Flexible Nailing Research Articles

Flexible Intramedullary Nailing of Pediatric Femoral Fractures.

Flexible intramedullary nailing is performed for femoral fractures in pediatric patients who may be too large for spica cast immobilization but who have substantial growth remaining and who are not a candidate for rigid intramedullary nailing. Flexible nailing allows the surgeon to obtain correct alignment of the femur fracture so as to allow for healing without a lower extremity deformity. The patient is positioned on a radiolucent table, flexible nails are chosen according to the diameter of the medullary canal, medial and lateral incisions are made along the distal aspect of the thigh, and access to the canal is obtained with use of a drill-bit of the appropriate size. Flexible nails are contoured to place the apex at the location of the fracture site and then passed 1 at a time up to the fracture through the medial and lateral corticotomies. Fracture reduction is obtained, and the nails are passed across the fracture 1 at a time. Leave a small amount of nail prominent at the entry site; the nails are then cut and advanced with a tamp. Spica cast immobilization, rigid intramedullary nailing, external fixation, and submuscular plating. Flexible nailing provides relative stability of a femoral fracture similar to external fixation, submuscular plating, and rigid nailing; however, external fixators come with pin-track complications and infections, as well as a bulky device external to the thigh. Submuscular plating is beneficial for length-unstable fractures but is a longer procedure and implant removal is more difficult. In an older child with growth remaining, a rigid femoral nail is an option with similar outcomes to flexible nailing; however, the implant is harder to remove. Flexible nailing provides a cosmetic incision with reliable relative fixation in length-stable fractures, and easy removal of implants with equal or even improved outcomes compared with other surgical techniques. The outcomes of this procedure are excellent. Most pediatric femoral fractures treated with flexible nailing heal well with few complications. Angulation at the fracture site is the most common complication and is more common in fractures of the proximal or distal third of the femur1. Worse outcomes occur in older children and children who are heavier1. Outcomes are improved when flexible nailing is done in length-stable fractures; however, postoperative immobilization in a single-leg spica cast or knee immobilizer can augment fixation in fractures that are not stable. Implant irritation can occur at the insertion site; however, the implants are easy to remove once the fracture has healed. There is a substantially lower rate of malunion when stainless-steel nails (6%) are utilized compared with titanium nails (23%). Consideration should therefore be given to the use of stainless-steel nails for pediatric femoral fractures2. Use a radiolucent table with either a post or a sheet for counter-traction aids during reductionUse stainless-steel nailsPass the easier nail firstAdvance into the femoral neck or trochanteric apophysisDo not wrap rods around each otherCut off the machined tip of the nail and custom-contour the nail in patients with poor bone quality.

Results of flexible nails for fixation of tibial diaphysis fractures in children

Background: Fracture tibia is one of the most common fractures in the pediatric age group. It accounts about 15% of cases. In majority of cases, close reduction and plaster application is the mainstay of treatment. Objectives: The objective was to assess the outcome of flexible nails in the treatment of tibial diaphysis fractures in children and to evaluate the results regarding the union rate and complications including limb length discrepancy, angular deformities, and pain. Materials and Methods: This prospective descriptive case–control study which included 30 children with 30 unilateral tibial diaphysis fractures in which the physis were open, all were closed, and open (type 1 and type 2) fractures, and with displaced transverse, short oblique, and spiral fractures, in which the trial of close reduction was failed. All patients are admitted and operated at West Erbil Emergency Hospital. Alignment of fractures, any infection, delayed union, nonunion, limb length discrepancy, motion of knee joint, time of complete union, and skin irritation were assessed with minimum follow-up period of 6 months. Results: In the current study, the complete union was achieved in 9–11 weeks in 20 (66.7%) patients, while in 6 (20%) patients, achieved in 12 weeks, and in 4 (13.3) patients, achieved in 13–16 weeks that were regarded as a delayed union. In 6 (20%) patients, there were nail protrusion and skin irritation, no shortening more than 0.5 cm was recorded, shortening <0.5 cm recorded in 12 (40%) patients, and no lengthening was recorded. In 3 (10%) patients, the angulations in coronal and sagittal views were 5°–10°. There was no case of nonunion. Conclusion: Elastic nails are an effective way for the treatment of the pediatric tibial diaphysis fractures. It is a simple and easy method but with radiation risk, although elastic nails have complications, all are avoidable and minor that will be managed with minimal intervention.

