Intramedullary Nailing Group Research Articles

Both-bone forearm fractures in children

Six small retrospective cohort studies shed little light on whether intramedullary nailing (IMN) or open reduction internal fixation (ORIF) with plate fixation is more effective in treating both-bone forearm fractures in children. No statistically significant difference between treatment groups was found with regard to functional outcomes or the average magnitude of radial bowing. Small sample sizes may have precluded detection of statistically significant differences. In one study, a statistically significant difference was found in the average radial bow location in the IMN group as compared with both the ORIF group and normative values. Cosmetically, IMN provided significantly better results (ie, smaller incision / scar length) than ORIF as assessed by two studies. For both nonunion / delayed healing and complications, rates varied widely between studies and did not consistently favor one treatment method over the other. Randomized controlled studies with larger sample sizes and longer follow-up periods are needed to determine which treatment option is optimal. Use of validated outcomes measures is recommended.

A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia

We compared the outcome of closed intramedullary nailing with minimally invasive plate osteosynthesis using a percutaneous locked compression plate in patients with a distal metaphyseal fracture in a prospective study. A total of 85 patients were randomised to operative stabilisation either by a closed intramedullary nail (44) or by minimally invasive osteosynthesis with a compression plate (41). Pre-operative variables included the patients' age and the side and pattern of the fracture. Peri-operative variables were the operating time and the radiation time. Postoperative variables were wound problems, the time to union of the fracture, the functional American Orthopaedic Foot and Ankle surgery score and removal of hardware. We found no significant difference in the pre-operative variables or in the time to union in the two groups. However, the mean radiation time and operating time were significantly longer in the locked compression plate group (3.0 vs 2.12 minutes, p < 0.001, and 97.9 vs 81.2 minutes, p < 0.001, respectively).After one year, all the fractures had united. Patients who had intramedullary nailing had a higher mean pain score (40 = no pain, 0 = severe pain), [corrected] but better function, alignment and total American Orthopaedic Foot and Ankle surgery scores, although the differences were not statistically significant (p = 0.234, p = 0.157, p = 0.897, p = 0.177 respectively). Three (6.8%) patients in the intramedullary nailing group and six (14.6%) in the locked compression plate group showed delayed wound healing, and 37 (84.1%) in the former group and 38 (92.7%) in the latter group expressed a wish to have the implant removed. We conclude that both closed intramedullary nailing and a percutaneous locked compression plate can be used safely to treat Orthopaedic Trauma Association type-43A distal metaphyseal fractures of the tibia. However, closed intramedullary nailing has the advantage of a shorter operating and radiation time and easier removal of the implant. We therefore prefer closed intramedullary nailing for patients with these fractures.

Displaced Isolated Fractures of the Tibial Shaft Treated with Either a Cast or Intramedullary Nailing. An Outcome Analysis of Matched Pairs of Patients.

Ninety-nine patients with displaced, isolated fractures of the tibial shaft were treated with closed reduction and either a cast (n = 52) or intramedullary (IM) nailing (n = 47). Of the patients that returned for long-term follow-up, 25 matched pairs of patients were identified and compared with regard to time to union, function, and return to work. All outcomes studied were significantly better following IM nailing compared with those following management with a cast. Function was better and fewer complications were seen in the IM nailing group compared with those who received casting.

Fraturas da extremidade distal da tíbia tratadas pela haste intramedular e placa em ponte: comparação do tempo de exposição à radiação nos dois métodos

OBJECTIVE: To compare the exposure time to radiation in patients with distal third fractures of the tibia treated with intramedullary nail and bridge plate. METHODS: In 33 fractures intramedullary nails were used, and in 41 fractures plates were used. In the intramedullary nail group, according to the AO classification, 14 patients had type A fractures, 15 patients had type B fractures and four had type C fractures. Twelve patients had closed fractures and 21 had open fractures. In the plate group, 10 patients had type A fractures, 22 patients had type B fractures and nine had type C fractures. 27 patients had closed fractures and 14 had open fractures. RESULTS: A significant difference was observed in exposure time to radiation between the patients treated with the intramedullary nail and the plate (p = 0.0001). The group treated with the intramedullary nail had a significantly higher exposure time to the radiation than the group treated with the plate. Comparing the type of fracture (A, B and C), it was observed that there is no considerable difference in exposure time to radiation between the intramedullary nail technique (p = 0.19) and the plate technique (p = 0.80). CONCLUSION: Fractures of distal third of the tibia treated with intramedullary nail show considerably higher exposure time to radiation than fractures treated with the bridge plate, independent of fracture type.

