Elastic Stable Intramedullary Nailing Research Articles

Corrective osteotomy in symptomatic midshaft clavicular malunion using elastic stable intramedullary nails

It is our goal to present an alternative, less invasive surgical technique for corrective osteotomy in symptomatic midshaft clavicular malunion using elastic stable intramedullary nails (ESIN) and to present our results in a consecutive patients series. Between January 2003 and December 2006, five patients aged between 23 and 44 years presented with a symptomatic malunion after nonoperative treatment of displaced midshaft clavicular fractures. Corrective osteotomy was performed without bone grafting. The osteotomy sites united in all patients after a mean of 4.4 months. The nails were removed in all patients after 7 months. At final follow-up, DASH and Constant Scores were significantly improved compared to preoperative values. Patients were significantly more satisfied with cosmetical appearance and overall outcome. Clavicular shortening was also significantly improved. Elastic stable intramedullary nailing leads to favourable results in corrective osteotomy of malunited midshaft clavicular fractures. We therefore recommend this technique for corrective osteotomy of symptomatic midshaft clavicular malunions.

Nonunion of forearm shaft fractures in children after intramedullary nailing

The elastic stable intramedullary nailing (ESIN) is the current treatment of choice for unstable forearm shaft fractures in children. There is no large study on paediatric nonunion of forearm shaft fractures in children after intramedullary nailing. There are only sporadic reports on nonunions after ESIN in children. The aim of this study was to define predisposing factors of nonunions in paediatric forearm fractures. All children who had been treated for forearm fractures by ESIN in our hospital from 1990 to 2006, and all children treated elsewhere surgically and being followed up at our institution were included in the study. In these children, we identified all patients who did not show bony consolidation of the fracture after 6 months from ESIN. Over a period of 16 years, 537 patients were primarily treated in our hospital and 55 children had been initially treated in a different institution. Six children were identified to fulfill the criteria of having developed a pseudarthrosis. Of these six children, three patients had been primarily treated in another hospital and three were our original patients. The average age was 11.1 years (9-14 years). There were only pseudarthroses of the ulna to be observed. In five children, the pseudarthrosis was in the middle third and in one patient in the distal third of the ulna. There were five closed fractures and one first-degree open fracture. Five times an open reduction of the ulna had been performed because closed reduction and insertion of the ESIN was impossible, whereas the radius had been treated closed in five cases and open in one case for intramedullary stabilization. Three cases were refractures, in one child it was a second refracture. In one case, we identified a technical error as cause of the development of the pseudarthrosis. Four children needed a revision surgery. In these children, the ulna was plated. Two patients showed spontaneous healing of the pseudarthrosis. In five patients, there was a hypertrophic pseudarthrosis present and in one case was hypotrophic pseudarthrosis. The reintervention was necessary because of increasing deformity in four patients and implant failure in one case. In conclusion, Non-unions after forearm fractures are observed in children and adolescents mainly in the middle third of the ulna. With the need of initial open reduction or the presence of an open fracture in the first instance, the risk of developing a pseudarthrosis. It may also be higher in such cases, which represent a refracture. Despite the small risk of developing a pseudarthrosis after forearm fracture, the indication for ESIN is clear. The surgical trauma needs to be as minimal as possible in cases with open reduction with as little as possible compromise of the blood circulation of the affected bone.

Intramedullary nailing for metacarpal 2–5 fractures

Twenty-eight patients with 31 closed fractures (27 acute fractures and four with malalignment after conservative treatment) of the metacarpal bones 2-5 were treated with only one elastic stable intramedullary nail and followed prospectively. Treatment protocol was without immobilization or physiotherapy. These patients were reviewed at a mean follow-up time of 15 months for ultrasound results as well as functional outcome concerning complications, pain, range of motion, and grip strength measured with a Vernier-Dynamometer. Satisfaction of the patients was investigated by Clients Satisfaction Questionnaire. Radiographs before nail removal, ultrasound, and clinical examination always showed complete union of the fracture without deviation of axis. All patients gained full range of motion without any limits in daily activity and sports. There was no loss of grip strength compared with the other hand. Patients' satisfaction was very high, especially because of almost no postoperative pain and lack of immobilization. This method can be offered as an effective and safe alternative in the treatment of closed displaced fractures of the 2-5 metacarpus without significant complications.

