Flexible intramedullary nailing in pediatric lower limb fractures

Seventy-three children (48 boys and 25 girls; mean age, 5.7 years) with unilateral femoral or tibial shaft fractures were treated using elastic intramedullary nails at the authors' institution. There were 61 simple type A fractures (84%) and 12 wedge type B fractures (16%). All but 3 children had closed fractures. Associated injuries were seen in one third of the cases. All fractures were reduced by closed manipulation. Union was achieved in all cases without additional intervention. Technical problems occurred in few patients. Improper nail length was seen in 4 cases. None of the study patients developed deep infection. No angulation greater than 15 degrees was found after femoral fractures. Nine patients had length discrepancy greater than 10 mm. Spiral fractures showed a tendency for shortening whereas transverse fractures were more associated with post-traumatic lengthening. No significant axial malalignment or shortening was seen in tibial fractures. Torsional differences of greater than 15 degrees were detected by computed tomography or navigated ultrasound examination in nearly half of the patients; however, only 4 children had clinically apparent gait changes. The study confirms the satisfactory results of treating pediatric lower limb fractures using elastic nails. Proper surgical technique and intraoperative control of limb alignment can help avoid postoperative deformities.     

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 ...     

CT scanogram for limb length discrepancy in comminuted femoral shaft fractures following IM nailing

IntroductionLeg length discrepancy (LLD) following intramedullary nailing of femoral fractures is not uncommon. We designed a prospective study to evaluate the efficacy of routine postoperative computed tomography (CT) scanograms for evaluation of limb length discrepancy in patients with comminuted Winquist III or IV femoral shaft fractures treated with intramedullary nailing.MethodsThe study consisted of 15 patients with Winquist III and 13 with a Winquist IV femoral shaft fracture pattern with an average age of 37 years. The mechanisms of injury were motor vehicle collision (13), gunshot wound (12) and falls (three). All patients were treated with a statically locked intramedullary femoral nail (18 antegrade and 10 retrograde). A CT scanogram evaluated limb length in all patients. A discrepancy of greater than 20 mm was considered for correction during the same admission. An LLD of 15–20 mm was discussed with the patient extensively for correction.ResultsIn the 28 patients included in our study, the average limb length discrepancy was 9.1 mm with a range of ?43.5 mm short to 10.3 mm long. The LLD was less than 10 mm in 18 patients (64%), 10–15 mm in four patients (14%), 15–20 mm in three patients (11%) and more than 20 mm in three patients (11%). Measurement of discrepancy as small as 0.5 mm showed that 18 patients were fixed with shortening and in 10 patients the operated femur was longer. Tibia lengths were also evaluated separately. Though none of the tibiae had a previous fracture, only three patients (10%) had tibiae of equal length. In 13 patients, an unequal tibia partially corrected the LLD whilst in 12 it added to the discrepancy. Five patients with LLD of greater than 15 mm underwent correction.ConclusionsA postoperative scanogram in patients with comminuted femoral shaft fractures treated with intramedullary nailing is useful to evaluate LLD and allows for early intervention. The ideal length where correction is necessary remains unclear.     

Pediatric femoral shaft fractures treated by flexible intramedullary nailing

Background: Nowadays pediatric femoral fractures are more commonly managed with operative treatment rather than conservative treatment because of more rapid recovery and avoidance of prolonged immobilization. Children between the ages of 5e13 years are treated either by traction plus hip spica and flexible/elastic stable retrograde intramedullary nail, or external fixators in the case of open fractures. The aim of this study is to evaluate the outcome of pediatric femoral shaft fractures treated by stainless steel flexible intramedullary nail in children between 5 and 13 years of age. Methods: There were 32 cases of femoral shaft fractures which were all fixed with stainless steel flexible intramedullary nail under fluoroscopy. Long leg cast was applied at the time of fixation. Partial weight bearing was started 2 weeks after surgery. Patients were evaluated in follow-up study to observe the alignment of fracture, infection, delayed union, nonunion, limb length discrepancy, motion of knee joint, and time to unite the fracture. Results: We were able to follow up 28 out of 32 patients. The patients were 8.14 years of age on average. The mean hospital stay after operation was 4 days and fracture union time was 9.57 weeks. There were 3 cases of varus angulation, 2 cases of anterior angulation, and 4 cases of limb lengthening. Conclusion: Patients aged between 5 and 13 years treated with flexible intramedullary nail for closed femoral shaft fracture have rapid union and recovery, short rehabilitation period, less immobilization and psychological impact, and cost-effective.     

