Complications amd Problems in Intramedullary Nailing of Children's Fractures

Elastic stable intramedullary nailing (ESIN) is well established for stabilizing pediatric diaphyseal and special metaphyseal limb fractures. Expanding its application requires the evaluation of problems and complications to prevent uncritical use. Four pediatric surgical departments participated in a retrospective study. Between 1990 and 1998, 937 fractures were treated by ESIN. Major indications were forearm and femur fractures. Continuous documentation of treatment, postoperative course and follow-up formed the basis of evaluation. Analysis was subdivided into intraoperative problems, postoperative problems, and complications. Intraoperative problems (6.5%) were characterized by open reduction, cortical perforation by a nail tip with subsequent instability and by iatrogenic bursting of a third fragment. Postoperatively, 6.4% of patients showed soft tissue irritation due to nail ends or joint effusions. Complications (8.4%) included axial deviation >10° or instability of osteosynthesis in 5.3% and nerve injuries in 1.4%. Delayed healing, pseudarthrosis, osteomyelitis and synostosis were only observed in isolated cases, 5 children sustained a refracture. Severe complications are rare, problems arise from suboptimal technique and incorrect indication. Detailed knowledge of technical principles and procedural recommendations constitutes the mainstay in prevention.     

ESIN in Femur Fractures

Abstract Background and Purpose: Elastic stable intramedullary nailing (ESIN) is gaining increasing popularity, but studies with high case loads are rare. It was the aim of four experienced pediatric trauma centers to give an update of indications for ESIN, postoperative management, and complications. Patients and Methods: Data of the last 100 ESIN cases of each department before June 30, 2003 were collected by reviewing the charts and X-rays. Among these 400 collected ESINs 65 femoral shaft fractures (16%) were found. The patients age ranged between 23/4 and 151/4 years. The middle third of the shaft was affected 42 times (65%), 13 fractures (20%) were in the proximal third of the diaphysis, and ten (15%) in the distal part of the femur, five dia- and five metaphyseal. Mainly transverse fractures were treated (52%), followed by 38% oblique or spiral fractures and 10% wedge or comminuted fractures. Two open reductions were required. Median hospitalization time was 6 days. Nails were extracted after a mean of 178 days. Results: Six skin irritations (wound infections, hematoma, seroma), one patient with myositis ossificans and one with constant pain at too long nail end were found. Three cosmetically relevant scarrings were observed during follow-up. Relevant axial deviations at fracture healing in two and shortening in one fracture could be seen, all caused by technical failure. Conclusion: ESIN meets all demands for an optimal fracture healing in children. Still, a considerable percentage of complications is observed, mainly caused by the surgeon himself, which can be avoided by exact indication and technique. Postoperative management has yet to be standardized.     

Determining the development stage of the ossification centers around the elbow may aid in deciding whether to use ESIN or not in adolescents’ forearm shaft fractures

Background and purpose — Elastic stable intramedullary nailing (ESIN) is the preferred method of operative stabilization of unstable pediatric forearm shaft fractures. However, the decision whether to use ESIN or open reduction and internal fixation (ORIF) in older children or teenagers is not always straightforward. We hypothesized that the development stage of the elbow would aid in evaluating the eligibility of the patient for ESIN.Patients and methods — All eligible children, aged <16 years who were treated with ESIN in Oulu University Hospital, during 2010–2019 were included (N = 70). The development stages of 4 ossification centers were assessed according to the Sauvegrain and Diméglio scoring. The proportion of impaired union vs. union was analyzed according to bone maturity, by using the optimal cutoff-points determined with receiver operating characteristics (ROC).Results — Development stage ≥ 6 in the olecranon was associated with impaired union in 20% of patients, compared with none in stages 1–5 (95% CI of difference 8% to 24%). Trochlear ossification center ≥ 4 was associated with impaired union in 17% of patients (CI of difference 7% to 36%) and lateral condyle ≥ 6 in 13% of patients (CI of difference 3.4% to 30%). Proximal radial head ≥ 5.5 was associated with impaired union in 18% of patients (CI of difference 7% to 39%).Interpretation — Recognizing the rectangular or fused olecranon ossification center, referring to stage ≥ 6, was in particular associated with impaired fracture healing. This finding may aid clinicians to consider between ESIN and plating, when treating forearm shaft fracture of an older child or teenager.