Elastic Stable Intramedullary Nailing Was Effective in Displaced Midshaft Clavicular Fractures

Elastic Stable Intramedullary Nailing Was Effective in Displaced Midshaft Clavicular Fractures

Die elastische stabile intramedulläre Nagelung als Therapiealternative in der Versorgung kindlicher Humerusschaftfrakturen

We report about our experiences with the elastic stable intramedullary nailing (ESIN) of traumatic humeral shaft fractures in children and adolescents. Children with traumatic humerus shaft fractures who were treated by ESIN were included. All patients underwent clinical follow-up examinations. 31 children (average age 11.4 years) with traumatic humeral shaft fractures could be included. There were 14 oblique, 12 transverse and 5 wedge fractures. In 5 cases the fracture was located in the proximal third, in 22 cases in the middle third and in 4 cases in the distal third. After an average period of 32 months a follow-up-examination with the Constant-Murley score was performed. All children attained 100 points and all patients could take part in sports activities like before the accident. 30 children and their parents were very satisfied with the treatment success and 1 patient was satisfied. The following complications were seen: 1 postoperative damage of the radial nerve in a patient with secondary fracture dislocation (complete remission), 1 skin irritation, 1 fracture dislocation with axial deviation, 1 secondary dislocation of the nails after a second accident and 1 secondary axial deviation. Elastic stable intramedullary nailing (ESIN) of humerus shaft fractures has a low complication rate if attention is paid to biomechanical principles. The observed complications are based on mistakes concerning the indication or technical errors. The ESIN shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction. The ESIN of humeral shaft fractures is a minimally invasive, simple and well reproducible technique with a steep learning curve. Because of the excellent objective and subjective results, the operative stabilization of humerus shaft fractures with ESIN should be recommended to the patients and their parents.

Dislozierte Klavikulafrakturen im Kindes- und Jugendalter: Wer profitiert von einer Operation?

Displaced midclavicular fractures in children are generally treated non-operatively. But there is a lack of age-related data concerning the functional and cosmetic results following conservative treatment and patients' content with the treatment. In patients with displaced midclavicular fractures complications and pain was evaluated in relation to treatment option and age. Outcome was measured with the Constant Shoulder Score, a client satisfaction questionnaire (ZUV-8) about the satisfaction with the treatment and the cosmetic result and ultrasound of both clavicles. A review of emergency room and fracture clinic records revealed 101 children and adolescents in whom displaced midclavicular fracture had been treated between 1/1997 and 12/2007. The follow-up included 59 patients with 60 fractures 1-10 years after the accident. Of those, 50 fractures were treated with a sling and 10 by operation. All patients under the age of ten were treated conservatively and reached very good functional and cosmetic results. Only an eight-year-old girl suffered from a painful pseudarthrosis. After resection and stabilisation by flexible intramedullary nailing, the outcome was excellent. Patients over the age of ten received a conservative treatment in 28 cases and ten had an operation (K-wires fixation n=2, elastic stable intramedullary nail n=8 in 7 patients). Functional outcome independent of treatment method was as good as in younger children, but the global and cosmetic satisfaction score was much lower. Older patients with a non-operative treatment suffered from more pain and were dissatisfied with the long immobilisation. The method of choice in children under the age of ten with a displaced clavicular fracture is the non-surgical treatment supported by sufficient pain medication. Older children reach good results but suffer from more pain and are dissatisfied by the cosmetic results and immobilisation. Because of this, active older children and adolescents with a displaced clavicular fracture benefit from elastic stable intramedullary nailing.

Evaluation of Severely Displaced Radial Neck Fractures in Children Treated With Elastic Stable Intramedullary Nailing

We performed a retrospective case study of 28 consecutive severely displaced radial neck fractures (Judet types III and IV) in children treated with elastic stable intramedullary nailing using the Metaizeau technique. We reviewed all preoperative radiographs and classified the injuries according to Judet. All patients were asked to return for later assessment. They underwent physical examination; radiographs were taken; and they were asked for subjective assessment. An evaluation of clinical results was performed using the Mayo Elbow Performance Score (MEPS). According to Judet classification there were 13 type III and 15 type IV fractures. Using the MEPS, excellent results were achieved in 23 cases (82%) and good results in 5 cases (18%). The average MEPS was 97 points. Five patients complained of mild pain. Three malunions were observed. Elastic stable intramedullary nailing is a minimally invasive technique, allowing stable fixation and providing excellent to good outcomes with a low complication rate. We performed a retrospective level 4 study of case series.

