Elastic Stable Intramedullary Nail Fixation Research Articles

Modified elastic intramedullary nail internal fixation for distal tibial metaphyseal junction fracture.

To investigate the application of modified elastic intramedullary nail and the outcomes between modified elastic stable intramedullary nailing and traditional elastic stable intramedullary nailing in children with distal tibial metaphyseal junction fracture. A retrospective study was conducted. From January 2018 to January 2021, a total of 36 children with distal tibial metaphyseal junction fracture were treated in our hospital. All of them were treated with closed reduction and elastic stable intramedullary nailing internal fixation. A total of 18 children were treated by modified elastic stable intramedullary nailing and 18 children were treated by traditional elastic stable intramedullary nailing. Postoperative imaging, clinical efficacy, and complications were analyzed. The mean follow-up time was 20 (15-36) months in modified group and 22 (16-33) months in traditional group. There were no complications such as infection, loss of reduction, and unequal length of lower limbs in modified group while loss of reduction occurred in two cases in traditional group. In these two cases of loss of reduction, we preformed manual reduction and replacement of long leg casts, and there was no loss of reduction, and the patient achieved a good prognosis. In the last follow-up, American Orthopaedic Foot & Ankle Society score was used. In modified group, excellent outcome achieved in 17 cases, good outcome achieved in 1 case, and satisfactory therapeutic effect was achieved. In traditional elastic stable intramedullary nailing group, excellent outcome achieved in 14 cases, and good outcome achieved in 4 cases. There was no statistical difference in the scores between the two groups. It was concluded that modified elastic stable intramedullary nailing fixation is a safe and effective treatment.

Comparison of ESIN and other minimally invasive techniques for anterior pelvic ring injury: a finite element analysis and case-control study.

A novel technique, percutaneous elastic stable intramedullary nail fixation (ESIN), proposed by our team for the treatment of anterior pelvic ring injury. Finite element analysis and retrospective case-control study were used to compare biomechanical properties and clinical outcomes between ESIN and other techniques. Four groups of finite element models of pelvic anterior ring injury were simulated, including ESIN (model A), retrograde transpubic screw fixation (RTSF, model B), subcutaneous internal fixator (model C), and external fixator (model D), and a vertical downward load of 500 N was applied to the S1 vertebral endplate. Stress and displacement distributions of intact pelvis, displacement distributions of pubic fracture fragments, and stress distributions of fixation devices were analysed. Then 31 patients with anterior pelvic ring injury (15 in the ESIN group and 16 in the RTSF group) were reviewed. Clinical outcomes were evaluated at the final follow-up. Postoperative complications were also recorded. Under 500N loading, the intact stability of the pelvis was compared as follows: model B (20.58mm, 121.82MPa), model A (20.80mm, 129.97MPa), model C (22.02mm, 141.70MPa), and model D (22.57mm, 147.06MPa). The regional stability of superior pubic ramus was compared as follows: model B (9.48mm), model A (10.16mm), model C (10.52mm), and model D (10.76mm). All 31 patients received follow-up at least 12 months postsurgery (range 12-20 months). Age, sex, injury mechanism, fracture type, time between the injury and operation, American Society of Anesthesiologists score, intraoperative blood loss, hospital stay, follow-up period, time to union, and Majeed scores did not differ significantly between the two groups ( P >0.05). However, the differences in the duration of unilateral surgery, unilateral intraoperative fluoroscopy and one-time success rate were significant ( P <0.05). With sufficient biomechanical stability and minimally invasive advantage, the percutaneous technique using ESIN can be used to successfully treat anterior pelvic ring injuries. In addition, advantages over RTSF include a shorter duration of surgery, reduced requirement for intraoperative fluoroscopy, and a higher one-time success rate. ESIN therefore constitutes a good alternative to RTSF.

Elastic stable intramedullary nail fixation versus submuscular plate fixation of pediatric femur shaft fractures in school age patients: A PRISMA-compliant systematic review and meta-analysis.