Pediatric forearm shaft fractures comprise 6% of all childhood fractures. They occur most frequently in children aged 5–14 years (Wall 2016, Joeris et al. 2017, Alrashedan et al. 2018). Most can be treated nonoperatively, and this is particularly recommended in children < 9 years (Zionts et al. 2005, Franklin et al. 2012). Older children are more prone to complications such as nonunion and redisplacement (Asadollahi et al. 2017). Their longer fracture healing time and less pronounced remodeling capacity have resulted in a trend toward operative management recently (Sinikumpu et al. 2012).Elastic stable intramedullary nailing (ESIN) is the preferred method to fix forearm shaft fractures in children. The method spares periosteal blood supply and surgical wounds are usually far from the fracture. ESIN produces good angular and longitudinal stability (Wall 2016). In older children and teenagers open reduction and internal fixation (ORIF) is optional (Herman and Marshall 2006). Their fractures are more prone to complications and even minor displacement may result in shortening and angulation, thus decreasing pro- and supination, similarly to adult patients (Rehman and Sokunbi 2010). However, the calendar age of a patient does not always match the maturation of the skeleton, making it challenging to select between pediatric-like or adult-like treatment.Bone age of the patient would help the clinician when choosing between ESIN and plating in older children. Bone age could be assessed by additional radiographs of the hand or iliac spine. However, keeping in mind that there are several ossification centers in the elbow, which develop in a particular order in a growing child, we hypothesized that higher development stage of elbow ossification centers would be associated with impaired healing of forearm shaft fractures stabilized by ESIN. We aimed to find a method to predict impaired union of forearm shaft fractures treated by ESIN, by using the Sauvegrain classification system for bone age (Sauvegrain et al. 1962).     

The Use of ESIN in Humerus Fractures

Abstract Background: The aim of this study was to collect data of patients treated by elastic stable intramedullary nailing (ESIN), regarding epidemiology, indications, results, and complications. Patients: Altogether, 400 patients with fractures of the humerus, the lower arm, the femur and the lower leg, treated with ESIN, were evaluated. The participating hospitals, each collecting 100 patients, were the Department of Pediatric Surgery, Inselspital of the University of Bern, Switzerland, the Department of Pediatric Surgery, University of Graz, Austria, the Department of Pediatric Surgery, St. Hedwigs Hospital Regensburg, Germany, and the Department of Pediatric Surgery, Dr. von Hauners Childrens Hospital of the University of Munich, Germany. This study concentrates on 123 patients (30.8%) with humeral fractures. Of these, 29 had sustained proximal humeral fractures, 14 shaft fractures, and 80 distal humeral fractures. Results: In most cases good and excellent results with regard to functional and cosmetic outcome were observed. Rare, but typical problems and complications included implant dislocations, secondary axial deformations, and temporary nerve damages. Conclusion: ESIN of the humerus is now the standard operation to treat proximal and shaft fractures in childhood. ESIN of supracondylar fractures has advantages if performed by an expert, though the surgital technique is not simple.     

Elastisch – Stabile Markraumschienung (ESMS) von Unterarmschaftfrakturen im Kindesalter

Objectives

A fast, minimally invasive technique for the treatment of displaced forearm shaft fractures in childhood using internal bone cavity splinting, while providing early mobilization with no need for plaster immobilization, is presented.

Indications

Open, dislocated forearm shaft fractures until II° degree, for patients ranging from 4 to 18 years of age asking for fast mobility and safe stabilization avoiding potential re-displacement.