Management of Metadiaphyseal Proximal Radius Fractures.

Metadiaphyseal proximal radius fractures blur the distinction between the radial neck and radial shaft fractures. Operative management presents unique technical challenges both in terms of surgical approach and fixation method. We discuss relevant anatomy, safe surgical approach, and options and techniques for fracture fixation. We describe 6 patients who achieved satisfactory functional outcomes, even in cases of severe bone loss secondary to ballistic trauma. An extensile dorsal approach with exposure of the posterior interosseous nerve is recommended when normal soft tissue intervals have not already been extensively disrupted. Robust fixation can be achieved by contouring and repurposing a variety of plates such as a variety of mini fragment plates (2.4 mm T or Y-plates), flexible nails, or even distal radius plates.

Intramedullary Nailing of Paediatric Tibial Fractures: Comparison between Flexible and Rigid Nails.

To describe patient characteristics and to compare outcomes of children undergoing rigid intramedullary nailing of tibial fractures as compared with those operated on using elastic intramedullary nailing. A retrospective review of 26 children who have undergone flexible intramedullary nailing of tibial fractures and 30 children with rigid nailing at our university hospital between 2008 and 2017. The patient charts and radiographs were evaluated to identify demographic characteristics and several variables were measured preoperatively, as well as 6-12 weeks postoperatively in addition to final follow-up radiographs. Twenty-six patients (26/26, 100%) treated with a flexible nail and 14 patients (14/30, 46.7%) treated with a rigid nail had open proximal tibial physis (p < 0.001). An acceptable postoperative alignment was obtained in 20 patients (20/26, 76.9%) in the elastic stable intramedullary nail group and in 29 patients (29/30, 96.7%) in the rigid group (p = 0.026). Some complications occurred in four patients (4/26, 15%) in the elastic stable intramedullary nail population and seven patients (7/30, 23%) in the rigid intramedullary nail population (p = 0.46). Malunion occurred in six patients (6/26, 23%) in the elastic stable intramedullary nail group and in none of the patients treated with a rigid intramedullary nail (p = 0.005). Younger children with tibial fractures who weight 50 kg or less and with proximal tibial growth plates wide open can be treated with elastic stable intramedullary nail while more mature adolescents benefit from rigid intramedullary nailing.

Ender's nailing of displaced tibia shaft fractures in children - A nine-year experience.

Displaced fractures of the tibial shaft in children can be effectively treated with minimal complications with flexible nails. Our aim is to evaluate the outcome of displaced paediatric tibia shaft fractures treated with Ender's nails. We retrospectively reviewed the records of all unstable tibial fractures treated between 2010 and 2018, in our institution. Only children with a minimum of six months follow-up and complete clinical data were considered for the study. Of the 72 patients who fulfilled the inclusion-exclusion criteria, 8 were lost for follow-up and hence we had 64 patients included for the study. There were 54 boys and 10 girls, with an average age of 10.9 years(4 to 17 years). The average follow-up was 16.9 months (6 to 47 months). There were nine open fractures. Two nails were used in 52(81.25%) patients while a single nail was used in 6(9.37%) patients and three nails were used in 6(9.37%) patients. The union rate was 100% with an average union time of 10.6 weeks. There were 17 (26.5%) patients with delayed union but none required intervention. One (1.56%) child had a malunion >10° (recurvatum of 11.9° and varus of 8.1°). Radiographs at the final review demonstrated >5° of coronal plane malalignment in eight patients (12.5%) and >5° sagittal plane malalignment (recurvatum) in six patients (9.37%). There was an associated fibular fracture in 50 children and there was no significant association between the presence of fibular fracture and malalignment (p>0.05). All children who presented for implant removal had full range of movement at the knee and ankle joint and no limb length discrepancy. We report the largest series of paediatric tibial shaft fractures treated with Ender's nails. Ender's nail is a simple and cost-effective option for treating these fractures with excellent union rates and minimal complications.

