Flexible intramedullary nailing in children: nail to medullary canal diameters optimal ratio

Canal Fill of the Forearm Bones When Placing Intramedullary Nails in the Pediatric and Adolescent Populations

BACKGROUND

In the lower extremity, studies have suggested an optimal nail diameter to medullary canal diameter (ND/MCD) ratio to minimize postoperative complications. The goal of this study was to determine whether a correlation exists between the occurrence of complications, angulation, and range of motion and the ratio of the ND/MCD in the upper extremity.

METHODS

A total of 85 radius and ulna fractures treated with flexible intramedullary nails had ND/MCD ratios measured. Random-effects models were developed to determine the association between complications and ND/MCD ratio, angulation and ND/MCD ratio, and range of motion and ND/MCD ratio. The results were reported for unadjusted models and adjusted models.

RESULTS

Of the 85 forearm fractures treated with intramedullary nailing, there were 3 complications. The average follow-up was 6 months. The ND/MCD ratios were categorized as <0.50, 0.50 to 0.59, and ≥0.60. There was not a significant association between the different ratios and angulation, or risk of complication. There was an association between the ND/MCD ratio ≥0.60 and decreased pronation of -1.58° (-2.77° to -0.38°) and supination of -2.68° (-4.91° to -0.46°) (P < .05).

CONCLUSION

This study found that there was not an association between the nail to canal diameter ratio and postoperative angulation in forearm fractures treated with flexible intramedullary nails. When choosing a flexible nail for forearm fractures, there does not appear to be an optimal ratio; it is therefore reasonable to use the ND that passes more easily.

Recovery of Gait in Children and Adolescents After Pediatric Femoral Shaft Fracture Treated With Intramedullary Nail Fixation: A Longitudinal Prospective Study

BACKGROUND

Femoral shaft fractures in school-aged children are commonly treated with intramedullary nail fixation. Outcomes such as time to healing, alignment and non-union, leg length discrepancy, and refractures, and other complications are often reported based on radiographic findings. There are limited reports on physical function, including objective quantitative measures. The aim was to study the progress and recovery of gait after femoral shaft fracture in children and adolescents.

METHODS

Inclusion criteria were individuals 6 to 16 years of age with a femoral shaft fracture treated with intramedullary nails. Exclusion criteria were pathologic fractures and other physical impairments or injuries that influenced gait.At 6 and 12 weeks, assessments of mobilization and weight bearing were performed at clinical hospital follow-ups.At 3, 6, 9, and 12 months, physical examinations of passive range of motion, stair walking, and three-dimensional gait analysis, including temporospatial, movement (kinematics), and force (kinetics) data, were performed.

RESULTS

Seventeen participants, with a median of 9.2 (interquartile range 6.5 to 11.3) years of age were included. At 6 weeks, 14 of 16 (88%) used walking aids and at twelve weeks, 25% did. Sixty-nine percent could walk up and down stairs at 6 weeks and 100% at 12 weeks. At 3 months, 3 participants walked with a speed below 100 cm/second and had clear deviations in gait pattern compared with the control group. Three participants had no deviations in gait patterns at 3 months. Gait patterns had normalized in most participants at 6 months. Hip and knee extension moments were decreased up to 6 months compared with the control group. Hip extensor muscle work was increased on the fractured side compared with the control group.

CONCLUSIONS

Early recovery, between 6 and 12 weeks postoperatively, was noted in basic performance tests after femoral shaft fractures in children and adolescents. Three-dimensional gait analysis revealed normalization of gait patterns at 6 months. Information on the expected time and degree of recovery of physical function could guide the rehabilitation process.

LEVEL OF EVIDENCE

Level III.

Outcomes of Elastic Stable Intramedullary Nailing for Surgical Treatment of Pediatric Tibial Shaft Fractures

BACKGROUND

This retrospective study aimed to assess radiographic and clinical outcomes, characterize demographic, injury, and fracture characteristics, and elucidate the rate of postoperative complications and associated factors in a large cohort of children treated with elastic stable intramedullary nail for diaphyseal tibial fractures at two large pediatric referral centers.

METHODS

Medical records were reviewed for demographic clinical and radiographic parameters at injury, surgery, and all subsequent clinical visits until radiographic healing was observed and/or for a minimum of 6 months postoperatively.

RESULTS

A total of 146 patients (79.5% male) were included. The mean (SD) age was 11.8 (63.0) years. Radiographic union occurred by 3 months in 56.6% of patients. Nine patients had delayed union, and four had nonunion. By 3 months postoperatively, 97.2% of patients had progressed to full weight bearing and 92.5% had full range of motion of the knee and ankle. Subgroup analyses revealed that patients with open fractures were found to be more than eight times at increased risk of developing delayed union (.6 months, odds ratio = 8.71).

CONCLUSION

Elastic stable intramedullary nail remains a safe and effective treatment of open and closed pediatric diaphyseal tibial fractures. A small yet notable risk of residual angular deformity, delayed union, and nonunion remains, although rates may be better than previously reported.

Radial and ulnar medullary canal diameter in children: Anatomical limitations of elastic stable intramedullary nailing

INTRODUCTION

Surgery is inevitable for children who cannot achieve the ideal reduction in forearm fractures. The biggest limitation of the elastic stable intramedullary nail (ESIN) fixation method is the diameter of the medullary canal. This study aimed to measure the medullary canal diameters of the radius and ulna at different ages in children.

METHODS

The forearm radiographs of 540 children were retrospectively reviewed. All background characteristics, including weight, sex, maturity of the radius and ulna, and length of the radius and ulna, were measured and recorded. Children with radius and ulnar diameters shorter than 2 mm were analyzed by statistical regression analysis by SPSS software.

RESULTS

When we set 2 mm as the minimum medullary canal diameter, our results showed that patients aged 3-12 years had radius and ulnar diameters under this limit. The regression analysis of risk factors with the 2 mm diameter limitation had significant differences based on age (P = 0.006) and sex (P = 0.033). There was no significant difference between patients based on weight (P = 0.056), ulnar length (P = 0.946), radius length (P = 0.503), radius maturity (P = 0.655), or ulnar maturity (P = 0.774).

CONCLUSIONS

The average medullary canal diameter remained constant until 12 years of age. However, the average diameter length did not increase significantly after the age of 12 years. The incidence of medullary canal diameter shorter than 2 mm was correlated with age and sex. Our results suggest that surgeons should pay attention to the medullary diameter of the anteroposterior and lateral radiographs to determine the ESIN diameter.

Leg length discrepancy after skeletal maturity in patients treated with elastic intramedullary nails after femoral shaft fractures in childhood

PURPOSE

The purpose was to study radiographic and perceived leg length discrepancy after skeletal maturity in patients treated for femoral shaft fractures with elastic stable intramedullary nails in childhood.

