Flexible Intramedullary Nail Fixation Research Articles

Origin and factors for overgrowth in pediatric fractures of the femoral shaft after flexible intramedullary nail fixation.

Leg length discrepancy is a common complication following flexible intramedullary nail (FIN) fixation for femoral shaft fractures in adolescents. This retrospective study was designed to evaluate the possible cause of femoral overlengthening in children with femoral shaft fracture. We retrospectively included 138 patients diagnosed with femoral shaft fractures between June 2012 and December 2022 and reported the clinical/radiological outcomes after at least half a year of surgery. We have introduced a new parameter, distal physis growth proportion (DPGP), which can be used to predict the origin of femoral growth. The mean DPGP value of 138 samples was 50.9%, of which 24 (17.4%) were greater than 70% and 114 (82.6%) were less than 70%. In the group with nail-canal diameter ratio (NCD) values greater than 60%, the proportion of patients with DPGP values exceeding 70% was significantly higher compared to the group with NCD values less than 60%. However, there was no significant difference between gender, fracture side, fracture type, mode of reduction, associated craniocerebral injury or the distance from fracture site to distal articular surface of femur. In children with femoral shaft fractures treated with FIN fixation, the number of patients with DPGP lesser than 70% far exceeded the number of patients with DPGP greater than 70%, indicating the significant role of fracture end stimulation in femoral lengthening.

Elastic nail versus plate for treatment of single close fracture of femur shaft

This study aims to describe the outcome of pediatric flexible nails versus plates for the treatment of femur fracture. We reviewed the medical records of 28 femur fractures in children treated with flexible nail insertion and 26 children treated with plate fixation from January 2017 to December 2019. The mean age of the children was 8.88 ± 1.86 years. Data were obtained from patient charts. Union of bones was found in all the operated children, 28 (51.9%) of the group flexible nails, while no union was found in 3 (5.6%) of the group plate with screws. Delay union was found in 5 (9.3%) of the plate with screws, while in the group of flexible nails was in 2 (3.7%). Malrotation was found in 2 (3.7%) of the flexible nails and in 1 (1.9%) in the plate and screw. Bursa was found only in the flexible nails with 7 (13%) (p = 0.007). Re-fracture was found only in the group of plates with screws with 5 (9.3%) (p = 0.021). The limbs were shortened only in 1 (1.9%) patient with flexible nails. Superficial infection was high in the group plate with screws group 4 (7.4%). Deep infection was found to be high among 3 (5.6%) of the group plate & screw. We conclude that flexible intramedullary nail fixation of fracture shaft femur in children is a very acceptable way of treatment and is associated with minimal complications.

Does postoperative immobilization affect final alignment of pediatric femur fractures treated with flexible intramedullary nailing?

Flexible intramedullary nail (FIN) fixation of pediatric femur fractures is a popular method of fixation in children. Typical immobilization options include spica casting, long leg cast, knee immobilizers, or no immobilization and the decision to use each is usually left to surgeon preference. Our primary aim is to evaluate whether different postoperative immobilization status influences outcomes, namely radiographic alignment at the time of healing. A retrospective chart review was conducted of all patients with femur fractures treated with FIN fixation at a pediatric hospital from April 2018 through July 2022. Postoperative immobilization protocols were recorded and separated into two groups, patients who were immobilized (IMM) and patients who were not immobilized (NoIMM). Radiographs were evaluated for fracture alignment immediately following surgery and at the time of healing. Patients demographic, fracture, and postoperative clinical characteristics were compared between the two groups (NoIMM vs. IMM). A total of 41 patients were treated for diaphyseal femur fractures with FINs at our institution during the study period. No significant difference was observed in alignment at healing. Our results suggest that either immobilization or no immobilization after flexible intramedullary nailing of pediatric femoral shaft fractures are viable options when postoperative immobilization status is left to the surgeon's discretion.

Incidence of secondary interventions after early spica casting for diaphyseal femur fractures in young children.