Comparative study on the complications of antebrachium fractures treated with flexible nailing in paediatric and adolescent age group

Background: Antebrachium fractures in paediatric age group, which are unstable are more commonly treated nowadays using intramedullary titanium elastic nailing. Recent studies have showed a higher complication rates in adolescent population when compared to the paediatric counterpart. The aim and objective of this study is to compare the complication rates and outcome in paediatric and adolescent population treated using flexible nail. Methods: An ethical committee approved study was conducted in Rajah Muthiah Medical College, Chidambaram from May 2018 to September 2020 on both bone forearm fractures in paediatric and adolescent population. In our study 20 cases of both bone forearm fractures, of which 10 belonging to paediatric age group (age less than 10 years) and 10 cases belonging to adolescent age group (age more than 10 years) treated with flexible intramedullary nail (TENS). These cases were followed up for period of 1 year and complications were quantified on the basis of Clavien – Dindo classification. Outcomes were analysed based on Martus et al. grading system. Results: Out of 20 forearm fractures treated with tens nail in each age group, mean age was found to be 13.6 years in adolescent group and 9.2 years in paediatric group. Mean follow up period were42 weeks in adolescent category and 40 weeks in paediatric category. Average time and duration from the point of injury to the surgical procedure was 2 to 3 days in both groups. Closed reduction and internal fixation with tens nailing was done in 13 cases (8 paediatric and 5 adolescent group) and open reduction was needed in the remaining 7 cases (2 paediatric and 5 adolescent). The overall result of our study showed that complications were slightly higher in adolescent age group, when compared to the paediatric counterparts. P value between the two groups was not significant. Conclusion: Tens nailing is an excellent technique for paediatric and adolescent fractures of forearm with very good functional outcome. Even though complications were seen in adolescent age group, it was significantly lower than those associated with other surgical techniques. However, with lesser complication rate in paediatric age group, we conclude that in fractures requiring surgical fixation, TENS nailing is more advantageous than other surgical options.

Functional outcome of flexible nailing in unstable fractures of both bones of forearm in paediatric population

Aim and Objective: Antebrachium fractures are one of the common fractures in paediatric population. Fractures of forearm comprises of about 40% in the fractures of paediatric population [1]. These fractures usually have a high degree of remodelling potential and are usually managed non operatively by closed reduction and maintaining it in a plaster cast. Nowadays the trend for management of these fractures changes towards operative management because of increasing complications by nonoperative methods. The aim of this study is to evaluate the functional outcomes of unstable both bone forearm fractures treated operatively using titanium elastic nailing. Materials and Methods: Study was conducted in the department of orthopaedics at Rajah Muthiah Medical College and Hospital. Total of 20 patients aged were treated using TENS. Closed reduction with internal fixation under c-arm guidance was done in 13 cases and open reduction with internal fixation was done in 7 cases.Results: Patients were followed up for a period of 6 months. Results were analysed with respect to union of fracture, symptoms with activities, range of motion of joints adjacent to the fracture using Price et al. criteria and Anderson et al. criteria. In all cases fractures united at an average of 8 - 10 weeks without any malunion. All 20 cases had excellent outcomes. 3 patient had nail prominence on the ulnar entry side leading to superficial pin site infection.Conclusion: Fixation of both bone fractures of forearm using titanium elastic nailing systems showed many advantages over the conventional plating methods, in terms of smaller incision, minimal soft tissue meddling during fracture fixation, prompt osseous healing, maximum range of motion at the earliest, decrease in complication rate with excellent clinical and radiological results. Thus, titanium elastic nailing used intramedullary is an effective treatment option for the treatment of unstable both bone forearm fractures in paediatric population.