METHODS

Thirty-five adults underwent standing radiographs and answered a questionnaire regarding perception of leg length discrepancy. Demographic data, fracture characteristics, angulation, stability of fixation, and callus formation, at time of fracture, were assessed.

RESULTS

Mean age at fracture was 10.2 (4.9-16.7) years, and mean follow-up time was 11.1 (3.8-16.8) years. In 8 of 35 participants, the fractured limb was 11-15 mm longer than the non-fractured, and in 16, 1-10 mm longer. In eight participants, the fractured limb was 1-10 mm shorter than the non-fractured, and in three participants, 12-23 mm shorter. The younger the child, the greater the lengthening (R_s = -0.49, p = 0.003). The greater the femoral angulation at time of fracture, the greater the shortening (R_s = 0.42, p = 0.013). There was no significant correlation between stability of fixation or callus formation 1 month postoperatively and radiographic leg length discrepancy after skeletal maturity. Fourteen (40%) had perception of leg length discrepancy at follow-up, of whom eight had a radiographic leg length discrepancy of 10-24 mm.

CONCLUSION

Treatment with elastic stable intramedullary nail of femoral shaft fracture in childhood may result in radiographic leg length discrepancy. Younger children were more prone to lengthening and should possibly be assessed before skeletal maturity. The degree of fracture stability or callus formation at the time of fracture did not significantly affect leg length discrepancy. Perception of leg length discrepancy was not necessarily associated with a radiographic leg length discrepancy (≥10 mm).

LEVEL OF EVIDENCE

level IV, case series.

Outcomes and complications following flexible intramedullary nailing for the treatment of tibial fractures in children: a meta-analysis

INTRODUCTION

Tibial shaft fractures are common occurrence in children and surgical treatment is sometimes required, particularly in unstable or open fractures, and in polytrauma. The aim of this study was to investigate the available evidence on the efficacy and safety of flexible intramedullary nailing (FIN) for both open and closed tibia fractures in children, exploring the main surgical outcomes and rate of complications.

MATERIALS AND METHODS

Pubmed/Medline, Scopus and Cochrane Central databases were searched following the PRISMA guideline. Studies reporting on the outcomes of FIN for paediatric tibia shaft fractures were included. Weighted means were evaluated for surgical outcomes. Meta-analysis of proportion and odd ratios were used to analyse total complication rates and differences between open and closed fractures.

RESULTS

Twenty-eight studies (835 patients) were included; the mean age was 11.0 ± 3.0 years. The mean follow-up was 22.5 ± 13.5 months; the mean time to full weight-bearing was 7.5 ± 3.7 weeks. The total complication rate was 28.1% (minor = 20.7%, major = 6.3%); this was greater in open fractures (13.6% vs 5.1%, p = 0.007). The rate of union was 97.5%, with a mean time to union of 11.9 ± 7.2 weeks. Malunion was found in 8.5% cases, delayed union in 3.8%, non-union in 1.4%, symptomatic hardware in 5.1%, leg-length discrepancy in 5.0%, superficial infections in 2.3%, deep infections in 1.0%, compartment syndromes in 1.4%, and refracture in 0.2%. Almost all patients returned to unrestricted physical activity.

CONCLUSIONS

FIN offers excellent outcomes for the treatment of paediatric tibia shaft fractures. Patients presenting with an open fracture have a higher but acceptable complication rate. Comparative studies are needed to clarify if other treatments have superior outcomes.

Elastic Stable Intramedullary Nailing and Temporary External Fixation for the Treatment of Unstable Femoral Shaft Fractures in Children Aged 5-11 Years Old: A Retrospective Study of 28 Cases

PURPOSE

Unstable femoral shaft fractures (UFSFs) in children aged 5-11 years remain challenging due to their intrinsic instability. The aim of this study was to evaluate the clinical and radiographic outcomes of UFSF in children aged 5 to 11 years managed by the combined use of ESIN and temporary EF.

METHODS

Children with UFSF (long oblique and comminuted) treated by ESIN and temporary EF were retrospectively reviewed. Sex, age at injury, side involved, type of fracture, presence or absence of associated lesions or neurovascular complications, type of treatment, time from trauma to surgery, duration of surgery, radiation exposure and length of postoperative immobilization were collected from the medical charts. Radiological and functional outcomes were evaluated according to Beaty's and Flynn's criteria, respectively.

RESULTS

A total of 28 consecutive patients with closed or open (Gustilo type I or II) UFSF were reviewed (18 boys and 10 girls). The mean age at injury was 8.7 ± 1.6 years (range, 5-11); the average weight was 38.1 ± 7.6 kg (range, 26-55). The mean hospital stay was 3.7 ± 1.4 days (range, 2-7), and the mean time to EF and ESIN removal was 6.5 ± 1.1 weeks (range, 4-8) and 9.4 ± 1.6 months (range, 6-12), respectively. Twenty-seven out of 28 patients had excellent radiographic outcomes according to Beaty's criteria, and 24/28 had excellent functional outcomes according to Flynn's criteria. Overall, 4 complications (14.3%) were recorded. No statistically significant correlation was found between complication rates and sex, age, weight or fracture characteristics (P < 0.05).

CONCLUSIONS

The combined use of ESIN and temporary EF provides good clinical and radiological outcomes in children with UFSF aged between 5 and 11 years, with a reduced complication rate.

Defining length stability in paediatric femoral shaft fractures treated with titanium elastic nails

INTRODUCTION

Optimal paediatric femoral shaft fracture patterns or lengths amenable to titanium elastic nail stabilization have not been well defined. The purpose of this study is to identify radiographic parameters predictive of treatment failure with flexible intramedullary nails based upon fracture morphology.

METHODS

A retrospective review was performed of all femoral shaft fractures treated with flexible intramedullary nails over a five-year period. All patients with at least six weeks of postoperative radiographic imaging were included. Fracture characteristics included location, pattern, length, obliquity, angulation, translation and shortening. Postoperative radiographs were reviewed to determine shortening and angulation.

RESULTS

There were 58 patients with 60 femoral shaft fractures stabilized with titanium nails, with 46 healing within acceptable parameters and 14 considered malunions. Six of the 14 malunions developed complications requiring early unplanned intervention. No patients in the treatment success group had a complication. Between the treatment success and failure groups, fracture pattern, location, length, obliquity, angulation, translation or shortening were not statistically different. Mean nail canal fill was significantly lower in the failure group (0.72 versus 0.81; p = 0.0146), with a receiver operating characteristic curve identifying canal fill 76% as the optimal threshold.

