Flexible Nailing Research Articles

Tibia Fractures in Children: A Single-Centre 11-Year Retrospective Study for Evaluating the Management and Outcomes in an Acute General Orthopaedic Hospital.

Introduction Tibia fractures are children's most typical lower limb fractures affecting their general and mental well-being. This study aims to evaluate the management and outcomes of displaced tibia fractures. Methods A retrospective study was conducted to review children up to 16 years of age with displaced tibia shaft fractures who received treatment in our department from January 2011 to December 2021. Fractures managed in the operating theatre and patients who completed follow-up until fracture healing were included in the study. Treatment procedures were assessed, and outcome was measured by hospital stays, complications and revision procedure incidences. Results The study included 74 patients (75 fractures, including one re-fracture). The patient's ages ranged from 2 to 16 years (median age: 11 years). Seven patients sustained open fractures (Gustilo I, II). Tibia diaphysis was the most common site of involvement. A total of 43 patients were treated by manipulation under anaesthesia and cast. Surgical fixation was directly proportional to increasing age (p<0.05). Overall, 74% of patients were treated by fixation when age was >10 years. Three patients needed conversion of casting to surgical fixation. One patient had re-fracture following a secondary injury after six months of initial tibia shaft fracture treated by casting. Five patients had complications, including delayed union, pin site and surgical site infections. Antibiotics were adequate to manage infections except in one patient who needed debridement. The average hospital stay was three days. The median number of follow-up X-rays was 4. The planned removal of all flexible nails, and the circular frame was done between 2 and 15 months, except for one that had delayed union. All the patients underwent clinical and radiological union at the end of the follow-up. Conclusion The treatment plan was dependent on the individual need of the patient and the fracture pattern. Children older than 10 years were more likely to undergo surgical fixation. The majority of fractures were treated by manipulation and cast in operating theatres. Better logistic support in the emergency department could reduce the burden on the operating theatre.

Management of Infected Femoral Nonunion by Arched External Fixator Augmented by Flexible Intramedullary Nails

Abstract Purpose: The aim of this study is to evaluate the functional and radiological outcome of the management of infected femoral nonunion by arched frame augmented by flexible intramedullary nails. Patients and Methods: In this retrospective case series study, 20 cases were included. All patients had chronically infected nonunited fracture femur. The mean age of the included patients was 33 years. The site of the femoral fracture was midshaft in 12 patients, proximal third of femur in 6 patients, and distal third in 2 cases. Initially, the fracture was open in 17 patients and closed in 3 patients. Four of the included patients had diabetes mellitus. Ten cases were smokers and six of them were heavy smokers. All cases were managed by arched frames, augmented by flexible intramedullary nails. Functional and radiological evaluation was performed using the Association for the Study and Application of the Methods of Ilizarov (ASAMI) scoring system. Results: The mean follow-up was 18.45 months. All cases achieved union except two cases (10%). According to ASAMI bony score, 11 patients (55%) were excellent, 6 (30%) were good, 1 was fair (5%), and 2 (10%) showed poor results. According to ASAMI functional score, 3 patients were excellent, 15 (75%) were good, 3 (15%) were fair, and 2 (10%) showed poor results. Conclusion: The management of infected nonunion of the femur by arched frame and intramedullary flexible nails provides a stable fixation, with acceptable functional and radiological results. Level of Evidence: Level IV case series study.

Treatment of Pathological Fracture of Radius due to Multiple Myeloma with Elastic Intramedullary Nail and Cement Augmentation: Expanding the Indications of Elastic Nails.

Pathological fractures of the proximal radius are exceedingly rare. Here, a case of an 81-year-old female diagnosed with multiple myeloma 15 years ago who suffered a pathological fracture of her left proximal radius is presented. Due to the fracture's proximity to the elbow joint and the lack of adjacent healthy bone tissue, a resourceful surgical intervention was implemented using a pediatric flexible nail supplemented by polymethacrylate cement injection. Six weeks post-operatively, the patient had alleviation of the pain with fully functional forearm. This novel approach could possibly aid in the treatment of other long bone pathological fractures due to neoplastic metastases.

Evaluation and Management of Pediatric Humeral Shaft Fractures.

Diaphyseal humerus 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 with various immobilization techniques, 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, and the multiplanar motion of the shoulder joint can accommodate for greater variations in alignment than many other long bone fractures. Complications such as radial nerve palsy are possible with both open and closed injuries, and mal/nonunions, although rare, can occur. Overall, treatment should be predicated on a full evaluation of the patient, fracture, local soft tissues, and any concomitant injuries.

