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.     

Retrograde nailing with subsequent screw fixation for ipsilateral femoral shaft and neck fractures

Introduction Although ipsilateral femoral shaft and neck fractures are difficult to treat, there is still no consensus on the optimal treatment of this complex injury. We report the results of treating the 17 fractures with a standard protocol of retrograde nailing for diaphyseal fractures and subsequent screw fixation for the femoral neck fractures. Materials and methods Seventeen injuries (16 patients) sustained femoral shaft fractures, which were treated with retrograde intramedullary nails and subsequent screw fixation. Femoral neck fracture was noted before the operation in all patients except one. A femoral shaft fracture was always addressed first with unreamed retrograde nailing. Then, the femoral neck fracture was treated by cannulated screws or dynamic hip screw according to the level of fracture. Results The average time for union of femoral shaft fractures was 27.3 (14–60) weeks. Nonunion occurred in five patients, who required bone grafts or changes of fixation. The average time for union of femoral neck fractures was 11 (8–12) weeks. All united, except for one case of nonunion with avascuar necrosis, which was a Garden stage IV fracture. Functional results using Friedman–Wyman criteria were good in 16 cases, and fair in one. The only fair result was nonunion of the femoral neck, which had the joint arthroplasty. Conclusion Retrograde nailing of femoral shaft fractures can provide an easy fixation and a favorable result for ipsilateral femoral neck fractures.This study was conducted at Kyungpook National University Hospital, Daegu, South Korea. The authors have and will not receive any financial benefit in association with the present paper.     

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.     

Locked intramedullary femoral nailing without fracture table or image intensifier

The present retrospective study aims to evaluate the outcome in 41 patients of femoral shaft fractures, who had closed intramedullary nailing in lateral decubitus position without fracture table or image intensifier. Mean age was 33.2 (range, 18–70) years. The cannulated reamer in proximal fragment (as intramedullary joystick) and Schanz screw in the distal fragment (as percutaneous joystick) were simultaneously used to assist closed reduction of the fracture without the use of image intensifier. Closed reduction was successful in 38 patients. Open reduction was required in 3 patients. Schanz screw was used for closed reduction in 12 patients. Average number of intra-operative radiographic exposures was 4.4. Two patients had exchange nailing using large diameter nails. One patient had nonunion. Angular and rotatory malalignments were observed in seven patients. We are of the opinion that the present technique is a safe and reliable alternative to achieve closed locked intramedullary nailing and is best suited to stable, less comminuted (Winquist–Hansen types I and II) diaphyseal fractures of the femur.     

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.     

Distal tibia fractures: management and complications of 101 cases

Distal tibia fractures are complex injuries with a high complication rate. In this retrospective and multicentre study we attempted to detail complications and outcomes of this type of injury in order to determine predictive factors of poor results. Between 2002 and 2004, 104 patients were admitted for 105 distal tibia fractures. One hundred patients (101 fractures) were reviewed with an average follow-up of 19 months (range, 12–46). Internal fixation, external fixation, limited internal fixation (K-wires or screws), intramedullary nailing and conservative treatment were used. Outcome parameters included occurrence of complications, radiographic analysis, evaluation of the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score and measures of the ankle range of motion. The average functional score was 76 points (range, 30–100 points), and complications occurred in 30 patients. Predictive factors of poor results were fracture severity, complications, malunion and the use of external fixation. We believe that external fixation must be reserved for trauma with severe skin injury, as a temporary solution in a two-staged protocol. For other cases, we recommend ORIF with early mobilisation.     

非扩髓闭合交锁髓内钉治疗股骨干骨折

目的　观察与分析闭合非扩髓交锁髓内钉技术治疗股骨干骨折的临床疗效与优点。方法　应用闭合非扩髓交锁髓内钉技术治疗新鲜股骨干骨折 2 83例。 2 83例患者均进行了 1次以上随访 ,随访时间为 3个月～ 4年 (平均随访时间 30个月 )。结果　骨折愈合时间 9～ 15周 ,平均 12周。术后3个月时 ,膝关节伸屈活动已与伤前相仿 ,无一例发生感染 ,无患肢疼痛、肿胀或关节僵硬等并发症。2 4例C型骨折中有 3例患肢短缩 1cm ,2例患肢轻度内翻 ,但成角 <7° ,1例交锁髓内钉在远端交锁螺钉孔处发生断裂。结论　闭合非扩髓交锁髓内钉内固定手术创伤小、保留了骨折处的血肿、不剥离骨折周围软组织、较少破坏骨内膜血供 ,为骨折愈合提供了良好的条件。同时 ,可进行早期功能锻炼 ,从而可防止关节肿胀、僵硬等骨折并发症发生 ,是目前治疗股骨干骨折较为理想的方法     