Nonunion of the ulna after elastic stable intramedullary nailing for unstable forearm fractures: a case series

Elastic stable intramedullary nailing (ESIN) for displaced forearm fractures in children has shown good results over the last two decades. To our knowledge, nonunion as complications after ESIN fixation of displaced forearm fractures is not well reported in English literature. In our institute, and over a period of 10 years, we identified three cases of nonunion of the ulna after ESIN fixation of unstable and displaced forearm both bone fractures. Two patients had closed fractures and one patient had an open fracture. There was no deep infection in any case. All cases after revision surgery went into union.

Screw Osteosynthesis of Proximal Femur Fractures in Children

Optimal reposition and stable fixation of M/1 and M/2 fractures are necessary. Careful operation and urgent surgery prevent complications. M/1 and M/2 fractures of the proximal femur in children > 4 years. E/1 fractures are fixed with Kirschner wires. M/3 fractures are fixed with elastic stable intramedullary nailing. Fractures up to the age of 4 are fixed with Kirschner wires. Surgical approach via a lateral incision. Anatomic fixation of the fracture with two to three cannulated screws. No weight bearing during the first 4-6 weeks. Physiotherapy is optional. Magnetic resonance imaging at least 1 year after the fracture or immediately in case of problems to control the vascular situation of the femoral head. Due to the rarity of these fractures, only few results from large series have been published. M/1 fractures show a higher complication rate than M/2 fractures. The risk of avascular necrosis has to be estimated at up to 40%.

Complications of elastic stable intramedullary nails in paediatric fractures

Complications of elastic stable intramedullary nails in paediatric fractures

Comparative study of elastic stable intramedullary nailing and bone plate set in treatment of femoral shaft fractures in children

Objective To investigate and evaluate the efficacy of elastic stable intramedullary nailing (ESIN) and bone plate set (BPS) in the treatment of femoral shaft fractures in children. Methods The study involved 39 children with femoral shaft fractures, of whom 18 children were treated with ESIN (ESIN group) and the other 21 with BPS (BPS group). In ESIN group, the nails were insert-ed through a micro incision in the medial and lateral epicondyle after closed reduction under C - arm ob-servation. In BPS group, the plates were placed on the lateral side of femur by means of open reduction and internal fixation. Results All the patients were followed up for 4-20 months (mean 10 months), which showed fracture healing in all the patients. The mean operation time, incision length, perioperative blood loss, length of hospital stay, time of fracture healing and time of weight bearing were (40.0±17.0) minutes, (2.0±0.6) cm, (30.0±8.0) ml, (7.0±1.5) days, (8.0±1.2) weeks and (6.0 ±1.0) weeks respectively in ESIN group, and (70.0±25.0) minutes, (12.0±1.1) cm, (150.0±30.0) ml, (14.0±5.2) days, (13.0±1.9) weeks and (4.0±1.3) weeks respectively in BPS group, with statistical difference between two groups (P < 0.05). Conclusions Compared with BPS, ESIN has the advantages of less operation wound, less perioperative blood loss and shorter time for fracture healing. ESIN can protect the microenvironment important for the fracture healing, and is one of ideal op-tions for treatment of femoral shaft fracture in children. Key words: Femoral fractures; Child; Fracture fixation, intramedallary; Bone plate

L’embrochage centromédullaire élastique stable des fractures diaphysaires du tibia chez l’enfant

Surgical stabilization is rarely indicated for tibial fractures in children. The purpose of this study was to determine the importance and the complications associated with elastic stable intramedullary nailing (ESIN) in pediatric tibial fractures. We retrospectively reviewed 12 tibias in 11 patients that were treated by ESIN between 2000 and 2007 in our institution. Children ranged in age from seven to 14 years. There were ten closed and two open fractures. The average time union was 11 weeks. Four patients (36%) had five complications: one major (malunion > 10°) and four minors (1 leg length discreparancy < 12 mm, 1 superficial infection, 1 delayed union and 1 malunion < 10°). We believe that ESIN of pediatric tibia fractures is an effective treatment option.

Femoral lengthening over elastic stable intramedullary nailing in children using the monolateral external fixator

The authors report preliminary results of femoral lengthening performed with monolateral external fixation over elastic stable intramedullary nailing in children. Seven femoral lengthenings were performed in six patients, at a mean age at surgery of 6.6 years (range 1.5-12 years). All lengthenings were performed due to limb length discrepancy (congenital hypoplasia in four patients, growth arrest secondary to neonatal infective osteoarthritis in one, type II sacral agenesis in one). In six cases the elastic nails realised a bipolar ascending construct, in one case a descending construct. Cases were reviewed at a mean time from removal of external fixator of 34.2 months (range 15-75 months). The mean lengthening obtained was 4.8 cm (range 3.8-6.0 cm). Mean consolidation index was 42.9 days/cm. No case of axial deviation requiring surgery and no case of deep infection were recorded. No case of fracture of the regenerate occurred after removal of the external fixator. There were two premature consolidations requiring mobilisation under general anaesthesia, and a case of failure of consolidation requiring surgery. The technique reported provides indisputable biomechanical advantages, particularly increasing stability at the site of osteotomy. The characteristics of implants make this method ideal for lengthenings in children.