Studies of clinical outcomes that compare the elastic stable intramedullary nail (ESIN) with the submuscular plate (SMP) were controversial. The meta-analysis was performed to summarize existing evidence, aiming to determine whether ESIN was superior to SMP in pediatric femur shaft fractures. Search strategies followed the recommendations of the Cochrane collaboration. Electronic searches such as PubMed, Embase, Web of Science, Cochrane were systematically searched for publications concerning ESIN and SMP from the inception date to March 2023. Two investigators independently searched, screened, and reviewed the full text of the article. Disagreements generated throughout the process were resolved by consensus, and if divergences remain, they were arbitrated by a third author. This study included 8 articles, comprising a total of 561 patients with a similar baseline. Compared to the SMP, the ESIN had shorter operation time (mean difference = -16.16; 95% CI = -22.83 to -9.48, P < .00001), and less intraoperative blood loss (mean difference = -53.62; 95% CI = -58.89 to -48.36, P < .00001), but had a higher incidence of implant irritation (odds ratio [OR] = 6.49; 95% CI = 3.01 to 13.98, P < .0001), lower limb malalignment (OR = 2.60; 95% CI = 1.12 to 6.04, P = .96) and overall complications(OR = 4.14; 95% CI = 2.51 to 6.84, P < .0001). And there was no significant difference in radiation time, length of hospital stay, limb length discrepancy, infection rate, delayed union rate and unplanned revised surgery rate (P > .05). Compared to the SMP, the ESIN offers shorter operative time, and less blood loss. However, the SMP is superior to ESINs in complication rates, especially regarding implant irritation and malalignment. Both methods could achieve excellent satisfactory functional outcomes. Thus, the SMP is an alternative choice in the pediatric femur shaft fracture.

Elastic-stable intramedullary nailing for radial neck fractures in children: clinical and radiological outcomes and risks for poor prognosis

Introduction. Radial neck fractures in children are rare and account for 1-3% of all childhood trauma. Severe displacement of the fracture can lead to a higher incidence of complications, such as limited range of motion (ROM ), pain, instability, neurovascular trauma, premature physeal closure, cubitus valgus, radial head overgrowth, avascular necrosis and improper ossification. The treatment outcome depends on the injury type, treatment method and presence of complications. Aim. The purpose of the study was to assess the outcome of patients treated with elastic-stable intramedullary nailing (ESIN) regarding different radial head angulations and to search for risk factors of a poor outcome. Materials and methods. Twenty-six consecutive patients treated between October 2020, and March 2022, due to radial neck fracture were included in the study. Closed reduction and ESIN fixation were performed. If failed, A K-wire assisted reduction or open reduction was performed. A radiological evaluation was performed pre- and post surgery and at the last follow-up. At the last follow-up visit, the elbow range of motion (ROM ) was measured and the Mayo Elbow Performance Score (MEPS) was established. The followup was after 25 months. Results. The angulation before surgery was 42.4° and the next day after surgery was 6.9°, p = 0.0001. Further correction was observed and at the last follow-up it was 2.5°, p = 0.001. We found no complications besides one skin irritation by an implant and 2 reduced ROM . The MEPS was 97.7. The difference in MEPS between Judet IVB (angulation before surgery&gt; 80°) 92.5 and other patients 98.6 was significant, p = 0.04674. There was no significant difference in MEPS, ROM , between patients immobilized in a plater cast versus in a sling, Conclusions. Closed reduction with the use of ESIN can be considered a safe procedure with a low rate of complications. Patients with an angulation &gt;80° revealed worse functional effects. Cast immobilization did not reveal a negative or a positive impact on the treatment result.

Treatment of fifth metacarpal neck fracture in adolescents with minimally invasive surgery: percutaneous Kirschner wire fixation versus elastic stable intramedullary nailing.

This retrospective study compared two minimally invasive surgical methods for fifth metacarpal neck fractures in adolescents: percutaneous Kirschner wire (K-wire) fixation and elastic stable intramedullary nailing (ESIN). This study involved 42 adolescents aged 11 to 16 years with fifth metacarpal neck fractures treated by either K-wire fixation (n = 20) or ESIN (n = 22). The palmar tilt angle and shortening were compared on radiographs preoperatively and 6 months postoperatively. Total active range of motion (TAM), the visual analogue scale score for pain, and the Disabilities of the Arm, Shoulder and Hand score for upper limb function were recorded at 5 weeks, 3 months, and 6 months postoperatively. The mean TAM was significantly greater in the ESIN than K-wire group at all postoperative time points. The mean external fixation time was 2 weeks longer in the K-wire than ESIN group. One patient in the K-wire group developed infection. There was no statistically significant difference between the two groups in other postoperative outcomes. ESIN fixation has the advantages of greater stability, better activity, a shorter external fixation time, and a lower infection rate than K-wire fixation in the treatment of fifth metacarpal neck fractures in adolescents.