Background:Children aged 6 months to 5 years with diaphyseal femur fractures are typically treated with spica casting, as recommended by the American Association of Orthopaedic Surgeons clinical practice guideline. We aimed to determine the incidence of secondary interventions after early spica casting for femur fractures in children aged 6 years or less.Methods:This was a retrospective cohort study of patients aged 6 years or less with diaphyseal femur fractures treated with early spica casting at a single Canadian tertiary care, level 1 trauma pediatric centre between January 2005 and May 2015.Results:A total of 246 patients were included (190 boys [77.2%] and 56 girls [22.8%] with a mean age of 2.28 yr [standard deviation (SD) 1.35 yr]). Nine patients (3.7%) required early secondary interventions (cast wedging in 8 and flexible intramedullary nail fixation in 1). At last follow-up, 51 patients (20.7%) had clinically measurable limb length discrepancy (LLD) (mean 9.4 mm [SD 3–25 mm]), and 1 patient (0.4%) had mild clinical valgus deformity. Older, heavier patients with initial fracture shortening of 20 mm or more had a higher likelihood of developing a clinically measurable LLD. No patient required surgical intervention after fracture union to correct acquired LLD or angular deformity.Conclusion:Early spica casting for diaphyseal femoral fractures in children aged 6 years or younger had a low rate of complications and return to the operating room, Although 21% of patients had a clinically measurable LLD at last follow-up, no patient required secondary intervention after fracture union to correct acquired LLD or angular deformity. These findings have relevance for the Canadian health care system, especially during the COVID-19 pandemic.

Flexible Intramedullary Nail Fixation With Supplemental External Fixator for Unstable Pediatric Femur Fractures: A Case Series

Introduction: Flexible intramedullary nail fixation (FIN) has become the preferred mode of treatment for femur fractures in elementary school aged children. One clear limitation of FIN is the inability to control length unstable femur fractures. This case series evaluates radiographic union rates, fracture alignment, and postoperative complications for a novel technique of FIN and adjunct external fixation in length unstable femur fractures. Materials and Methods: A retrospective chart review was performed using current procedural terminology coding to identify 10 pediatric femur fractures utilizing flexible nail fixation with supplemental external fixation in length unstable femur fractures. Electronic medical records were used to obtain demographic information and length of operative time. A picture archiving and communication system was utilized to review radiographs. Results: Combined FIN fixation and supplemental external fixation were used in ten pediatric patients with length unstable femur fractures. The average age at time of injury was 6.4 years (range: 3 to 8 years). The average duration of external fixation was 30 days with no pin site complications including infection or refracture. Average time to union was 54 days with no radiographic loss of reduction. There were no documented intraoperative or postoperative complications. Conclusions: The cases reviewed in this study support that in addition to FIN fixation for unstable pediatric femur fractures, a supplemental external fixator provides a viable option with all fractures obtaining union, acceptable alignment, no loss of reduction, and no postoperative complications. This technique may provide another tool in the orthopedist armamentarium and possibly as an alternative to submuscular plating.

Percutaneous leverage technique for reduction of radial neck fractures in children: technical tips.

PurposePaediatric radial neck fractures are challenging to treat. Multiple strategies exist for reduction and fixation; there is no clear consensus on the best surgical technique to achieve reduction. The percutaneous leverage technique is a method for reduction of radial neck fractures that has previously been described by Wallace, though there is a lack of published literature on this technique. We present a technical note and a modest case series on our modification to the percutaneous leverage technique accompanied by intramedullary fixation.MethodsWe describe a retrospective series of patients who underwent the modified percutaneous leverage technique for paediatric radial neck fracture reduction followed by flexible intramedullary nail fixation at a single Level I trauma centre from 2008 to 2016. This technique involves making a small incision over the dorsal border of the ulna and using a blunt curved surgical forceps to dissect towards the ulnar border of the radius just distal to the radial neck fracture site. The curved forceps is then used to push the radial shaft away from the ulnar shaft which reduces the radial neck fracture. Intramedullary fixation is then utilized to stabilize the reduction. Pre- and postoperative radiographs and clinical data from the medical record were reviewed, and patient, injury and treatment characteristics as well as complication rates are summarized.ResultsWe successfully treated a series of eight radial neck fractures with the modified percutaneous leverage technique. This technique allows for a small incision and a minimally invasive method for the reduction of paediatric radial neck fractures. This allowed for subsequent intramedullary fixation and early postoperative elbow mobilization. In our series, no patients developed synostoses or sustained peripheral nerve injuries using this technique.ConclusionThe modified percutaneous leverage technique followed by intramedullary fixation is a safe and effective technique for fixation of displaced paediatric radial neck fractures.Level of EvidenceLevel IV

