Limitations in Use of Elastic Stable Intramedullary Nailing (ESIN) in Children with Disorders of Bone Mineralization.

Abstract

Elastic intramedullary nails (ESIN) have been the treatment of choice in many long bone fractures in children for more than 20 years. The introduction of ESIN has drastically reduced tissue traumatization during fracture fixation procedures and decreased the risk of growth cartilage damage, as well as allowing for preservation of the natural biology of closed fracture healing. The objective of the present report is to draw attention to a small group of patients with bone mineralization disorders, who consequently demonstrate decreased mechanical resistance of the skeletal system, in whom indications for using ESIN fixation are limited. The study group consisted of 6 patients who met the criteria for using ESIN fixation, but did not demonstrate a satisfactory outcome. The inclusion criteria included age below 18 years, appropriate ESIN nail insertion technique with correct calculation of nail diameter (2/5 of the medullary canal diameter), body mass < 50 kg and achieving appropriate prebending that is the prerequisite of three-point intramedullary support. The patients' medical records and radiographs were analyzed and they were invited for clinical and radiological follow-up examinations. All six patients demonstrated a gradually increasing bending deformity of the long bone axis. Additionally, in three patients, there was intrusion of terminal parts of the nails into the bone. In one patient with bone fibrous dysplasia, the proximal epiphysis was perforated by the flattened ends of the nails. In all patients, the removal of the ESIN fixation was followed by single or double-level corrective osteotomies and Rush pin fixation. In cases of long bone fractures in children with metabolic bone disorders in whom the bone structure is weakened and the bones themselves are easily deformed, more rigid intramedullary fixation with Rush or Fassier-Duval type nails as primary osteosynthesis should be considered.