Clinical and functional outcome of elastic stable intramedullary nailing in pediatric femoral fractures in the age group of 5-16 years

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Fractures of the femur are the most incapacitating fractures. The best treatment for children between five to sixteen years of age is still debated. The ESIN has the benefits of early immediate stability to the involved bone segment, permitting early mobilization and return to the normal activities of the patients, respect for the physes, minimal scarring with lower complications. The purpose of this study was to present this study results following fixation of femoral shaft fractures with titanium elastic nails between the age 5-16 years of age.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A total 52 patients in the age group of 5-16 years with femoral shaft fractures were stabilized using flexible nailing. Clinical and radiological follow-up was for a minimum period of 24 months. The final results were analysed using Flynn’s criteria.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Mean age at surgery was 7.4 years (range 5.6-14.3 years). The average duration of surgery was 65.3 (45-95) minutes and the mean duration of hospital stay was 8 (5-14) days. Skin irritation due to nail ends was the most common complication followed by significant lengthening (n=6), infection (n=2), significant shortening (n=2), varus angulation (n=2) and delayed union (n=2). The final outcome was excellent in 65.4% cases, satisfactory in 30.8% cases and three patients had poor outcomes as per Flynn's scoring criteria.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; In this study, ESIN showed good clinical and radiographic results in the age group 5 to 16 years, with minimal complications and high parent satisfaction consistent with previous studies but lesser number of mid adolescent age groups in the present study is a limitation.&lt;/p&gt;

Safety, efficacy and functional outcome of flexible nailing (ESIN) in unstable fractures of both bones of forearm in children

Background: Elastic intramedullary nailing has been designed and is being used. Elastic intra-medullary nailing, a minimally invasive technique, confers elastic and stable osteo-synthesis. Elastic stable intra-medullary nailing (ESIN) consists of introducing one or two elastic nails through the metaphyseal flare into the medullary canal, advancing them through the fracture site and then impacting them into the opposite meta-physis. Methods: The prospective descriptive study was carried out in our Hospital from March 2017 to February 2018. The follow-up study continued till 0ctober 2018. Thus, the recruitment period was of 12 months and the follow-up period was a mean of 12. 8 months (range: 8 to 19 months). Functional outcome was measured according to the Daruwalla’s clinical grading, Price et al. criteria; and UEF index (46, 64). Results: The excellent to good results as per UEFI questionnaire was 96.16%. Excellent to good results were obtained using Daruwalla’s & Price et al. measurements. Conclusion: Elastic intramedullary nailing gives good results in paaediaric forearm fractures.

3D 프린팅을 활용한 네일아트 오브제 개발 프로세스 연구 -수복(壽福) 문양을 중심으로-

초록·키워드 목차 오류제보하기 Nails has seen explosive growth in the beauty industry because nail art is a creative way to expresses wearers" beauty and personality. With 3D printing technology, nail design becomes more flexible and accessible. The research process is as follows. First, the concept of 3D printing, output methods, materials, and the latest industry trends are reviewed. Second, the health and longevity pattern was collected through literature research such as thesis, academic journals, newspapers, and photos of modern design. The idea of nail designs is to develop the pattern of health and longevity in the Joseon period. Third, four nail designs were developed using the motifs of talisman symbols such as peach, bat, pine, and butterfly. 3D Nurbs Modeling software rhino program is used to create nail designs. The results are as follows. First, a flexible nail design can be repeatedly produced through rhino, a 3D modeling program. Second, it is possible to express a variety of designs of health and longevity patterns easily. Third, various objects can be produced beyond the limitations of existing nail designs. The main contribution of this study is to provide a foundation of knowledge on nail art design with 3D printing. Therefore, 3D printing technology will improve nail arts and boost to the beauty industry. #Nail Design(네일디자인) #Pattern of Health and Longevity(수복문양) #3D Art(3D 아트) #3D Printing(3D 프린팅) ABSTRACTⅠ. 서론Ⅱ. 이론적 배경Ⅲ. 3D 프린팅을 활용한 네일아트 오브제 제안 프로세스Ⅳ. 3D 프린팅을 활용한 네일아트 오브제 제작Ⅴ. 결론참고문헌

