Limb length discrepancy following titanium elastic nailing in paediatric femoral shaft fractures

The authors performed a prospective study to evaluate limb length discrepancy in children following titanium elastic nailing for femoral shaft fractures. Thirty-seven children (28 boys and 9 girls) were included in the study. The average time to radiological union in our study was 7.8 weeks (range: 5 to 14). Results after 3 years were evaluated for 29 children. Limb lengthening was noted in the first year in 15 children: at the time of nail removal, an average of 10.6 mm and at the end of one year 8.7 mm. After three years only nine were lengthened an average of 2.7 mm. An average of 12.6 mm shortening was seen in four patients at the time of nail removal, reduced to 12.1 mm at the end of one year. After three years three remained short, an average of 11.7 mm. No limb length discrepancy was seen in 10 patients. We conclude that limb length discrepancy is common following elastic nailing in paediatric femoral fractures, with lengthening being more frequent than shortening. Lengthening tends to decline with time at an average rate of around 1.5 mm per year.     

Open versus closed intramedullary nailing of femoral shaft fractures

A retrospective study was performed including only fractures involving the middle three fifths of the femoral shaft with a minimum of 2 years followup. There were 65 fractures in Group I treated with the closed technique utilizing the image intensifier. These were compared with 65 fractures treated with open reduction and nailing. Followup averaged 4 years (Group II). Group 1 had 92% satisfactory results; Group II achieved 97% satisfactory, not statistically significantly different. Our recommendations are delaying the procedure did not appear to be advantageous; excluding the fractures with segmental bicortical loss, there are limited indications for locked nails in these fractures; the decision to use a specific type of internal fixation should be based on the fracture pattern, the surgeon's experience, and the equipment available; if a closed technique is chosen, be prepared to open the fracture if a satisfactory closed reduction cannot be attained. This, in our study, did not increase the risk of reducing the functional result.     

Flexible intramedullary nailing in paediatric femoral shaft fractures

This retrospective study aims to evaluate the efficacy of flexible intramedullary (IM) nails as a fixation device of paediatric femoral shaft fractures. A total of 36 children with 37 closed fractures were treated by this method. The patients ranged in age from 7.2 to 13.5 years and the mean follow-up was 25.5 months. All patients had open femoral growth plates at the time of surgery. All fractures united and none of the patients needed re-operation. Complications included pain/irritation at the insertion site,⁶ superficial wound breakdown¹ and one case of delayed union. No major complications were recorded. After nail removal, all children had full range of hip and knee motion. At final follow-up, although radiographs revealed that 44% of the children had malalignment at the fracture site in one or both planes, none of the children presented with clinical malalignment of the fractured limb. Maximum angulation that was calculated on the coronal plane was 5° into varus and on the sagittal plane 7° of anterior angulation (apex posteriorly). Leg-length discrepancy was assessed clinically and radiographically when needed. A total of 50% of the children had a leg-length inequality but none of them complained of a functional problem. Flexible nailing of diaphyseal fractures of the femur is a reliable method with a small learning curve and allows early mobilisation. Most of our minor complications were technique related and could be avoided.     

闭合复位带锁髓内钉治疗股骨干骨折

目的：探讨闭合复位带锁髓内钉治疗股骨干骨折的临床疗效.方法：自2006年3月至2011年12月采用闭合复位带锁髓内钉治疗103例股骨干骨折患者,其中男76例,女27例;年龄19～55岁,平均36岁.按照AO分型：A型64例,B型27例,C型12例;开放性骨折13例（Gustilo Ⅰ型5例,Ⅱ型8例）.观察术后患者骨折愈合时间,并采用膝关节HSS评分标准对术后1年膝关节功能恢复情况进行评价.结果：术中发生股骨颈骨折1例,股骨近端骨折1例,均于术中更换重建钉固定,术后骨折愈合.术中发生腓总神经损伤1例,营养神经治疗4个月后恢复.103例患者全部获得随访,时间12～28个月,平均22个月.全部患者获得骨性愈合,愈合时间3～9个月,平均5个月.髋关节功能全部恢复正常,术后1年膝关节行HSS评分平均90.89±5.06.结论：注重手术操作,力求闭合复位,减少并发症,带锁髓内钉是治疗股骨干骨折的首选方法.     

