A critical analysis of postoperative complications of antebrachium ten-nailing in 35 children

Background: Unstable antebrachium diaphyseal fractures in children are nowadays increasingly treated operatively by elastic intramedullary nailing. Aim: Aim of the study was to critically assess both radiological and functional outcome of antebrachium fractures treated by titanium elastic nail (TEN) in a pediatric cohort. Material and Methods: This retrospective study investigated 75 consecutive children, who were treated for antebrachium shaft fractures at Tampere University Hospital during the time period from January 2001 to December 2005. All the fractures were classified according to OTA. Thirty-five children (mean age 12.3 years) were treated by TEN-nailing. Twenty four of the forearm fractures were instable, five were open, five were re-fractures and one had ulnar nerve deficit. In all but one patient both forearm bones were fractured. Twelve (34%) operations were managed by closed reduction, open reduction was needed in 23 (66%) patients. In 29 cases both bones were fixed with TEN-nail. In the four patients with re-fracture in both ulna and radius only the radius was TEN-nailed. In one case radius was fixed with TEN-nail and ulna with K-wire and in another case radius was fixed with TEN-nail and ulna with plate. Fracture pattern, mode of reduction, surgical approach, short- and long-term complications and outcome were recorded. Results: Twenty three (66%) patients achieved healing of the fractures without any limitation in range of motion. Twelve patients with postoperative complication were followed up 31-74 (median of 54) months. Eleven (31%) patients had minor postoperative complications and one (0,3%) patient had a Volkmann's ischemic contracture. Five of complicated patients had more than one problem. Immediate post-operative problems were noted in these five patients. At follow-up visits four patients complained of ulnar nail discomfort, two had neural symptoms. Additionally, three children suffered from re-fractures. Discussion: Despite various minor complications, TEN-nailing is considered suitable treatment for unstable forearm shaft fractures. Most of the problems were related to poor technical performance in nailing.     

Current indications for intramedullary bundle nailing

Hackethal developed the nailing procedure named after him in 1959. The original method consisted in two steps: a non-sterile step in which mechanical reduction was performed with a traction device and a sterile step, i.e. nailing. The rationale of Hackethal nailing is an elastic jamming, which can only be achieved by obeying four rules: jamming of the nails in the cortical window, jamming then in the waist of the medullary cavity, spreading the bunch of nails in the metaphysis and filling up the conus of the medullary cavity with short nails. Hackethal believed it was possible to achieve an elastic jamming in all transverse and short oblique fractures of the shaft. He used his technique in fractures and non-unions of femur, tibia, humerus, radius and ulna. Extensive indications led to overuse of the method and resulted in a major rate of complications. Meanwhile, plating of shaft fractures has proved to involve an unexpectedly high rate of complications, and locking nails and new types of fixators have enlarged the surgeon's armamentarium for stabilization of fractures. Therefore, it seemed important to determine the present indications for Hackethal nailing. We confined Hackethal nailing to fractures of the middle third of the shaft in the upper extremity. All second- and third-degree open fractures were treated with fixators. In a 13-year period we performed Hackethal nailing of the humerus in 53 cases, of the radius in 20, of the ulna in 17, and in both of the forearm simultaneously in 12 cases. Plating and Hackethal nailing were combined for the treatment of forearm fractures in 10 cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

弹性髓内钉治疗儿童股骨干骨折

目的探讨弹性髓内钉治疗儿童股骨干骨折的方法和疗效。方法采用弹性髓内钉内固定治疗儿童股骨干骨折32例。结果 32例均获随访,时间5～12个月,骨折全部愈合。按Flynn评分标准:优26例,良6例。无骨不愈合、畸形愈合和骨骺损伤等。结论弹性髓内钉内固定具有微创、不累及骨骺、并发症少等特点,是治疗儿童股骨干骨折的有效方法。     

Elastic stable intramedullary nailing of tibial shaft fractures in children

Most pediatric tibia shaft fractures are amenable to nonoperative treatment with satisfying results, yet surgical stabilization is necessary in certain cases. The purpose of our study was to determine the effectiveness and the complications associated with elastic stable intramedullary nailing in severe pediatric tibial fractures. We retrospectively reviewed 24 tibia shaft fractures in 24 patients that were treated operatively by elastic stable intramedullary nailing between 1997 and 2005 at our institution. Extensive review of all charts and radiographic data was completed at Cincinnati Children's Hospital Medical Center. There were 8 closed and 16 open fractures. The average union time for all tibia fractures was 20.4 weeks. The average union time for closed and open fractures was 21.5 and 20.2 weeks, respectively. Complications include 2 (8%) neurovascular, 2 (8%) infections, 2 (8%) malunions, and 1 (4%) leg-length discrepancy. Although complications do exist, elastic stable intramedullary nailing of pediatric tibia shaft fractures using Nancy nails is an effective treatment option.     

