Flexible Intramedullary Fixation Research Articles

Operative treatment of pediatric diaphyseal both-bone forearm fractures with flexible intramedullary fixation

Operative treatment of pediatric diaphyseal both-bone forearm fractures with flexible intramedullary fixation

Redefining Optimal Nail to Medullary Canal Diameter Ratio in Stainless Steel Flexible Intramedullary Nailing of Pediatric Femur Fractures.

The ideal canal fill for flexible intramedullary fixation of pediatric femoral shaft fractures is considered to be 80% based upon relatively few clinical studies. The purpose of this study is to assess the relationship between the summed nail to intramedullary canal diameter (ND/MCD) ratio and alignment at radiographic union following flexible intramedullary nailing (FIMN) of pediatric femoral shaft fractures. An Internal Review Board approved, retrospective review of a consecutive series of patients who sustained a femoral shaft fracture treated by retrograde, stainless steel FIMN was performed at a single level 1 pediatric trauma center from 2005 to 2012. Preoperative radiographs were analyzed to determine fracture pattern, location, and isthmic canal diameter. ND/MCD ratio was calculated using the sum of the known nail diameters and the measured isthmic diameter. Radiographs at bony union were reviewed to measure shortening, coronal angulation, and sagittal angulation. ND/MCD ratio was analyzed to determine correlative factors with final radiographic outcomes. In total, 261 children underwent retrograde FIMN at an average age of 8.2 years (range, 2.2 to 17.0 y). ND/MCD ratio of ≥80% was seen in 108 (41.4%) patients. When compared with those with <80% ND/MCD ratio, there were no significant differences in age (8.8 vs. 8.0 y), sex (76.9% vs. 71.0% males), or body mass index (18.5 vs. 17.2 kg/m). There were significantly more length unstable fractures in the <80% ND/MCD ratio group (49.4% vs. 29.7%; P<0.01). Radiographic outcome was no different with respect to coronal angulation (2.7 vs. 3.0 degrees), sagittal angulation (3.0 vs. 3.2 degrees), or shortening (2.5 vs. 4.1 mm). ND/MCD ratio of ≥70% was seen in 176 (67.4%) patients and, when compared with the <70% ND/MCD ratio group, there were no differences in shortening (3.3 vs. 3.9 mm), coronal angulation (2.8 vs. 3.0 degrees), or sagittal angulation (3.0 vs. 3.4 degrees). Finally, 6.9% of the population (18 patients) had ND/MCD ratios <60% and did not demonstrate a significant increase in shortening, coronal, or sagittal angulation compared with groups with higher ND/MCD ratios. No group had an increased rate of infection, implant removal, nonunion, or need for reoperation. In a large series of consecutive patients treated with retrograde stainless steel FIMN there does not appear to be any correlation between the ND/MCD ratio and radiographic outcome. Stainless steel flexible IM nails seem to maintain fracture alignment without an increase in complications at lower ND/MCD ratios than previously reported as "optimal." Level III.

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.

Management of pediatric forearm fracture, a prospective study comparing the outcome of open reduction internal fixation with plate and screws method and closed reduction flexible intramedullary nailing method

Background and Objectives: to compare the outcome of open reduction-internal fixation with plate and screws method and closed reduction-flexible intramedullary nailing method in the management of pediatric patients with unstable forearm fractures as regard to functional and cosmetic outcome. Patients and Methods: The final assessments of 42 pediatric patients between the ages of 5 to 15 years old, who were operated from April 2010 to February 2011 for both-bone forearm fractures in Erbil Teaching Hospital and Private Hospital with adequate follow up, were done and their medical records were prospectively evaluated. Results:42 children with unstable forearm fractures 21 were treated with open reduction and internal fixation of both radius and ulna using plate and screws (Group1)(mean age ,13years) and 21 were treated with close reduction and flexible intramedullary fixation (Group2)( mean age ,11years). Patient characteristics in the 2 groups were compared. In Four patients of Group 2, closed reduction was not possible because of soft tissue interposition that required open reduction with minimum incision at the fracture site. All patients achieved bone union; the mean union times were similar (P value=0.81), only one patient in each group had delayed union. Operating times were shorter in flexible nailing group (100 minutes in Group1 vs. 69 minutes in Group2, p&lt;0.001). Conclusions: There was no significant difference in union rate between the methods. The functional outcome between the two groups was compared; there was no significant difference between them. Like other investigators, we also found 90.5% of excellent functional outcomes after the treatment of unstable forearm fractures by means of plating. As indicated in the literature, we found 95% of excellent functional results after flexible intramedullary nailing.