Flexible Nails versus Plate for Fixation of Fracture Shaft Femur in Children from 5-12 Years

Flexible Nails versus Plate for Fixation of Fracture Shaft Femur in Children from 5-12 Years

Displaced Tibia Fractures in Adolescents: Closed Reduction and Casting Versus Flexible Intramedullary Nails.

Although there has been a recent trend towards the operative intervention of pediatric diaphyseal tibial fractures, there is sparse literature that supports this trend. This study compares the outcomes in children between 10 and 18 years of age with diaphyseal tibial fractures who undergo nonoperative treatment with closed reduction and casting (CRC) to those who undergo operative treatment with flexible intramedullary nailing. A retrospective chart review was performed of all patients between 10 and 18 years of age who underwent treatment for tibia fractures at the authors home institution between 2005 and 2018. Radiographs and medical records were reviewed for the duration of immobilization, time to fracture healing and complications including delayed union, malunion, nonunion, and surgical site infection. All statistical analysis was performed using an αof 0.05. One hundred forty one patients (81.8% males) were included in the final analysis. Patients treated with flexible nailing took an average of 7 weeks ( P <0.001) longer than patients treated with CRC to achieve radiographic healing. The average time to full weight-bearing activities was longer by 1 week in the patients treated nonoperatively with CRC ( P =0.001). There was no statistically significant difference in the malunion rates between the 2 groups ( P =0.067), but delayed union and nonunion were exclusively seen in the flexible nailing group. There was a total of 40 complications among 33 (23.4%) patients, most of whom were in the CRC cohort (60.6%, n=20), but there was no statistically significant difference in complication rates between the 2 cohorts. Most adolescents presenting with closed diaphyseal tibial fractures of moderate severity can be successfully treated both nonoperatively with CRC and operatively with flexible intramedullary nailing. However, we recommend an initial attempt at nonoperative treatment be performed in these patients due to the association of more severe complications with flexible nailing. Level III.

纵轴流玉米柔性脱粒装置设计与试验研究

In order to reduce the problems of high grain breakage rate and uncleaned material rate in the threshing and separating device of longitudinal axial flow corn, a threshing device of "front flexible nail tooth + rear pressure spring elastic short grain rod" was designed and the threshing elements were arranged spirally on the conical threshing drum. Discrete element method and field test were used to verify the feasibility of threshing drum design, and EDEM simulation software was used to obtain the appropriate guide plate Angle parameter range. Single factor test was carried out on each experimental factor under high and low water content conditions, and four factors suitable working range was obtained.On this basis, four factors and three levels orthogonal test were carried out on grain breakage rate and undepurated rate, rotational speed of roller, feeding rate, cylinder-concave clearance and deflector angle as experimental factors. Range and variance analysis were used to analyze the rotational speed of roller, feeding rate, cylinder-concave clearance and deflector angle. The results showed that:Under the conditions of low water content, the threshing effect is the best under the conditions of feeding rate of 8kg/s,rotational speed of roller of 450 r/min, cylinder-concave clearance of 45 mm, and deflector angle of 70°.Under the conditions of high water content,the best threshing effect was achieved under the conditions of feeding rate of 7kg/s, rotational speed of roller of 450 r/min, cylinder-concave clearance of 40 mm and deflector angle of 75°. Compared with the conventional threshing separation device, the grain breakage rate of low moisture content decreased by 39.4% and the uncleaned material rate decreased by 63.9%.The grain breakage rate of high moisture content was reduced by 45.5%, and the uncleaned material rate was reduced by 66.7%, which was better than the conventional longitudinal axial flow threshing separation device. The research results can provide reference for the design and optimization of longitudinal axial flow corn harvester.

Tibial shaft fractures in children: flexible intramedullary nailing in growing children especially weighing 50 kg (110 lbs) or more.