Extra-Articular Distal Tibia Fractures: A Mechanical Evaluation of 4 Different Treatment Methods

This cadaveric biomechanical study compared the mechanical properties of standard plating (SP), locked plating (LP), intramedullary nailing (IMN), and angular stable intramedullary nailing (ASN) for the treatment of axially unstable distal tibia metaphyseal fractures (OTA type 43.A3) with an intact fibula. A distal tibia metaphyseal fracture was created in 30 fresh frozen cadaveric specimens by performing an osteotomy 30 mm above the plafond. The fibula was left intact. Specimens were divided into 4 groups. Specimens underwent fracture fixation with a standard distal tibia plate, a medial locked plate, an intramedullary nail, or an angular stable intramedullary nail. Specimens were loaded vertically along the tibial axis to 700 N, followed by cyclical loading at 700 N for 10,000 cycles, and then to failure. The IMN group demonstrated greater stiffness and load to failure than the LP group, which was greater than the SP group. The ASN group was not different in terms of stiffness and load to failure from the LP group for the number of specimens tested. The IM group required the greatest energy to failure, and all groups were significantly greater than the SP group. Under axial loading conditions with an intact fibula, both IMN and LP provide stable fixation. There was no advantage to the use of an ASN over a standard IMN. IMN resulted in the highest stiffness, load to failure, and failure energy for OTA type 43.A3 fractures with as little as 3 cm of distal bone stock.

Prospective comparative study of three internal fixation methods for treatment of both-bone forearm fractures in older children

Objective To evaluate and compare the outcomes of three internal fixation methods, ulna compression plate and radial elastic stable intramedullary nailing (ESIN), double ESIN and double plating, for the treatment of both-bone forearm fractures in older children. Methods From February 2004 to July 2008, 45 older children with both-bone forearm fractures that failed manual closed reduction or were unstable were recruited for the prospective comparative study. They were randomized into 3 groups with 15 each: who were treated with ulna compression plate and radial elastic stable intramedullary nailing (ESIN) (group A), double ESIN (group B) and double plating (group C). The intraoperative and perioperative indexes, the radiographic findings, the clinical outcomes and postoperative complications were compared. Results Group A and group B resulted in a lower blood loss and shorter surgery time than group C (statistically significant). However no significant differences were found between group A and group B. There was statistically significant difference on tourniquet use time among the three groups, group B being shorter than group A and group C. There was no significant difference on postoperative pain score within 5 days after the surgery among the three groups. Fracture union rate of group A at 3 months was significantly higher than group B, while no significant differences were found between group B and group C and between group A and group C. There was no statistically significant difference on fracture union among the three groups at 6 months. The incidence of loss of forearm rotation and complications was lower in group A than in group B and group C, however the difference was not statistically significant. Conclusion Based on surgery trauma, incidence of fracture union, clinical outcomes and complications, ulna compression plate and radial elastic stable intramedullary nailing shows superiority in the treatment of both-bone forearm fractures in older children. However double ESIN has the advantages of being minimally invasive and easy for secondary hardware removal. Key words: Fractures; bone; Child; Prospective studies; Literal fiatior

The clinic observation of the treatment of tibial fracture with two kinds of intramedullary nail

Objective To evaluate the treatment results of interlocking nail and axial controlled dynamic intramedullary nail for tibial fractures.Methods Of the 56 patiens who were treated by operation,32 patiens were treated by interlocking nail (interlocking nail group),and the others by axial controlled dynamic intramedullary nail (axial controlled dynamic intramedullary nail group).Results The patients were followed up 6-10 months.The operative time of interlocking nail group was 98 minutes on average,and the mean healing time was 22 weeks;While the average operative time of the axial controlled dynamic intramedullary nail group was 63 minutes,the mean healing time was 18 weeks in this group.The excellent rate was 88.3% and 95.83% in the two groups respectively.A statistically significant was observed between the two groups in operative time,mean healing time and excellent rate.Conclusions Compared with interlocking nail,axial controlled dynamic intramedullary nail can achieve satisfactory results in treating tihial factures and has advantages in less operative time and mean healing time. Key words: Tibial fracture; Interlocking nail; Axial controlled dynamic intramedullary nail

Intramedullary Nailing Versus Percutaneous Locked Plating of Extra-Articular Proximal Tibial Fractures: Comparison of 56 Cases

To compare extra-articular proximal tibial fractures treated with intramedullary nailing (IMN) or percutaneous locked plating (PLP) and assess the ability of each technique to obtain and maintain fracture reduction. Retrospective clinical study. : Level 1 Trauma Center. Beginning with the first use of PLP of the proximal tibia at our institution, all skeletally mature patients with surgically treated proximal extra-articular tibial fractures were reviewed. Between August 1999 and June 2004, 29 patients treated with intramedullary nails and 43 patients treated with percutaneous locked plates were identified. Patients with at least 1-year follow-up included 22 IMN and 34 PLP cases, which formed the final study group. Final outcomes were assessed for the IMN and the PLP groups by comparing rates of union, malunion, malreduction (defined as >5 degrees angulation in any plane), infection, and removal of implants. The IMN and PLP groups showed similar age and gender demographics. Average length of follow-up was 3.4 years in the IMN group (15-67 months) and 2.7 years in the PLP group (12-66 months). Open fractures made up 55% of the IMN group and 35% of the PLP group. Final union rates (after additional procedures for nonunions after the index procedure) were similar between groups (IMN = 96% and PLP = 97%). Implant removal in the PLP group was 3 times greater than in the IMN group, (P = 0.390), whereas an apex anterior (procurvatum) malreduction deformity occurred twice as frequently in the IMN group (P = 0.103). Additional surgical techniques (eg, blocking screws) were frequently used during reduction within the IMN group and infrequently used within the PLP group (P = 0.0002). Neither technique resulted in a statistically significant loss of final reduction confirming the stability of each construct. Neither IMN or PLP showed a distinct advantage in the treatment of proximal extra-articular tibial fractures. Apex anterior malreduction however was the most prevalent form of malreduction in both groups. Additional surgical reduction techniques were frequently needed with IMN, whereas removal of implants seems to be more commonly needed with PLP.