CONCLUSION

This is the first study to measure the length and obliquity of paediatric femoral shaft fractures and to determine their relationship to radiographic alignment after healing. None of the preoperative fracture characteristics were predictive of malalignment or shortening. We recommend the use of larger nail sizes in the treatment of paediatric femoral shaft fractures, especially if there is concern for residual instability.

LEVEL OF EVIDENCE

IV.

Displaced distal femur metaphyseal fractures: clinical and radiographic outcome in children aged 6-16 years treated by elastic stable intramedullary nailing

Fractures of the distal femur metaphysis (DFM) are rare. The main objective of this study was to retrospectively evaluate the clinical and radiographic outcomes of displaced DFM fractures in children treated by elastic stable intramedullary nailing (ESIN). We retrospectively reviewed 24 DFM fractures, including five pathological fractures secondary to non-ossifying fibroma (mean age, 10.9 years; range, 6-16) who underwent surgical treatment by ESIN. The patients were followed radiographically and clinically on a regular basis. Sixteen boys and eight girls were included in the study. Radiographically, all fractures healed, but five healed with complications. Most of the DFM fractures were transverse (n = 18, 75%), and all patients but two (91.7%) underwent closed reduction and stabilization of the fracture. All the patients were pain-free at their last follow-up. All regained full normal activities, although five patients developed a postoperative complication (20.8%). At the last follow-up visit, all fractures achieved union including the two cases of nonunion; moreover, none of the patients showed any signs of growth arrest or disturbances in radiological and clinical assessment. On the ESIN outcome measure scale, 12/24 patients (50%) had excellent results, 11/24 (45.8%) had good-satisfactory results and 1/24 (4.2%) had poor results. Fracture of the DFM can be challenging due to the relatively short length of the distal fragment, the proximity of the growth plate and the tendency of the distal fragment to displace. Following the surgical principles and understanding the anatomical constraints of the distal femur help to obtain satisfactory clinical and radiological results.

[Complication rate after femoral shaft fractures in childhood and adolescence depending on patient factors and treatment measures]

Hintergrund

Die Behandlung der Femurschaftfrakturen bei Kindern war in den letzten Jahren einem zunehmenden Wandel unterzogen. Die früher dominierenden Therapieverfahren wurden durch minimal-invasive Techniken (z. B. elastisch stabile intramedulläre Nagelung [ESIN]) weitgehend abgelöst. Ziel der vorliegenden Studie war der Vergleich der Komplikationsraten in Abhängigkeit sowohl von Patientenfaktoren als auch von verschiedenen Behandlungsverfahren.

Material und Methoden

Bei der vorliegenden Arbeit handelt es sich um eine retrospektive röntgenmorphometrische Datenauswertung. Es wurden die Patientenakten und Röntgenbilder von 101 Kindern, die an zwei Level-I-Traumazentren behandelt wurden, ausgewertet.

Ergebnisse

In 19 % der Fälle wurde eine konservative Therapie durchgeführt. Bei den operativen Verfahren dominierte die ESIN-Technik (n = 60). Revisionspflichtige Komplikationen fanden sich nach konservativer Therapie bei ca. 10 % der Kinder. Bei den operativ behandelten Kindern musste in über 6 % der Fälle eine Revisionsoperation durchgeführt werden. Die ESIN-Stabilisierung zeigte bei den operativen Verfahren mit ca. 3 % die niedrigste Revisionsrate. Wurden im Verhältnis zum Markraumdurchmesser zu dünne ESIN-Drähte verwendet, so zeigte sich eine um 30 % höhere Komplikationswahrscheinlichkeit. Bei Kindern unter 3 Jahren und Adoleszenten war die Komplikationswahrscheinlichkeit erhöht.

Diskussion

In der durchgeführten Studie zeigt sich ein moderates Komplikationsrisiko bei der Behandlung von Femurschaftfrakturen bei Kindern. Das Komplikationsrisiko nach Fixateur-externe-Anlage und konservativer Behandlung war in dieser Studie am höchsten. Die ESIN-Technik zeigt insgesamt das geringste Komplikationsrisiko. Die vorliegende Arbeit konnte die bekannten Limitationen der ESIN-Technik in Abhängigkeit von Alter und Gewicht bestätigen.

Risk Factors for Adverse Radiographic Outcomes After Elastic Stable Intramedullary Nailing of Unstable Diaphyseal Tibia Fractures in Children

OBJECTIVES

Elastic stable intramedullary nails (ESIN) are commonly utilized to treat unstable pediatric tibia fractures but have been associated with complications. The purpose of this study was to identify risk factors for adverse radiographic outcomes after ESIN of pediatric tibia fractures.

METHODS

A retrospective review of all patients who underwent diaphyseal tibia fracture stabilization with ESIN between 2010 and 2018 at 3 pediatric level 1 trauma centers was performed. Inclusion criteria were open growth plates, no intra-articular or physeal fracture involvement, and radiographic follow-up until union. Patient demographics, injury mechanism, fracture characteristics, and implant fill relative to the medullary canal were recorded. Radiographic outcome measures included achievement of and time to union, residual angular deformity, and additional procedures.

RESULTS

One hundred seventy-two patients met inclusion criteria and were followed for a mean of 1.2 years. Nonunions were observed in 3% of the patient cohort. Another 10% required >6 months to heal, but did not require further surgical intervention. Angular deformities were common with 57% having a residual deformity ≥5 degrees and 14% having a residual deformity ≥10 degrees. Of the patients with a residual deformity between 5 and 10 degrees, 3% were symptomatic, where as 26% of the patients with a residual deformity ≥10 degrees were symptomatic. Greater angular deformities were associated with open fractures, compartment syndrome, and longer time to union. Patient age, weight, tibial comminution, and canal fill were not associated with nonunions or malunions.

CONCLUSIONS

ESIN of pediatric tibia fractures results in reliable healing for a majority of patients, but poses risks for residual angular deformities and delayed healing. Open fractures and compartment syndrome were associated with adverse radiographic outcomes.

Poor prognostic factors of femoral shaft fractures in children treated by elastic intramedullary nailing

Introduction: Femoral shaft fractures in pediatric patients are treated by elastic intramedullary nailing using titanium or stainless-steel nails. The elastic stable intramedullary nailing behaves as an internal splint, promoting early mobilization. This type of treatment involves a minimally invasive approach, no damage to the growth plates, and no impairment of femoral head blood supply. Purpose: The aim of our study was to identify the negative predicting factors that might lead to an increased complication rate after elastic stable intramedullary nailing of femoral shaft fractures in children. Methods: We conducted a retrospective study on 137 patients with femoral shaft fractures treated by elastic stable intramedullary nailing. Patients’ age ranged between 4 and 17 years. We used data from the medical records of the patients to evaluate postoperative complications. Plain radiographs were analyzed to determine the fracture type, fracture location, and postoperative complications such as delayed union, angular deformities, and limb length discrepancies. Multivariate analysis was conducted to identify predictors for poor outcomes. Results: Complications occurred in 29 patients (21%) and consisted of delayed union, axial deformities, or lower limb length discrepancies. In the group of patients that suffered from complications, mechanism of injury, age, and weight were significant. They were older by an average of 5 years; half of them weighed more than 50 kg and over a half were involved in a road traffic accident. Conclusions: Elastic nailing is a successful tool to treat femoral shaft fractures. Three factors were demonstrated to influence the outcome. The mechanism of injury, age > 11 years, and weight > 50 kg are the most important and are predictors for development of complications such as delayed union or deformity.