Currently the gold standard in surgical treatment of displaced tibial shaft fractures in children with open growth cartilage is elastic stable intramedullary nailing (ESIN). The purpose of this study is the analysis of indications, complications, and duration of treatment using intramedullary flexible nails in children who are still growing but especially weighing 50 kg or more. Hospital records from 2017 to 2020 were retrospectively reviewed to identify the children from 4 to 17 years of age with displaced tibial shaft fractures admitted to the hospital. Only children with open growth cartilage, with a minimum of 6 months of follow-up and complete clinical data, were included. Studies of 91 children xwere analyzed. The average patient age at the time of the injury was 10.88 ± 2.82 years. In the entire group, 31.9% children weighed 50 kg or more, and 68.1% of the children were below this weight. All children were treated using ESIN. The mean time to nail removal was 8.4 ± 4.09 months in the whole group of children stabilized with ESIN. There were no differences in the two groups depending on the weight ( P = 0.637). Only two adverse events were observed. This study demonstrates that the use of ESIN in displaced tibial shaft fractures in growing children weighing 50 kg or more is acceptable and safe. The discussion to be made is whether it is still an acceptable method of treatment for this type of fracture due to the progressive obesity epidemic in children and adolescents.

Clinical study of surgical management of paediatric diaphyseal fractures of femur by Titanium Elastic Nailing System (TENS)

Femoral shaft fractures are the most common major paediatric injuries managed by the orthopedic surgeon. Non-surgical management, usually with early spica cast application, is preferred in younger children. In the older child, traction followed by casting, external fixation, flexible IM Nails and plate fixation have specific indications. Potential complications of treatment include shortening, angular or rotational deformity, delayed union, Nonunion, over growth, skin problems and scarring. Risks of surgical management includes re-fractures after external fixator or plate removal, osteonecrosis after rigid IM nails fixation and soft tissue irritation caused by ends of flexible nails.

EARLY OUTCOMES OF FLEXIBLE INTRAMEDULLARY NAILING IN PEDIATRIC SHAFT OF FEMUR FRACTURES

Objective: To study the early outcomes and complications of fixation of pediatric shaft of femur fractures using flexible intramedullary nail.&#x0D; Study Design: Prospective observational study.&#x0D; Place and Duration of Study: Orthopedic Department, Bahawal Victoria Hospital Bahawalpur, from Jan to Jun 2021.&#x0D; Methodology: Children between the ages of 5-11 years with shaft of femur fractures were included in the study. Fixation of fracture was done using elastic intramedullary nail. Final outcomes of fixation were observed using Flynn and Schwend Scoring System. Six-month follow-up was done in all cases. Data was analyzed using SPSS-20.&#x0D; Results: Total 70 cases having shaft of femur fracture were included in the study. Age range of cases was 5-11 years with mean age of 7.75 ± 1.66 years and mean weight of 24.44 ± 4.77 kilograms. Mean diameter of femur medullary canal was 7.48 ± 0.63 millimeters and mean diameter of flexible nail was 3.03 ± 0.26 millimeters. Mean post-operative period of radiological union of fracture was 8.57 ± 1.05 weeks. Per-operatively, fracture site was approached in 4 (5.7%) cases. Migration of nail was not seen in any case. Final outcomes according to Flynn and Shwend Score were excellent in 62 (88.5%), satisfactory in 7 (10%) and poor in 1 (1.4%) case.&#x0D; Conclusion: Fixation of shaft of femur fracture using flexible intramedullary nailing technique is safe and reliable with good outcomes among children between 5-11 years of age.

Unplanned Return to the Operating Room (UpROR) After Pediatric Diaphyseal Femoral Fractures.

Femoral fractures are the most common cause of fracture-related admissions. Unplanned return to the operating room (UpROR) is a major event and imposes a substantial burden on the family and health care system. The purpose of this study was to determine the incidence of complications and early UpROR during the first 6 months following treatment of femoral fractures and their risk factors. In an institutional review board-approved study, a retrospective review of all patients who were treated for a femoral fracture during a 10-year period at a pediatric tertiary care center was performed. Patients less than 18 years old with a diaphyseal fracture and complete records were included, and nondiaphyseal or pathologic fractures, as well as underlying metabolic or genetic disorders, were excluded. All clinic visits in the first 6 months after treatment were reviewed, and all complications and UpRORs were extracted. Patients were grouped based on their age (below 5, 5 to 11, above 11 y old) at initial treatment, and statistical tests were used to infer differences between groups. Overall, 841 fractures in 832 patients were included, with a mean age of 5.5±4.8 years fracture, of which 72% were male. A total of 106 complications (12.6%) and 45 UpRORs (5.3%) were encountered during the study period. Patients with and without UpROR had similar demographics and injury and treatment characteristics. Loss of reduction was the most common reason for UpROR (58%), followed by implant-related complications. Flexible nails had the highest risk of UpROR among patients who were initially treated surgically (P=0.03). Our findings indicate that children under the age of 5 years have a 5% risk of UpROR in the first 6 months after the fracture, mainly for repeat spica casting due to loss of reduction. Patients aged 5 years or older have an ∼6% risk of UpROR, mainly related to complications of flexible nails. The findings of this study are important when consulting families on different treatments of diaphyseal femoral fractures. Therapeutic level III-retrospective cohort study.