静力型交锁髓内钉动力化治疗下肢骨干骨折延迟愈合

目的 探讨静力型交锁髓内钉动力化治疗下肢骨干骨折延迟愈合的效果。方法 对27例骨折应用静力型交锁髓内钉固定后的股骨和胫骨骨干延迟愈合患者，行近侧或远侧锁钉取出术进行动力化治疗。其中股骨干延迟愈合17例，胫骨干延迟愈合10例。结果 随访7—48个月，平均19．5个月。术后3—7个月(平均3．3个月)获临床愈合。无感染、断钉、关节损伤和内固定取出后再骨折。结论 静力型改为动力型是治疗交锁髓内钉固定后股骨和胫骨骨干延迟愈合的有效方法。应用时注意选择适当的手术时机，选择取出锁钉也要得当。     

带锁髓内钉治疗股骨骨折骨不连

目的探讨带锁髓内钉治疗股骨骨折骨不连的治疗效果。方法对23例股骨骨折骨不连患者采用带锁髓内钉内固定治疗,术后早期应用CPM机锻炼。结果23例均获6～24个月随访,术后12～19周,平均16．3周骨折愈合。患肢膝关节功能较术前明显改善。结论带锁髓内钉是治疗股骨骨折骨不连较理想的方法。     

髓内钉结合空心钉治疗股骨髁部骨折

目的 :观察逆行髓内钉结合空心钉治疗股骨髁部骨折的临床疗效。方法 :回顾性分析2009年6月至2015年6月收治的股骨髁部粉碎性骨折患者13例,均使用逆行髓内钉结合空心钉治疗,男6例,女7例;年龄19~76岁,平均46.1岁。闭合性骨折10例,开放性骨折3例;骨折按AO分型:C1型4例,C2型7例,C3型2例。术后观察骨折复位及膝关节功能恢复情况。结果:13例全部获得随访,时间12~36个月,平均24个月。X线复查示骨折愈合时间为18~24周,平均21周,无内固定物松动、断裂及再骨折病例。手术后1年膝关节HSS评分90.07±4.99。结论:股骨逆行髓内钉结合空心螺钉治疗股骨髁间骨折临床疗效优良,能提高股骨髁部骨折的解剖复位率,减少并发症发生,促进膝关节功能恢复。     

Treatment of diaphyseal forearm fractures in children by intramedullary Kirschner wires

BACKGROUND: This article presents a retrospective analysis of a case series of diaphyseal forearm fractures in children treated with intramedullary Kirschner wires (K-wires). METHODS: Seventy-four diaphyseal forearm fractures in children (63 male subjects and 11 female subjects) with a mean age of 11 years (range, 4-15 years) were treated with percutaneous intramedullary K-wires. Under fluoroscopic control, a standard K-wire (diameter, 1.5-2.0 mm, depending on the age) was introduced into the distal radial metaphysis, proximal to the epiphysis. The K-wire was then advanced proximally across the fracture. For the ulna, the wire was introduced antegrade from the proximal end. The tip of the K-wire was prebent to 30 degrees to facilitate closed reduction of the displaced fracture. RESULTS: All fractures healed between 6 and 10 weeks with minimum complications and excellent clinical results. CONCLUSION: This surgical technique is convenient, effective, and safe for treating displaced diaphyseal forearm fractures in children.     