Flexible intramedullary nailing of displaced diaphyseal forearm fractures in children

INTRODUCTION: This study analyses the results of 50 displaced diaphyseal forearm fractures in children treated with flexible intramedullary nailing. METHODS: Between 1999 and 2002 we treated 50 children aged between 5 and 15 years, with diaphyseal fractures of the forearm using Flexible intramedullary nailing (FIN). Both bones were fractures in 45 patients, radius only in 4 and ulna only in 1. The indications for fixation were instability (26), re-displacement (20), and open fractures (4). RESULTS: 24 patients were reduced closed, followed by nailing, while 26 fractures required open reduction of either one bone(16 cases) or both bones(10 cases) prior to nailing. Bony union of all fractures was achieved by an average of 7 weeks (range 6 weeks to 4 months) with one delayed union. Pronation was restricted by an average of 20 degrees in 9 patients. Two patients developed post operative compartment syndrome requiring fasciotomy. Three patients were lost to follow-up. INTERPRETATION: FIN led to early bony union with acceptable bony alignment in all 47 patients available at final follow-up. We therefore recommend FIN for the treatment of unstable diaphyseal forearm fractures in children.     

Elastic nailing of tibia shaft fractures in young children up to 10 years of age

IntroductionAlthough tibia shaft fractures in children usually have satisfactory results after closed reduction and casting, there are several surgical indications, including associated fractures and soft tissue injuries such as open fractures. Titanium elastic nails (TENs) are often used for pediatric tibia fractures, and have the advantage of preserving the open physis. However, complications such as delayed union or nonunion are not uncommon in older children or open fractures. In the present study, we evaluated children up to 10 years of age with closed or open tibial shaft fractures treated with elastic nailing technique.MethodsA total of 16 tibia shaft fractures treated by elastic nailing from 2001 to 2013 were reviewed. The mean patient age at operation was 7 years (range: 5–10 years). Thirteen of 16 cases were open fractures (grade I: 4, grade II: 6, grade IIIA: 3 cases); the other cases had associated fractures that necessitated operative treatments. Closed, antegrade intramedullary nailing was used to insert two nails through the proximal tibial metaphysis. All patients were followed up for at least one year after the injury. Outcomes were evaluated using modified Flynn's criteria, including union, alignment, leg length discrepancies, and complications.ResultsAll fractures achieved union a mean of 16.1 weeks after surgery (range: 11–26 weeks). No patient reported knee pain or experienced any loss of knee or ankle motion. There was a case of superficial infection in a patient with grade III open fracture. Three patients reported soft tissue discomfort due to prominent TEN tips at the proximal insertion site, which required cutting the tip before union or removing the nail after union. At the last follow-up, there were no angular or rotational deformities over 10° in either the sagittal or coronal planes. With the exception of one case with an overgrowth of 15 mm, no patient showed shortening or overgrowth exceeding 10 mm. Among final outcomes, 15 were excellent and 1 was satisfactory.SummaryEven with open fractures or soft tissue injuries, elastic nailing can achieve satisfactory results in young children, with minimal complications of delayed bone healing, or infection.     

Femoral shaft fractures in childrenElastic stable intramedullary nailing in 31 cases

We report our experience with elastic stable intramedullary titanium nailing (ESIN) of femoral shaft fractures in children. From 1998 to 2001, we treated 31 children (20 boys), median age 6 (4–11) years, with ESIN for 29 closed and 2 grade I open femoral shaft fractures. We reviewed 30 children clinically after median 1.5 (1–3) years. Their median hospital stay was 6 (2–20) days. All fractures were radiographically united at a median of 7 (5–9) weeks. The nails were removed in 29 children after a median of 22 (6–38) weeks postoperatively. At follow-up, we found a leg-length discrepancy up to 1 cm in 6 children and 10 degrees of internal rotational deformity in 1 child. No angular deformity had occurred. Elastic stable intramedullary nailing seems to be a safe method for the treatment of femoral shaft fractures in children between 4 and 11 years of age.     