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

IntroductionOptimal 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.MethodsA 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.ResultsThere 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.ConclusionThis 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 evidenceIV     

Retrograde versus antegrade nailing of femoral shaft fractures

OBJECTIVES: To compare union rates and complications of retrograde intramedullary nailing of femoral shaft fractures with those of antegrade intramedullary nailing. DESIGN: Retrospective. SETTING: Level I trauma center. PATIENTS: Two hundred eighty-three consecutive adult patients with 293 fractures of the femoral shaft who underwent stabilization with antegrade or retrograde inserted femoral nails were studied. There were 140 retrograde nails and 153 antegrade nails. Twelve fractures in twelve patients were excluded (three in patients who died early in the postoperative period, three in patients because of early amputation, four in patients who were paraplegic, and two in patients who fractured through abnormal bone owing to metastatic carcinoma), leaving 134 fractures treated with retrograde nails and 147 treated with antegrade nails. One hundred four femurs treated with retrograde nails (Group R) and ninety-four femurs treated with antegrade nails (Group A) had sufficient follow-up and served as the two study groups. The average clinical follow-up was twenty-three months (range 6 to 66 months) for Group R and twenty-three months (range 5 to 64 months) for Group A. Both groups were comparable with regard to age, gender, number of open fractures, degree of comminution, mode of interlocking (i.e., static or dynamic), and nail diameter (p > 0.05). INTERVENTION: Retrograde intramedullary nails were inserted through the intercondylar notch of the knee, and antegrade nails were inserted through the pirformis fossa using standard techniques. MAIN OUTCOME MEASURES: Union, delayed union, nonunion, malunion, and complication rates. RESULTS: After the index procedure there were no significant differences in healing or incidence of malunion between Group R and Group A (p > 0.05). Healing after the index procedure occurred in ninety-one (88 percent) of the femurs in Group R and in eighty-four (89 percent) of the femurs in Group A. In Group R, there were seven delayed unions (7 percent) and six nonunions (6 percent). In Group A, there were four delayed unions (4 percent) and six nonunions (6 percent). Healing ultimately occurred in 100 (96 percent) femurs from Group R and in ninety-three (99 percent) femurs from Group A. In Group R, there were eleven malunions (11 percent), and in Group A, there were twelve malunions (13 percent). When patients with ipsilateral knee injuries were excluded, the incidence of knee pain was significantly greater for Group R patients (36 percent) than for Group A patients (9 percent) (p < 0.001). When patients with ipsilateral hip injuries were excluded, the incidence of hip pain was significantly greater for Group A patients (10 percent) than for Group R patients (4 percent) (p < 0.05). CONCLUSIONS: Retrograde and antegrade nailing techniques provided similar results in union and malunion rates. There were more complications related to the knee after retrograde nailing and more complications related to the hip after antegrade nailing.     

Cost analysis of managing paediatric femoral shaft fractures: flexible intramedullary nailing versus non-operative management

This retrospective study aimed at comparing the cost of operative treatment versus non-operative treatment in the management of isolated paediatric femoral shaft fracture, in a single Trauma and Orthopaedic unit in a district general hospital in South East England. Patients were divided into three groups according to their treatment, and the cost was analysed depending on their requirements for hospital stay, theatre, physiotherapy, radiographs and plaster cast. Sixty-two children were admitted to our trauma unit with an isolated femoral shaft fracture from January 2001 to April 2005. There is a significant variation in the cost between the 16 patients treated with operative flexible nailing in comparison with those treated non-operatively either by traction alone (31 patients), or by traction followed by cast (15 patients). Operative treatment was shown to reduce the inpatient stay by approximately 75% (mean of 9.8 days in the operative group in comparison to 39.3 days in the non-operative group). It has also reduced the overall cost for treatment by more than 60% in comparison to traction alone and by almost 30% in comparison to using traction followed by casting.     

Percutaneous skeletal joysticks for closed reduction of femoral shaft fractures during intramedullary nailing.

Closed locked intramedullary nailing remains the most common method for treating femoral shaft fractures. At times a closed reduction of these fractures can be difficult. A percutaneous skeletal joystick represents a simple method that can aid in the reduction maneuver.     

闭合与切开复位弹力钉固定儿童不稳定型股骨干骨折

[目的]比较闭合复位与有限切开复位弹性钉结合尾帽治疗儿童不稳定型股骨干骨折的临床疗效及影像学结果。[方法]回顾性分析本院2012年1月～2016年6月收治的54例年龄5～13岁的股骨干不稳定型骨折患儿资料,其中30例采用闭合复位弹性钉结合尾帽固定(闭合组);24例采用有限切开复位弹性钉结合尾帽固定(切开组)。比较两组患儿的围手术期、随访和影像资料。[结果]两组患者手术均顺利,术中无神经、血管损伤。切开组手术时间及术中平均透视时间均明显小于闭合组(P<0.05),但两组在术中失血量、住院时间差异无统计学意义(P>0.05)。随访20～25个月,平均(22.28±1.65)个月。两组患者在术后部分负重时间、骨折愈合时间和末次随访时Harris评分的差异均无统计学意义(P>0.05)。随访过程中,出现退针钉尾激惹闭合组4例,切开组1例,均在骨折愈合取出弹性钉后症状完全消失。末次随访时,成角>5°者闭合组8例,切开组3例;两组均无旋转畸形;下肢长度差异>1cm者闭合组8例,切开组4例。两组患儿均无骨折不愈合、延迟愈合,弹性钉取出后无再发骨折,无髋、膝关节活动受限等并发症。影像评估方面,切开组Beaty评级满意率(91.67%)显著高于闭合组(53.33%)(P<0.05);切开组Flynn髓内钉疗效评级优秀率(62.50%)显著高于闭合组(16.67%)(P<0.05)。[结论]有限切开复位弹性钉结合尾帽固定治疗不稳定型儿童股骨干骨折可以获得更好的骨折对位与固定,并发症更少,而且明显缩短了手术时间及放射线暴露,是一种更为优良的治疗方法。     