Nonunion of humeral shaft fractures following flexible intramedullary nail fixation

Introduction: The treatment of humeral shaft fractures ranges from conservative modalities to operative fixation, including plate osteosynthesis and intramedullary fixation. Nonunion is a complication of conservative and operative interventions but is more often associated with elastic nailing. This article discusses the successful outcomes for treatment of nonunion of humeral shaft fracture achieved by Locking Compression Plate (LCP) with autogenous bone grafting. Methods: Fifteen cases of nonunion of humeral shaft fracture primarily treated with Elastic nail were included in this study. The study population comprised 12 males and 3 females with an average age of 31.2 years with minimum follow up of 12 months. Eleven fractures were defined as atrophic nonunion, and 4 as hypertrophic. All fractures were managed by open reduction and internal fixation with LCP and autogenous cancellous bone graft with mean follow-up period of 14 months.Results: All cases showed union at subsequent follow-up with an average of 14 weeks (range 12-16 weeks). Complications included one patient with radial nerve neuropraxia which recovered spontaneously within 3 months of surgery, and a patient with superficial wound infection which was managed by debridement and antibiotics. At the final follow-up, shoulder and elbow functions of the operated limbs were satisfactory (4 Excellent, 11 Good results with an average ASES score of 46). Conclusion: Fixation by LCP with cancellous bone graft is reliable and effective treatment for nonunion of humeral shaft fracture. The combined use of LCP and autogenous cancellous bone graft is able to achieve both rigid fixation and improve osteogenesis.

Leg Length Discrepancy and Angular Deformity after Flexible Intramedullary Nail fixation in Pediatric Femoral Shaft Fractures

Objective Femoral fracture is one of the most frequent fractures in children and complications occurs such as malunion and leg length discrepancy after internal fixation using flexible intramedullary nail. The author intended to consider operational treatment using flexible intramedullary nailing through a quantitative data including age, pattern and location of fracture for angulation, and leg length discrepancy. Methods A retrospective survey was performed by 30 cases of child patients who underwent internal fixation using flexible intramedullary nail for femoral shaft fracture. Using a simple radiography, duration of union and angulation were measured. Leg length discrepancy was evaluated by scanogram. By measuring each 2 times at an interval of 1 week by 2 observers, error among observers and error in observer were excluded. For statistical validation, t-test and lineal regression analysis were used. Results Immediate postoperatively, valgus condition of 7 degrees was represented and affected side was represented to show varus of 5.6 degrees on average in 46.6% of child patients. The more age of patient is young, more angulation was represented to be significantly taken place in transverse fracture rather than oblique fracture, but depending on fracture location, significant difference was not observed. Leg length discrepancy showed overgrowth of 6.39 mm on average. And cases of overgrowth over 5 mm being were represented and age of all the child patients was below 9 years old. As a result of statistical analysis, it was observed that the age is younger, leg length discrepancy was prone to be occurred, and its significant relevance with fracture form or fracture location was not represented. Conclusion Transverse fracture is represented at the time of performing internal fixation using flexible intramedullary nail. Occurrence rate of angulation and leg length discrepancy was high but follow-up period is required to be extended even after the time when growth is completed on a long-term basis and in case of imperfect correction, additional treatment such as physeal plate stapling is required. Bone shortening and lengthening may be required and it is considered to be a useful method for femoral shaft fracture of children. Key words: Femoral fractures; Fracture fixation; Intramedullary nailing; Leg length inequality; Lower limb deformity