Contraindications

Higher degree open fractures with soiled wounds, sclerosized, impassable bone marrow cavity and acute osteomyelitis.

Surgical technique

Closed in-axis reduction of the fracture. Insertion and forward pushing of the pre-bent intramedullary nails through small incisions. Finally, after picking up the fragments, the nail tips were fixed in opposition for stable fixation of the fragments.

Postoperative management

Mobilization and weight bearing is possible immediately postoperation. To reduce the postoperative pain, the injured limb may be optionally immobilized by a splint or sling for approximately 1 week. Sports are permitted after 8 weeks. Removal of implants is recommended after 6 to 8 months.

Results

Between January 2000 and July 2003, 141 children (99 boys and 42 girls) suffering a displaced forearm shaft fracture were operated on with intramedullary nailing (ESIN). The average age of the children was 9.3 years (range 2–15 years). In the majority of cases, the left forearm was injured [left side 80 (61%), right side 51 (39%)]. The hospital stay lasted for an average of 1.1 days (range 0–5 days). In 108 patients closed reduction and ESIN of radius and ulna was possible. Open reduction was necessary in 23 children mainly due to soft tissue interposition (radius: 9, ulna: 6, radius and ulna: 8). 129 patients (98.5%) finally showed a favorable long-term outcome with complete bony consolidation, good functional and aesthetic result, and no neurological impairment. Thirteen children (9.9%) showed (minor) postoperative complications, in 11 (8.4%) of them full recovery was observed in due course or after removal of implants. In 2 patients surgical revision was required (neurolysis: 1 because of persistent dysaesthesia; removal of implants: 1 due to infection).     

Submuscular Plating Versus Elastic Intramedullary Nailing in Children with Femoral Shaft Fracture; a systematic review and meta-analysis

IntroductionElastic stable intramedullary nailing (ESIN) is currently the technique of choice for pediatric femoral fractures. Submuscular plating (SMP) allows reliable healing associated with an early range of motion. The following systematic review and meta-analysis was carried out to reveal the functional and surgical outcomes of SMP and ESIN for fixation of pediatric femoral fractures and to aid in the decision-making processes for those who perform these procedures.MethodsAn extensive systematic literature review was implemented from inception to 23 February 2022. All clinical studies included had patients that were younger than 18 years old with femoral shaft fractures that compared outcomes between SMP and ESIN. Studies including patients with pathological fractures, closed femoral physis, multiple fractures, or refractures were excluded.ResultsThis meta-analysis included six articles encompassing 568 patients. Of them, 206 patients were treated with SMP, while 362 were subjected to ESIN procedure. There was significantly more blood loss among patients treated with SMP (MD -45.45; 95% −61.62, −29.27; p < 0.001). The risk of postoperative adverse surgical events was significantly higher among patients subjected to the ESIN (RR 2.97 19.5; 95% 1.27, 6.98; p = 0.01). The mean hospital stay was significantly shorter among patients subjected to ESIN (SMD -1.47; 95% −2.43, −0.51; p = 0.003). Patients subjected to SMP showed significantly more EFOs when comparing Flynn Scores (OR 0.24; 95% 0.09, 0.64; p = 0.004). There was no significant difference between SMP and ESIN regarding the mean operation time, limb length discrepancy, and mean time to union.ConclusionsChildren with femoral shaft fractures can be managed effectively and safely with SMP. There was a similar surgical outcome between SMP and ESIN, but SMP had more EFOs. While SMP was associated with a low risk of postoperative adverse surgical events, it was associated with a more significant blood loss and prolonged hospital stays.     

Elastic stable intramedullary nailing (ESIN) in the adolescent patient—perils,pearls, and pitfalls

Purpose

Elastic stable intramedullary nailing (ESIN) has become the treatment of choice for diaphyseal long-bone fractures in children. This paper reviews the complications and limitations of this method which can occur when applying this osteosynthesis to patients within the adolescent age group.

