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.