L’inchiodamento endomidollare nell’infanzia

Elastic stable intramedullary nailing has become a well-accepted method of osteosynthesis of diaphyseal fractures in children and adolescent. The reasons include rare necessity of a postoperative cast, primary bone union with avoidance of growth plate injuries and minimal invasive surgery.

Paediatric diaphyseal forearm refractures after greenstick fractures: Operative management with ESIN

Background One of the complications of forearm shaft fracture is refracture. Elastic stable intramedullary nailing represents an alternative method for refracture treatment to cast immobilisation for another five to seven weeks. Operative treatment often necessitates an open reduction in most cases due to blocked or narrowed medullary canals. The purpose of this study was to examine the expense of the operative procedure, technique (closed or open intramedullary nailing) and postoperative complications in diaphyseal forearm refractures. Methods We retrospectively examined the expense of operative procedure in 21 children with diaphyseal forearm refractures treated with ESIN. Results In 18 cases, closed reduction with nailing was possible; three required an open reduction. In nine patients a closed medullary cavity was present; only two of them needed an open reduction. None of the patients had complications (wound healing, osteomyelitis, rupture of the extensor pollicus longus). Swelling appeared in four patients, paraesthesia of the thumb in one. Free functional movement was achieved in all children. Long term results: No re-refracture occurred. One patient suffered from meteorosensitivity. Twelve are able to do the same sporting activities as before injury. Conclusion ESIN seems to be one choice for treatment in refracture of the forearm, as in most cases the operative reduction can be performed in a closed way by means of “tricks and hints”.

Elastic Stable Intramedullary Nailing Versus Nonoperative Treatment of Displaced Midshaft Clavicular Fractures-A Randomized, Controlled, Clinical Trial

To compare elastic stable intramedullary nailing (ESIN) with nonoperative treatment of fully displaced midshaft clavicular fractures in adults. The study was a randomized, controlled, clinical trial. Level 1 trauma center. Sixty patients between 18 and 65 years of age participated and completed the study. They were randomized to either operative or nonoperative treatment with a 2-year follow-up. Thirty patients were treated with a simple shoulder sling and 30 patients with ESIN within 3 days after trauma. Complications after operative and nonoperative treatments, Disabilities of the Arm, Shoulder and Hand (DASH) score and Constant Shoulder Score for outcome measurement, and clavicular shortening. Fracture union was achieved in all patients in the operative group, whereas nonunion was observed in 3 of 30 patients of the nonoperative group. Two symptomatic malunions required corrective osteotomy in the nonoperative group. Medial nail protrusion occurred in 7 cases in the operative group. Implant failure with revision surgery was necessary in 2 patients after an additional adequate trauma. DASH scores were lower in the operative group throughout the first 6 months and 2 years after trauma, with a significant difference during the first 18 weeks. Constant scores were significantly higher after 6 months and 2 years after intramedullary stabilization. Patients in the operative group showed a significant improvement of posttraumatic clavicular shortening; they were also more satisfied with cosmetic appearance and overall outcome. ESIN of displaced midshaft clavicular fractures resulted in a lower rate of nonunion and delayed union, a faster return to daily activities, and a better functional outcome. Clavicular shortening was significantly lower, and overall satisfaction was higher in the operative group.

Use of end caps in elastic stable intramedullary nailing of femoral and tibial unstable fractures in children: Preliminary results in 11 fractures

Elastic stable intramedullary nailing (ESIN) is used routinely world-wide for treating femoral and tibial shaft fractures in children before skeletal maturity. Overall, ESIN allows rapid limb mobilisation with few complications. However, many centres have experienced some complications resulting from secondary fracture displacement, especially in heavy adolescents and in spiroid or complex fractures due to changes in the nail's position, leading to limb shortening, malrotation and malalignment. End caps were designed by the AO expert group to address these complications. The purpose of this study is to evaluate the efficiency, safety and tolerance of this new device in our first series of ten patients and 11 fractures. Prospective follow-up of our first ten patients operated on with end caps. Our results show that there were no serious complications at a mean follow-up of 13.1 months. There was only one 10-mm leg shortening in a patient in whom the end caps could not be properly inserted. There were no infections, no additional pain and no skin irritation. The use of end caps eased the removal of the nails after bone healing, thereby preventing the formation of ossification over the tips of the nails and appeared to protect the skin next to the nail tip. These results seem to prove the advantage of using end caps when performing ESIN in lower limb shaft fractures in children. A longer follow-up that includes more patients and a randomised prospective study should be carried out in the future to determine more precisely the indications of this new device.