Methods

Each topographic site where ESIN is used was analyzed individually and systematically. Technical errors, indicational problems, and mistakes during the rehabilitation process are pointed out and recommendations are given on how to avoid failure.

Results

ESIN can be safe and efficacious within certain limits also in the adolescent age group. Whenever errors and mistakes occur in combination, e.g., applying ESIN to a patient with a multi-fragmented fracture and a high body mass index (BMI), the adolescent age group is less forgiving to indicational “stretching” than the pediatric age group.

Conclusions

The best prophylaxis for failure of ESIN is a stable and symmetric construct with correctly sized implants. This holds even more true for the adolescent patient. Using ESIN in difficult situations such as longitudinally unstable fractures, patients with a body weight >50 kg, or away from the diaphysis should be considered and followed up carefully. If possible, these patients should be treated in specialized pediatric trauma centers.     

An Observational Cohort Study of the Adoption of Elastic Stable Intramedullary Nailing for the Treatment of Pediatric Femur Fractures in Kumasi,Ghana

Background

In high- and middle-income countries, elastic stable intramedullary nailing (ESIN) is the commonest treatment of femur fractures in children 5–11 years of age. At Komfo Anokye Teaching hospital (KATH) in Kumasi, Ghana, prior to this study all pediatric femur fractures were treated with skin traction to union. This study was designed to report the early results and costs of the adoption of ESIN at KATH to provide data to other low- and middle-income sites considering adoption of this surgical technique.

Methods

An observational cohort study that included 84 pediatric patients ages 3–14 years presenting with closed femur fractures and treated with either skin traction or ESIN. Multivariate logistic regression was used to compare the rate of treatment success between treatment groups.

Results

Treatment success (coronal and sagittal angulation less than 10 ° and shortening less than 15 mm at osseous union) was achieved in 92 % of the ESIN group versus 67 % of the skin traction group (odds ratio for ESIN group 9.28 (1.6–54.7); p = 0.0138). Average length of stay was significantly lower in the ESIN group (p = 0.001), but charges to patients were higher in the ESIN group (p < 0.001) because of the high cost of implants.

Conclusions

The initial experience of operative treatment of femoral shaft fractures in children using ESIN was positive, with improved rates of treatment success and no surgical complications. Because of the high cost of implants, direct costs of treatment remained higher with ESIN despite reductions in length of hospital stay.     

Clinical Efficacy of Minimally Invasive Elastic Stable Intramedullary Nailing for Limb Long Bone Fractures in Children

ObjectiveThe aim of the present paper was to investigate the clinical efficacy of minimally invasive elastic stable intramedullary nailing (ESIN) for long bone fractures in children.MethodsA total of 350 children with limb fractures from June 2012 to June 2018 were recruited and randomized into two groups: an ESIN group (n = 175) treated with elastic stable intramedullary nailing, and an MPIF group (n = 175), treated with metal plate internal fixation. Both groups received the same physical examination and routine medication. Operation related indexes, clinical efficacy, complications, and postoperative quality of life scores were analyzed and compared.ResultsThe operation time, intraoperative blood loss, hospitalization time, and fracture healing time in the ESIN group were 43.74 ± 4.96 min, 8.14 ± 1.34 mL, 5.97 ± 1.88 days, and 55.89 ± 5.61 days, respectively, which were all significantly less than those in the MPIF group (all P < 0.001). In terms of common complications after limb fracture treatment, there were 6 cases of osteomyelitis, 5 cases of skin irritation response, and 7 cases of inflammatory granuloma in the MPIF group. There were 2 cases of skin irritation response and 5 cases of inflammatory granuloma in the ESIN group. The incidence of postoperative complications in the ESIN group was 4.00%, which was significantly lower than that in MPIF group (10.29%) (P < 0.05). The effective rate for recovery condition in the ESIN group (93.71%) was significantly higher than that in the MPIF group (P < 0.001). The quality of life scores after treatment in both groups were improved, while the score in the ESIN group was significantly higher than that in the MPIF group (79.43%) (P < 0.001). The postoperative satisfaction rate in the ESIN group (94.29%) was significantly higher than that in the MPIF group (86.29%) (P < 0.05). The quality of life scores after treatment in both groups were improved, while the score in the ESIN group was significantly higher than that in the MPIF group (P < 0.001). The postoperative satisfaction rate and the acceptance rate for adjacent joint function in the ESIN group (100%) were significantly higher than those in the MPIF group (92.00%) (P < 0.0001).ConclusionElastic stable intramedullary nailing is a minimally invasive procedure for long bone fractures in children. It can effectively improve the operation‐related indicators and postoperative quality of life and reduce the incidence of complications.     

