弹性髓内钉固定与外固定支架治疗儿童股骨干骨折疗效比较

目的：比较弹性髓内针与外固定支架治疗儿童股骨干骨折的疗效。方法：2002年9月至2008年8月治疗儿童股骨干骨折共67例,使用弹性髓内针治疗儿童股骨干骨折36例,男23例,女13例,年龄5～11岁,平均（7.1±1.6）岁;外固定支架治疗31例,男19例,女12例,年龄3～12岁,平均（6.5±2.3）岁。所有病例均为闭合复位,对两种不同内固定术后骨折愈合时间、术后并发症进行比较分析。结果：全部病例均获随访,时间9～24个月,平均（12±3）个月。弹性随内针组治疗小儿股骨骨折在骨折临床愈合时间和骨性愈合时间均短于外固定支架组（P〈0.05）。外固定支架组,继发钉道感染5例,骨折延迟愈合3例,再骨折2例,螺钉断裂1例;弹性髓内针组钉尾激惹3例。结论：弹性髓内针治疗儿童股骨干骨折有很大优势,而对高能量骨折及多发伤的病例外固定支架则不失为一种良好的选择,股骨近端和远端骨折尽量避免使用弹性髓内针固定。     

Pedal nail pathology: biomechanical implications

Proper treatment of pedal nail disorders requires a thorough understanding of the underlying etiology. As a class, biomechanical abnormalities constitute an important cause of pedal nail dystrophy. These biomechanical etiologies have been presented with regard to the three body planes. Treatments using biomechanical and orthopedic principles were explored, with an emphasis on counteracting abnormal dynamic and static forces. Additionally, sports that have a high correlation of nail pathologies have been discussed with prevention as the key element to treatment.     

Proximal femoral neck penetration after flexible intramedullary nailing for pediatric femur fractures: a rare complication

Flexible intramedullary nailing is a common method used to treat pediatric femur fractures. Complication rates can be high, but most complications are considered minor and do not result in additional unplanned surgeries. Proximal nail penetration is a complication that has only been described once before. The penetration may be asymptomatic, but is still best to be avoided. Two cases of proximal nail penetration of the femoral neck region during nail insertion are presented. A review of the literature with regard to complications and suggestions for avoidance of proximal nail penetration is offered.     

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.     

Treatment of severe deformities of the toenails by the modified Zadik method with artificial skin.

A number of operations have been devised to treat ingrowing toenails and pincer nails, and they have given good aesthetic and functional results. However, there have been few reports of operations for the treatment of severe nail deformities caused by damage to the matrix of the nail by injury, or by inappropriate removal of the nail or intractable onychomycosis or cardiovascular or neurological disorders. In 1950, Zadik reported a radical technique for ingrown nails and pincer nails: after avulsion of the nail, the matrix was excised completely and the posterior nail wall was sutured to the nail bed as an advancement flap. We have treated 23 severe deformities other than ingrown nails and pincer nails in 14 patients by the modified Zadik method with artificial skin. As a result, symptoms including pain were alleviated in all patients. The nail plate did not regenerate, and no patient had aesthetic complaints.     

Identification of Common Nail and Skin Disorders

Narrative ReviewThe following review discusses the more common disorders of the perionychium and skin likely to be observed by the hand therapist. To assist the therapist in recognition of abnormalities, the anatomy, physiology, and basic function of the normal nail unit are described. Indications of when disorders of the nail, resulting from trauma, infections, and neoplasms, require referral to another practitioner are discussed. Characteristics of abnormal skin conditions are described with an emphasis on differentiating benign from malignant lesions. By knowing the suspicious characteristics of nail and skin disorders, the upper extremity therapist can positively impact the well-being of his or her patients through quick referral, leading to early diagnosis and treatment of potentially serious disease.Level of Evidence5.     

Heritable nail diseases

Heritable nail diseases are associated with a great variety of inherited diseases and syndromes. Well over 60 HEDs and numerous other inherited nail abnormalities are known to exist. A classification system of these disorders, as well as the specific nail change found in each, has been presented. Table 1 has been included to correlate many of the nail disorders with their corresponding inherited disease or syndrome. Clinically, inherited nail diseases may appear to be of questionable importance. In cases of primary presentation or poor historical background, however, these subtle nail changes may prove useful in arriving at or substantiating a diagnosis.     