Predictors of Open Reduction in Pediatric Femur Fractures Treated With Flexible Nails

Closed reduction (CR) is sufficient to reduce the majority of femur fractures treated with flexible intramedullary nailing (FIN). No previous study has examined factors associated with failed CR of pediatric femoral shaft fractures treated with FIN. We sought to determine preoperative factors associated with failed CR. We hypothesized that fracture, patient, and surgeon characteristics would impact the need for open reduction (OR). A retrospective review of children treated for femur fracture between 2012 and 2017 at a tertiary pediatric hospital was performed. Comparisons were made between 2 groups: FIN with CR group and FIN that required OR group. Demographic and baseline characteristics were compared between treatment groups using either χ tests or Fisher exact tests for categorical variables and general linear models for continuous variables. Odds ratios with 95% confidence intervals were calculated using univariate logistic regression tests. Of 449 consecutive pediatric femur fractures treated at our center, 85 children were treated with FIN and constituted the study cohort. CR failed in 14 patients (16.5%) necessitating OR of the fracture site. Significant differences between study groups were found in fracture location (P=0.018), the mechanism (P=0.003), and displacement on the anteroposterior radiograph (P=0.027). Surgical time was found to be longer in the OR group (P=0.010). We identified 3 preoperative predictors of OR for FIN including fractures caused by high energy mechanisms (odds ratio=7.5), distal third fractures (odds ratio=15.3), and fracture displacement on the anteroposterior view (odds ratio=1.06). Surgeon years in practice, patient weight, age, and time from injury to surgery were not associated with OR. This study presents 3 preoperative risk factors that predict the need for OR of femur fractures treated with FIN. Surgical time was longer in cases that required OR. Our findings suggest that surgeons should avoid lengthy attempts at CR and consider a lower threshold for OR of at-risk fractures or use another technique other than flexible nails. Level III-prognostic.

Elastic Stable Intramedullary Nailing of Pediatric Tibial Fractures.

Most pediatric tibial shaft fractures (75%)1 can be treated nonoperatively; however, unstable and open fractures require surgical intervention. Titanium elastic nails have become a popular technique for fixation of pediatric tibial shaft fractures. They act as internal splints that impart relative stability to the fracture, promoting callus formation at the fracture site2. After the patient is placed in the supine position, the proximal tibial physis is marked using fluoroscopy. An anteromedial and anterolateral incision are made distal to the physis. Entry holes are created in the proximal part of the tibia, and appropriately sized titanium nails are introduced into the bone. Nail size should be 40% of the width of the canal, yielding 80% canal fill when 2 nails are used. The nails are prebent into a gentle C-shape to increase cortical contact at the apex so that 3-point fixation is achieved. The nails are passed to the fracture site, and the fracture is then reduced. The nails are then passed across the fracture site and stopped proximal to the distal tibial physis. The nails are then cut and tamped distally until there is just a short portion of nail left out of the proximal part of the tibia so that the nails can be removed once the fracture is healed. The wounds are then closed, and postoperative immobilization is applied. Many pediatric tibial shaft fractures can be treated with closed reduction and cast immobilization. Open fractures, or fractures that fail nonoperative management, can be treated with external fixation, open reduction and internal fixation (ORIF), or intramedullary stabilization3. Anatomic reduction and fracture compression can be achieved with ORIF; however, a drawback to this technique is the lack of soft-tissue coverage in the diaphyseal area of the tibia, which can lead to infection and wound-healing problems4. External fixation has traditionally been the technique of choice for open tibial fractures; however, with the ability to use flexible tibial nails in both open and closed tibial fractures, external fixation is now reserved for open fractures with large soft-tissue defects or in fractures with segmental bone loss. Intramedullary flexible nailing can be used in both open and closed tibial fractures, provides excellent fracture fixation, and utilizes incisions that are more cosmetically appealing to patients5,6. Outcomes following flexible nailing for pediatric tibial fractures are excellent. In a study of 19 patients undergoing flexible nailing for tibial shaft fractures, 18 had excellent or satisfactory results7. Compared with patients who had external fixation, those treated with flexible nails had less pain, shorter time to union, and better functional outcomes2. Compared with patients treated with ORIF, those who underwent flexible intramedullary nailing spent less time in the operating room and had lower rates of wound complications4. In the immediate postoperative period, clinicians should be aware of the risk of compartment syndrome, particularly in patients with high-energy injuries, older patients (>14 years old), and heavier patients (>50 kg)8. There is also an increased risk of soft-tissue irritation and fracture malunion in heavier patients treated with flexible nails9,10. Nail size should be 80% of the canal diameter (e.g., two 4.0-mm nails should be chosen for a canal that measures 10 mm).Nails should be properly contoured to avoid corticotomy of the far cortex during insertion; apex of the bend should be positioned at the level of the fracture.During insertion, leave room to advance nails further after they are cut proximally.Do not bury the proximal nail tips beneath the cortex as extraction will be difficult.Ensure that the ends of the nails are not lying up against the proximal tibial physis as this may cause premature growth arrest.