Diaphyseal forearm fractures in children treated with intramedullary fixation: outcome of K-wire versus elastic stable intramedullary nail

Intramedullary fixation of children's diaphyseal forearm fractures is becoming the surgical technique of choice, in those cases that warrant surgical intervention. This method offers both technical advantages and patient benefits over alternative techniques and implants that have been used in the past. We present a two-centre study assessing the outcome of either Kirschner wires or elastic stable intramedullary nails (ESIN) as the method of fracture stabilisation in such diaphyseal forearm fractures.A total of 36 children underwent K-wire fixation and 24 children underwent ESIN fixation. All fractures united with no resultant subjective disability. The complication rate following K-wires was 16% and that following nail fixation 9%. Loss of forearm rotation was documented in four children in the K-wire group and three children stabilised with nails.These results confirm an excellent outcome following intramedullary fixation. We have demonstrated no difference in outcome between K-wires and ESIN, although the nails do offer some theoretical advantages.     

Management of displaced radial neck fractures in children: percutaneous pinning vs. elastic stable intramedullary nailing

Background

The treatment of radial neck fractures in children varies according to the displacement, angulation, and skeletal maturity. There is a general agreement that displaced radial neck fractures with more than 30° angulations (Judet type III and IV fractures) should be surgically treated. There are several treatment possibilities for Judet type III and IV fractures including percutaneous pin reduction, elastic stable intramedullary nailing (ESIN), and open reduction with or without internal fixation. In this retrospective study we compared the clinical and radiographical outcomes, and complications following intramedullary versus percutaneous pinning in displaced radial neck fractures in children.

Materials and methods

Between 2000 and 2011, 20 patients were treated using closed reduction: in 12 cases we used percutaneous pinning, and in 8 cases we used ESIN. According to Judet classification the two groups were composed as follows: 10 (77 %) type III and 3 (23 %) type IV fractures in the percutaneous pinning group; 4 (57 %) type III, and 3 (43 %) type IV fractures in the ESIN group.

Results

After an average of 42 months, excellent results in Mayo elbow performance scores (MEPS) were obtained in 71 and 69 % of ESIN and percutaneous pinning groups respectively, with good results in the remaining cases apart from one fair case (8 %) in the percutaneous pinning group. After a radiological evaluation, all fractures healed in excellent or good alignment. When comparing the two groups, the subjects treated with the ESIN technique had higher range of motion (ROM) in flexion, extension and pronation. No patients developed complications, except three cases of asymptomatic enlargements of the radial head, reported only in the percutaneous pinning group.

Conclusion

In this research the clinical outcome, assessed with the MEPS, and the radiological alignment, were comparable between the subjects that were treated with percutaneous pinning and those with ESIN techniques; whereas the ESIN technique demonstrated higher ROM in flexion, extension and pronation. The ESIN technique seems to be the ideal approach both for the higher ROM values and for the absence of complications.     