Titanium Elastic Nails Are a Safe and Effective Treatment for Length Unstable Pediatric Femur Fractures

BACKGROUND

Controversy exists regarding the treatment of length unstable pediatric femoral shaft fractures. The purpose of this study was to investigate the outcomes of skeletally immature children with length unstable femur fractures treated with titanium elastic nails (TENs).

METHODS

A retrospective review was conducted on all patients with femoral shaft fractures at a tertiary care pediatric hospital from April 2006 to January 2018. Patients with femoral shaft fractures treated with TEN and minimum 6 months follow-up were included. Exclusion criteria were age 11 years or above, weight >50 kg, pathologic fracture, and neuromuscular disorders. Femur fractures were categorized into 2 groups: length unstable (spiral, comminuted, or long oblique fractures) versus length stable (transverse and short oblique). Complications and reoperations were compared between the groups.

RESULTS

A total of 57 patients with 58 femoral shaft fractures were included. The mean age was 5±2 (1 to 11) years and mean follow-up was 20.4±18.1 (6.0 to 81.2) months. The mean weight was 22.9±7.7 (11.0 to 40.5) kg. There was no difference in age (P=0.32), weight (P=0.28) or follow-up length (P=0.57) between patients with length unstable fractures and those with length stable fractures. A total of 32/58 (55%) fractures were length unstable and 26/58 (45%) were length stable. Mean time to union was 4.6 months, and there was no significant difference in mean time to union between the 2 groups (P=0.71). Thirty-one complications occurred in 27 patients. There was no difference between groups in the incidence of major complications requiring revision surgery (P=0.68) and minor complications that did not require revision surgery (P>0.99).

CONCLUSIONS

In children with femoral shaft fractures treated with TEN, there was no difference in the incidence of complications or reoperations between those with length unstable fractures and those with length stable fractures. TEN are a safe and effective choice for operative fixation of length unstable femoral shaft fractures in children.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

The optimal choice for length unstable femoral shaft fracture in school-aged children: A comparative study of elastic stable intramedullary nail and submuscular plate

The utilization of elastic stable intramedullary nail (ESIN) in length unstable femoral shaft fractures in children remains controversial, and the results in different studies vary a lot. This study aims to investigate the clinical outcomes of ESINs versus submuscular plate (SMP) in length unstable femoral shaft fractures.Patients aged 5 to 11 years old with length unstable femoral shaft fractures treated at our institute from January 2008 to January 2018 were included and categorized into ESIN and SMP group. The preoperative data and operative variables were collected from the hospital database, and postoperative data including complications were collected at follow-up visits.In all, 77 patients (8.1 ± 1.9 years old, male 45, female 32) in ESIN group and 45 patients (8.0 ± 2.2 years old, male 26, female 19) in SMP group were included in this study. Comparing operative variables, there was significantly less operative time, reduced estimated blood loss (EBL) and shortened hospital stay for ESINs as compared with SMP (P < .001). However, the fluoroscopy frequency was not significantly different between these 2 fixation methods (P = .42). As for elective removal surgery, there was significantly reduced operative time, EBL and shortened hospital stay for ESINs as compared with SMP (P < .001).Both ESIN and SMP are safe and effective choices for length unstable femoral shaft fractures in children aged 5 to 11 years. In ESIN, extra care is required to provide additional immobilization using spica cast or brace. Compared with SMP, ESIN is able to deliver comparable clinical outcomes with less EBL, operative time and shorter hospital stay.

The Association of Metal Frame Construct of ESIN and radiographic bone healing of pediatric forearm fractures

INTRODUCTION

The gold-standard surgical procedure of both-bone forearm shaft fracture repair is elastic stable intramedullary nailing (ESIN). Disadvantages effects of ESIN have suggested to be a consequence of inappropriate surgical techniques, while recommendations are not always followed. The purpose of the study was to analyze the effect of inadequate metal frame construct on impaired fracture healing, refracture and changing alignment.

MATERIALS AND METHODS

It is a population-based study including all consecutive patients, aged less than 16 years, who had been treated for forearm shaft fracture by ESIN during the ten-year period 2009-2018. Altogether 71 patients were included. Non-union, delayed union, and re-fracture during the following 12 months were taken as the main outcome, while inferior metal frame construct of ESIN and the surgical technique characteristics were taken the explanatory factors. Radiographic loss of reduction was a secondary outcome and a change >5° in alignment at any postoperative follow-up exam was recognized.

RESULTS

Two out of 71 fractures (3%) failed to unite, and ossifying operation was needed. Five cases (7%) showed delayed bone healing, but they ossified in five months without any intervention. These seven patients (10%) had been treated more often with larger nails (> 0.7x MCD) (p = 0.027) and by open reduction (p = 0.02), compared with thinner nails and closed reduction, respectively. Two (3%) patients had a second fracture; however, they happened 2 years after the initial injury. Other surgery or fracture related factors didn't associate with impaired ossifying. Regarding the secondary outcome, altogether 24 (35%) of the analyzed 67 patients showed >5° change in alignment during the postoperative follow-up but only one patient had clinically significant instability that required re-reduction. The alignment changed more usually in distal-third fractures, compared with middle or proximal third fractures (p = 0.019).

CONCLUSIONS

ESIN resulted in good radiographic bone healing in the vast majority (90%) of the patients and completely perfect metal frame construct was not required.

Limb lengthening and deformity correction in children with abnormal bone

Flexible intramedullary nailing (FIN) provides multiple advantages in limb lengthening and progressive deformity correction in combination with external fixation. The article presents brief literature review and authors' experience in limb lengthening of abnormal bone (Ollier's disease, fibrous dysplasia, osteogenesis imperfecta). Titanium and, especially, hydroxyapatite-coated bent elastic nails in combination with external fixator are appropriate in limb lengthening of abnormal bone in children. FIN left in situ after lengthening procedure and external frame removal should be applied for long-term reinforcement of lengthened bone in patients with abnormal bone (metabolic bone disorders, skeletal dysplasias with compromised bone tissue development). The FIN respects bone biology, which is mandatory for good bone consolidation. Osteoactive properties of intramedullary elastic implants are favorable for bone formation and as well as for stable position of nails without risks of migration in long-term follow-up.