The diagnosis and treatment of a special rare type of Monteggia equivalent fractures in children.

To explore the characteristics, mechanism, treatment, and prognosis of head-neck separation type of Monteggia equivalent fractures in children. Patients with this injury were reviewed retrospectively. The lesion was characterized by a fracture of the ulnar with radial neck fracture but without dislocation of the radial head. Our classification was based on the direction of displacement and angulation of fractures on radiographs, divided into the extension-valgus type and flexion-varus type. The fractures were treated with reduction and internal fixation, depending on the fracture type. The clinical results were evaluated by using radiology and the Mayo Elbow Performance Score (MEPS). A total of 12 patients were followed up for an average of 40.5 months. The ulnar fractures were treated with closed reduction (CR) and K-wire fixation in one patient, elastic stable intramedullary nail (ESIN) fixation in four patients, open reduction (OR) and plate fixation in five, with no fixation in two. CR with ESIN fixation was successful in 11 patients with radial neck fractures, but one underwent OR and K-wire fixation. All fractures healed on time, with fewer complications (avascular necrosis in one patient, and bulk formation of metaphysis in another). The therapeutic efficacy was evaluated by using MEPS and was found to be excellent in 10 patients, good in one, and fair in another. The head-neck separation type of Monteggia equivalent fractures in children is rare. Its characteristics are different from that of Monteggia fracture. The length and anatomic structure of the ulna should be restored and stabilized first, while the radial neck fracture should be treated with CR and ESIN fixation. Satisfactory clinical results can be achieved with fewer complications.

Bone cemented K-wire fixation versus elastic stable intramedullary nailing fixation of paediatric proximal humerus fractures: A prospective cohort study.

The objective of this study is to compare the treatments of pediatric displaced proximal humerus fractures with external-fixation technique using the combination of K-wires and bone-cement versus close reduction and internal fixation technique using elastic stable intramedullary nail. From April 2016 to March 2020, 72 children with proximal humeral fractures were allocated to group A and 44 children with proximal humeral fractures were allocated to group B. Patients in group A were treated with bone-cemented K-wire fixation, and patients in group B were treated with elastic stable intramedullary nailing. The function of the upper limb was assessed using the Shortened Version of the Disabilities of the Arm, Shoulder and Hand questionnaire and Neer score. Patient satisfaction was assessed using the 10-cm visual analogue scale. Bone healing was achieved in group A and B after a mean time of 6.1 ± 1.2 and 6.4 ± 1.1 weeks, respectively. The mean surgical time of groups was 33 ± 9 and 54 ± 12 minutes, respectively. The mean Quick Disabilities of the Arm, Shoulder and Hand questionnaire score of groups were 0.5 ± 1.4 and 0.7 ± 1.5, respectively. Based on Neer score, we obtained 69 excellent and 3 good results in group A, and 41 excellent and 3 good results in group B. There were significant differences regarding duration of operation, cost of treatment, and postoperative angle at bone healing (P < .05). The external cemented K-wire fixation is a useful and reliable alternative technique for the treatment of severely displaced proximal humerus fractures in children. The technique is a minimally invasive procedure with minimal complications.

Ultrasound assistance in treatment with elastic stable intramedullary nail fixation in radial and ulnar fractures in children.

Radial and ulnar fractures are one of the most common fractures in children. When closed reduction of fractures fails, elastic stable intramedullary nail (ESIN) fixation can mostly be used under the guidance of fluoroscopy. In this study, we evaluated the effect of ultrasound (US) as assistance for radial and ulnar fracture reduction and the insertion of ESINs. There were 56 patients with midshaft radial and ulnar fractures included in our hospital from March 2019 to August 2021. After applying the inclusion and exclusion criteria and according to the treatment method, they were divided into the US group (patients treated with US assistance) and the conventional group (C-group, patients treated with fluoroscopy guidance). All patients' clinical data were collected. Operation time, fluoroscopy times, radiation dose, and post-operative complications were analyzed. The elbow function was evaluated using the Mayo Elbow Performance Index. There were 26 patients in the US group and 30 in the C-group. The average operation time was 44.5±19.4 min in the US group and 65.1±16.2 min in the C-group. There were significant differences regarding the surgery time, fluoroscopy time, and radiation dose between the groups (all p = 0.001). The average follow-up time was 13.5±3.1 months. No significant difference was found regarding radial nerve injury, extensor pollicis longus rupture, non-union or delayed union, ulnar nerve injury, or acute compartment syndrome. There was no difference in elbow function at the final follow-up. US guidance can be adopted for the treatment of displaced radial and ulnar fracture reduction and the insertion of ESINs. It can significantly decrease fluoroscopy times, radiation doses, and duration of surgery.