Functional outcome of modified technique of intramedullary fixation of diaphyseal humeral fractures

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The aim of this study was to evaluate the functional outcomes with intramedullary fixation using flexible nails and to follow up for any other complications.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Study was a prospective study in Lata Mangeshkar Hospital, Nagpur during 2014 to 2016. All the patients enrolled in the study were briefed about the nature of the study. All cases in this series were operated by combined antegrade and retrograde approach.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Total of 30 patients of closed diaphyseal humeral fractures was studied. Maximum i.e., 16 (53.33%) were in the age range of 21-40 years, followed by 10 (33.33%) patients in the range of 41-60 years. 21 (70%) cases had fracture union between 10-16 weeks with a score&lt;strong&gt; &lt;/strong&gt;of 8 points, followed by 8 (26.67%) patients with fracture union duration&lt;strong&gt; &lt;/strong&gt;of less than 10 weeks with a score of 10 points. Only one of the patients landed up with non-union. The mean functional score of patients at 3rd month was 64.03±4.99, 9th month was 73.46±2.56. 86.66% patients had good to fair outcome, 3.33% patient each had excellent and poor outcome.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Comparing results of our study with other studies, we found that our results are almost comparable but not better than open reduction and plating. Complications encountered in our series are comparatively less compared to those encountered during interlock nailing. The trauma to rotator cuff is minimum and this method is good alternative method. Thus, multiple nailing gives better functional outcomes as compared to locked nail. &lt;/p&gt;

Management of Pediatric Tibial Shaft Fractures

Diaphyseal tibia fractures in the pediatric population have dynamic treatment strategies that depend on injury pattern, mechanism, patient skeletal maturity and size. Treatment strategies include closed reduction and cast immobilization, flexible nails, uniplanar or multiplanar external fixation or plate osteosynthesis. Accepted parameters for sagittal and coronal alignment vary based on age and potential for remodeling, although all fractures should have minimal rotational malalignment and less than 1 cm of shortening. Stable union generally occurs in 3 to 4 weeks for the common toddler's fracture and 6 to 8 weeks in other fracture patterns. Complications such as compartment syndrome are possible with both open and closed injuries, and nonunions, although rare, are more common in patients treated with external fixation or flexible nailing. Overall, treatment should be predicated on a full evaluation of the patient, fracture, local soft tissues, and any concomitant injuries.

Management of paediatric humeral shaft fractures and associated nerve palsy.