Use of external fixation for juxta-articular fractures in children

In this article, the use of external fixation in the management of juxta-articular fractures in paediatric patients is discussed. Basic principles of Ilizarov technique are described for distal radial, distal femoral, distal humeral and distal tibial fractures. Common indications for external fixation in pediatric fractures are comminuted, complicated, and/or open fractures, particularly at the distal humerus, distal radius, distal femur and distal tibia. There are several benefits of external frame fixation in these type of injuries in children. This method avoids additional injury to the growth plate as K-wires are not placed through it. It enables careful reduction without interfragmentary compression and correct anatomic alignment. There is no soft tissue dissection and periosteal blood supply is preserved. External fixation ensures primary fracture stability even in presence of comminution and high adjustment capability. Immediate joint motion and early weight-bearing are further advantages. Joint bridging is an option in severe bone loss or soft tissue injuries.

Retrograde Stainless Steel Flexible Nails Have Superior Resistance to Bending in Distal Third Femoral Shaft Fractures

BACKGROUND

It has been shown that retrograde titanium flexible intramedullary nails (Ti FIN) provide superior resistance to bending compared to antegrade Ti FIN in distal femur fractures. The purpose of this study was to compare resistance to torsional and bending forces of stainless steel (SS) FIN, with or without a locking screw, and Ti FIN in distal third femoral shaft fractures. We hypothesize that locked retrograde SS FIN will demonstrate greater resistance to both bending and torsional forces.

METHODS

Thirty adolescent synthetic femur models were used to simulate transverse distal femoral fractures at either 60 mm or 90 mm proximal to the distal femoral physis. The femurs were instrumented with antegrade Ti FIN, antegrade SS FIN, retrograde Ti FIN, retrograde SS FIN, or retrograde locked SS FIN. Three models for each construct at both osteotomy levels were tested. Models were analyzed to determine maximum resistance to bending and torsion.

RESULTS

In fractures 60 mm from the physis, retrograde SS FIN demonstrated statistically superior resistance to bending when compared with both antegrade and retrograde Ti FIN (P=0.001 and 0.008, respectively) and antegrade SS FIN (P=0.0001). Locked SS constructs showed a trend towards greater resistance to bending forces when compared with unlocked constructs (P>0.05). No significant difference was seen in resistance to bending when fractures were 90 mm proximal to the distal femoral physis between the five groups. No significant differences were observed in resistance to torsion in either the proximal or distal fracture models, regardless of construct type.

CONCLUSIONS

Retrograde SS FIN confer significantly greater resistance to bending forces for fractures 60 mm proximal to the distal femoral physis compared with Ti FIN or antegrade entry SS FIN. In fractures 90 mm from the physis, no differences were noted in our model. Our results support the use of retrograde SS nails in the pediatric patient with distal femoral shaft fractures.

LEVEL OF EVIDENCE

Level II-comparative biomechanical study.

Elastic stabile intramedullary nailing (ESIN) of diaphyseal femur fractures in children and adolescents: A strobe-compliant study

Elastic stabile intramedullary nailing (ESIN) is a well-established method to stabilize diaphyseal fracture of the femur (DFF) in children. We aimed to evaluate the minimal medullary canal diameter (MMCD) of the fractured femur relative to the diameter of the nails. We also analyzed the real anteversion angle (AVA) of the affected femur in comparison to the healthy femur.We retrospectively reviewed the medical records and plain X-ray images of children aged 2-15 years treated with ESIN for unstable femoral shaft fractures between 2004 and 2012. We measured MMCD on preoperative plain X-ray images. Nail diameter (ND) and any postoperative complications were extracted from the medical records. At follow-up conducted at a median of 40 months (range: 4-103 months) after the operation, we obtained Dunn X-ray images of both hips. Particular emphasis was placed on postoperative torsional differences in relation to age, weight, and maturity of the growth plate.We analyzed the relationship between postoperative rotational malalignment and the ratio of ND to MMCD.Median age of the 22 children at the time of injury was 7.5 years (range: 2-15 years). Median body weight was 25 kg (range: 13-57 kg). Median MMCD amounted to 8.6 mm (range: 5.5-11.0 mm). Median ND/MMCD was 36.9% (range: 27.3%-47.4%). Radiological analyses revealed a median of 27.0° (range: -22.0° to +49.0°) of real AVA in the affected leg and 32.5° (range: 18.0°-48.0°) in the healthy leg.Three children (13.6%) experienced a grade III complication (Clavien-Dindo classification of surgical complications; CDCSC). Two of these children suffered retrotorsion of the femoral neck, while the third child experienced diminished anteversion.Overall, 3 of 22 children (13.6%) suffered a CDCSC-grade III complication (i.e., retrotorsion of the femoral neck in two children and diminished anteversion of the femoral neck in one child). We recommend obtaining Dunn images at the end of the operation to confirm correct rotational alignment after stabilization with ESIN. Further prospective studies are required to confirm our findings.

Pediatric tibia and femur fractures in patients weighing more than 50 kg (110 lb): mini-review on current treatment options and outcome

The main objective of this paper is to review the current literature on treatment of tibial and femur fractures in children and adolescents guided by body weight in patients weighing 50 kg (110 lb) or more. A secondary aim of this mini-review was to determine, as per literature review, whether weight  > 50 kg (110 lb) is an identifiable factor associated with increased complication rate. A search of the PubMed/MEDLINE, EMBASE and Cochrane Database of Systematic Reviews databases from 1954 to September 2017 was performed to identify papers related to pediatric tibia and femur fractures in children weighing more than 50 kg (110 lb). Abstracts were screened, and relevant full-text articles were retrieved for further review. Reference sections of identified papers were also screened to identify further literature. All levels of evidence were included. Overall, seven full-text articles dealing with pediatric tibia or femur fractures in patients weighing more than 50 kg (110 lb), and one article reporting on both femur and tibia fractures in this patients' population, have been identified (n = 8 full-text article included). The articles reviewed a total of 679 children. In particular, 48/438 femur shaft fractures (mean weight: 51.7 kg or 113.9 lb) and 91/241 tibia fractures (mean weight: 53.3 kg or 117.5 lb) met the inclusion criteria. The overall rate of complications was 27.9%. In particular, the rate of complication was 51.7 and 29.6% in children with femur and tibia fracture weighing more than 50 kg (110 lb), respectively (p < 0.05). Elastic stable intramedullary nailing (ESIN) has become the treatment of choice for displaced tibia and femur shaft fractures in children between six and 12-15 years of age. Unstable fracture pattern, higher age and higher weight have been reported as potential risk factors associated with poor outcomes in children and adolescents treated with ESIN for displaced long bone fractures of the lower extremity, in particular femur shaft fractures. Despite these findings, data reporting exclusively on ESIN-treated long bone fractures in children weighing 50 kg (110 lb) or more remain scant.