Retention of flexible intramedullary nails following treatment of pediatric femur fractures

Introduction Flexible intramedullary nails are commonly used for the treatment of diaphyseal femur fractures in children. Although, their removal after fracture healing is advocated by some, there are no definitive studies to support the routine removal of these implants. The purpose of this study is to determine the natural history of children with diaphyseal fractures of the femur treated with flexible intramedullary nails and no scheduled nail removal. Material and methods We performed a retrospective case series of 24 consecutive children treated at our tertiary pediatric referral center for closed diaphyseal femur fractures. All children had intramedullary fixation with flexible titanium nails. The main outcomes measured are fracture healing, incidence of hardware removal, and pain assessment with the use of a follow-up telephone questionnaire. Results All the patients healed their fractures. The average follow-up time was 3.6 years. A total of six patients had removal of nails for any reason at an average of 15 months post-injury. The survivorship free of revision due to persistent pain was 72% at 5 years of follow-up. Twenty-two patients were reached by phone for a final follow-up questionnaire. There was no difference in reports of residual symptoms of pain among those who did have nails removed and those who did not (P = 0.626). Conclusions Among children with femur fractures treated with flexible intramedullary nailing without scheduled implant removal, about a quarter may ultimately require a second procedure for nail removal due to persistent discomfort. Moreover, up to half of patients can have residual non-debilitating pain at 2–5 years post-injury regardless of presence or absence of the implant. Whether this is a previously unrecognized adverse outcome of this injury or treatment approach, or due to routinely leaving nails in will have to be assessed in future controlled trials.     

Interlocking intramedullary nailing for ipsilateral fractures of the femoral shaft and distal part of the femur.

A review of the data on 684 fractures of the femur that had been treated with intramedullary nailing led to the identification of twenty-three patients who had had a fracture of the shaft of the femur with an accompanying ipsilateral supracondylar fracture (twelve patients, group I) or a concomitant ipsilateral intercondylar fracture (eleven patients, group II). The group-I fractures had been treated with interlocking nailing without supplemental fixation. In group II, ten fractures were stabilized with interlocking nailing and supplemental screw fixation and one, with interlocking nailing and a supplemental plate and screws. The average time to union for all fractures was nineteen weeks (range, twelve to thirty-six weeks), and the average duration of clinical and radiographic follow-up was thirty months (range, nine to fifty-nine months). In group I, alignment of the femur was within 5 degrees of normal in ten of the twelve fractures. In group II, seven intra-articular fractures healed in anatomical alignment, three had slight articular displacement (1.0 to 3.0 millimeters), and one had displacement of more than 3.0 millimeters. The average range of motion of the knee at the most recent follow-up was 0 to 120 degrees in group I and 0 to 115 degrees in group II. Two patients (both in group II) needed a reoperation for a previously unrecognized fracture of a femoral condyle in the coronal plane; post-traumatic arthritis developed in both. No patient in either group had loss of fixation or failure of the implant. We concluded that ipsilateral diaphyseal, supracondylar, and intercondylar fractures of the femur can be adequately stabilized with interlocking nailing and supplemental intercondylar screw fixation. The presence of a fracture in the coronal plane of a femoral condyle (AO type-B3 and type-C3 injuries) is a relative contraindication to the use of this technique.     

Intramedullary locked nailing in the treatment of proximal femoral fractures]

INTRODUCTION: The aim of the study is evaluation of results of operative treatment the proximal femoral fractures with intramedullary locked nailing. MATERIAL AND METHOD: In years 1996-2004 44 patients were treated because of proximal femoral fractures with closed reduction and stabilization with intramedullary locked nailing. There were 15 women and 29 men in average age 60 years (18-95 years). There were 2 femoral neck fractures and 42 peritrochanteric fractures. The fracture of femoral shaft in 2 patients accompanied the fracture of proximal part of femur. The morphology of fractures was estimated according to AO classification. Clinical results were evaluated with Harris hip score (HHS). RESULTS: The average follow up is 8 months (from 6 to 24 months). There was good reduction of 27 fractures on postoperative radiograms. The average 15 degrees of varus lack of reduction was noted in 17 peritrochanteric fractures (from l0 to 35 degrees). There were mainly 31.A.3 unstable fractures according to AO classification. 3 patients died during three postoperative months from causes not connected with operative treatment. 39 fractures united in the period from 10 to 16 weeks. Delayed union--after 6 months occurred in 2 persons. Fatigue fracture of intramedullary rods occurred to both of this patients. The average Harris Hip Score was 86 points (from 70 to 100 points) after union of fractures. CONCLUSIONS: (1) The use of intramedullary locked nailing in the treatment of fractures of proximal part of femur leads to union without additional immobilization. (2) Closed intramedullary locked nailing in the treatment of unstable intertrochanteric fractures is connected with the risk of varus malalignment of fragments, which does not delay union, but decreases functional outcome. (3) Proper operative technique decreases the number of intra- and postoperative complications.     

