Intramedullary Nailing In Children Research Articles

Modified elastic intramedullary nail internal fixation for distal tibial metaphyseal junction fracture

Objective: To investigate the application of modified elastic intramedullary nail and the outcomes between modified elastic stable intramedullary nailing and traditional elastic stable intramedullary nailing in children with distal tibial metaphyseal junction fracture. Methods: A retrospective study was conducted. From January 2018 to January 2021, a total of 36 children with distal tibial metaphyseal junction fracture were treated in our hospital. All of them were treated with closed reduction and elastic stable intramedullary nailing internal fixation. A total of 18 children were treated by modified elastic stable intramedullary nailing and 18 children were treated by traditional elastic stable intramedullary nailing. Postoperative imaging, clinical efficacy, and complications were analyzed. Results: The mean follow-up time was 20 (15–36) months in modified group and 22 (16–33) months in traditional group. There were no complications such as infection, loss of reduction, and unequal length of lower limbs in modified group while loss of reduction occurred in two cases in traditional group. In these two cases of loss of reduction, we preformed manual reduction and replacement of long leg casts, and there was no loss of reduction, and the patient achieved a good prognosis. In the last follow-up, American Orthopaedic Foot & Ankle Society score was used. In modified group, excellent outcome achieved in 17 cases, good outcome achieved in 1 case, and satisfactory therapeutic effect was achieved. In traditional elastic stable intramedullary nailing group, excellent outcome achieved in 14 cases, and good outcome achieved in 4 cases. There was no statistical difference in the scores between the two groups. Conclusion: It was concluded that modified elastic stable intramedullary nailing fixation is a safe and effective treatment.

Modified Kirschner wire percutaneous rotation prying reduction combined with elastic stable intramedullary nailing in children with Judet IV radial neck fracture

PurposeThis study was to investigate the feasibility and treatment effect of using modified Kirschner wire (K-wire) percutaneous rotation prying reduction combined with Elastic Stable Intramedullary Nailing (ESIN) in children with Judet IV radial neck fracture.MethodsA retrospective analysis was conducted on 47 children with Judet IV radial neck fracture who underwent treatment with modified K-wire percutaneous rotation prying reduction combined with ESIN from April 2019 to November 2022, including 25 males and 22 females, with an average age of 8.79 years old (ranging from 5 to 14). The study recorded the surgical time, fluoroscopy time, reduction time, and reduction quality evaluated according to the Metaizeau radiological standard. During the last follow-up, the flexion-extension and forearm rotation function of the affected and healthy sides were recorded, and the Mayo Elbow Performance index was used to evaluate the elbow joint function.ResultsThe average duration of the operation was 25.51 min (ranging from 14 to 43 min), with a mode of 2 reset times (ranging from 1 to 5) and 8 fluoroscopic times (ranging from 4 to 15). Based on the Metaizeau radiological standard for assessing reduction quality, 45 cases were deemed excellent, while 2 cases were considered good. Following 3–4 weeks of postoperative long-arm cast immobilization, exercises were performed to promote elbow joint and forearm rotation. The ESIN was removed after satisfactory fracture healing around 4 months postoperatively. The average follow-up period was 26.79 months (ranging from 5 to 48). At the final follow-up, the range of motion for the affected limb in flexion, extension, pronation, and supination was (140.23 ± 4.80)°, (4.43 ± 3.98)°, (84.09 ± 4.97)°, and (83.83 ± 4.55)°, respectively. There was no statistically significant difference compared to the healthy side, which had a range of motion of (141.36 ± 3.27)°, (5.28 ± 2.25)°, (85.66 ± 3.20)°, and (84.98 ± 2.57)° (P > 0.05). According to the Mayo Elbow Performance index, 44 cases were rated as excellent and 1 case was considered good.ConclusionThe modified K-wire percutaneous rotation prying reduction combined with ESIN is an effective treatment for severe radial neck fractures in children. This technique offers several advantages, including the ability to easily “capture” significantly displaced radial heads, achieve rapid and accurate reduction, and reduce radiation exposure.

Surgical approach for elastic stable intramedullary nail in pediatric radius shaft fracture: a systematic review.

When using elastic stable intramedullary nailing in children's distal radius shaft fractures, the surgical approach can either be lateral or dorsal. The aim of this article was to carry out a systematic review of the literature comparing the two types of approaches in terms of complications. An electronic search of databases was performed. Titles of articles were screened, and abstracts and full text were read. Data were extracted in terms of demographics and complications. The dorsal approach had a 2.6% rate of extensor pollicis longus tendon rupture, whereas the lateral approach had a 2.9% rate of transient superficial radial nerve palsy and 0.3% rate of permanent damage. These complications should be considered when deciding between the two surgical approaches.