Flexible intramedullary nail removal using a broken screw removal set

The use of flexible titanium intramedullary nails for management of pediatric long bone fractures and some adult fractures has become common. Nail removal after union can be challenging and often requires a larger exposure than nail placement to allow the insertion of grasping devices, such as pliers. A percutaneous technique for the removal of flexible intramedullary nails using extraction bolts from a broken screw removal set is presented. The technique is especially useful when the end of the nail is not prominent and where a hollow reamer from the same set can expose the nail end for the extraction bolt to be used.     

A Surgical Approach to Ingrown Nail: Partial Matricectomy Using CO2 Laser

BACKGROUND: Ingrown nail is a deformity characterized by a transverse overcurvature of the lateral nail plate that causes nail fold inflammation. Currently recommended surgical procedures vary considerably. OBJECTIVE: We report our experience with a modified partial matricectomy and nail edge excision with CO2 laser. METHODS: A total of 116 ingrown nail edges in 77 patients were treated with the procedure. RESULTS: The incidence of recurrence was 2 of 76 cases (2.6%). CONCLUSION: This new surgical approach was found to be effective and is presented as an alternative treatment technique.     

Risk factors for re-fracture in children with diaphyseal fracture of the forearm treated with elastic stable intramedullary nailing

A retrospective study aims to investigate predisposing factors leading to re-fracture in patients with nails still in place and to identify potential correlations between nail size-to-medullary canal diameter ratio and re-fracture, working to the hypothesis that a higher ratio correlates with a higher risk of re-fracture. Rates of re-fracture with nail still in place after forearm elastic stable intramedullary nailing are higher in younger pediatric patients. Re-fractures occurred at a mean age of 6.7 years (range 5–8.7). While the role of body frame and bone medullary diameter remains unclear, there are grounds for adjusting treatment strategy for age, weight and bone medullary diameter to achieve effective outcome. History of previous forearm fracture and open treatment may also be further risk factors.     

Treatment of subtrochanteric fractures of the femur: a study of intramedullary compression nailing

The results of prospective treatment of 31 patients with subtrochanteric fractures using the Derby intramedullary nail are presented. The nail design, plus cerclage wires in unstable cases, allows axial compression of the fracture, to give rigid fixation and load-sharing between bone and nail. Twenty-seven patients were followed up for an average of 21.7 months. There were no mechanical failures of the nails, and all 27 fractures united, two in minimal varus. Relatively early mobilization of the patients with isolated fractures occurred.     

Nail-patella syndrome: long term evolution

Nail-patella syndrome is a rare dysplasia characterized by a typical tetrad: hypoplasic nails, hypoplasic or absent patella, radial head dislocation and iliac horns. We review eight patients, four men and four women, aged from 20 to 70 years. The main complaint at consultation was with their knees due to patellar instability and pain. Five of them required surgical treatment due to patellar dislocation and three patients were not treated. The Krogius-Lecène procedure was performed in four patients with a good result following the Insall classification of pain and instability and with an average follow-up of 24 years (range, 18-28 years). Patellectomy was performed in the eldest patient due to femoropatellar arthritis present at first consultation. No patients presented with elbow or nail disorders or with iliac horns.     

Nail Biopsy: Assessment of Indications and Outcome

BACKGROUND: For years, nail biopsy has been shunned as a difficult and scarring procedure, which is seldom required in day-to-day practice. Only a few studies with a limited number of patients have been carried out to assess its utility in dermatology. METHODS: We studied 270 patients with nail disorders (both infectious and noninfectious). In 205 cases, the clinical diagnosis could be confirmed with the help of routine diagnostic aids, in the form of potassium hydroxide preparation, fungal culture, and biopsy of associated skin lesions. In the remaining 65 cases, various types of nail biopsies were carried out after ruling out contraindications to nail surgery. RESULTS: Overall, the histopathologic changes were found to be diagnostic in 63% of cases. Findings were more characteristic in infectious disorders of the nail unit. The diagnostic yield varied with the type of biopsy procedure. Side effects in the form of scarring and nail dystrophy were seen in 29.2% of the patients. DISCUSSION: Nail biopsy is useful, especially in cases with isolated nail involvement, an absence of skin lesions, and disorders such as twenty-nail dystrophy. It should be advocated in cases in which the routine diagnostic procedures fail to yield results. Proper selection of cases, choice of biopsy technique, and attention to the surgical procedure help in minimizing the side effects associated with the procedure. CONCLUSION: Nail biopsy was found to be a simple, safe, and useful procedure, especially in cases in which the clinical diagnosis is otherwise obscure.     