Treatment of unstable femoral shaft fractures with closed interlocking intramedullary nailing

From 1979 to 1982, 64 femoral shaft fractures in 62 patients were treated by closed interlocking nailing at Harborview Medical Center, Seattle, WA, U.S.A., and Parkland Memorial Hospital, Dallas, TX, U.S.A. Twenty-nine patients sustained multiple system injuries and 29 of the involved extremities (45%) had at least one additional injury. There were 17 (26%) open fractures. Static mode nailing was used to treat 52 fractures; dynamic mode nailing was performed for 12 fractures. Patient follow-up averaged 17 months (range 7-41 months). The average time to union was 13.5 weeks. Normal femoral length within 1 cm was achieved in 97% of cases. Knee range of motion averaged 127 degrees. Complications (9%) included two delayed unions, one nonunion, two cases of shortening or lengthening of more than 1 cm, and one case of malunion with angulation or more than 10 degrees. The delayed unions and nonunions healed after one additional procedure. This study shows that closed interlocking nailing is a safe, effective technique that provides stable fixation in most unstable femoral shaft fractures. This technique represents a major advance in the treatment of difficult femoral shaft fractures that would be poorly suited for standard closed nailing.     

Flexible intramedullary nailing versus external fixation of paediatric femoral fractures

Treatment outcomes were compared in two groups of children with femoral diaphyseal fractures which were treated with external fixation (20 fractures) or flexible intramedullary nailing (20 fractures). These 40 children were between 5.4 to 14.1 years of age. The duration of the operation averaged 52 minutes for the external fixator compared with 70 minutes for the flexible nail group. The time taken to gain full weight bearing, full range of movements and return to school was shorter in the flexible intramedullary nail group. There was a higher complication rate in the external fixator group than in the flexible nail group. At final review, three patients in the external fixator group had pain, two had leg-length discrepancy of up to 1 cm, and four had malalignment of 5 degrees -10 degrees. In the nailing group, there were no leg-length discrepancies or malalignments. We recommend the use of flexible intramedullary nailing for fractures of the femoral shaft in children which require surgery, and reserve external fixation for open or severely comminuted fractures.     

Slotted versus non-slotted locked intramedullary nailing for femoral shaft fractures

Summary Experimentally, two slotted nails, the Grosse-Kempf nail and the AO/ASIF universal femoral nail, were compared to the non-slotted Grosse-Kempf nail and control bone using a cadaver femoral osteotomy. The stiffnesses and strengths of the osteotomies fixed with slotted nails in 10–30° torsion were 6–8% and the values of non-slotted nails 40% of control bone. The maximal moments were 14–18% and 48%, respectively. In the clinical range of torsion, the implant-bone construct never failed or was deformed. Clinically, 46 femoral shaft fractures were randomized to treatment with Grosse-Kempf nails, 24 with slotted nails and 22 with non-slotted nails. Four complications in the slotted nail group and three in the non-slotted nail group were considered to be independent of the choice of nail and did not affect the end result. Three splinterings of the distal fragment, one resulting in a change of the osteosynthesis implant to a condylar plate, were considered to result from the high stiffness of the non-slotted nail. Osteosynthesis of femoral shaft fractures using slotted nails has not resulted in healing disturbances, which could be accounted for by the high torsional elasticity of the nail; there seems to be no indication for high-stiffness nails in femoral fractures.     