Treatment of severely displaced proximal humeral fractures in children with retrograde elastic stable intramedullary nailing

We report our experience of elastic stable intramedullary nailing (ESIN) of severely displaced proximal humeral fracture Type III and IV according to Neer in children. Thirty-five children (mean age 12.7 years) with 19 Salter-Harris Type II epiphyseal fractures and 16 children with metaphyseal fractures of the proximal humerus were treated with ESIN by one-nail or two-nail-technique. There were the following complications: two perforations of the nail at the head of the humerus with loss of position, one loss of position without nail perforation, one misplacement of a nail, one revision due to haematoma and two difficult removals of metal. For follow-up examinations after 26 months the children were classified by use of the Constant-Murley score. On average they gained 99 points. All children were able to resume their sporting activities as before. For the treatment of displaced proximal humeral fractures in children more than 10 years old the retrograde ESIN represents a safe minimal invasive surgical procedure.

Use of Elastic Stable Intramedullary Nailing for Treating Unstable Forearm Fractures in Children

The majority of the pediatric diaphyseal forearm fractures are treated with closed reduction and the application of an above elbow cast for a varying period, depending on the age of the child. Some forearm diaphyseal fractures require osteosynthesis mainly because of the presence of an unacceptable angular deformity, fracture instability, presence of an open injury or failure of conservative management in the form of redisplacement in the cast after manipulation. We present our experience with elastic stable intramedullary nailing (ESIN) for displaced and unstable pediatric diaphyseal fractures. A consecutive series of 21 patients treated with ESIN between 1997 and 2005 have been reviewed retrospectively. There were 14 boys and 7 girls with a median age of 11.8 years. All fixations were protected in an above elbow plaster cast. Patients were followed up for an average of 12.8 months (Range, 12-21.5 months). Clinical and radiologic union was achieved within 13 weeks after the procedure in 19 children. One patient had delayed union of the ulna which finally united at 9 months after operation without any further intervention. Another patient had nonunion of ulna that required autologous bone marrow injection after 1 year before full consolidation occurred. Complications were all modest and transient and eventually all patients achieved a good functional clinical outcome. We think that the technique has many merits over a more traditional plating technique including a minimally invasive technique, a less time consuming procedure and easier metal work removal. We think that cosmesis is perhaps the most important to our patients because the wounds are small and less conspicuous than the traditional Henry approach for plating which leaves a long unsightly volar forearm scar. We think that ESIN is an attractive treatment option for displaced and unstable diaphyseal forearm fractures in children.

Minimally Invasive Intramedullary Nailing of Midshaft Clavicular Fractures Using Titanium Elastic Nails

In up to 31% of cases, nonsurgical treatment of midshaft clavicular fractures leads to unsatisfactory results such as nonunion, brachial plexus irritation, shortening and limited function of the shoulder. To date, various implants have been developed for open reduction including intramedullary wires, screws, and plates. This study discusses elastic stable intramedullary nailing of midshaft clavicular fractures. Between 2000 and 2005, 31 midshaft clavicular fractures were treated by intramedullary nailing with a titanium elastic nail (TEN). Subjective and clinical outcome were evaluated after an average follow-up of 26 (6-46) months. Patients were divided into three groups: patients with isolated clavicular fractures (group 1, n = 9); patients with additional injuries (group 2, n = 15), and patients with multiple injuries (group 3, n = 7). Nonunion was not observed. No patient sustained a refracture after TEN removal. Medial migration of the TEN in seven patients and iatrogenic perforation of the lateral cortex in one patient required secondary shortening on five occasions. Nail breakage after fracture healing was observed twice. Subjective outcome did not differ significantly between the three groups. Constant and Murley Score and the Disability of the Arm, Shoulder, and Hand Questionnaire Score showed no significant difference in the clinical outcome of the three groups. Intramedullary fixation of midshaft clavicular fractures with a TEN is a safe minimally invasive surgical technique achieving primary stability for practice. It can be seen as an alternative to plate or screw fixation or nonsurgical treatment, as it produces excellent cosmetic and functional results regardless whether patients suffered from isolated clavicular fractures, additional injuries, or multiple traumas.