Therapeutic effect of Peter-Williams intramedullary nail in children with tibia fracture due to osteogenesis imperfecta

Objective To study the method and therapeutic effect of Peter-Williams intramedullary nail in children with tibia fracture due to osteogenesis imperfecta. Methods A total of 30 children of tibia fracture due to os-teogenesis imperfecta, including 17 males and 13 females in Department of the Third Orthopaedics and Osteogenesis Imperfecta Center, Tianjin Wuqing District People′s Hospital from June 2015 to January 2017, were operated on the shaft of tibia with Peter-Williams intramedullary nail.Twelve cases were left tibia fracture, 13 cases were right tibia fracture, and 5 cases were bilateral tibia fracture.Twenty of 35 tibias were accompanied with no tibial deformity, and 15 of 35 tibias were accompanied with different degrees of anterior arch bowing deformity.The movement and life self-care ability were evaluated according to Functional independence measure (WeeFIM) evaluation form. Results All of the children were followed up for an average of 18 months(ranging from 10 to 26 months). The average operating time was 1.2 hours(0.75-2.50 hours). The average bleeding was 60 mL(30-100 mL). The average bone healing time was 10 weeks(8-16 weeks). Patients began to exercise on bed after removing plaster, and to walk after X-ray showing bone healing.Parents of all children were satisfied with surgical operation, and the WeeFIM score was improved by (60.76±15.57) scores (64-85 scores) preoperatively to (82.00±7.50) scores (75-91 scores) postoperatively.There was a statistically significant difference in scores before and after the treatment(t=2.765, P=0.003). There was no infection, osteomyelitis, nerve damage, or vascular damage. Conclusions Therapy of Peter-Williams intramedullary nail in children with tibia fracture due to osteogenesis imperfect is advantaged.It causes less blood, less damage, with no intruding joint, correcting deformity and improving lower limb functions and life quality. Key words: Osteogenesis imperfecta; Peter-Williams intramedullary nail; Tibia fracture

Evaluation of Complications from Stainless-Steel Flexible Intramedullary Nailing in Children’s Femoral Shaft Fractures and Recommendations for Continued Use

[b]Background.[/b] Flexible intramedullary nailing is currently considered the treatment of choice for femoral diaphyseal fractures in school-aged children. The purpose of our study was to critically evaluate and analyze the complications of stainless steel flexible intramedullary nailing in children's femoral shaft fractures. (mean age, 8.2 years) with a femoral shaft fracture treated with stainless steel flexible intramedullary nailing from January 1, 2009 to July 31, 2015 and evaluated for complications.[b]Results.[/b] All fractures united in a mean time of 9.2 weeks. Minor complications were noted in 19 patients, and major complications were noted in two patients. The Flynn score was excellent in 74 patients, satisfactory in 23 patients, and poor in three patients.[b]Conclusions.[/b] 1. Stainless steel flexible intramedullary nailing in children's femoral shaft fractures is associated with minimal complications. 2. These complications are not related to the alloy of the implant and are mostly due to the long nail end; these complications can be prevented easily. 3. Stainless steel flexible intramedullary nailing is also cost effective, and we recommend its use be enhanced for the treatment of femoral shaft fractures in children.

Pediatric femoral shaft fractures treated by flexible intramedullary nailing

BackgroundNowadays pediatric femoral fractures are more commonly managed with operative treatment rather than conservative treatment because of more rapid recovery and avoidance of prolonged immobilization. Children between the ages of 5–13 years are treated either by traction plus hip spica and flexible/elastic stable retrograde intramedullary nail, or external fixators in the case of open fractures. The aim of this study is to evaluate the outcome of pediatric femoral shaft fractures treated by stainless steel flexible intramedullary nail in children between 5 and 13 years of age. MethodsThere were 32 cases of femoral shaft fractures which were all fixed with stainless steel flexible intramedullary nail under fluoroscopy. Long leg cast was applied at the time of fixation. Partial weight bearing was started 2 weeks after surgery. Patients were evaluated in follow-up study to observe the alignment of fracture, infection, delayed union, nonunion, limb length discrepancy, motion of knee joint, and time to unite the fracture. ResultsWe were able to follow up 28 out of 32 patients. The patients were 8.14 years of age on average. The mean hospital stay after operation was 4 days and fracture union time was 9.57 weeks. There were 3 cases of varus angulation, 2 cases of anterior angulation, and 4 cases of limb lengthening. ConclusionPatients aged between 5 and 13 years treated with flexible intramedullary nail for closed femoral shaft fracture have rapid union and recovery, short rehabilitation period, less immobilization and psychological impact, and cost-effective.