Flexible intramedullary nails for unstable fractures of the tibia in children: a retrospective evaluation of effectiveness

Background Flexible intramedullary nailing is gaining popularity as an effective method for treating long-bone fractures in children. Patients and methods We retrospectively reviewed the records and radiographs of 56 unstable fractures of the tibia in 54 children treated between March 2006 and May 2010. Of the 56 fractures, 13 were open. All had been followed up for at least 2 months after removal of the nails. Results There were no nonunion cases. The mean time to clinical and radiological union was 10 weeks. Complications included residual angulation of the tibia, leg-length discrepancy, deep infection and failures of fixation. All achieved excellent functional outcome. Conclusion Flexible intramedullary fixation is an easy, safe and effective method of management of both open and closed unstable fractures of the tibia in children.

A Comparison of Locked Versus Nonlocked Enders Rods for Length Unstable Pediatric Femoral Shaft Fractures

Stainless steel flexible Enders rods have been used for intramedullary fixation of pediatric femur fractures with good success. Despite intraoperative anatomic alignment, length unstable femur fractures can present postoperatively with fracture shortening. The purpose of this study was to review all length unstable pediatric femoral shaft fractures in which Enders rods were used and compare those that were locked to those that were not locked. A retrospective clinical and radiographic review of all patients at a single institution undergoing flexible intramedullary fixation for length unstable femoral shaft fractures from 2001 to 2008. A length unstable fracture was defined as either a comminuted fracture or a spiral fracture longer than twice the diameter of the femoral shaft. A total of 107 length unstable femoral shaft fractures fixed with Enders rods were identified, of which 37 cases (35%) had both Enders rods "locked" through the eyelet in the distal femur with a 2.7 mm fully threaded cortical screw. Patient demographics, clinical course, complications, fracture characteristics, and radiographic outcomes were compared for the locked and nonlocked groups. There were no statistical differences between the groups in demographic data, operative variables, fracture pattern, fracture location, time to union, femoral alignment, or major complications. Shortening of the femur and nail migration measured at 1 to 6 weeks postoperatively was significantly greater for the nonlocked cases. The medial and lateral locked Enders rods moved 1.3 and 1.9 mm, respectively, and the unlocked Enders each moved 12.1 mm (P < 0.05). At final follow-up there were significantly more (P < 0.05) clinical complaints in nonlocked group, including limp, clinical shortening, and painful palpable rods. Locking Enders rods for length unstable pediatric fractures is an excellent option to prevent shortening and resulted in no additional complications, added surgical time, or increased blood loss. Level III.

Complications After Titanium Elastic Nailing of Pediatric Tibial Fractures

A retrospective review of 60 diaphyseal tibia fractures (31 closed and 29 open fractures) treated with flexible intramedullary fixation was conducted. All charts and radiographs were reviewed. Children ranged in age from 5.1 to 17 years. Fifty patients with 51 fractures were followed up until union and comprised the study group. The mean follow-up period for these 50 patients was 79 weeks. Forty-five fractures achieved bony union within 18 weeks (mean, 8 weeks). Five patients (11%) had delayed healing (3 had delayed unions that ultimately healed with casting or observation, and 2 had nonunions that required secondary procedures to achieve union [1 patient underwent a fibular osteotomy, and 1 underwent exchange nailing with a reamed tibial nail]). These 5 fractures ultimately healed, with a mean time to union of 41 weeks. Patients with delayed healing tended to be older (mean age, 14.1 years) versus the study population as a whole (mean age, 11.7 years). In addition to delayed union, other complications were observed in the study population. One patient healed with malunion (13-degree valgus), requiring corrective osteotomy. One patient with a grade II open fracture was diagnosed with osteomyelitis at the fracture site after attaining bony union. Two patients developed nail migration through the skin, requiring modification or nail removal. The fixation of pediatric diaphyseal tibia fractures with titanium elastic nails is effective but has a substantial rate of delayed healing, particularly in older patients.

Stainless Steel Flexible Intramedullary Fixation of Unstable Femoral Shaft Fractures in Children

To assess the role of stainless steel flexible intramedullary fixation in unstable pediatric femur fractures, we compared a group of 41 stable (transverse or oblique) fractures with a group of 40 unstable (spiral and/or comminuted) fractures treated with stainless steel (Ender) nails placed through a single lateral insertion. The fractures were followed up until clinical and radiographic union was evident with an average follow-up period of 13 months. All fractures were healed at an average of 1.4 months. No infections or refractures occurred. Although minor radiographic angular deformities and shortening were present in both groups, no patient had a clinically detectable angular deformity. Two patients with stable fracture patterns had 10 to 20 degrees of asymmetry in foot progression angles, and 1 patient with an unstable fracture pattern (Winquist grade IV comminution) had a 3-cm limb length difference at final follow-up. Stainless steel flexible intramedullary fixation is effective for unstable pediatric femur fractures if cortical abutment is present.

Flexible intramedullary nails for unstable fractures of the tibia in children

Flexible intramedullary nailing is gaining popularity as an effective method of treating long-bone fractures in children. We retrospectively reviewed the records and radiographs of 56 unstable fractures of the tibia in 54 children treated between March 1997 and May 2005. All were followed up for at least two months after the removal of the nails. Of the 56 tibial fractures, 13 were open. There were no nonunions. The mean time to clinical and radiological union was ten weeks. Complications included residual angulation of the tibia, leg-length discrepancy, deep infection and failures of fixation. All achieved an excellent functional outcome. 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.