Elastic Stable Intramedullary Nailing for Pediatric Humeral Shaft Fractures Under Ultrasonographic Guidance: A Retrospective Study.

ObjectiveFixation with an elastic stable intramedullary nail (ESIN) is a widely used technique for the treatment of humeral shaft fractures. Ultrasonography (US) is used as an auxiliary tool and alternative to radiography during surgery to reduce radiation damage, but whether it is effective in pediatric patients is not known. In this study we evaluated the utility of US in the treatment of pediatric humeral shaft fractures by closed reduction and fixation with an ESIN.MethodsChildren who were admitted to our hospital with humeral shaft fractures were retrospectively examined from January 2016 to March 2019. The patients were divided into 2 groups, US (treated by US-guided closed reduction and ESIN fixation) and non-US (treated with the same technique but with intraoperative radiography instead of US). The postoperative functional recovery of the 2 groups was compared.ResultsThe study population comprised 28 boys and 17 girls (age range: 4–16 years) with humeral shaft fractures. US significantly reduced radiation exposure during the operation (P = 0.008), and intraoperative US facilitated the detection of nerve and vascular injury and aided surgical planning. There was no difference between the 2 groups in postoperative recovery based on the Constant–Murley shoulder score (CMS).ConclusionsThese results demonstrate that US-guided closed reduction and ESIN fixation for humeral shaft fractures can limit radiation exposure and help doctors to determine the optimal surgical strategy to avoid radial nerve injury.

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

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 &lt; 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.

Overgrowth of the Femur After Internal Fixation in Children With Femoral Shaft Fracture-A Multicenter Study.

To evaluate overgrowth after internal fixation for pediatric femur fracture and to identify any factors related with overgrowth in terms of fracture type and fixation method. Retrospective comparative study. Multicenter, children's hospital and general hospital. Eighty-seven children between 4 and 10 years of age were included. Length-stable fracture was noted in 49 children, and length-unstable fracture was found in 38 children. Thirty-six children were treated by minimal invasive plate osteosynthesis (MIPO), and elastic stable intramedullary nail fixation (ESIN) was used in 51 children. The degree of overgrowth after internal fixation compared to fracture type, fracture site, and surgical method. Multivariable logistic regression analysis was conducted to identify factors related with overgrowth. The average overgrowth of the femur was 10.5 ± 7.3 mm. There was no patient who required correction for final leg length discrepancy (>2 cm). There was no significant difference in overgrowth between ESIN (9.9 ± 7.2 mm) and MIPO (11.2 ± 7.6 mm) (P = 0.417). Overgrowth was similar among length-unstable fractures (12.3 ± 7.4 mm) and length-stable fractures (9.2 ± 7.0 mm), although it was statistically greater in length-unstable fractures (P = 0.048). In the MIPO group, length-unstable fractures were associated with an increased log odds of 6.873 for overgrowth of the femur (P = 0.042). Femur overgrowth after internal fixation seems to not be a clinically significant problem, regardless of whether that be for length-stable or length-unstable fractures and whether they were treated by MIPO or ESIN. Length-unstable fracture may be a risk factor for overgrowth in children. However, the difference is very small, and the postoperative overgrowth would likely not be a significant factor in deciding the surgical plan. Therapeutic Level III. See Instructions for authors for a complete description of levels of evidence.

Evaluating the safety and feasibility of a new surgical treatment for forearm fractures in older children: study protocol for a randomised controlled trial