PurposeThe aim of this study is to review the management of all paediatric humerus diaphyseal fractures treated at a single institution over a 20-year period.MethodsRetrospective review from between 1996 and 2016 identified 96 humerus shaft fractures in paediatric patients (0 to 17 years). After excluding those deceased from inciting trauma, pathological and perinatal fractures, 80 patients remained for analysis. Data collected included age, fracture type, displacement, nerve palsy, treatment, complications and time to union. Radiographs were reviewed at the time of injury and at latest follow-up.ResultsOf 80 paediatric humeral diaphyseal fractures, 65 (81%) were treated with immobilization. In all, 15 (19%) fractures were treated with surgical stabilization. Most common indications were fracture displacement, open fractures and to improve mobilization in patients with multiple injuries. Fractures were stabilized with a plate (eight), flexible nails (five), external fixation (one) and percutaneous pinning (one). The operative group, compared with the nonoperative group, was older, had more high-energy mechanisms, more open fractures and increased fracture displacement. All patients in the nonoperative and operative groups went on to union with minimal complications. A nerve palsy was present in five patients (6%)with three of the five involving the radial nerve (4%). All nerve palsies were observed and had full neurological recovery.ConclusionOver a 20-year period nonoperative management of paediatric humerus shaft fractures was successful in the majority of patients. Operative stabilization, when rarely indicated, had a low complication rate and improved radiographic alignment. All nerve injuries fully recovered without surgical intervention.Level of evidenceIV

Intramedullary Flexible Nailing for Diaphyseal Fractures of Forearm Bones in Children.

Objectives Most of the fractures of the bones of the forearm in children are successfully treated conservatively with closed reduction and casting. The outcomes remain variable and the patients may require additional fracture manipulation or formal surgical intervention due to residual angulations. The present study assesses the radiological and functional outcomes of treating displaced forearm fractures in children with intramedullary flexible titanium elastic nailing. Methods A total of 31 patients aged between 7 and 15 years old with displaced forearm fractures underwent flexible titanium elastic nailing. The patients were followed-up for a mean period of 8.51 months (range: 6–12 months) and were assessed for radiological and functional outcomes. The Price criteria were used to assess the functional outcome. Results Out of 31 patients, 21 patients underwent closed reduction, and 10 required a minimal opening of the fracture site during reduction. A total of 29 patients had excellent results with normal forearm and elbow range of motion (ROM), and 2 patients had good results. In all patients, good radiological union was seen at an average time of 7.9 weeks. Five patients had minor complications, such as skin irritation over the prominent ulnar nail ( n = 2), superficial nail insertion site infection ( n = 2), and backing out of the ulnar nail ( n = 1), requiring early removal. Conclusion Flexible nailing is an efficient application of internal fixation for shaft fractures of both bones of the forearm in children, enabling early mobilization and return to the normal activities of the patients, with low and manageable complications.

Minimally invasive intramedullary fixation with flexible nails in the treatment of metatarsal neck fractures

Objective: This study was designed to retrospectively assess patients with deviated central metatarsal neck fractures subjected to reduction and fixation with flexible intramedullary nails. Methods: Thirty-six patients (36 feet) diagnosed with acute fractures of one or more metatarsals and whose therapeutic indication was exclusively surgical were evaluated between June 2010 and August 2011. Considering the metatarsophalangeal joint, such injuries should be located up to two centimeters in the proximal direction of this segment, with plantar deviation greater than 10 degrees and translation greater than three millimeters in any plane. Minimally invasive intramedullary fixation with two flexible titanium nails was used when adequate stability was not obtained with the use of one nail. The visual analog scale (VAS), American Orthopedic Foot &amp; Ankle Society (AOFAS) forefoot score and specific statistical tests were used. Results: There was a significant (p&lt;0.001) improvement in the results until 6 months of follow-up. There was no significant difference (p&gt;0.05) in the results between 6 and 12 months of follow-up. The average time of consolidation was 8 weeks, and there were no complications during the period evaluated. Conclusion: This technique provided a significant (p&lt;0.001) improvement in the VAS and AOFAS forefoot scores at 6 months of follow-up. Between 6 and 12 months of postoperative follow-up, we did not observe a significant (p&lt;0.05) difference in the results of the analysis due to stabilization of the condition and fracture consolidation. Although the results were considered excellent, the level of evidence of studies should be increased to effectively demonstrate the efficacy of this technique. Level of Evidence IV; Therapeutic Studies; Case Series.

Fassier-Duval Rods are Associated With Superior Probability of Survival Compared With Static Implants in a Cohort of Children With Osteogenesis Imperfecta Deformities.