Management of penetrating pneumatic nailgun injuries of the knee

Of 36 patients who presented over a 3-year period with nailgun injuries, nine of these injuries were found to have penetrated into the knee joint. Six of these injuries were treated by operative nail removal, curettage of the nail tract, and examination of the joint. The remaining three patients had nail removal, followed by irrigation of the joint in the emergency room. All nine injuries had antibiotic prophylaxis before and after nail removal. In three of six patients treated by operative irrigation and debridement, a piece of clothing or nailgun resin was discovered in the nail tract or floating within the knee joint. None of the patients in the group treated by operative nail removal, joint visualization, irrigation, and nail tract curettage experienced any complications, whereas one patient treated nonoperatively developed a septic knee. Due to the unique nature of these nailgun puncture wounds, we strongly advocate operative nail removal, curettage of the nail tract, visualization of the joint, and use of prophylactic antibiotics in the treatment of nailgun arthrotomies.     

A biomechanical study on flexible intramedullary nails used to treat pediatric femoral fractures

Flexible intramedullary nails have been indicated to treat femoral fractures in pediatric patients. The purpose of this study was to examine the stability of simulated transverse fractures after retrograde intramedullary flexible nail fixation. Various nail diameter combinations were tested using composite femurs in bending, torsion, and a combined axial/bending test where a vertical compressive force was applied to the femoral head. The cross-sectional percent area fill of the nails within the femurs was also determined. In 4 point bending, the greatest repair stiffness was 12% of the intact stiffness. In torsion, the greatest stiffness was 1% of the intact stiffness for either internal or external rotation. The greatest repair stiffness was 80% of the intact stiffness for a compressive load applied to the femoral head. Nail combinations with single nail diameters greater than 40% of the mid-shaft canal width, as measured from an AP radiograph, prevented the fracture from being reduced and left a posterior gap. Flexible intramedullary nails may be of value in the treatment of pediatric femoral fractures, but care must be taken to insert nails that are correctly sized for the canal and to protect the healing fracture from high torsional and bending loads.     

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.     

Massive fat emboli syndrome after unsuccessful unreamed nailing of the tibia

A patient is presented in whom massive fat emboli syndrome (FES) developed after the unsuccesful treatment of a solitary tibial fracture with an unreamed tibial nail. Ultimately, a reamed tibial nail was inserted. Several risk factors for the development of FES were identified retrospectively in this particular case: a very small medullary canal, a large-diameter unreamed tibial nail, reaming of a small medullary canal and insertion of a thick reamed tibial nail. Even in the presence of patients with solitary lesions and without obvious risks for FES, one should always take this dangerous complication into account.     

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.     

Results of the proximal femoral nail anti-rotation (PFNA) in elderly Chinese patients

A prospective study is presented of 87 unstable intertrochanteric fractures treated with the proximal femoral nail anti-rotation (PFNA) with a follow-up of one year. Of the patients 76% were female. The average age was 75.3 years. The fracture was treated by closed reduction and intramedullary fixation. Pre-injury activity level was recovered in 77% of the patients. Fractures united in all patients. Mechanical failure and cut-out were not observed. A technical problem related to the mismatch of the proximal end of the nail was observed in 11 cases. Nine patients presented with thigh pain due to the redundant proximal end of the nail. The results of the PFNA were satisfactory in most elderly Chinese patients. However, the proximal end of the nail was not matched with the specific anatomy of some short elderly patients. Further modifications of the nail are necessary for the elderly Chinese population.     

Bone mineral density deficiency in children.

With the development of improved diagnostic and treatment options, reduced bone mineral density in children is receiving increased attention. The etiology of osteopenia in healthy children is multifactorial and incompletely understood, but poor calcium intake during the adolescent growth spurt may be an important (and potentially reversible) factor. Other clinically relevant causes of reduced bone mineral density in children include osteogenesis imperfecta, rickets, juvenile rheumatoid and other chronic arthritides, osteopenia associated with neuromuscular disorders, and idiopathic osteoporosis. To provide effective treatment, it is important to understand the process of normal skeletal mineralization, the techniques of bone mineral density measurement, the pathophysiology of osteopenia, and the evaluation and treatment options for the general pediatric population as well as for patients with specific pediatric disorders.