BackgroundBoth-bone forearm fractures are a common fracture, accounting for 3.4% of all paediatric fractures. For now, elastic stable intramedullary nailing (ESIN) and open reduction and internal fixation (ORIF) are the common surgical procedures for paediatric both-bone forearm fractures. Both ORIF and ESIN have their shortcomings. Therefore, we need to find another surgical treatment which can decrease the rate of complications and improve the clinical efficacy. Our study plans to test hybrid fixation, using an ESIN fixation for the radius and an ORIF for the ulna. Our study will conduct a randomised controlled trial (RCT) comparing double plate fixation with hybrid fixation for treatment of both-bone forearm fractures in older children between 10 and 16 years of age. The objectives of this trial are to compare the effectiveness between double plate fixation and hybrid fixation for treatment of both-bone forearm fractures in older children.MethodsAn RCT will be conducted, and the participants included will be randomly divided into either the hybrid fixation group or the double plate fixation group, at a ratio of 1:1. The primary clinical outcome measures are the Disabilities of the Arm, Shoulder and Hand score and radiological evaluation. Secondary clinical outcome measures are intraoperative blood loss, surgical duration, visual analogue scale score after surgery, hospital duration after surgery and complications. Follow-up will be conducted at 2 weeks and 1, 3, 6 and 12 months postoperatively.DiscussionThe trial will provide a new surgical treatment for forearm fractures in older children. Our hypothesis is that there is no clinically relevant difference in the primary outcome measures between the two treatment groups.Trial registrationChinese Clinical Trial Registry, ChiCTR1800018060. Registered on 26 August 2018.

Antegrade elastic stable intramedullary nail fixation for paediatric distal radius diaphyseal metaphyseal junction fractures: A new operative approach

Background and purposeThe treatment of paediatric distal radius diaphyseal metaphyseal junction (DRDMJ) fractures is a challenge. The purpose of this study was to introduce a new operative approach at the proximal “safe zone” of the posterior interosseous nerve (PIN) to treat paediatric DRDMJ fractures and analyse the safety and efficacy of antegrade elastic stable intramedullary nail (ESIN) fixation. MethodsThirty paediatric patients with unstable and displaced DRDMJ fractures were treated by antegrade ESIN fixation from November 2015 to September 2017. We created the entrance site at the posterolateral side of the proximal radius and 2˜4 cm distal to the articular surface of the radius, using the ESIN to immobilise the fractures. In the study, we reviewed patient demographics, complications, time until removal, and intraoperative time for hardware removal. ResultsComplete fracture healing was achieved between 6 and 12 weeks after surgery. Except for 3 patients presenting with irritation of the skin, we did not observe any complications. Radiologically, no secondary displacement, nail migration, loss of fixation, consolidation delay, non-union, or refracture was noted. ConclusionsThe antegrade ESIN fixation is a minimally invasive, easy-to-learn, alternative operative method to treat paediatric DRDMJ fractures. Level of evidenceTherapeutic Level IV.

Cortical erosion after elastic stable intramedullary nail fixation for pediatric long bone fractures: Case series according to the site

BackgroundElastic stable intramedullary nail (ESIN) is widely used for treatment of long bone fractures in children. However, migration of the nail or cortical bone erosion in children has been reported. This study was conducted to investigate the incidence of cortical erosion according to the site and cortical erosion type. Materials and methodsA total of 221 normally developing children (223 fractures) who were treated with ESIN for fractures of the long bones without cortical breakage at immediate postoperative radiography and with the ESIN in position for more than 6 months were included. Two pediatric orthopaedic surgeons reviewed all the radiographs. Cortical bone erosion was defined when the two investigators agreed that there was cortical breakage by the ESIN. ResultsPenetration of nails through the bone cortex was observed in 25 patients (11.2%). Fifteen patients (6.7%) showed cortical erosion at the diaphysis and ten patients (4.5%) showed protrusion of the tip of the ESIN at the metaphysis–diaphysis junction. The average time for hardware removal in patients with cortical erosion was 14.2 months. ConclusionCortical bone erosion by ESIN could occur in pediatric long bones without any iatrogenic problem or disease related to the bony structure. Erosion at diaphysis was more common than at metaphysis–diaphysis junction. Cortical erosion should be considered in children who retain their ESIN for a long time.

Comparison of three fixation methods in treatment of tibial fracture in adolescents.