The survival of Fassier-Duval (FD) telescoping rods as compared with static implants in children affected by osteogenesis imperfecta is not well characterized. The purpose of this study was to compare risk of lower extremity implant failure in FD rods versus static implants. Data were retrospectively collected from patients with osteogenesis imperfecta who underwent surgical treatment using either FD rods or static implants (Rush rods, flexible nails, or Steinmann pins) between 1995 and 2015. The timing of implant failure was the primary outcome variable of interest. Comparisons were limited to limbs with no previous history of implants. Cox-proportional hazards regression analyses were used to compare the hazard of implant failure across implants. Negative binomial regression analyses were used to compare the incidence of surgical procedures in the 2 implant groups. The final cohort consisted of 64 limbs (n=21 patients). The static implant group (n=38) consisted of 24 Rush rods (63%), 14 flexible nails (37%), and 2 Steinmann pins (5%). The hazard of implant failure in the static implant group was 13.2 times [95% confidence interval (CI), 2.5-69.6; P=0.0024] the hazard of implant failure in the FD rod group. The hazard of implant failure among females was 4.8 (95% CI, 1.4-16.7; P=0.0125) times the hazard of implant failure among males. The total surgery rate in the static implant group was 7.8 (95% CI, 1.8-33.0; P=0.0056) times the total surgery rate in the FD group. Among surgically naive limbs, FD rods were associated with significantly improved probability of survival compared with static implants. Level II-retrospective study.

Paediatric forearm refractures- management and outcome: a prospective study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Forearm fractures are one of the commonest injuries accounting for 40% of paediatric fractures with a refracture rate of nearly 5%. Forearm refractures are increasing probably due to poor bone mineralization as a result of decreased physical activity, Vitamin D deficiency. These are treated by conservative measures with closed reduction and casting or by surgical fixation with flexible nails or plates. There are no definitive guidelines for management of forearm refracture and implant removal.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; The study is aimed at the epidemiology, methods and difficulties of management and functional outcome of forearm refracture treatment. A prospective study of all the cases of forearm refracture who presented to our institution from 2010 to 2016 with refractures treated either by conservative methods or by IMN. All cases were followed up for 2 years and functional outcome was assessed serially according to price et-al criteria.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Our study contained 17 males and 8 females between 6 years and 14 years. 76% refractures occurred before 16 weeks and majority had only tricortical union at this time. 42% patients underwent surgical fixation following refracture. Price et al criteria showed excellent results in 72% of patients.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Forearm refractures in children can be treated both conservatively and surgically like a primary fracture depending on the indications but needs 2 to 3 more weeks of immobilization. A good functional outcome was obtained in majority of the cases. We suggest using splints till quadricortical union is achieved to prevent chances of refracture.&lt;/p&gt;

Dimensions of the paediatric femur: anatomical limitations of flexible intramedullary nailing.

PurposeAlthough spica casting remains the benchmark for treating diaphyseal femur fractures in preschool children, some authors advocate using flexible intramedullary nails in certain situations. The aim of the current study was to evaluate the anatomic feasibility of flexible nailing in young children.MethodsConsecutive patients between the ages of zero and ten years with normal femurs who received femur radiographs at a tertiary paediatric hospital over a two-year period were included. Anteroposterior femur radiographs were evaluated for length and isthmus width measurements. Each femur was templated for flexible nail size. The proportions of each age group capable of accommodating two flexible nails up to 4.0 mm in size were determined and compared.ResultsA total of 381 full-length femur radiographs were reviewed. There was a strong, direct linear relationship between age and femoral length (R2 = 0.896) and a moderate correlation between age and femoral isthmus width (R2 = 0.417). Although the percentage of femurs able to accommodate flexible nails continued to increase with age, this increase did not represent a significant difference when comparing preschool-aged children with older age groups.ConclusionsAge and femoral length demonstrated a strong, positive correlation while age and isthmus width had weaker correlation. The ability of femurs to accommodate flexible nails increased with age with most children age two years and older able to accommodate two flexible nails of at least 2.5 mm in size.Level of EvidenceIII