Use and abuse of flexible intramedullary nailing in children and adolescents

Elastic stable intramedullary nailing (ESIN) has became a well-accepted method of osteosynthesis of diaphyseal fractures in children and adolescents for many reasons including the following: no need for postoperative cast, primary bone union with avoidance of growth plate injury, and minimum invasive surgery. OPERATIVE TECHNIQUE: The principle is to introduce 2 elastic nails, titanium or stainless steel, into the medullary canal through a metaphyseal approach. The bended nails must have their maximum of curve at the level of the fracture, and their orientation, most often face to face, is in charge of the reduction and, so far, the stabilization, of the fracture. The usual size of the nails is equal to 0.4 times the diameter of the medullary canal. As far as possible, a bigger diameter is better than a thinner one. Most fractures of the femur are treated with a bipolar retrograde ESIN when some distal fractures need an antegrade subtrochanteric approach. Forearm fractures need a combined retrograde radial and antegrade ulnar through the posterolateral part of the olecranon. Humerus and tibial diaphyseal fractures may also be treated with ESIN.Complications are mainly caused by technical errors including too-thin nails, asymmetry of the frame, and malorientation of the implants. Nonunion was never observed in fractures of the femur and the forearm; osteomyelitis rate is 2%, and mean overgrowth of the femur is less than 10 mm before the age of 10 years.Indications of ESIN are fractures of the diaphysis: all the fractures of the femur between the age of 6 years and the end of growth except for the severe open grade III fractures, all the unstable fractures of the forearm, and some unstable fractures of the humerus and the tibia during adolescence or before the end of growth. In addition, ESIN is indicated in polytraumatism and multiple injuries. CONCLUSIONS: The good results of this reliable technique are obtained when surgeons have a good knowledge of it, especially in the understanding of the principle of the correction of the fracture and its stability.     

Elastic Stable Intramedullary Nailing (ESIN) in Lower Leg Fractures

Abstract Purpose: This study analyzes the results of elastic stable intramedullary nailing (ESIN) of the lower extremity in children and possible complications of this method. Patients and Methods: The data of 47 pediatric patients (38 male, nine female, mean age 9.8 years, range 1–16 years) treated from 2001 to 2003 with ESIN of the lower leg at the Departments of Pediatric Surgery in Bern, Switzerland, Graz, Austria, Munich, Germany, and Regensburg, Germany, were reviewed. Children with isolated tibia fractures as well as children with fractures of tibia and fibula were included. In all children the implants were inserted antegrade followed by cast-free mobilization.Results: The majority (77%) of the children were operated on within 1 day after trauma. Mean duration of surgery was 58 min (range 20–140 min), mean hospital stay 8.9 days (range 2–20 days). Full weight bearing was achieved within 12 up to 87 days (mean 46 days) after trauma. Implants were removed after radiologically proven fracture consolidation (mean 188 days after implantation). Trauma-related complications (n = 7; 15%) were compartment syndrome necessitating fasciotomy in four patients; osteomyelitis, peroneus paresis and refracture were reported in one child each. Surgical complications were present in four children (9%): pseudarthrosis (inadequate implants), wound infection at the implantation site, implant dislocation (unstable fixation) and fracture dislocation (distal fracture) occurred in one child each. Finally, all fractures healed in good alignment. Conclusion: High-energy trauma of the lower leg is associated with a significant rate of trauma-related complications. Compliance with guidelines for indication and technique may prevent surgical complications.     

Intramedullary nails for pediatric diaphyseal femur fractures in older, heavier children: early results

Purpose

A common treatment for pediatric femur fractures is intramedullary nail (IMN) insertion. Elastic stable intramedullary nails (ESINs) are often used for these procedures in heavier patients, but the potential for complications and malunion is greater. We describe here a rigid IMN specifically designed for adolescents, the adolescent lateral entry femoral nail (ALFN). The purpose of this study was to compare the recovery and complications for patients treated with ESINs to those treated with the ALFN.

Methods

Our study design was a retrospective cohort study. We performed a review of medical records of 22 children ages 10–17 requiring surgical fixation of a femur fracture for a 2½-year period. Patients selected for the study had traumatic diaphyseal femur fractures and were treated with ESINs without end-caps or ALFNs. Our analyses evaluated injury, surgical, and outcome information for all patients.