Dimensions of the paediatric femur: anatomical limitations of flexible intramedullary nailing

PURPOSE

Although spica casting remains the benchmark for treating diaphyseal femur fractures in preschool children, some authors advocate using flexible intramedullary nails in certain situations. The aim of the current study was to evaluate the anatomic feasibility of flexible nailing in young children.

METHODS

Consecutive patients between the ages of zero and ten years with normal femurs who received femur radiographs at a tertiary paediatric hospital over a two-year period were included. Anteroposterior femur radiographs were evaluated for length and isthmus width measurements. Each femur was templated for flexible nail size. The proportions of each age group capable of accommodating two flexible nails up to 4.0 mm in size were determined and compared.

RESULTS

A total of 381 full-length femur radiographs were reviewed. There was a strong, direct linear relationship between age and femoral length (R² = 0.896) and a moderate correlation between age and femoral isthmus width (R² = 0.417). Although the percentage of femurs able to accommodate flexible nails continued to increase with age, this increase did not represent a significant difference when comparing preschool-aged children with older age groups.

CONCLUSIONS

Age and femoral length demonstrated a strong, positive correlation while age and isthmus width had weaker correlation. The ability of femurs to accommodate flexible nails increased with age with most children age two years and older able to accommodate two flexible nails of at least 2.5 mm in size.

LEVEL OF EVIDENCE

III.

Nail Fit: Does Nail Diameter to Canal Ratio Predict the Need for Exchange Nailing in the Setting of Aseptic, Hypertrophic Femoral Nonunions?

OBJECTIVES

To evaluate patient-independent risk factors for aseptic femoral hypertrophic nonunion requiring exchange nailing, with particular reference to the fit of the nail at the isthmus within the canal.

DESIGN

Retrospective case control study.

SETTING

Level 1 trauma center.

MAIN OUTCOME MEASUREMENTS

Between 2008 and 2012, 211 patients without any patient-dependent risk factors for nonunion were treated with a locked reamed intramedullary nail for a femoral shaft fracture. Twenty-three cases went on to hypertrophic nonunion requiring exchange nailing (treatment group) and 188 cases went on to union (control group). Patient-independent risk factors for exchange nailing were documented.

RESULTS

Patient-independent risk factors for exchange nailing were poor fracture reduction [Odds ratio (OR): 11.5, 95% confidence interval (CI), 4.0-33.4, P < 0.001], open fracture (OR: 7.6, 95% CI, 3.0-19.6, P = 0.004), Winquist classification of 4 (OR: 4.4, 95% CI, 1.9-6.7, P = 0.016), and poor nail fit (OR: 10.3, 95% CI, 5.1-28.4, P < 0.001). Multivariate analysis revealed nail fit as an independent predictor of femoral nonunion requiring exchange nailing (OR: 11.4, 95% CI, 6.9-15.2, P < 0.001). Moreover, we found a direct relationship between increasingly poor nail fit and increased risk of exchange nailing, with the criterion occurring at a nail fit ratio <70%.

CONCLUSION

When proceeding to femoral fracture reamed intramedullary nailing, we recommend a minimum nail fit of 70% at the isthmus and ideally 90% or more, to avoid surgical reintervention.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pediatric Orthopedic Trauma: An Evidence-Based Approach

The management of pediatric fractures has evolved over the past several decades, and many injuries that were previously being managed nonoperatively are now being treated surgically. The American Academy of Orthopaedic Surgeons has developed clinical guidelines to help guide decision making and streamline patient care for certain injuries, but many topics remain controversial. This article analyzes the evidence regarding management of 5 of the most common and controversial injuries in pediatric orthopedics today.

The effect of canal fill on paediatric femur fractures treated with titanium elastic nails

PURPOSE

Traditional teaching for fixation of paediatric femur fractures recommends 80% nail diameter/medullary canal diameter ratio (ND/MCD) for successful maintenance of reduction. Prior studies have investigated this with stainless steel Enders nails. Our aim was to assess the impact of ND/MCD on maintenance of reduction and malunion rates in paediatric femur fractures treated with flexible intramedullary nails (FINs).

METHODS

Retrospective data was collected on all paediatric patients treated with FINs for diaphyseal femur fractures at a single tertiary care institution over a ten-year period. Patients with co-morbidities affecting bone quality were excluded. Patients were subdivided into groups based on ND/MCD.

RESULTS

A total of 66 patients met inclusion criteria. Mean ND/MCD was 76.3% (32.9% to 98.8%, SD 14.3). In all, 50% (n = 33/66) of patients had > 80% ND/MCD, and only 13.6% (n = 9/66) of patients had less than 60% ND/MCD. When controlling for fracture stability, ND/MCD had no correlation with mean shortening (p = 0.07) There was no correlation between ND/MCD and angulation in the sagittal (p = 0.96) or coronal plane (p = 0.20). Three patients fit malunion criteria. ND/MCD for these patients were 40%, 67% and 79%.

CONCLUSION

There was no correlation between ND/MCD and shortening or malangulation. The majority of patients in this series with less than 80% fill with FIN healed within acceptable parameters.

LEVEL OF EVIDENCE

III.

Redefining Optimal Nail to Medullary Canal Diameter Ratio in Stainless Steel Flexible Intramedullary Nailing of Pediatric Femur Fractures

PURPOSE

The ideal canal fill for flexible intramedullary fixation of pediatric femoral shaft fractures is considered to be 80% based upon relatively few clinical studies. The purpose of this study is to assess the relationship between the summed nail to intramedullary canal diameter (ND/MCD) ratio and alignment at radiographic union following flexible intramedullary nailing (FIMN) of pediatric femoral shaft fractures.

METHODS

An Internal Review Board approved, retrospective review of a consecutive series of patients who sustained a femoral shaft fracture treated by retrograde, stainless steel FIMN was performed at a single level 1 pediatric trauma center from 2005 to 2012. Preoperative radiographs were analyzed to determine fracture pattern, location, and isthmic canal diameter. ND/MCD ratio was calculated using the sum of the known nail diameters and the measured isthmic diameter. Radiographs at bony union were reviewed to measure shortening, coronal angulation, and sagittal angulation. ND/MCD ratio was analyzed to determine correlative factors with final radiographic outcomes.