Femoral shaft fractures in children: elastic stable intramedullary nailing in 31 cases

We report our experience with elastic stable intramedullary titanium nailing (ESIN) of femoral shaft fractures in children. From 1998 to 2001, we treated 31 children (20 boys), median age 6 (4-11) years, with ESIN for 29 closed and 2 grade I open femoral shaft fractures. We reviewed 30 children clinically after median 1.5 (1-3) years. Their median hospital stay was 6 (2-20) days. All fractures were radiographically united at a median of 7 (5-9) weeks. The nails were removed in 29 children after a median of 22 (6-38) weeks postoperatively. At follow-up, we found a leg-length discrepancy up to 1 cm in 6 children and 10 degrees of internal rotational deformity in 1 child. No angular deformity had occurred. Elastic stable intramedullary nailing seems to be a safe method for the treatment of femoral shaft fractures in children between 4 and 11 years of age.     

Femoral shaft fractures in children

We report our experience with elastic stable intramedullary titanium nailing (ESIN) of femoral shaft fractures in children. From 1998 to 2001, we treated 31 children (20 boys), median age 6 (4-11) years, with ESIN for 29 closed and 2 grade I open femoral shaft fractures. We reviewed 30 children clinically after median 1.5 (1-3) years. Their median hospital stay was 6 (2-20) days. All fractures were radiographically united at a median of 7 (5-9) weeks. The nails were removed in 29 children after a median of 22 (6-38) weeks postoperatively. At follow-up, we found a leg-length discrepancy up to 1 cm in 6 children and 10 degrees of internal rotational deformity in 1 child. No angular deformity had occurred. Elastic stable intramedullary nailing seems to be a safe method for the treatment of femoral shaft fractures in children between 4 and 11 years of age.     

Delayed union and non-union of the ulna following intramedullary nailing in children

Most studies report little or no problem with union following intramedullary nailing of fractured forearm bones in children. The bone involved in the occasional delayed union is not mentioned except for one delayed union of the ulna following an open fracture. The present paper specifically highlights problems with union of the ulna following nailing in children. It reports two cases of delayed union and one non-union following nailing of closed fractures of both forearm bones. In all cases, the radius united in good time. We discuss the anatomical reasons and surgical techniques that predispose the ulna bone to delayed union and non-union and recommend surgical precautions to avoid this.     

Outcome of intramedullary nail for fixation of osteoporotic femoral shaft fractures in the elderly above 60

IntroductionIntramedullary nailing is an acceptable treatment option for femoral shaft fracture in young patients but not extensively studied in the elderly with osteoporotic fractures. Plate fixation for osteoporotic femoral shaft fractures have a high rate of complications and delayed healing time, and the most acceptable treatment is intramedullary nailing. This study evaluated the healing time and incidence of complications in osteoporotic femoral shaft fractures after intramedullary nailing.Patients &MethodsThis was a retrospective study that included 16 patients above 60 years old with osteoporotic femoral shaft fractures operated between January 2015 and December 2018. Patients with metastatic fractures or with atypical fractures were excluded. Thirteen patients had low-energy injuries such as a simple fall from standing height or lower and twisting injuries. The remaining 3 patients sustained high-energy-mechanism of injury. No patient received bisphosphonate except 2 patients received oral bisphosphonate for a period of 6 and 8 months, respectively.ResultsSixteen patients (12 females and 4 males) with mean age 69.5 ± 3.7 presented with femoral shaft fracture were operated with intramedullary nail, 10 patients were fixed with trochanteric entry nails with proximal neck screws, and 6 patients were fixed with piriformis entry nails. In 9 patients, closed reduction of fracture was achieved while 7 patients required open reduction, of which 5 fracture required cerclage wire addition. The mean bone healing time was 5.35±1.2 months. Intraoperative extension of femoral fractures during intramedullary nail insertion was observed in two cases that required open reduction and addition of cerclage wires around the fracture. The overall incidence of complications was 18.7%.ConclusionsIntramedullary nailing for osteoporotic femoral shaft fracture is a good acceptable option in elderly patients with reasonable healing time with no major complications.     

弹性髓内钉在儿童肱骨干骨折治疗中的应用

目的探讨弹性髓内钉治疗儿童肱骨干骨折的临床效果。方法对37例肱骨干骨折(经手法复位不满意或手法复位石膏固定后再移位)患儿采取闭合复位、小切口弹性髓内钉内固定治疗。除2例因手法复位失败采用有限切开复位外,其余均采用闭合复位。分别于术后3、6、12个月对患儿肩、肘关节功能进行评分。结果 37例均获随访,时间6～24个月,2例因钉尾过长或折弯致肱骨进针点疼痛和钉尾刺激反应,拔钉后症状消失。骨折全部骨性愈合,愈合时间3～6个月。均无感染、短缩、旋转畸形以及骨骺、神经损伤等并发症发生。采用Constant和Murley肩关节评分系统、Mayo肘关节功能评分系统评价疗效,术后12个月疗效:优20例,良15例,可2例,优良率为94.59%。结论弹性髓内钉内固定治疗儿童肱骨干骨折创伤小,可早期活动,愈合快,并发症少。     