The role of reamed intramedullary nailing in the treatment of nonunions and malunions following femoral shaft fractures

Summary This retrospective consecutive clinical series describes our satisfactory experience with reamed intramedullary femoral nailing in the treatment of nonunions, axial or rotational deformities as well as length discrepancies following the primary treatment of femoral shaft fractures. 31 patients (32 fractures) treated at our institution from 1992 to 1997 were reviewed for age, gender, cause of injury, type of femur fracture, primary treatment, indication for secondary nailing, operative procedure, complications, need for additional procedures and time for consolidation. 3 patients were lost for follow-up, leaving 28 patients (29 fractures) for evaluation. The average follow-up was 79 weeks (range 24 to 192). The indications for secondary nailing were: 18 nonunions, 7 rotational or axial deformities, 4 length discrepancies. Consolidation was achieved in 25 patients (26 fractures) at an average time of 38 weeks (range 12 to 104). Nonunion was recorded in 3 patients. They were treated successfully with an additional procedure (one exchange intramedullary nailing and two autologous bone grafts). The reamed intramedullary interlocking nail offers many advantages, especially a good initial and middle term stability which is important in case of a slow process of consolidation. By the treatment of atrophic and long lasting nonunion, simultaneous bone grafting seems to be indicated. We conclude that interlocking reamed femoral nailing is a safe treatment option for nonunions and malunions following primary treatment of femoral shaft fractures, resulting in successful union without additional procedure in 26 of 29 fractures in this series.     

Unreamed Nailing of Diaphyseal and Metaphyseal Fractures of the Femur

Background: Femoral intramedullary nails with antegrade or retrograde options for insertion and different locking possibilities have extended the indications to include both diaphyseal and metaphyseal fractures. Patients and Methods: A prospective series of 63 patients were treated with three different unreamed nailing and interlocking techniques selected according to the predominant fracture location. Median age of the 30 women and 33 men was 39 (17–97) years. High-energy injuries had occurred in 37 patients. Antegrade nailing and interlocking with standard technique was used in 29 diaphyseal fractures, antegrade nailing and placement of the proximal locking device to the femoral head was performed in eleven proximal fractures with involvement of the intertrochanteric region, and retrograde nailing and standard interlocking was done in 23 mainly distal fractures. Results: We encountered two types of major mechanical complications: angular malalignment and protrusion of the nail into the knee joint following compression in the fracture. Angular malalignment was found in four fractures. One midshaft fracture was fixed in a valgus reduction. Varus malalignment and loss of fixation occurred in two high subtrochanteric fractures after proximal locking with a spiral blade. In another midshaft fracture redisplacement in varus occurred. Compression in the fracture with protrusion of the nail by 2–10 mm into the knee joint following retrograde nailing was observed in six osteoporotic patients. Only two of these patients had significant knee problems. The median time to union – 4 months – did not differ significantly between the fixation groups. Conclusions: Thus, there are still problems after nailing very proximal and distal fractures. Most postoperative complications were seen after retrograde nailing of distal fractures, but the consequences of fixation failure in very proximal fractures were worse. Nevertheless, a protocol that takes advantage of the different options for nail introduction and locking depending on the fracture location seems promising. Received: January 6, 2002; revision accepted: October 8, 2002 Correspondence Address Karl Akke Alberts, MD, PhD, Department of Orthopedics, Karolinska Hospital, 17176 Stockholm, Sweden, Phone (+48/8) 517-70000, Fax -72695, e-mail: akke.alberts@ks.se     

Retrograde flexible intramedullary nailing in children's femoral fractures

We treated 31 femoral shaft fractures in 28 children with a mean age of 6.7 (5-10) years with retrograde flexible intramedullary nailing. There were 16 isolated fractures, while 12 children had associated injuries. The average time for union was 10.5 weeks and there were no delayed unions. There was one broken nail requiring change of treatment, but no infection or refractures. At follow-up after a mean time lapse of 27 months there was no limb-length inequality exceeding 1 cm and no malunion. We feel that femoral fractures in patients aged 5-10 years can be safely treated with retrograde flexible intramedullary nailing with minimal risk of surgical complications.     