Tibial fractures are the most common musculoskeletal injury in adolescents. The optimal management of tibial fractures in adolescents is controversial. In this study, we compared the outcomes including complications of three fixation methods in tibial fractures of adolescents and explored the factors associated with the complications. A retrospective cohort study about 83 diaphyseal tibial fractures in 79 children and adolescents, who were treated with plate fixation (PF), elastic stable intramedullary nail fixation (ESINF), or external fixation (EF), was conducted. After adjustment for age, weight, energy of the injury, polytrauma, fracture level and pattern, and extent of comminution, treatment outcomes were compared in accordance with the length of the hospital stay, time to union, and complication rates including many factors. The mean age of the patients was 13.4 years, and their mean weight was 44.2 kg. There was a loss of reduction in two of 33 fractures treated with ESINF and four of 13 treated with EF (P < 0.001). At the time of final follow-up, three patients (two treated with EF and one treated with ESINF) had ≥2.0 cm of shortening. Four of the 32 patients (33 fractures) treated with ESINF underwent a reoperation (two due to loss of reduction and one each because of delayed union and nonunion). Six patients treated with EF required a reoperation (four due to loss of reduction, one for malunion and one for replacement of a pin complicated by infection). Two fracture treated with PF required refixation attributing to nonunion and malunion. A multivariate analysis with adjustment for baseline differences showed that EF was associated with a 7.56-times (95% confidence interval 3.74-29.87) greater risk of loss of reduction and/or malunion than ESINF. All three treatments had satisfactory outcomes, and EF was correlated with the highest rate of complications in our series of adolescents treated with a tibial fracture. However, we cannot currently recommend that all fractures might be suitable for ESINF. The choice of fixation will remain influenced by surgeon preference in term of expertise and experience, patient and fracture characteristics, and patients and family preferences.

Elastic Stable Intramedullary Nailing for Treatment of Pediatric Tibial Fractures

Introduction: Tibia fractures in the skeletally immature patient can usually be treated with above knee cast or patellar tendon bearing cast. The purpose of our study was to evaluate epidemiology and outcome of Elastic stable intramedullary nailing fixation of pediatric tibial shaft fractures treated at our institution.&#x0D; &#x0D; Methods: Over a period of one year, fifty pediatric patients of tibial shaft fractures, with average age of 9.68 yr (SD=2.37), were treated with elastic stable intramedullary nail. Demographic data, union and complication rate were evaluated.&#x0D; &#x0D; Results: There were 36 closed and 14 open fractures. The average time to union was 11.6 weeks (SD=2.65) for close and 14.3 weeks (SD=2.62) for open fracture. There were no instances of growth arrest, remanipulations, or refracture.&#x0D; &#x0D; Conclusion: We conclude that flexible intramedullary fixation is an easy and effective method of management of both open and closed unstable fractures of the tibia in children.

Comparison of hybrid fixation versus dual intramedullary nailing fixation for forearm fractures in older children: Case-control study

ObjectiveThe aim of the present study was to compare the clinical outcomes of hybrid fixation using elastic stable intramedullary nailing (ESIN) for the radius and plate screw fixation for the ulna (Hybrid group) with dual ESIN fixation (D-ESIN group) for both-bone forearm fractures in children between 10 and 16 years of age. MethodsFifty patients with both-bone forearm fractures (28 patients in the Hybrid group and 22 patients in the D-ESIN group) were reviewed. Functional outcomes were evaluated according to the criteria of Price et al. Radiological results were assessed by fracture union at three and six months and bone union time. Postoperative complications were also recorded. ResultsThe times of fluoroscopy intraoperatively and duration of immobilization postoperatively were significantly lower in the Hybrid group (P < 0.05). The union rate of the ulna at three months postoperatively in the hybrid group was significantly higher than that in the D-ESIN group (P < 0.05). The average time of bone union was significantly shorter in the hybrid group than that in the D-ESIN group (P < 0.05). There were no differences according to the satisfactory rate and degree, the major and minor complications between the groups. ConclusionHybrid fixation is superior in terms of the times of fluoroscopy intraoperatively, duration of immobilization postoperatively, delayed union rate of the ulna and the average time of bone union. Therefore, hybrid fixation is an alternative treatment for both-bone forearm fractures in children between 10 and 16 years of age.

Application of elastic stable intramedullary nailing fixation for treatment of long bone fractures in children

Elastic stable intramedullary nailing (ESIN) is a well-accepted fixation method of long bone fractures in children.The advantages of ESIN include primary bone union with avoidance of growth plate injury and minimum invasive surgery.The good results of ESIN are obtained when surgeons have a good knowledge of the principle of the correction of the fracture and its stability, especially in the understanding of the unique pathophysiology characteristics of pediatric fractures.This review discussed the biomechanical mechanisms of ESIN, and the principles, indications and contraindications of ESIN in the treatment of pediatric long bone fractures.The article also comprehensively introduced the application of ESIN in femur, tibia, fibula, humerus, ulna, radius, clavicle and metacarpal bone fractures.The technique details of nailing, preoperative planning, positioning of the patient, sizing of the nail, entry points for the nail, reduction maneuvers for safe passage of nails through the fracture site, and postoperative management were also introduced in this review. Key words: Elastic stable intramedullary nailing; Fracture; Child