Treatment of humeral shaft fractures by a single elastic stable intramedullary nail in children

Objective The aim of this study was to assess the effectiveness of intramedullary fixation of displaced humeral shaft fractures in skeletally immature children using a single elastic stable intramedullary nail. Background Almost all pediatric humeral shaft fractures can be treated successfully using closed methods. Some patients, however, require internal fixation either because of an inability to maintain an adequate reduction, significant soft tissue injury, or concomitant fractures. In this study, the functional and radiological results of the management of humeral shaft fractures in children using a single retrograde elastic intramedullary nail will be evaluated. Patients and methods Twenty pediatric patients ranging in age from 6 to 16 years (mean age 10 years) were treated surgically using a retrograde single elastic intramedullary nail. Relative surgical indications included open fractures, inability to maintain an acceptable reduction, concomitant lower extremity fractures, and closed head injury. Two patients had associated radial nerve injury at presentation. Among the patients, 16 were males and four were females. Results The patients were followed for a mean of 5.5 months, with a range from 4 to 6 months. Radiographically, all fractures healed in good alignment. Solid union occurred from 5 to 10 weeks, with a mean of 8 weeks. There were no intraoperative complications, including neurologic or vascular injury, and two patients developed superficial wound infections postoperatively. Conclusion It was found that single elastic intramedullary nail fixation with the aid of a functional arm brace is an adequate technique for the treatment of humeral shaft fractures in pediatric patients when surgical stabilization is indicated. This simple minimally invasive technique provides stable fixation, with minimal soft tissue stripping at the fracture site, and led to bone union in all the cases studied. Level of evidence Case series, level IV.

R-T4.1 Treatment of tibia fractures with titanium elastic intramedullary nail in children

R-T4.1 Treatment of tibia fractures with titanium elastic intramedullary nail in children

Outcomes from Treatment of Simple Bone Cyst in the Long Bones with Flexible Intramedullary Nailing in Children and Adolescents: A Retrospective Cases Series

Outcomes from Treatment of Simple Bone Cyst in the Long Bones with Flexible Intramedullary Nailing in Children and Adolescents: A Retrospective Cases Series

Book Review: Pierre Lascombes: Flexible intramedullary nailing in children: The Nancy University manual

Book Review: Pierre Lascombes: Flexible intramedullary nailing in children: The Nancy University manual

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

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

Use and Abuse of Flexible Intramedullary Nailing in Children and Adolescents

Elastic stable intramedullary nailing (ESIN) has became a well-accepted method of osteosynthesis of diaphyseal fractures in children and adolescents for many reasons including the following: no need for postoperative cast, primary bone union with avoidance of growth plate injury, and minimum invasive surgery. The principle is to introduce 2 elastic nails, titanium or stainless steel, into the medullary canal through a metaphyseal approach. The bended nails must have their maximum of curve at the level of the fracture, and their orientation, most often face to face, is in charge of the reduction and, so far, the stabilization, of the fracture. The usual size of the nails is equal to 0.4 times the diameter of the medullary canal. As far as possible, a bigger diameter is better than a thinner one. Most fractures of the femur are treated with a bipolar retrograde ESIN when some distal fractures need an antegrade subtrochanteric approach. Forearm fractures need a combined retrograde radial and antegrade ulnar through the posterolateral part of the olecranon. Humerus and tibial diaphyseal fractures may also be treated with ESIN. Complications are mainly caused by technical errors including too-thin nails, asymmetry of the frame, and malorientation of the implants. Nonunion was never observed in fractures of the femur and the forearm; osteomyelitis rate is 2%, and mean overgrowth of the femur is less than 10 mm before the age of 10 years. Indications of ESIN are fractures of the diaphysis: all the fractures of the femur between the age of 6 years and the end of growth except for the severe open grade III fractures, all the unstable fractures of the forearm, and some unstable fractures of the humerus and the tibia during adolescence or before the end of growth. In addition, ESIN is indicated in polytraumatism and multiple injuries. The good results of this reliable technique are obtained when surgeons have a good knowledge of it, especially in the understanding of the principle of the correction of the fracture and its stability.

The principles of elastic stable intramedullary nailing in children

Elastic nailing is the foremost method of surgically stabilizing children's long bone fractures. This article traces the history of the method, summarizes the scientific basis, both biological and biomechanical, and assesses the broad indications.