The role and efficacy of retrograding nailing for the treatment of diaphyseal and distal femoral fractures: a systematic review of the literature

The aim of this analysis has been to evaluate the efficacy of retrograde nailing in the treatment of distal femur and femoral shaft fractures. Articles were extracted from the Pubmed database and the retrieved reports were included in the study only if pre-specified eligibility criteria were fulfilled. Moreover, a constructed questionnaire was administered, aimed at assessing the quality of the outcomes. Twenty-four articles were eligible for the final analysis, reviewing a total of 914 patients (mean age of 48.8 years) who sustained 963 distal and diaphyseal femoral fractures. The overall mortality rate was 5.3%. The incidence of infection was 1.1% and for septic arthritis of the knee was 0.18%. In patients with distal femoral fractures, the mean time to union and rate to union were 3.4 months and 96.9%, respectively. The mean range of knee motion was 104.6 degrees . The rates of knee pain, malunion and re-operations were 16.5, 5.2 and 17%, respectively. Patients with femoral shaft fractures had a mean time to union 3.2 months, whilst the rate of union was 94.2%. The mean range of knee motion was 127.6 degrees . The rates of knee pain, malunion and re-operations were 24.5, 7.4 and 17.7%, respectively. We concluded that retrograde intramedullary nailing appears to be a reliable treatment option, mainly for distal femoral fractures. However, in the management of diaphyseal fractures, retrograde intramedullary nailing is associated with high rates of knee pain and lower rates of fracture union.     

Treatment of reverse oblique trochanteric femoral fractures with proximal femoral nail

Treatment of reverse oblique trochanteric femoral fractures is still challenging. We present the results of our proximal nailing surgery performed for reverse obliquity intertrochanteric fractures using two lag screws and evaluated the quality of the reduction, operative time, complications and functional status of the patients. Fifteen patients with AO/OTA 31 A-A3 fractures were treated by proximal femoral nailing in our trauma centre. The mean Harris hip score was 74.66 (range 65–96) and the mean Barthel activity score was 15.71 (range 12–20). The mean duration of surgery was 48 minutes and the average consolidation time was 8.6 weeks. No intraoperative complications or postoperative technical failures and no stress shielding as evidenced by the lack of cortical hypertrophy at the level of the tip of the implant were detected. Intramedullary nailing with proximal femoral nails may be a good option in the treatment of reverse obliquity intertrochanteric fractures.     

Antegrade nailing of femoral shaft fractures combined with neck or distal femur fractures

Introduction Complex femoral fractures pose considerable therapeutic challenges to orthopedic surgeons. We present a retrospective review of 25 patients with complex femoral fractures treated with intramedullary locked nailing and supplemental screw fixation.Materials and methods Fifteen patients with ipsilateral femoral neck and shaft fractures (group 1) and 10 patients with ipsilateral femoral shaft and distal femur fractures (group 2) were treated from 1990 to 1998. High-energy injuries occurred in all patients. There were 4 open fractures. Antegrade, locked nailing of diaphyseal fractures was performed in all cases. Supplemental screws for the neck were used in all patients in group 1 and in 3 patients in group 2.Results All of the fractures united during the follow-up. Five patients in group 1 underwent reoperation (33.3%): one due to a delayed union, the second due to an implant failure, the third due to a nonunion of a neck fracture, and the last two because of an initially missed femoral neck fracture. None of the patients in group 2 underwent reoperation. Angular malalignment of the shaft was found in 6 fractures in group 1 (average 4.8^o, range 3^o–11^o) and in 4 fractures in group 2 (average 6^o, range 3^o–12^o). Shortening of the limb occurred in 3 patients in group 1 (average 1.4 cm, range 1–1.8) and in 1 patient in group 2 (2 cm). Loss of fixation was seen in 1 patient in each group. Avascular necrosis and infection were not seen in any case in both groups.Conclusion Femoral intramedullary nails with antegrade or retrograde options for insertion and different locking possibilities have extended the indications to include both diaphyseal and metaphyseal fractures. New nail designs, usually more expensive than the conventional nails, have been introduced into the market for this purpose. One has to keep in mind that antegrade, locked nailing of femoral shaft fractures combined with neck or distal femur fractures is a technically demanding but efficacious procedure. The success rate is high when the technique is meticulously implemented.