Abstract
BackgroundElastic stable intramedullary nailing (ESIN) is accepted widely for treatment of diaphyseal femur fractures in children. However, complication rates of 10 to 50 % are described due to shortening or axial deviation, especially in older or heavier children. Biomechanical in vitro testing was performed to determine whether two modified osteosyntheses with end caps or a third nail could significantly improve the stability in comparison to classical elastic stable intramedullary nailing in a transverse femur fracture model.MethodsWe performed biomechanical testing in 24 synthetic adolescent femoral bone models (Sawbones®) with a transverse midshaft (diaphyseal) fracture. First, in all models, two nails were inserted in a C-shaped manner (2 × 3.5 mm steel nails, prebent), then eight osteosyntheses were modified by using end caps and another eight by adding a third nail from the antero-lateral (2.5-mm steel, not prebent). Testing was performed in four-point bending, torsion, and shifting under physiological 9° compression.ResultsThe third nail from the lateral showed a significant positive influence on the stiffness in all four-point bendings as well as in internal rotation comparing to the classical 2C configuration: mean values were significantly higher anterior-posterior (1.04 vs. 0.52 Nm/mm, p < 0.001), posterior-anterior (0.85 vs. 0.43 Nm/mm, p < 0.001), lateral-medial (1.26 vs. 0.70 Nm/mm, p < 0.001), and medial-lateral (1.16 vs. 0.76 Nm/mm, p < 0.001) and during internal rotation (0.16 vs. 0.11 Nm/°, p < 0.001). The modification with end caps did not improve the stiffness in any direction.ConclusionsThe configuration with a third nail provided a significantly higher stiffness than the classical 2C configuration as well as the modification with end caps in this biomechanical model. This supports the ongoing transfer of the additional third nail into clinical practice to reduce the axial deviation occurring in clinical practice.
Highlights
Fractures of the femoral diaphysis are the second most frequent location of fractures affecting the lower extremity in children (20–26/100,000 children per year) [1, 2] and comprise 1 to 2 % of all fractures in children [3, 4]
Following the guidelines of the German Society of Paediatric Surgery, children beyond the age of 3 years should be treated with elastic stable intramedullary nailing (ESIN osteosynthesis) even in complex fractures or children older than 12 years as long as sufficient stability can be achieved [6]
Elastic stable intramedullary nailing (ESIN) osteosynthesis is said to produce a rapid recovery and a faster reintegration of children and adolescents and lack possible negative effects of immobilisation compared to conservative treatment, especially in schoolchildren [7, 8]
Summary
Fractures of the femoral diaphysis are the second most frequent location of fractures affecting the lower extremity in children (20–26/100,000 children per year) [1, 2] and comprise 1 to 2 % of all fractures in children [3, 4]. Following the guidelines of the German Society of Paediatric Surgery, children beyond the age of 3 years should be treated with elastic stable intramedullary nailing (ESIN osteosynthesis) even in complex fractures or children older than 12 years as long as sufficient stability can be achieved [6]. Most complications were observed as a result of instability in complex fracture types and older children weighing more than 40 kg [9, 13, 14] Because of these instabilities, other authors used additional immobilisation (e.g. application of a cast), additional screws, and an additional external fixation or recommended submuscular plating or external fixation [10, 15,16,17]. Elastic stable intramedullary nailing (ESIN) is accepted widely for treatment of diaphyseal femur fractures in children. Biomechanical in vitro testing was performed to determine whether two modified osteosyntheses with end caps or a third nail could significantly improve the stability in comparison to classical elastic stable intramedullary nailing in a transverse femur fracture model
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