Nancy nail versus intramedullary-wire fixation of paediatric forearm fractures

Intramedullary nailing provides effective fracture fixation with satisfactory functional outcome without the risks associated with plating. Unfortunately, elastic stable intramedullary nailing devices are not always available in every hospital. We have examined the outcome of 23 children who underwent intramedullary fracture fixation of one or both forearm diaphyseal fractures in our department. We have compared the outcome of intramedullary Nancy nailing with the use of standard, available K-wires to achieve intramedullary fixation. We have assessed, over a 12-month period, rates of union (100% in both groups), function of the forearm and complication rates. We have found no significant increase in the rates or severity of complications when using K-wires compared with Nancy nails. Both groups had equal excellent functional outcome. We advocate that if elastic stable intramedullary nailing devices are unavailable, a K-wire can be used to achieve three-point compression of a paediatric forearm diaphyseal fracture.     

Distale Ulnafraktur als Begleitverletzung des körperfernen Speichenbruchs

The distal radius is one of the commonest sites of fracture, and this injury is sometimes associated with fracture of the distal ulna. In recent years, surgical treatment of distal radius fractures has consisted increasingly in internal fixation with locking plates followed by early functional postoperative treatment. The associated injury to the distal ulna has so far not received much attention in the literature. Various techniques have veen described for its treatment: Kirscher wire fixation, tension band wiring, and internal fixation with screws and plates. Following positive results with elastic stable intramedullary nailing (ESIN) in the treatment of shaft fractures in children this technique was also applied in in fractures in adults (forearm, clavicle). Use of this technique for stabilisation of distal ulnar fractures has not previously been reported. In the course of a prospective longitudinal study (EBM level II), in 26 patients with an average age of 73.6 (42-88 years), bone healing in anatomical position was achieved in all cases within 6-12 weeks after closed reduction and anterograde ESIN with subsequent treatment that did not involve immobilization. No length differences of more than 2 mm and no functionally relevant deviations of the ulnar axis were observed. Apart from 3 cases of nail perforation at the distal end of the ulna, which had no clinical manifestations, there were no complications. ESIN offers a minimally invasive option for the treatment of unstable fractures of the distal ulna associated with distal radius fractures; it allows functional aftertreatment and can be regarded at least as an alternative to open reduction with internal fixation.     

Bundle nailing of forearm fractures. Indications and results

Hackethal developed the nailing procedure named after him in 1959. The rationale of Hackethal nailing is an elastic jamming, which can only be achieved by obeying four rules: jamming of the nails in the cortical window, jamming then in the waist of the medullary cavity, spreading the bunch of nails in the metaphysis and filling up the conus of the medullary cavity with short nails. We confined Hackethal nailing to closed and first-degree open fractures of the 2nd-5th sixth of the shaft of the forearm. If closed reduction and nailing were impossible, we performed a plate fixation (AO), in second- or third-degree open fractures we treated with fixators (Orthofix). In a 13-year period we performed Hackethal bundle nailing in 65 patients with 115 fractures. In 54% patients surgery was performed within the first 8 hours following admission. We used two or three nails passing the fracture and one short nail. Except for 1 case, in which we needed a plaster of Paris, we achieved rational stability. On average, the nails were removed after 11.5 months. The healing and complication rates were assessed by follow-up examination of 49 patients. The results were excellent and good in 71.5% patients, satisfactory 11.4% and poor in 17.1%. Complications consisted of a 2.1% infection rate (osteitis), 3.1% non-union, 2.1% with a synostosis, 1% refracture (during removal of the nails) and 3.1% migration of nails, combined with tendon rupture. We have seen 1 case with metallosis. In conclusion with our confined spectrum of indications Hackethal nailing is a low-risk method, which leads to a rational stability and early bone healing.     

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).     

Screw elastic intramedullary nail for the management of adult forearm fractures

Background:

The failure of the conventional nailing of both forearm bones or isolated fractures of radius and ulna pose a potential problem of nail migration and rotational instability, despite the best reduction. The purpose of this paper is to evaluate the results of screw elastic intramedullary nail for the treatment of adult diaphyseal fractures of both forearm bones, which effectively addresses the problems associated with the conventional nailing systems for the forearm fractures.

Materials and Methods:

Seventy-six adults with forearm fractures (radius and ulna or isolated fracture of the single bone) were retrospectively evaluated. Fifty males and 26 females with the mean age of 38 years (range, 18-70 years) underwent closed reduction and screw intramedullary nail fixation. Ten patients required limited open reduction. The fractures were classified according to the AO/OTA system. The average followup was 12 months (range, 6 to 18 months).