RESULTS

In total, 261 children underwent retrograde FIMN at an average age of 8.2 years (range, 2.2 to 17.0 y). ND/MCD ratio of ≥80% was seen in 108 (41.4%) patients. When compared with those with <80% ND/MCD ratio, there were no significant differences in age (8.8 vs. 8.0 y), sex (76.9% vs. 71.0% males), or body mass index (18.5 vs. 17.2 kg/m). There were significantly more length unstable fractures in the <80% ND/MCD ratio group (49.4% vs. 29.7%; P<0.01). Radiographic outcome was no different with respect to coronal angulation (2.7 vs. 3.0 degrees), sagittal angulation (3.0 vs. 3.2 degrees), or shortening (2.5 vs. 4.1 mm). ND/MCD ratio of ≥70% was seen in 176 (67.4%) patients and, when compared with the <70% ND/MCD ratio group, there were no differences in shortening (3.3 vs. 3.9 mm), coronal angulation (2.8 vs. 3.0 degrees), or sagittal angulation (3.0 vs. 3.4 degrees). Finally, 6.9% of the population (18 patients) had ND/MCD ratios <60% and did not demonstrate a significant increase in shortening, coronal, or sagittal angulation compared with groups with higher ND/MCD ratios. No group had an increased rate of infection, implant removal, nonunion, or need for reoperation.

CONCLUSIONS

In a large series of consecutive patients treated with retrograde stainless steel FIMN there does not appear to be any correlation between the ND/MCD ratio and radiographic outcome. Stainless steel flexible IM nails seem to maintain fracture alignment without an increase in complications at lower ND/MCD ratios than previously reported as "optimal."

LEVEL OF EVIDENCE

Level III.

Flexible intramedullary nailing for treatment of proximal humeral and humeral shaft fractures in children: A retrospective series of 118 cases

BACKGROUND

The aim of this study was to analyze outcomes of treatment and complications in children treated with flexible intramedullary nailing (FIN) due to humeral fracture.

HYPOTHESIS

The FIN for treatment of humeral fractures in children would allow an early functional and cast-free follow-up with a quick pain reduction and low complication rate.

PATIENTS AND METHODS

From May 2002 until May 2016 case records of all children who underwent fixation with titanium intramedullary nails because of humeral fracture were retrospectively reviewed. The study included 118 patients treated with FIN for proximal humeral or humeral shaft fracture. The average age at the time of trauma was 12 years. Mean follow-up was 77 months. Left hand was affected in 51% of patients. The most common mechanism of injury was fall (n=58), followed by sports injuries, road traffic accidents, pathological fractures, motorbike accidents and bicycle riding.

RESULTS

There were no residual valgus/varum deformities. All patients achieved complete radiographic healing at a mean of 7.5 weeks. Nine complications were recorded: 1 humeral shaft fracture in patient with osteogenesis imperfecta, 4 entry site skin irritations, 2 skin infections and 2 radial nerve injuries. There were no cases of delayed union, nonunion or mal-union. After removal of the nails, all patients regained full function and all complications resolved.

DISCUSSION

The FIN for humeral fractures is a minimally invasive, simple and well reproducible technique with very low complication rate.

CONCLUSION

The FIN for treatment of humeral fractures shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction.

LEVEL OF EVIDENCE

Level IV - retrospective study.

Low complication rate of elastic stable intramedullary nailing (ESIN) of pediatric forearm fractures: A retrospective study of 202 cases

Elastic stable intramedullary nailing (ESIN) has been established as state of the art treatment for forearm fractures in children, if operative stabilization is required. Their use has been expanded to single bone shaft fractures, and also more complex injuries such as Monteggia fractures or Monteggia-like lesions. A wide range of complications has been reported in the literature, up to 70% in certain investigations. The purpose of this study was to assess the complication rate after ESIN treatment of forearm fractures in children and adolescents in a representative cohort of patients from a level 1 trauma center in Germany.Between 2000 and 2015, we retrospectively analyzed all patients, up to the age of 16 years, with forearm fractures, who were operatively treated using ESIN in our department of general and trauma surgery. The main outcome measurements were the rates of postoperative complications after ESIN such as re-fracture, malunion, nonunion, tendon lesion, wound infection, and limited range of motion.In all, 201 consecutive patients with 202 forearm fractures were included in this study. Age averaged 9.7 years (range 3-16 years). Fifteen (7.4%) fractures were open. Fractures were 82.2% diaphyseal both-bone forearm fractures. Follow-up averaged 10.2 months (range 0.7-176.3 months). Complications were 10 re-fractures, 2 malunions, 3 extensor pollicis longus tendon ruptures, 1 superficial wound infection, and 2 limited range of motions. Fourteen (6.9%) children required a secondary operative intervention for their complication. Time to implant removal averaged 3.8 months (range 0.4-16.3 months).Elastic stable intramedullary nailing is a minimally invasive and reliable technique with a low complication rate. Both-bone forearm fractures and single bone fractures, and also Monteggia and Monteggia-equivalent fractures can be successfully treated with this method. As a major complication, re-fractures are frequently seen, even with ESIN in situ.

Current approaches to flexible intramedullary nailing for bone lengthening in children

Limb-length discrepancies and extremity deformities are among the most common non-traumatic orthopaedic conditions for which children are hospitalised. There is a need to develop new treatment options for lower-limb length discrepancy in order to ameliorate treatment outcomes, avoid or reduce rates of complication and provide early rehabilitation. The authors report on the basic principles, experimental and clinical data, advantages, problems and complications of a combined technique associating the Ilizarov method and flexible intramedullary nailing (FIN) in limb lengthening and deformity correction in children. They describe features of the use of hydroxyapatite-coated intramedullary nails in patients with certain metabolic bone disorders and in cases where bone consolidation has been compromised. The advantages of bone lengthening using a combined technique (circular fixator plus FIN) are a lower healing index, quicker distraction-consolidation, a reduced rate of septic and bone complications, the ability to correct deformities gradually and the increased stability of bone fragments during the external fixation period and after frame removal.

Fracture union in percutaneous Kirschner wire fixation in paediatric tibial shaft fractures

PURPOSE

To evaluate the efficacy of intramedullary Kirschner wires for the treatment of unstable tibial shaft fractures in children.

METHODS

This prospective study was conducted at the Department of Orthopaedic Surgery in Maharishi Markandeshwar Medical College from June 2005 to June 2010. Sixty-six children having closed fracture of the tibial shaft with a mean age of 7.7 years (range, 2-14 years) were recruited from emergency and outpatient department. They were treated with percutaneous intramedullary Kirschner wires. The clinical results of our study were rated on the basis of the criteria of union, nonunion, delayed union or malunion. All children were followed for one year.