Open versus closed nailing of femoral fractures in the polytrauma patient

Thirty-four patients with severe multiple injuries underwent either open or closed nailing of 35 femoral fractures. Open nailing was performed in 17 femurs and closed nailing in 18 femurs. The average abbreviated injury score was 27 in both the open group (range: 17-45) and closed group (range: 22-36). Soft tissue injuries were present in eight (47%) cases in the open group compared to three (16%) in the closed group. The treatment protocol was similar in both groups. Intramedullary nailing was delayed an average of 11 days in the closed group. This was significantly different than the open group where the average time to nailing was less than 24 hours (p less than 0.001). Reamed nails were used in all cases except for two in the closed group. The median time to fracture healing was 5.0 months in the open group and 4.1 months in the closed group, with an average follow-up of 18 months in both groups. Two cases required reoperation (one nonunion and one shortening at the fracture site). Both these cases were in the open group. There were no superficial or deep infections in either group. Closed reamed intramedullary nailing is recommended for treatment of diaphyseal femur fractures in patients with severe coexistent injuries. Open nailing should be reserved for cases in which an adequate reduction cannot be achieved by closed methods.     

Complications of titanium elastic nails for pediatric femoral shaft fractures

Limited data exist about complications of titanium elastic nails (TNs) for femur fracture management in pediatric patients. Thirty-nine patients with 43 femoral shaft fractures were identified whose average age was 6.0 years. There were 21 complications (1 intraoperative, 20 postoperative) in 43 femur fractures (49%). There were two major postoperative complications: one septic arthritis after nail removal and one hypertrophic nonunion. Minor postoperative complications were pain at the nails in 13 extremities, nail erosion through the skin in 4, and one delayed union. There was an association between the prominence of TNs and nail pain or skin erosion. Fracture angulation and outcome were associated with the patient's weight and size of the nails implanted. Technical pitfalls exist with this implant and can be minimized by leaving less than 2.5 cm of nail out of the femur and by using the largest nail sizes possible.     

Retrograde nailing for distal third femoral shaft fractures: a prospective study

PURPOSE. To evaluate the postoperative knee function and results of unreamed retrograde nailing for distal third femoral shaft fractures. METHODS. Between January 2002 and 2003 inclusive, a consecutive series of 27 patients (with 28 fractures) who underwent retrograde nailing were prospectively evaluated. Outcome measures were union time, initiation of weight bearing, deformity and shortening, functional length of the nail, knee function assessed using a modified Knee Society Knee Score. Correlations between union time and other variables were also studied. RESULTS. In these patients 26 (93%) of the 28 fractures achieved union, of which 5 underwent dynamisation; the mean union time for the other 21 fractures was 4.4 months. Angular malalignment was present in 4 patients and shortening in 4 others. There was negligible correlation between union time and variables of nail-canal diameter mismatch, functional length of nail, fracture geometry, or initiation of partial weight bearing ambulation. Knee flexion of more than 100 degrees was achieved in 26 patients. 19 patients had anterior knee pain and 10 had instability. By the end of one year, excellent or good scores for pain and function were recorded in 77% and 73% respectively, of the 26 patients. CONCLUSION. In view of such favourable union rates but significant deterioration in overall knee joint function, at best retrograde nailing is a reliable alternative in the management of selected complicated fractures of the distal femoral shaft.     

Results of titanium elastic nailing in paediatric femoral diaphyseal fractures-report of 30 cases

Objective:Fractures of the femur are the most incapacitating fractures.For children aged 6-14 years,there is no clear consensus as to the preferred treatment.The conventional treatment of traction and ...     

弹性髓内针治疗儿童股骨干骨折

自2005年4月至2008年1月采用弹性髓内针(ESIN)治疗38例股骨干骨折患儿,疗效满意,现报告如下.     

保守治疗与钛制弹性髓内钉治疗移位锁骨中段骨折的疗效对比分析

目的 比较保守治疗与钛制弹性髓内钉(TEN)治疗明显移位锁骨中段骨折的疗效.方法 回顾性研究2005年2月至2007年9月间采用保守治疗(保守治疗组,100例)或TEN固定(TEN固定组,60例)治疗并获得随访的160例移位锁骨中段骨折患者资料.比较两组患者术后的肩关节功能(Constant评分和DASH评分)、患者对治疗结果的满意度、恢复正常生活的时间、并发症发生率、肩部外观及锁骨愈合后的X线表现.结果 所有患者术后获平均18个月(9～31个月)随访.保守治疗组和TEN固定组Constant评分分别为72.5分和90.5分(t=3.280,P=0.020),DASH评分分别为26.5分和2.4分(t=2.420,P=0.032);满意率分别为75.0%和96.7%(X2=1.450,P=0.042);恢复正常生活时间分别为6～8周和2～3周;并发症发生率分别为13.0%和3.3%(X2=1.890,P=0.020).保守治疗组28例肩部不对称,42例解剖位置愈合.TEN固定组肩部基本对称,56例解剖位置愈合.结论 TEN固定治疗移位的锁骨中段骨折,在肩部功能评分、满意率及并发症发生率等方面比保守治疗更有优势,因此不推荐使用保守治疗,TEN固定可作为一种有效的治疗方法.