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.

Operative Fixation of Pediatric Forearm Fractures: Does the Fracture Location Matter?

Background Flexible intramedullary nails (FNs) are successfully used to treat pediatric forearm fractures, especially midshaft fractures. Distal forearm fractures have been described as “difficult to manage” with FN insertion. The purpose of this study was to report the clinical and radiographic outcomes of using flexible nails in pediatric forearm fractures and the impact of fracture location on the outcome of the procedure. Methods This is a retrospective review of pediatric patients who presented with forearm fractures that were surgically treated with flexible nails between 2009 and 2018. Patient demographics, fracture location, and classification were reported. Intraoperative and postoperative complications were reported. The primary outcomes were fracture radiographic union, intraop and postop complications, and the need for additional surgical procedures. Results Fifty-nine patients were included, with a mean age of 11 years. All fractures healed with patients regaining full range of motion. The authors were able to use flexible nails successfully in 48/59 (81%) patients. In eleven cases (19%), FN fixation was not able to provide adequate fixation to maintain reduction. The method of fixation was changed from FN insertion to another method in nine cases. In two cases, FN fixation was augmented with another fixation method. Fractures within 3 inches of the distal articular surface were at a higher risk of intraoperative change/augmentation of the fixation method (29%) compared with fractures that occurred more than 3 inches from the distal articular surface (11%). Conclusion The majority of pediatric forearm fractures can be treated successfully with flexible nails. Surgeons involved in treating these fractures should pay attention to distal third fractures. Stabilizing the distally located fractures using FN fixation can be challenging. Surgeons should be prepared to use an alternative fixation method when needed.

Clinical Outcomes of Management of Pediatric Diaphyseal Forearm Fractures Using Flexible Elastic Nailing

Clinical Outcomes of Management of Pediatric Diaphyseal Forearm Fractures Using Flexible Elastic Nailing

Evaluations of Femoral Diaphyseal Fracture Treated by Flexible Nail versus Plate Fixation in Children: Meta-analysis study

The purpose of this Meta analysis study is to provide a good idea and characteristics about the optimal fixation methods for fracture shaft femur in children 5-14y of age based on the current evidence. Patients and Methods: An electronic research was performed in PubMed, Medline, Elsevier, Google scholar and Cochrane Library database to identify the relevant literatures that published until 20 May 2020. By using RevMAN5.4 software the data of operative, postoperative, follow up and the reported complicationswas analyzed for the meta-analysis. Results:the pooled data showed a statistically significant difference in Operative Time, Estimated Blood Loss, Union Time and Fracture Angulation. Conclusion: According to the pooled data results we suggest the use of flexible nails with stable femoral shaft fractures in school age children, due to the minimally invasive technique, early union and weight bearing. In other hand using plate fixation is more stable and has lower rate of fracture mal alignment more than retrograde flexible nail and can be use with the unstable fractures due to the rigid fixation.

The advent of elastic stable intramedullary nailing for the treatment of long bone fractures in skeletally immature patients

Introduction Management of pediatric long bones fractures is a complex and rapidly evolving field. Traditionally, casting and conservative techniques played a key-role in the management of fractures in skeletally immature patients. However, the surgical approach has evolved steadily over the past four decades or so and increasing evidence has been published supporting the advantages of fixation techniques over conservative methods. The purpose of this narrative review is to outline how innovations in orthopedic surgery have changed the rationale of treating long bones fractures in children and adolescents with focus on surgical techniques, particularly elastic stable intramedullary nailing (ESIN). Material and methods We aimed to describe the main trends in pediatric long bones fractures management and to identify its specificities and difficulties as well as the best standard of care. Results The introduction of ESIN has profoundly influenced the management of pediatric upper and lower extremity fractures. Overall, in comparison to conservative techniques, advantages of ESIN include minimally invasiveness, short hospital stay, primary bone union, early mobilization and progressive weight bearing, and good outcome with low complication rate. Moreover, the flexible nail can be used as a closed reduction tool itself. Conclusions Irrespective of the technique performed, the key-concepts remain 1) the proper understanding of the injury to treat; 2) the identification the main characteristics of the patient; 3) the pros and cons of each technique; and 4) the potential complications.