Results

Twenty-two patients were eligible for inclusion and were divided into two groups according to their treatment: the ESIN group with 7 patients and the ALFN group with 15 patients. We then performed a comparison of complications and recovery for these patients. The mean time to full weight-bearing was significantly less for the ALFN group (4.1 weeks; SD, 2.2), than the ESIN group (9.4 weeks; SD 3.9). There was no statistical difference in the incidence of major or minor complications.

Conclusions

Older, heavier pediatric patients treated for femur fracture with ALFNs had a shorter recovery time than similar patients treated with ESINs. However, the outcomes for both groups were satisfactory.     

Elastic stable intramedullary nailing is best for mid-shaft clavicular fractures without comminution: Results in 60 patients

Introduction

Elastic stable intramedullary nailing (ESIN) of displaced mid-shaft clavicular fractures is a minimally invasive technique which was reported to be an easy procedure with low complication rates, good cosmetic and functional results, restoration of clavicular length and fast return to daily activities. Recent studies, however, also report on higher complication rates and specific problems with the use of this technique. This prospective study compares ESIN with non-operative treatment of displaced mid-shaft clavicular fractures.

Methods

Between December 2003 and August 2007, 120 patients volunteered to participate. Of these, 112 patients completed the study (60 in the operative and 52 in the non-operative group). Patients in the non-operative group were treated with a simple shoulder sling. In the operative group, intramedullary stabilisation was performed within 3 days of the trauma. Clavicular shortening was determined after trauma and after osseous consolidation on thorax posteroanterior radiographs as the proportional length difference between the left and right side with the uninjured side serving as a control for clavicular length (100%). Radiographic union was assessed every 4 weeks on 20° cephalad anteroposterior and posterioranterior radiographs of the clavicle. Constant shoulder scores and DASH scores (DASH, disabilities of the arm, shoulder and hand) were assessed at final follow-up after 2 years.

Results

ESIN led to faster osseous healing and better restoration of clavicular length in simple fractures. We were not able to restore clavicular length in comminuted fractures using ESIN. Functional outcome at a mean follow-up of 24 months (range: 22-27 months) was better in the operative group. Delayed union and non-union accounted for the majority of complications in the non-operative group. In the operative group, telescoping was the main complication, which occurred in complex fractures with severe post-traumatic shortening only.

Conclusion

We recommend ESIN for all simple displaced mid-shaft clavicular fractures in order to minimise the rate of delayed union, non-union and symptomatic mal-union. We also recommend ESIN in comminuted fractures with moderate (≤7%) post-traumatic shortening, as they will heal with moderate shortening. In comminuted fractures with severe shortening, however, we recommend plate osteosynthesis in order to provide for stability, clavicular length and endosteal blood supply.     

Paediatric diaphyseal forearm refractures after greenstick fractures: Operative management with ESIN

Background

One of the complications of forearm shaft fracture is refracture. Elastic stable intramedullary nailing represents an alternative method for refracture treatment to cast immobilisation for another five to seven weeks. Operative treatment often necessitates an open reduction in most cases due to blocked or narrowed medullary canals. The purpose of this study was to examine the expense of the operative procedure, technique (closed or open intramedullary nailing) and postoperative complications in diaphyseal forearm refractures.

Methods

We retrospectively examined the expense of operative procedure in 21 children with diaphyseal forearm refractures treated with ESIN.

Results

In 18 cases, closed reduction with nailing was possible; three required an open reduction. In nine patients a closed medullary cavity was present; only two of them needed an open reduction. None of the patients had complications (wound healing, osteomyelitis, rupture of the extensor pollicus longus). Swelling appeared in four patients, paraesthesia of the thumb in one. Free functional movement was achieved in all children.Long term results: No re-refracture occurred. One patient suffered from meteorosensitivity. Twelve are able to do the same sporting activities as before injury.

Conclusion

ESIN seems to be one choice for treatment in refracture of the forearm, as in most cases the operative reduction can be performed in a closed way by means of “tricks and hints”.     