Flexible Intramedullary Nail Fixation in Paediatric Femoral Shaft Fractures

BACKGROUND: The objective of this prospective study is to assess the outcome of isolated closed fracture shaft femur, treated with flexible intra-medullary nailing technique in a cohort of 20 children. METHODS: The children with age ranging from 5-15 years with isolated closed fracture shaft femur were included in the study. All the patients were treated with flexible intra-medullary nails using a standard surgical technique. Postoperatively, the patients were mobilized non weight bearing. Patients were followed up at regular intervals and assessed for union clinically and radiographically. Once the signs of union were present, they were weaned off crutches gradually. Limb length, rotational alignment and recurvatum of knee were assessed clinically. RESULTS: The mean age of the children was 8.9 (5.2 – 13.1) yrs. All fractures attained union. The average time of follow-up was 23.6 (19-27) months. Recurvatum deformity of the knee was not seen in any of the patients. Five patients had limb length discrepancy ranging from -5 mm to +8 mm, but none of them needed any treatment for this problem. Four patients developed average 5.5 (5-7) degree of external rotation deformity which was well tolerated. CONCLUSION: We conclude that flexible intramedullary nail fixation of fracture shaft femur in children aged 5-15 years is a very acceptable way of treatment and is associated with minimal complications if the surgeon sticks to the proper way of applying this technique.

Flexible Intramedullary Nail Fixation in Paediatric Femoral Shaft Fractures

BACKGROUND: The objective of this prospective study is to assess the outcome of isolated closed fracture shaft femur, treated with flexible intra-medullary nailing technique in a cohort of 20 children. METHODS: The children with age ranging from 5-15 years with isolated closed fracture shaft femur were included in the study. All the patients were treated with flexible intra-medullary nails using a standard surgical technique. Postoperatively, the patients were mobilized non weight bearing. Patients were followed up at regular intervals and assessed for union clinically and radiographically. Once the signs of union were present, they were weaned off crutches gradually. Limb length, rotational alignment and recurvatum of knee were assessed clinically. RESULTS: The mean age of the children was 8.9 (5.2 – 13.1) yrs. All fractures attained union. The average time of follow-up was 23.6 (19-27) months. Recurvatum deformity of the knee was not seen in any of the patients. Five patients had limb length discrepancy ranging from -5 mm to +8 mm, but none of them needed any treatment for this problem. Four patients developed average 5.5 (5-7) degree of external rotation deformity which was well tolerated. CONCLUSION: We conclude that flexible intramedullary nail fixation of fracture shaft femur in children aged 5-15 years is a very acceptable way of treatment and is associated with minimal complications if the surgeon sticks to the proper way of applying this technique.

Factors related to leg length discrepancy after flexible intramedullary nail fixation in pediatric lower-extremity fractures.

This study assessed the factors related to leg length discrepancy after flexible intramedullary nailing in pediatric patients. A retrospective analysis was conducted of 27 patients with flexible intramedullary nail fixation. Twenty-three patients showed lengthening of the injured limb, and 23 showed lengthening of the injured femur or tibia, with 11 patients having a resultant leg length discrepancy greater than 10 mm. Age at the time of injury was the only factor that was significantly related to leg length discrepancy. Our results show that most patients experience lengthening in the injured bone, with significantly increased risk in younger patients.

Excessive Thumb Motion Causing Delayed Tendon Injury to Wrist First Extensor Compartment Associated with Flexible Nail

Aim: To withdraw the attention to the possible complication of tendons rupture in cases of intramedullary flexible nail fixating cases of pediatric both bone forearm fractures. Presentation of Case: A 16 years old boy with a history of right forearm both bones mid shaft fracture was managed with closed reduction and flexible intra-medullary nail fixation. The patient

Biomechanical analysis of a synthetic femur spiral fracture model: Influence of different materials on the stiffness in flexible intramedullary nailing