Use of flexible nails in children diaphyseal fractures. Five questions and answers

Introduction More than 40 years after the launch of elastic stable intramedullary nailing (ESIN) as a golden standard of the treatment of some fractures in children and adolescents. Material and methods This review is based on answers to five essential questions: The position of ESIN compared with other methods of treatment; The choice of the implants; The indications for ESIN today; How to avoid complications as much as possible? Do we remove the implants or not? Results The aspects of biomechanics, design, indications for ESIN in comparison to other treatment, surgical techniques depending on fractured bones, complications are presented in the article. Conclusion ESIN is an excellent method to fix long bone fractures in children and adolescents. Top one is definitively the fractures of both bones of the forearm, then the diaphyseal fractures of the femur and the tibia before the age to be eligible for a locking nail. However, some unstable fractures cannot be treated conservatively or with a locking nail, and an ESIN remains unstable. In these cases, we are allowed to propose to add an external fixator for 4 to 6 weeks, waiting for a good stabilisation of the fracture.

Radius Shaft Fractures-What Alignment is Acceptable at What Age? Plates or Flexible Nails?

The transition from pediatric to adolescent fractures can lead to uncertainty on what level of surgical correction is warranted as remodeling is limited in these older patients. Adolescent diaphyseal radial shaft fractures present several unique challenges; the radial bow must be restored to preserve forearm rotation and there are several clinical scenarios where plating, even in the skeletally immature child, is strongly recommended and will have more reliable results over flexible intramedullary nails. In addition, judging how much angulation, rotation, and displacement will remodel in the older child can be a challenging decision, even for experienced pediatric orthopaedists. This overview discusses parameters for acceptable alignment in these fractures, when surgical fixation should be considered, and circumstances where plating should be considered over flexible nails.

Operative Fixation Versus Cast Immobilization: Tibial Shaft Fractures in Adolescents.

Tibial shaft fractures are common injuries in the adolescent age group. Potential complications from the injury or treatment include infection, implant migration, neurovascular injury, compartment syndrome, malunion, or nonunion. Published literature was reviewed to identify studies which describe the management options, complications, and outcome of tibial shaft fractures in adolescents. Acceptable alignment parameters for tibial shaft fractures have been defined. Operative indications include open fractures and other severe soft tissue injuries, vascular injury, compartment syndrome, ipsilateral femoral fractures, and polytrauma. Relative indications for operative treatment are patient/family preference or morbid obesity. Closed reduction and cast immobilization necessitates radiographic observation for loss of reduction over the first 3 weeks. Cast change/wedging or conversion to operative management may be required in 25% to 40%. Flexible nailing provides relative fracture stability while avoiding the proximal tibial physis, but the fracture will still benefit from postoperative immobilization. Rigid nailing provides greater fracture stability and allows early weight bearing but violates the proximal tibial physis. Plate and screw osteosynthesis provide stable anatomic reduction, but there are concerns with delayed union and wound complications related to the dissection. External fixation is an excellent strategy for tibia fractures associated with complex wounds but also requires observation for loss of reduction. The majority of adolescent tibia shaft fractures can be successfully managed with closed reduction and cast immobilization. Unstable fractures that have failed cast treatment should be treated operatively. Flexible intramedullary nailing, rigid intramedullary nailing, plate and screw osteosynthesis, and external fixation are acceptable treatment options that may be considered for an individual patient depending upon the clinical scenario.

Paediatric diaphyseal forearm fractures: Is titanium elastic nailing a safe option?

Paediatric forearm fractures are common injuries accounting for 40% of all the fractures in children. They are traditionally treated conservatively with casting. However there has been short and long term complications associated with such treatment and in recent times, closed reduction and flexible nailing has shown favourable clinical outcomes. In this prospective study, we evaluated functional outcome in closed forearm diaphyseal fractures of children and adolescents treated with titanium elastic intramedullary nails. All cases achieved bony union at an average of eight weeks and excellent functional outcome without significant complications. Nails were removed under anaesthesia after radiological union. Intramedullary nailing with elastic nails is an effective method of treatment for these unstable diaphyseal fractures of forearm in children and adolescents.