Results:

The mean surgical time was 45 minutes (35 to 65 minutes). The meantime to union was 14 weeks (10-21 weeks). The results were graded as excellent in 50, good in 18 patients, and acceptable in eight patients, using the criteria of Grace and Eversman. We had superficial infection in three cases, one case of delayed infection, painful bursa in two cases, delayed union in two cases, malunion with dislocation of the DRUJ in two cases, injury to the extensor tendon of the thumb in one case, and one case of incomplete radioulnar synostosis.

Conclusion:

Closed reduction and internal fixation of forearm fractures by screw intramedullary nails reestablishes the near normal relationship of the fractured fragments. Screw intramedullary nail effectively controls both rotatory forces and the migration of the nail. It produces excellent clinical results in isolated fractures of either bones, as well as both bones of the forearm in adults.     

交锁髓内钉治疗尺桡骨骨折的临床研究

目的介绍交锁髓内钉治疗尺桡骨骨折的疗效。方法采用交锁髓内钉治疗尺桡骨骨折12例,其中桡骨髓内钉12根,尺骨髓内钉10根。结果 随访7~10个月,骨折愈合时间在2~4个月,有1例延迟至6 个月,没有不愈合的病例。大部分功能满意,只有2例C3型骨折遗留部分旋转功能受限。无伤口感染病例。有1例患者术后出现桡神经深支损伤症状,1个月后恢复,主要原因是在行桡骨近端锁钉时所致。结论交锁髓内钉治疗尺桡骨骨折具有创伤小、固定牢固、骨愈合率高及功能恢复快。     

Operative treatment of tibial fractures in children: are elastic stable intramedullary nails an improvement over external fixation?

BACKGROUND: Operative treatment of tibial fractures in children requires implants that do not violate open physes while maintaining tibial length and alignment. Both elastic stable intramedullary nails and external fixation can be utilized. We retrospectively reviewed our experience with these two techniques to determine if one is superior to the other. METHODS: We retrospectively reviewed the operative records and trauma registries of three institutions within our hospital system and identified thirty-five consecutive patients with open physes who had undergone operative treatment of a tibial fracture between April 1997 and June 2004. Four patients were excluded because they had been managed with locked intramedullary nails or with pins and plaster. Of the thirty-one remaining patients, sixteen had been managed with elastic stable intramedullary nails and fifteen had been managed with unilateral external fixation. The clinical and radiographic outcomes were compared. The functional outcomes were compared with use of the Pediatric Outcomes Data Collection Instrument. Complications related to treatment, such as malunion, delayed union, nonunion, infection, and the need for subsequent surgical treatment also were compared. RESULTS: Thirty-one patients with thirty-one operatively treated tibial fractures were available for evaluation. Fifteen patients had been managed with external fixation. Seven of these patients had a closed fracture, and eight had an open fracture. There were seven healing complications in this group, including two delayed unions, three nonunions, and two malunions. Sixteen patients had been managed with elastic stable intramedullary nailing. Eleven patients had a closed fracture, and five had an open fracture. The mean time to union for the intramedullary nailing group (seven weeks) was significantly shorter than that for the external fixation group (eighteen weeks) (p < 0.01). The functional outcomes for the intramedullary nailing group were significantly better than those for the external fixation group in the categories of pain, happiness, sports, and global function (the mean of the mean scores of the first four categories) (p < 0.01 for these comparisons). CONCLUSIONS: When surgical stabilization of tibial fractures in children is indicated, we believe that the preferred method of fixation is with elastic stable intramedullary nailing.     

S1otted锁式髓内钉治疗胫骨开放性骨折

作者应用Ｓ１ｏｔｅｄ锁式髓内钉治疗胫骨开放性骨折６４例,其中粉碎性骨折４７例。除２例失访,其余６２例骨折平均随访１．５年,骨折全部愈合。最终结果评分采用Ｊｏｈｎｅｒ－Ｗｒｕｈ评分标准,优６１例,良１例。６１例骨折平均愈合时间为５．６个月,１例延迟愈合（于术后１２个月愈合）,术后晚期发生胫前浅表感染１例,未影响骨折愈合。所有病例未发现髓内钉断裂和锁钉断裂、脱出及拨钉后再骨折等情况。作者认为Ｓ１ｏｔｅｄ髓内钉可用于胫骨干的各段骨析（包括高位和低位骨折）,对粉碎性骨折效果良好,且操作简单,不需特殊设备及器械,固定后能较好控制旋转,促进骨折愈合,是一种比较好的内固定方法。