State-of-the-art treatment of forearm shaft fractures

As the treatment of pediatric forearm shaft fractures has changed extensively over the past 30 years, it is worth discussing the current treatment modalities in these fractures. The recommendations are based on an ongoing evaluation of treatment procedures, problems, complications, and final results going back to 1976. Between 1976 and 1985, the 95.9% of fractures that were treated conservatively were tainted with bad functional results because a significant proportion healed with malalignment. The introduction of elastic-stable intramedullary nailing (ESIN) initiated a definitive change and the opportunity to stabilize unstable fractures with a less invasive method. Apart from some technical problems, the functional results of ESIN are very satisfactory. The external fixator is a good treatment for open, comminuted, or special distal dia-metaphyseal fractures in older children and adolescents. Therefore, we currently have a variety of methods to treat forearm shaft fractures in children using primary definitive fracture care (PDFC). The differentiated use of conservative and surgical measures should minimize final functional sequelae. A well-tried algorithm for this fracture region is outlined.     

Legg–Calvé–Perthes disease following Ender nail fixation of a pediatric femoral fracture

Introduction and importanceLegg–Calvé–Perthes disease (LCPD) sometimes occur in children, however it is difficult to diagnose it at the early stage especially in the cases there are no complaints of symptoms. Femoral shaft fractures in children cause various complications such as leg-length discrepancy, nonunion and malunion, refracture, and osteonecrosis of the femoral head. We presented a rare case in which a pediatric patient developed LCPD after femoral shaft fracture.Case presentationA healthy 8-year-old boy sustained a left femoral diaphyseal fracture following a pedestrian car accident. Fixation was achieved using retrograde Ender nails; bone union was confirmed at 3 months postoperatively, and the Ender nails were removed at 8 months postoperatively without any problems. Unfortunately, the morphological change of the ipsilateral femoral head and subtle symptoms were missed until the femoral head collapsed. LCPD was successfully treated with intertrochanteric varus osteotomy, which achieved a good clinical result.Clinical discussionAlthough the reason for the ipsilateral LCPD after the femoral shaft fracture is unclear, this case highlights the need for close postoperative follow-up of pediatric femoral fractures resulting from high-energy trauma to prevent the misdiagnosis of this coincidental complication.ConclusionThis case report describes a missed ipsilateral LCPD after a femoral diaphyseal fracture caused by high-energy trauma. Close postoperative follow-up with a detailed assessment and vigilant interpretation of postoperative radiography is imperative to avoid delayed/missed diagnosis of conditions for which early management may provide better outcomes.     

Pediatric forearm fractures with in situ intramedullary implants

Purpose

The purpose of this investigation is to present our institutional experience with fractures of the pediatric forearm with in situ intramedullary nails.

Methods

Six patients treated at our institution for forearm fracture with in situ intramedullary implants between 2004 and 2013 were reviewed. Patient demographics, injury and radiographic characteristics, method of treatment, time to union, and complications were collected from the medical record.

Results

485 patients with forearm fractures were treated with intramedullary implants and six patients presented with a fracture with in situ implants (1.2 %). Fractures in all six patients resulted from a second traumatic event after radiographic healing but before implant removal at a mean of 13.0 months from the initial procedure. One patient had an adequately aligned fracture and was treated with casting without reduction. The remaining five patients (83 %) returned to the operating room for treatment. Two patients underwent rod removal and placement of new intramedullary implants, and two patients were treated with rod removal and plating without attempt at closed reduction. One patient underwent closed reduction in the operating room with successful re-bending of the radial implant and replacement of the ulna implant. All patients went on to uncomplicated radiographic union at a mean 3.6 months.

Conclusions

The incidence of fracture of pediatric forearm with in situ intramedullary implants is low. This rare complication can be treated by several different methods, including revision TENS placement, revision to plate fixation, or in situ bending of rods, with the expectation for successful uncomplicated union.