THE OPERATIVE MANAGEMENT OF PEDIATRIC FRACTURES OF THE UPPER EXTREMITY

The vast majority of pediatric fractures of the upper extremity can and should be treated with closed reduction, immobilization, and close follow-up. However, there is an ongoing debate in the orthopaedic community regarding the exact role of surgical management in the treatment of pediatric fractures 1. In the past two decades, operative management of certain fractures (e.g., percutaneous pinning of displaced supracondylar fractures) has provided better results than closed management. Surgical management is clearly indicated for certain injuries, such as those requiring anatomical realignment of the physis or articular surface. Increasingly, however, surgical management is being used to maintain optimal alignment or to allow early motion. In many such cases, both nonoperative and operative methods have yielded good results and have vocal advocates. Certain technical advances, such as flexible intramedullary fixation and bioreabsorbable implants, have further increased enthusiasm for operative management of pediatric fractures. The goal of these lectures is to describe current concepts in the operative management of selected pediatric fractures of the upper extremity. The focus is on specific indications, techniques, and potential complications in managing fractures of the forearm and elbow in children. The full scope of pediatric fracture management is a subject for textbooks. For introductory information and descriptions of techniques of successful nonoperative management, the reader is directed to comprehensive sources 2. Forearm fractures are among the most common orthopaedic injuries in children, accounting for 30% to 50% of all pediatric fractures 3,4. Historically, almost all forearm fractures in skeletally immature patients were treated nonoperatively. Recent information regarding functional outcomes, however, has challenged many of the traditional tenets of forearm fracture care. Furthermore, with the advent of newer technology, instrumentation, and techniques of fracture fixation, the treatment options have expanded 5. ### Distal Radial Fractures Because of their proximity to the distal radial …

Intramedullary nailing of proximal phalangeal fractures

A retrospective review of 25 consecutive patients with 28 proximal phalangeal fractures was performed. Fractures of the thumb were excluded. Twenty-five fractures were closed and three were open. All fractures were reduced, closed, and fixed using flexible intramedullary fixation with 0.8-mm prebent nails. Fractures amenable to flexible intramedullary fixation include short oblique and transverse fractures. Contraindications include long oblique, spiral, and bicortical comminuted fractures. The average follow-up time was 10 months (range, 2-20). Five patients with six fractures were lost to follow-up evaluation. All of the remaining 23 fractures healed and there were no infections. An average of 2 degrees angulation was seen on anteroposterior x-ray films. One patient showed 4 degrees of angulation on the lateral x-ray film. No shortening was noted. One fracture showed appreciable malrotation of 10 degrees. Flexible intramedullary rodding of specific proximal phalangeal fractures provides excellent results with a low complication rate. Proper selection of fractures and good surgical technique are necessary to avoid complications.

Flexible intramedullary nailing for metacarpal fractures

A 5-year retrospective review of 83 patients with 98 metacarpal fractures was performed. Fractures of the thumb metacarpal were excluded. Ninety-six closed metacarpal fractures were reduced closed and fixed with flexible intramedullary fixation, using multiple 0.8-mm prebent rods. Two open metacarpal fractures were also fixed with this technique. Fractures amenable to flexible intramedullary fixation include short oblique and transverse fractures. Contraindications include long oblique and bicortical comminuted fractures. The average follow-up time was 9 months (range, 2 to 34 months) with 15 patients lost to follow-up examination. All fractures went on to heal. Three complications occurred: backing out of a rod in one case and bending of the rods after repeat trauma in two. There were no infections. Flexible intramedullary nailing of specific metacarpal fractures affords excellent results with a low complication rate. Proper selection of fractures and good surgical technique are necessary to avoid complications.

“Bouquet” osteosynthesis in metacarpal neck fractures: A series of 66 patients

The bouquet osteosynthesis for fractures of the metacarpal neck was first described by the author 19 years ago and is based on the Ender principle of flexible intramedullary fixation.2 This method consists of an open technique anterograde intramedullary fixation with three pre-bent Kirschner wires (K-wires) inserted into the reduced metacarpal head in divergent directions (Figs. 1 and 2). This method has gained popularity in Europe. 34 A series of 66 patients with a metacarpal fracture treated by the bouquet osteosynthesis is presented.

The operative stabilization of pediatric diaphyseal femur fractures with flexible intramedullary nails

Flexible intramedullary fixation is an excellent technique for the stabilization of pediatric diaphyseal femurfractures when an indication for operative repair exists. They can be applied in an antegrade and a retrograde manner and can be used to stabilize fractures from the subtrochanteric region of the proximal femur to a point approximately 4 cm proximal to the distal femoral growth plate.