Submuscular plating of pediatric femur fracture

Currently, surgical management of pediatric femur fracture consists of intramedullary nailing with flexible nails or rigid trochanteric entry nails. Rigid trochanteric entry nails are the implant of choice for femoral fractures in adolescents, whereas titanium elastic nails are popular for the management of length-stable diaphyseal femoral fractures in school-age children. However, higher complication rates have been reported in children with length-unstable diaphyseal femoral fractures treated with titanium elastic nails. These complications may require unplanned surgery. Fracture shortening or angulation can lead to nail prominence or exposure that may require nail shortening or removal. Recently, submuscular plating has been found to be a successful alternative option for management of length-unstable femoral fractures in school-age children. Submuscular plating can also be used in older and/or heavier children who have a femoral canal that is too small to accommodate a rigid intramedullary nail.     

弹性髓内钉治疗儿童股骨干骨折35例经验及文献综述

目的探讨弹性髓内钉治疗儿童股骨干骨折的效果并文献综述。方法 2007月7月至2014年6月,采用弹性髓内钉治疗儿童股骨干骨折35例,男28例,女7例,年龄5~13岁,平均年龄9.2岁,评估手术时间、术中出血量、住院时间、负重时间,骨折愈合时间及疗效评估。结果手术平均持续65 min(45~95 min),平均失血量为70 mL,平均住院8天(6~14天)。本组病例术后随访6~20个月,平均约14个月。所以患者均获得一期愈合,愈合时间6~9周,平均愈合时间约7.5周。无术后感染、骨不连、断钉、骨骺损伤等并发症发生。其中2例有钉尾激惹导致膝部皮肤轻度疼痛,在内固定取出疼痛消失。术后一年测量发现15例肢体不等长情况,其中3例患肢短缩,12例患肢延长,但均在1.5 cm内,对患者的行走无明显影响,并在随后的随访中发现肢体不等长现象得到纠正。按Flynnetal治疗评价标准测定,治疗效果痊愈31例,良好4例。结论弹性髓内钉治疗稳定性儿童股骨干骨折,具有手术时间短、失血量少、创伤小等优点。     

Intramedullary Kirschner wire (K-wire) fixation of femoral fracture in children

Purpose The aim of this study was to evaluate the efficacy of standard intramedullary Kirschner wires (K-wires) for the treatment of femoral shaft fracture in children. Methods We report the results of intramedullary K-wires nailing in 178 children with a mean age of 7.7 years (range, 4–14 years) from 2000 to 2005, retrospectively. A total of 184 diaphyseal femoral fractures were treated with both antegrade and retrograde nailing using the same principles of elastic stable intramedullary nailing (ESIN). The patients were followed for 12 months on average (range, 6–24 months). Results No major complication (limb length discrepancy >15 mm, non-union, avascular necrosis, knee joint stiffness) occurred during the observation period. All fractures healed within 7.1 weeks on average (range, 5–12 weeks). Associated injuries were seen in 16.9% of the cases. All but seven fractures were reduced by closed manipulation. Early mobilization and weight bearing was allowed. Intramedullary K-wires were removed after an average of 4.8 months (range, 3–12 months) without any complications. Conclusions In children, intramedullary fixation by using standard K-wires provides effective treatment for the diaphyseal femoral fracture that has excellent clinical results. Each intramedullary K-wire costs US $5, which adds a cost effective advantage to this method of treatment.     

Erfahrungen mit der elastisch stabilen intramedullären Nagelung (ESIN) diaphysärer Frakturen im Kindesalter

