail can still become stuck (incarcerated). Signs of impending incarceration are failure of the nail to advance with each blow. Do not continue trying to drive the nail, for nails have become so severely incarcerated they could not be removed. Simply take it out and ream to a larger size, then reinsert it. If the nail does become incarcerated, it has been reported that pouring iced saline (available as a cardioplegic solution from the heart room) down the interior of the nail will cause thermal shrinkage of the nail and allow extraction. If this is not successful, the next step is to make a several inch incision over the shaft of the bone in the region where the nail tip is incarcerated and use an oscillating saw to make a longitudinal slot in the shaft of the bone. This will allow the bone to expand by relieving its hoop stress, thus loosening the bone around the nail and allowing nail extraction.
Basic principle: You cannot heal without stainless steel