Background Flexible intramedullary nail fixation of dislocated diaphyseal femur fractures has gained wide acceptance for children and adolescents with open physes. Studies with a special emphasis on complications reveal frequent problems regarding stability, usually in complex fracture types such as spiral fractures and in older children weighing > 40 kg. This biomechanical study analyses how much the material of the nails influences the stiffness in a synthetic bone model. Methods Twenty-four composite grafts (Sawbones®, 4th generation, medullar canal of 10 mm) with an identical spiral fracture were used in three configurations of eight grafts. Elastic stable intramedullary nailing was performed in a retrograde C-shaped manner with two nails of equal size (2 × 3.5 mm). Close contact of the fragments could be achieved. We compared Group A (steel nails) with Group B and C (two types of titanium nails). All specimens underwent 4-point bending, torsion and axial compression in the 0° and 9° positions, and the results were analysed. Findings Group A (steel nails) revealed a significantly higher stiffness in all directions than Group B. Apart from compression in the 9° position this steel nail fixation showed significant higher stiffness than titanium nails of Group C. Comparing Group B and C did not show an systematic difference. Interpretation In this biomechanical study with composite artificial bones the use of steel Nails demonstrated the highest stiffness in our model when compared to two different titanium nail configurations. Apart from in cases of known allergy or planned MRI-examinations our results and data from the literature question the use of titanium nails.

Comparison of compression plate and flexible intramedullary nail fixation in pediatric femoral shaft fractures

The purpose of this study was to compare the results of compression plating and flexible intramedullary nailing for pediatric femoral shaft fractures. Thirty-eight consecutive patients with 40 femoral shaft fractures were evaluated. Twenty-two femoral segments were treated with a compression plate and 18 femoral segments were treated with flexible intramedullary nailing. The time to healing, operation time and complications were evaluated. The average operation time was statistically significantly shorter in the nailing group (P=0.039). Four implant failures occurred in the compression plate group whereas one non-union was observed in the flexible nailing group. Flexible intramedullary nailing seems to provide a high union rate with a shorter operation time when compared with plate fixation.

Intramedullary Flexible Nail Fixation of Unstable Pediatric Tibial Diaphyseal Fractures

Flexible intramedullary nail fixation provides excellent fixation in children with unstable tibial shaft fractures, but few published series demonstrate the results and complications with this technique in children. A retrospective review of 19 patients was performed, as well as a biomechanical analysis of two implant configurations. Outcome measures included union rates, residual deformity, and complications. Union occurred in all cases. Five patients (26%) had complications. None required repeat operation. Two (11%) angular deformities (>/=10 degrees) occurred with the medial C and S construct, versus none with the double C. The C and S construct was more stable to mechanical testing with axial and torsional loading. Flexible intramedullary nail fixation is a straightforward technique that reliably produces good results. While the C and S construct was superior in biomechanical testing, the double C construct is more reliable and straightforward and remains by far the authors' preferred technique.

Distal radio-ulnar joint subluxation following intramedullary nailing of the radius in a child

We describe a patient with fractures of both bones of the forearm in whom flexible intramedullary nail fixation of the radius alone led to ulnar malunion and a symptomatic distal radio-ulnar joint subluxation. This was successfully treated by ulnar osteotomy.

Acute Synovitis of the Knee Resulting From Intra-Articular Knee Penetration as a Complication of Flexible Intramedullary Nailing of Pediatric Femur Fractures: Report of Two Cases

Management of pediatric femur fractures using flexible intramedullary nail fixation is widely accepted. Few complications have been reported in the literature; these include primarily malunions and nonunions. The authors present two cases of a previously unreported complication—acute synovitis of the knee following intra-articular penetration of the knee joint by migration of a flexible nail.

Ender Nail Fixation of Pediatric Femur Fractures: A Biomechanical Analysis

Biomechanical testing was performed to determine the effects of flexible intramedullary nail fixation on simulated transverse and comminuted midshaft femur fractures using two Ender nails. A synthetic adolescent-size femur model was used. The axial and rotational stiffness values for the simulated comminuted fracture were equivalent to those of the transverse fracture under "touch-down weight-bearing" loads. These data suggest that length and rotational control of comminuted midshaft femur fractures with two divergent Ender nails may be sufficient for early mobilization.