The aim of this prospective clinical controlled trial was to investigate the early and midterm results of shaft fractures in children treated with elastic stable intramedullary nailing (ESIN). From January 1997 to December 2001, elastic stable intramedullary nailing was carried out on 112 children with 118 diaphyseal fractures. The mean age was 7.7 years. There were 51 fractures of the lower arm, 46 femoral fractures, 14 of the lower leg, and 7 of the humerus. A total of 92 children have been followed up for more than 12 months. The mean time of follow-up was 38 months.The mean time of fluoroscopy was 2.2 min. Open reduction was necessary in 3.4 %. In children with injuries of the lower extremity, full weight bearing was achieved after a mean period of 9.3 days. In 1.8% of the children, reoperation was necessary within the first 10 days after the operation. In 3.6 % there was painful skin irritation due to the protruding end of a nail. No infection or delayed union was observed. Implant removal was done after a mean time of 5.6 months. There was no rotational or angular deformity of more than 5 degrees in children with isolated fractures of the lower extremity. Mean lengthening of the injured leg was 2.4 mm. In three children who had fractures of the upper extremity, a deficit in range of motion of the adjacent joints was detected. The current results show that intramedullary fixation of displaced diaphyseal fractures in children with a flexible titanium nail is a safe, minimally invasive surgical technique producing excellent functional and cosmetic results.     

One-stage lengthening using a locked nailing technique for distal femoral shaft nonunions associated with shortening

OBJECTIVE: To assess the effectiveness of a one-stage lengthening using a locked nail technique for the treatment of distal femoral shaft nonunions associated with shortening. DESIGN: Retrospective. SETTING: University hospital. PATIENTS AND METHODS: During a 6-year period, 36 distal femoral shaft nonunions associated with shortening (>1.5 cm) were treated by the one-stage lengthening technique. Indications for this technique were distal femoral shaft aseptic or quiescent infected nonunions, 1.5-5 cm shortening, and a fracture level suitable for the insertion of two distal locked screws. The surgical technique involved skeletal traction using the femoral condyle, local débridement, lengthening by 相似文献   

Evaluation and compensation of lower limb length discrepancy after surgical treatment of developmental hip dysplasia

Summary The aim of this study was to find a solution for lower limb length discrepancy following surgical treatment of developmental hip dysplasia (DDH) in neglected cases. For this purpose, radiographic examination of 49 hips of 33 children with DDH was made. They were surgically treated by one-stage combined procedure that consisted of open reduction, modified innominate osteotomy and proximal femoral osteotomy. Mean age was 3.5 years and mean follow-up was 34.3 months. In bilateral cases this procedure did not cause notable lower limb length discrepancy. In unilateral cases, it was seen that limb length could be balanced by performing a modified innominate osteotomy producing transiliac lengthening in children older than 4 years. In children younger than 4 years there was no need to perform an acetabuloplasty producing transiliac lengthening because extensive femoral shortening was not needed and femoral overgrowth was sufficient to balance the length of lower limbs. Also avascular necrosis of the femoral head was observed as one of the important factors producing limb length discrepancy in variable degrees.This study was presented in part at the 20th World Congress of SICOT in Amsterdam, The Netherlands, 18–23 August 1996.     

Femoral lengthening over a humeral intramedullary nail in preadolescent children

BACKGROUND: Femoral lengthening over an intramedullary nail has been described in adults. A technique of femoral lengthening over a humeral intramedullary nail in children is described, and the results and complications are presented. METHODS: Nine preadolescent patients (average age, nine years and ten months) with femoral length discrepancy were treated with femoral lengthening over a humeral intramedullary nail. After nail insertion, a monolateral external fixator was placed with half-pins either anterior or posterior to the intramedullary nail, and lengthening was performed through a proximal osteotomy. RESULTS: The femora were lengthened a mean of 6.1 cm (range, 5.0 to 8.0 cm), 19.5% (range, 15.9% to 26.2%) of the preoperative femoral length. Patients had a mean lengthening index of 12.2 days/cm of length (range, 9.5 to 16.9 days/cm of length). Five complications including osteomyelitis, failure of the distal interlocking site, and femoral fracture at the distal end of the nail occurred in four patients; four of the complications led to surgical intervention. No case of proximal femoral valgus secondary to nailing through the greater trochanter had developed by the time of final follow-up. All patients were followed for a minimum of two years postoperatively, with a mean of 128 weeks (range, 111 to 161 weeks). CONCLUSIONS: The technique is effective but has a high rate of complications, including osteomyelitis, which developed in two of the nine patients. No avascular necrosis or proximal femoral valgus was noted.     