RESULTS

Children achieved union in a mean time of 8 weeks (range, 6-10 weeks). Postoperatively, three children (4.55%) had delayed union, one (1.52%) valgus deformity of lower leg, three (4.55%) post- operative knee pain and twelve (18.18%) skin irritation at pin site.Wires were removed after 8-22 weeks without any complications. No patient was lost to follow-up. The results were excellent in 95.45% and good in 4.55% children.

CONCLUSION

This technique is cost-effective, simple, quick to perform, safe and reliable and avoids pro- longed hospitalization with good results.

Complications of elastic stable intramedullary nailing of femoral shaft fractures in children weighing fifty kilograms (one hundred and ten pounds) and more

AIM

The purpose of this study was to assess treatment outcomes in children weighing 50 kg (110 pounds) or more with displaced femur shaft fractures treated by elastic stable intramedullary nailing (ESIN) and to identify potential correlations between nail size/medullary canal diameter ratio and outcome.

METHODS

Twenty out of 117 consecutive children surgically treated by ESIN for displaced fractures of the femoral shaft with no associated neurovascular injury weighed 50 kg (110 pounds) or more. All patients underwent regular clinical and radiographic follow-up for at least one year after their index surgery.

RESULTS

The average patient age at the time of injury was 13.1 years (25th and 75th interquartile range [IQR] = 11.7-14.5). The mean follow-up was 27.4 months (IQR = 18.4-36.8). Overall, nine (45 %) adverse events were observed. The rate of complications was higher among children weighting 55 kg and over (67 %) than in children weighing less than 55 kg (35 %) and among children aged 13 years old or older (72 %) than among children younger than 13 years old (11 %).

DISCUSSION

Femoral shaft fractures in children and adolescents weighing 50 kg (110 pounds) and over and older than ten years of age have an increased rate of complications.

CONCLUSION

Heavier patients have a greater chance of complications. In particular, patients younger than 13 years old and weighing less than 55 kg can be safely managed with ESIN, but older and heavier patients should preferably be treated with rigid fixation systems due to a greater complication rate. However, further studies are needed to consolidate the conclusions.

Slow Recovery of Weight Bearing After Stabilization of Long-Bone Fractures Using Elastic Stable Intramedullary Nails in Children

Stabilization of diaphyseal long-bone fractures using elastic stable intramedullary nails (ESIN) in children promises early mobilization and rapid resumption of full weight bearing. We evaluated the duration of postoperative functional rehabilitation after ESIN, measured by the time from stabilization until first partial weight bearing, full weight bearing, and resumption of school sports. Fifty children with unstable, displaced fractures of the femur or lower leg treated with ESIN between 2002 and 2012 were included in this retrospective analysis. We classified fractures according to the pediatric comprehensive classification of fractures (PCCF). Thirty-five children sustained a femur fracture, and 15 children had a fracture of the lower leg or tibia. The surgeons in charge applied an additional plaster cast in 7 of 15 children who suffered a lower leg fracture. The postoperative time interval until full weight bearing in the group of children who had suffered transverse or short oblique femur fractures was significantly shorter (median: 4.4 weeks; range: 0.1-9.1 weeks) than that in the group who had sustained more complex fracture patterns (median: 6.8 weeks; range: 2.9-13.9 weeks; P = 0.04). Similarly, transverse and short oblique lower leg and tibia fractures required less time until full weight bearing (median: 4.1 weeks; range 2.7-6.0 weeks) than complex lower leg fractures (median: 6.1 weeks; range: 1.3-12.9 weeks; P = 0.04). ESIN proved fairly effective in restoring full weight bearing in transverse or short oblique fractures of the lower extremities but was less effective in complex fractures.

[Femoral shaft fractures in children under 3 years old. Current treatment standard]

INTRODUCTION

Femoral shaft fractures in children are a common injury. Operative treatment is recommended for children above 3 years of age. The question of this investigation was the current clinical standard for the treatment of femoral shaft fractures in children under 3 years old.

MATERIAL AND METHODS

An e-mail questionnaire was sent to all clinics and hospital departments of the members of the German Society for Trauma Surgery and the German Society of Pediatric Surgery.

RESULTS

Out of 775 clinics and departments, 121 participated in the survey (16 %). From 2011 to 2012 overall 756 femoral shaft fractures of children 3 years and younger were treated of which 375 (50 %) were stabilized with elastic stable intramedullary nailing (ESIN), 183 (24 %) with an overhead extension, 178 (23 %) with a plaster cast and 9 (1 %) with external fixation. Finally, operative treatment was used in 51 % compared to 49 % with conservative treatment.

DISCUSSION

Obviously, operative treatment of femoral shaft fractures in children younger than 3 years is routinely used despite the fact that there is no evidential basis for this approach. There are good arguments for and against operative and conservative forms of treatment. Indications for operative treatment include multiple trauma, open fractures, body weight over 20 kg, child already free walking and lack of stable fixation with conservative treatment. To achieve more evidence for the existing recommendation of the American Academy of Orthopaedic Surgeons (AAOS) and the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF, Working Group of the Scientific Medical Specialist Societies), further investigations are needed.

Intramedullary fixation using Kirschner wires in children with osteogenesis imperfecta

BACKGROUND

Surgical treatment for osteogenesis imperfecta (OI) remains controversial. The use of elongating rods has become a mainstay in this treatment, and there have been many reports of the results of this procedure. In contrast, using nonelongating rods is considered to be the classic method. This older method is still used by surgeons who are concerned about the possibility of trauma on the articular surface due to arthrotomy at the insertion of the elongating rod or who are working in developing countries with fewer resources. We are among those who prefer the use of nonelongating rods to elongating rods. This article presents the results of intramedullary fixation using nonelongating rods such as Kirschner wires (K-wires) in children with OI and the proper timing of wire exchange to prevent further fracture.

METHODS

We treated 29 femora in 17 patients with OI by means of stabilization using K-wires. For these patients we calculated revision-free survival and analyzed the details of any fractures that occurred after the primary surgery. We also investigated the relations between the wire length ratio, which was defined as the ratio of the intramedullary wire length divided by the femoral length, and the fracture type.

RESULTS

The revision-free survival for the 29 primary procedures was 63% at 3 years, and 36% at 5 years. All fractures that occurred at the wire tip required additional surgery, whereas only 51% of fractures at other sites required additional surgery. The wire length ratio of wire-tip fractures was significantly lower than that of fractures at other sites. There is a significant difference in the incidence of wire-tip fractures and other fractures between ratios of 65% and 75%.

CONCLUSIONS

Wire exchange surgeries should be performed before the wire length ratio drops to <70%. This information could be useful for preventing further fractures that require surgery when OI patients are treated by intramedullary fixation with nonelongating rods.

LEVEL OF EVIDENCE

Level IV.