Fehler bei der Behandlung diaphysärer Frakturen der langen Röhrenknochen bei Kindern – Erfahrungen der norddeutschen Schlichtungsstelle

Statistics of the Arbitration Office of the North German Medical Boards for extrajudicial claim resolution show that nearly 30 % of all panel proceedings confirm medical malpractice. In proceedings concerning fractures in children the percentage rises to 63 % with significant differences in various fracture localisations. Between 2000 and 2011 the Arbitration Office dealt with 272 panel proceedings regarding the fracture treatment in children. In this study 83 proceedings concerning the treatment of diaphyseal fractures of the long bones are evaluated. The claims were related to the following specialities (p = number of proceedings, m = number of malpractices): orthopaedics/traumatology p = 46, m = 38; general surgery p = 17, m = 21; paediatric surgery p = 16, m = 13; anaesthesia p = 1, m = 1; general practitioner p = 2, m = 2. In 7 cases concerning obstetrics (4) and paediatrics (3) no malpractices could be established. In 5 cases two facilities/doctors were included in the same proceeding. On 17 occasions, 2 errors were made that were unrelated to each other. The overall frequency of malpractice was 69 % with no significant differences between the involved facilities. The diaphyseal fracture locations were: humerus p = 5, m = 2; radius and/or ulna (Monteggia fractures excluded): p = 29, m = 20; femur p = 29, m = 20; tibia (with or without fracture of the fibula): p = 20, m = 14. In conservative fracture treatment the following negligent adverse events were confirmed: severe skin lesions owing to either plaster extension or removal of the cast (11), omitted or insufficient reduction followed by consolidation in intolerable malposition (8), no inducement of corrective measures after consolidation in intolerable displacement (11). Following malpractices in the surgical treatment were classified as: no indication for surgical treatment (2), no osteosynthesis in spite of clear indication (3), technical failures in primary osteosynthesis (16), technical failures in repeated osteosynthesis (4), aspiration pneumonia due to missed intubation (1). The applied methods of osteosynthesis were intramedullary nailing, mainly ESIN p = 24, m = 12; plate p = 24, m = 5; fixateur externe p = 7, m = 5. The results of maltreated diaphyseal fractures were altogether moderate: transitional impairment due to delayed or repeated therapeutic measures with prolonged fracture healing, no functional loss 70 %, slight deformation of the forearm, minimal loss of mobility 21 %, remarkable deformation of the forearm with considerable impairment of mobility, especially pronation/supination, deformation of the radio-ulno-carpal joint unit 7 %. There are three main categories in the maltreatment of diaphyseal fractures: 1) Omission of fracture reduction with or without internal stabilisation in cases of relevant axial deviation by unjustified expectation of "spontaneous correction". 2) Omission of fracture reduction in cases of unmotivated or neglected secondary displacement. 3) Technical failures in performing of osteosynthesis resulting in instability or the creation of intolerable malposition requiring re-osteosynthesis. The high number of plate osteosyntheses in our series (44 %) is not representative for the general treatment of children's fractures in Germany. Most cases of plate osteosynthesis are related to corrective measures with clear indication. In nine casuistic representations the errors in treatment are explained. The evaluation of malpractice in the treatment of diaphyseal fractures in children confirms the consensus: correct assessment of fracture type, early adequate treatment and fracture control, early corrective measures after insufficient primary reduction or secondary dislocation, lead to fracture healing without any anatomic or functional deficiency. Reverse argument: fracture healing leading to anatomic and/or functional loss gives a very probable indication of malpractice.

ATTRITIONAL RUPTURE OF EXTENSOR POLLICIS LONGUS: A RARE COMPLICATION FOLLOWING ELASTIC STABLE INTRAMEDULLARY NAILING OF A PAEDIATRIC RADIAL FRACTURE

Elastic stable intramedullary nail fixation has become established as an acceptable method of treatment for diaphyseal fractures of both forearm bones in the paediatric population. It is considered safe, minimally invasive and does not compromise physeal growth. We report a case of delayed rupture of extensor pollicis longus due to attrition over the sharp edges of a protruding nail end after elastic stable intramedullary nailing of a paediatric radial diaphyseal fracture.