Lengthening of the femur over an existing intramedullary nail

Leg length discrepancies can occur despite successful union of femur fractures after intramedullary nailing (IMN). Often, the leg length discrepancy can result in significant disability to the patient, altered gait biomechanics, pelvic obliquity, and pain. Therefore, a successful clinical result for such deformities after IMN involves addressing the leg length inequality. Femoral reconstruction with an osteotomy around an existing intramedullary nail was introduced to address axial deformity correction and limb lengthening without changing or removing a previously inserted IMN. This technique uses the principles of lengthening over an IMN. The presence of the nail has minimized the time needed for the external fixator because the nail supports the regenerate bone or osteotomy during the consolidation phase. With this technique, surgery is minimized by avoiding the need for exchange nailing.     

Lengthening of congenital limb length discrepancy using callotasis: early experience of the Hospital for Sick Children.

Seventeen patients were reviewed after callotasis lengthening for congenital limb length discrepancy. The average age at lengthening was 10.8 years. Length discrepancy before lengthening ranged from 4.5 cm to 12 cm for the leg, and 24 mm to 30 mm for the forearm. At completion of the lengthening process, all but one patient had their discrepancy corrected successfully. The difficulties encountered were classified into problems, obstacles and complications. All patients suffered from superficial infection, but in only one case did this become a complication, resulting in a residual femoral discrepancy of 2 cm. Of the other three patients who suffered a complication, one fractured through the newly formed bone. The fracture was treated conservatively. In two further femoral lengthenings, the fixator had to be exchanged under general anaesthesia because it had reached its maximum excursion. Callotasis appears to be a safe and reliable method for correcting congenital limb length discrepancy in children.     

Unreamed femoral nailing

Sixty one femoral fractures treated with ACE unreamed titanium nail (AIM femoral nail, ACE Medical, Los Angeles, CA) were studied. Ten patients died before bony union and three were lost to follow up. Forty eight fractures were followed up for an average of 11.2 months (4-31 months). All fractures united except one in which plating and bone grafting was performed at 6 months due to failure of progression of union. The mean time to bony union was 6.2 months. There was no implant failure but one distal interlocking bolt broke at 6 weeks. No incidence of adult respiratory distress syndrome (ARDS) was observed. Malunion was seen in one patient whereas three cases had shortening of more than 2 cm. Our results show that unreamed femoral nailing using titanium nail is a safe and effective procedure for the treatment of femoral shaft fractures.     

Treatment of femoral shaft fractures in young children: comparison between conservative treatment and retrograde flexible nailing

Outcomes of pediatric femoral fractures treated with traction followed by cast (conservative treatment) were compared with flexible nailing treatment. Fifty-one femoral fractures (24 conservative, 27 nail) from 46 patients were studied retrospectively. Four cases of angular deformities greater than 10 degree were observed from the conservative treatment and none from the nailing group. Conservative treatment showed a wider variance of leg length discrepancy (LLD) and four cases showed severe LLD greater than 10 mm. The nailing group had no discrepancy. Retrograde flexible nailing may result in more reliable outcomes than conservative treatment for femoral fractures.     

Treatment of femoral shaft aseptic nonunion associated with broken distal locked screws and shortening

BACKGROUND: This retrospective study investigated the treatment of femoral shaft aseptic nonunions associated with broken distal locked screws and shortening. METHODS: In this study, 11 femoral shaft aseptic nonunions associated with both broken distal locked screws and shortening in 11 consecutive adult patients were treated. All nonunions were associated with at least 1.5 cm (range, 1.5-3.5 cm) shortening. These nonunions were treated by removal of locked nails, one-stage femoral lengthening, static locked nail stabilization, and corticocancellous bone graft supplementation. Postoperatively, ambulation with protected weightbearing was encouraged as early as possible. RESULTS: Ten nonunions were followed up for a median of 4.1 years (range, 1.8-5.5 years), and nine fractures healed at a median of 4 months (range, 3-6 months). The nonunion case had broken locked screws again at 5 months and was treated with exchange nailing. The fracture healed uneventfully at 4 months. No other complications occurred. CONCLUSIONS: The key to removal of broken screws is withdrawal of the nail slightly to release the incarcerated broken screw end. The screw end then is pushed out with a used Knowles' pin or a smaller screwdriver under image intensifier guidance. Concomitant one-stage femoral lengthening to treat nonunion with shortening has a high success rate.     