Delayed union and non-union of the ulna following intramedullary nailing in children

Most studies report little or no problem with union following intramedullary nailing of fractured forearm bones in children. The bone involved in the occasional delayed union is not mentioned except for one delayed union of the ulna following an open fracture. The present paper specifically highlights problems with union of the ulna following nailing in children. It reports two cases of delayed union and one non-union following nailing of closed fractures of both forearm bones. In all cases, the radius united in good time. We discuss the anatomical reasons and surgical techniques that predispose the ulna bone to delayed union and non-union and recommend surgical precautions to avoid this.

A flexible intramedullary nails for fractures in children.

©2004 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.86B7. 15273 $2.00 J Bone Joint Surg [Br] 2004;86-B:947-53. Over the past few years there has been a marked increase in the use of intramedullary fixation in the management of fractures of long bones in children. To some extent this reflects a more interventionist attitude among paediatric orthopaedic surgeons but is also due to technical developments, notably that of the elastic stable intramedullary nail (ESIN). The use of intramedullary devices to stabilise fractures is not new. In the mid-19th century, ivory pins were used for this purpose and were then gradually supplanted by various metal devices.1 These were generally rigid implants, although more flexible ones were introduced in in the 1930s. The school of rigid intramedullary fixation was typified by the Kuntscher nail, which achieved great stability in all planes by occupying the entire medullary cross-sectional area of the bone.2 However, its use in growing children was limited by the difficulties encountered in trying to avoid the physes. The Rush nail was introduced at about the same time as the Kuntscher nail.3 It was the forerunner of modern elastic intramedullary fixation in that the objective was to achieve three-point fixation on the inner aspect of the cortex. Unlike the stiff Kuntscher nail, the Rush nail was slightly flexible and it was intended that it should be pre-bent to the appropriate configuration before insertion.3 Rotational stability was poor, however, and in most situations the flexibility was insufficient to allow insertion points in the metaphysis which were well away from the active physis in children. Others, such as Hackethal4 and Marchetti,5 used bundles of thinner wires which filled the medullary cavity but with stabilisation achieved by splaying the ends of the wires within the bone well beyond the fracture. Ender6 developed this further with his nails, which were the first to feature adaptations to both ends of the nail in order to improve both control of insertion and quality of fixation. These nails could be safely inserted into the metaphysis which made them suitable for consideration in paediatric fractures. In the early 1980s, surgeons in Nancy, France, developed an elastic stable intramedullary nail based on a theoretical concept by Firica.7 Previous experience had suggested that elasticity and stability were not easily combined in one construct. However, working from the concept of three-point fixation used with a single Rush nail, these surgeons were able to improve stability significantly by using two pre-tensioned nails inserted from opposite sides of the bone. Metazieau, Ligier and their colleagues7 were able to show that titanium nails which were accurately contoured and properly inserted could impart excellent axial and lateral stability to diaphyseal fractures in long bones. Rotational stability was also better than had previously been experienced, although this was to remain the weakest point of the technique. The use of titanium nails allowed greater elasticity than was available in the steel nails of the Ender system. Most contemporary work on flexible intramedullary nailing in children’s fractures is based on the Nancy experience, although there remain pockets of Ender and Marchetti enthusiasts. For the purposes of this review, flexible intramedullary nailing is taken to mean elastic stable intramedullary nailing using the concepts espoused by the Nancy group.

Intramedullary nailing of femoral fractures in children through the lateral aspect of the greater trochanter using a modified rigid humeral intramedullary nail: preliminary results of a new technique in 15 children.

To evaluate the clinical results of intramedullary nailing of femoral shaft fractures using a rigid intramedullary nail placed through the lateral aspect of the greater trochanter in older children and adolescents. A retrospective study was carried out evaluating all skeletally immature patients with femoral shaft fractures treated using a modified rigid humeral intramedullary nail. Fifteen children and adolescents with displaced femoral diaphyseal fractures and open physes. Femoral shaft fractures in children and adolescents were stabilized using a modified humeral intramedullary nail placed through the lateral aspect of the greater trochanter. Patients were evaluated to determine time to union, final fracture alignment, hospital stay, complications, clinical outcome, and proximal femoral changes including avascular necrosis or proximal femoral valgus with femoral neck narrowing. Fifteen patients were followed for a minimum of 1 year (range 70-157 weeks). The average age of the patients was 12 years and 5 months (range 8 years and 2 months-17 years and 1 month). All fractures healed at a mean of 7 weeks (range 5-14 weeks) after fracture. The average hospital stay for patients with isolated femur fractures (8/15) was 2.8 days (range 1-5 days). At an average follow-up of 141 weeks (range 70-326 weeks), no patient had developed avascular necrosis, femoral neck valgus, femoral neck narrowing, or other complications. The technique of intramedullary nailing in children through the lateral aspect of the greater trochanter seems to be safe, effective, and well tolerated by patients.

Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children.

Recent reports have described osteonecrosis of the femoral head after intramedullary nailing of the femur through the piriformis fossa in children. Other reports have raised concerns about the development of femoral neck narrowing and valgus deformity of the proximal part of the femur after intramedullary nailing through the tip of the greater trochanter. We evaluated the radiographic changes in the proximal part of the femur following intramedullary nailing through the lateral trochanteric area at a minimum of two years postoperatively in twenty-five affected extremities. The mean age of the patients at the time of the index procedure was ten years and six months. A retrospective radiographic review was performed to look for proximal femoral changes. Specifically, the radiographs were examined for evidence of osteonecrosis. The articulotrochanteric distance, femoral neck diameter, and neck-shaft angle were measured on the initial and final radiographs. No patient had evidence of osteonecrosis of the femoral head. The articulotrochanteric distance decreased by a mean of 0.4 mm, the femoral neck diameter increased by a mean of 4.9 mm, and the neck-shaft angle decreased by a mean of 1.4 degrees. Compared with a group of seventeen patients with adequate initial and final radiographs of the contralateral side, the final mean articulotrochanteric distance was 4.5 mm less on the involved side than on the uninvolved side, the mean femoral neck diameter was 0.7 mm less on the involved side than on the uninvolved side, and the mean neck-shaft angle was 3.2 degrees less on the involved side than on the uninvolved side. No patient had development of clinically important femoral neck narrowing or valgus deformity. Statistically, the likelihood that these data represent a group with a mean 3-mm increase in the articulotrochanteric distance is <1%. The likelihood that these data represent a group with a mean 3.2-mm decrease in the ultimate femoral neck diameter is <1%. The likelihood that these data represent a group with a mean 5 degrees increase in the neck-shaft angle is <1%. Lateral transtrochanteric intramedullary nailing in children who are nine years of age or older does not produce clinically important femoral neck valgus deformity or narrowing, and we did not observe osteonecrosis of the femoral head after this procedure.

Flexible Intramedullary Nailing in Children's Femoral Shaft Fractures

Flexible Intramedullary Nailing in Children's Femoral Shaft Fractures

FEMORAL LENGTHENING OVER A HUMERAL INTRAMEDULLARY NAIL IN PREADOLESCENT CHILDREN

Femoral lengthening over an intramedullary nail has been described in adults. A technique of femoral lengthening over a humeral intramedullary nail in children is described, and the results and complications are presented. Nine preadolescent patients (average age, nine years and ten months) with femoral length discrepancy were treated with femoral lengthening over a humeral intramedullary nail. After nail insertion, a monolateral external fixator was placed with half-pins either anterior or posterior to the intramedullary nail, and lengthening was performed through a proximal osteotomy. The femora were lengthened a mean of 6.1 cm (range, 5.0 to 8.0 cm), 19.5% (range, 15.9% to 26.2%) of the preoperative femoral length. Patients had a mean lengthening index of 12.2 days/cm of length (range, 9.5 to 16.9 days/cm of length). Five complications including osteomyelitis, failure of the distal interlocking site, and femoral fracture at the distal end of the nail occurred in four patients; four of the complications led to surgical intervention. No case of proximal femoral valgus secondary to nailing through the greater trochanter had developed by the time of final follow-up. All patients were followed for a minimum of two years postoperatively, with a mean of 128 weeks (range, 111 to 161 weeks). The technique is effective but has a high rate of complications, including osteomyelitis, which developed in two of the nine patients. No avascular necrosis or proximal femoral valgus was noted.

Retrograde flexible intramedullary nailing in children's femoral fractures.

We treated 31 femoral shaft fractures in 28 children with a mean age of 6.7 (5-10) years with retrograde flexible intramedullary nailing. There were 16 isolated fractures, while 12 children had associated injuries. The average time for union was 10.5 weeks and there were no delayed unions. There was one broken nail requiring change of treatment, but no infection or refractures. At follow-up after a mean time lapse of 27 months there was no limb-length inequality exceeding 1 cm and no malunion. We feel that femoral fractures in patients aged 5-10 years can be safely treated with retrograde flexible intramedullary nailing with minimal risk of surgical complications.