Closed, locked intramedullary nailing of pediatric femoral shaft fractures through the tip of the greater trochanter

BACKGROUND: Closed femoral nailing is universally accepted as the treatment of choice in almost all diaphyseal femoral fractures in adults. Numerous authors reported favorable results applying the same surgical technique in the adolescent patient group. Nevertheless, reports of complications such as avascular necrosis and alteration of the proximal femoral anatomy have dampened the initial enthusiasm. The purpose of this paper was to evaluate the possible effect of closed intramedullary nailing through the greater trochanter on the proximal femoral anatomy. METHODS: We report the results of intramedullary nailing in 20 skeletally immature patients (13 men and 7 women) with a mean age of 14.4 years (range, 11-16 years). All were treated with closed, reamed, percutaneously performed nailing, using the tip of the greater trochanter as the nail insertion point. The patients were followed for 29 months in average (range, 19-37 months). RESULTS: No major complication (limb length discrepancy, avascular necrosis, coxa valga) occurred during the observation period. All fractures healed clinically and radiographically within 9 weeks in average (8-13 weeks) and all patients returned to the preinjury activity level. The mean ATD difference was 1.10 +/- 3.51 (range, -5-7 mm, 95% CI -0,54/2,74, p = 0.177). The mean LTA distance difference was 0.3 mm (range, -6-5 mm, p = 0.158), the mean femoral length difference was 1.9 mm (-9-12 mm, p = 0.122) and the overall limb length difference was 1.4 mm (-25-20 mm, p = 0.178). The mean neck-shaft angle difference was 0.20 +/- 1.74 (range, -3-4, p = 0.612) and the mean neck width was 0.60 +/- 1.50 (range, -3-3, p = 0.09). Fourteen nails (70%) were removed within 13 months in average (range, 10-18 months) without any complications. CONCLUSION: This study showed that with strict adherence to a surgical technique that respects the growing proximal femur and its vascular anatomy, using the tip of the greater trochanter as an entry point to the femoral canal, the proven advantages of closed, intramedullary nailing can safely be offered to the adolescent patient population as well.     

Treatment of severely displaced proximal humeral fractures in children with elastic stable intramedullary nailing

We report on our 8-year experience of using elastic stable intramedullary nailing for severely displaced proximal humeral fractures in children. Fourteen patients (mean age 13.4 years) with seven epiphyseal and seven metaphyseal fractures underwent intramedullary nailing, using single nail fixation in 12 cases. Clinical and radiological healing was achieved at 2.4 and 3.2 months, respectively. Complications included temporary shoulder and elbow stiffness in one and four cases, respectively, one nail breakage at removal, two cases with minor humeral shortening, and two cases with minor varus deformity. At the final (14.6-month) follow up all patients had a symptom-free full range of motion. Elastic stable intramedullary nailing is a valid method of treating severely displaced proximal humeral fractures in children.     

Intramedullary nailing of femoral fractures in children through the lateral aspect of the greater trochanter using a modified rigid humeral intramedullary nail: preliminary results of a new technique in 15 children

OBJECTIVES: To evaluate the clinical results of intramedullary nailing of femoral shaft fractures using a rigid intramedullary nail placed through the lateral aspect of the greater trochanter in older children and adolescents. DESIGN: A retrospective study was carried out evaluating all skeletally immature patients with femoral shaft fractures treated using a modified rigid humeral intramedullary nail. PATIENTS/PARTICIPANTS: Fifteen children and adolescents with displaced femoral diaphyseal fractures and open physes. INTERVENTION: Femoral shaft fractures in children and adolescents were stabilized using a modified humeral intramedullary nail placed through the lateral aspect of the greater trochanter. MAIN OUTCOME MEASUREMENTS: Patients were evaluated to determine time to union, final fracture alignment, hospital stay, complications, clinical outcome, and proximal femoral changes including avascular necrosis or proximal femoral valgus with femoral neck narrowing. RESULTS: Fifteen patients were followed for a minimum of 1 year (range 70-157 weeks). The average age of the patients was 12 years and 5 months (range 8 years and 2 months-17 years and 1 month). All fractures healed at a mean of 7 weeks (range 5-14 weeks) after fracture. The average hospital stay for patients with isolated femur fractures (8/15) was 2.8 days (range 1-5 days). At an average follow-up of 141 weeks (range 70-326 weeks), no patient had developed avascular necrosis, femoral neck valgus, femoral neck narrowing, or other complications. CONCLUSIONS: The technique of intramedullary nailing in children through the lateral aspect of the greater trochanter seems to be safe, effective, and well tolerated by patients.     

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.