The Effect of Distraction-Resisting Forces on the Tibia During Distraction Osteogenesis

Distraction-resisting forces that are generated during distraction osteogenesis can be responsible for complications, including a lag effect on fibular distraction leading to a tibiofibular distraction difference, tibial axial deviation, and distraction at the proximal and distal tibiofibular joints. We investigated the nature of distraction-resisting forces by studying their correlation with these parameters. One hundred and eleven tibial lengthening procedures in sixty-three patients were chosen. Seventy-six segments underwent lengthening with an Ilizarov ring fixator, and thirty-five segments had lengthening over an intramedullary nail. Serial radiographs were evaluated with regard to the amounts of tibiofibular distraction difference, proximal tibiofibular joint distraction, distal tibiofibular joint distraction, tibial axial deviation, and heel malalignment. Clinically, laxity at the knee was evaluated and fibular head instability was assessed. Variations in all of these parameters were evaluated with respect to tibiofibular joint fixation, etiology, skeletal maturity, lengthening over an intramedullary nail, and amount of lengthening. The mean tibiofibular distraction difference was 19.1 +/- 10.6 mm (range, 2 to 51 mm), the mean proximal tibiofibular joint distraction was 10.1 +/- 6.8 mm (range, 0 to 33 mm), and the mean tibial valgus angulation was 8.7 degrees +/- 4.4 degrees . At the time of the latest follow-up, twenty-eight segments (25%) had lateral knee joint laxity at 30 degrees of knee flexion and eight segments (7%) had fibular head subluxation at 90 degrees of knee flexion. Twenty-four (86%) of the twenty-eight cases of knee laxity were observed in skeletally immature patients. The tibiofibular distraction difference, proximal tibiofibular joint distraction, and tibial valgus angulation were significantly greater in the group without fixation of the proximal tibiofibular joint. A significant decrease in the tibial valgus angulation and knee laxity was found in patients with lengthening over an intramedullary nail. In the intramedullary nail group, after fixation of the proximal tibiofibular joint, the tibiofibular distraction difference and the proximal tibiofibular joint distraction decreased; however, the proportion of cases with clinically important tibial valgus angulation (>10 degrees ) increased significantly. Fixing both tibiofibular joints with a single Ilizarov wire decreases proximal tibiofibular joint distraction; however, more secure fixation would help to decrease the prevalence of delayed knee laxity. When tibial lengthening is performed over an intramedullary nail, avoiding proximal tibiofibular joint fixation will limit tibial valgus angulation. Limiting lengthening to <25% will decrease the proportion of cases with knee laxity, and limiting lengthening to <50% will significantly limit tibial valgus angulation.

Rotational stability of femoral osteosynthesis in femoral fractures – Navigated measurements

Rotational malalignment after intramedullary nailing of femoral fractures is common, and symptoms occur when malrotation reaches 15 degrees . Intraoperative measurement of rotation remains difficult, and multiple techniques have been described to address this. Regardless of the method used, rotational toggling may occur between the interlocking screws and the screw holes. We hypothesized that a clinically significant amount of rotation may occur with standard statically locked intramedullary nails. Mid-shaft diaphyseal fractures were created in 24 cadaveric femurs. Specimens were divided into 4 groups, and were stabilized with a statically locked intramedullary nail, a dynamically locked intramedullary nail, a compression plate, and a locking plate. Six additional femurs were kept intact as a control group. Specimens were mounted in a custom holding jig, which stabilized the constructs proximally and allowed free rotation distally. A computer navigation system was applied, and the femoral anteversion was measured. 4 N-m of internal and external torque was applied, and the change in version was measured. The statically locked nails rotated 14.2 degrees , and the dynamically locked group rotated 15.7 degrees . Both intramedullary nail groups showed significantly greater rotation than the plated groups. The compression plate specimens rotated 6.5 degrees on average, and the locked plate group rotated 3.8 degrees . Intramedullary femoral nailing with static or dynamic interlocking allows 15 degrees of rotation of the femur around the nail under physiologic load. This may exacerbate intraoperative errors in determining and setting rotation. Angular stable plates or nails may minimize this problem.

The Stress Response to Bilateral Femoral Fractures: A Comparison of Primary Intramedullary Nailing and External Fixation

Concern has recently been expressed with regard to the physiologic effects of primary intramedullary femoral nailing in seriously injured patients. "Damage control orthopaedics" techniques have been proposed, which comprise principally the use of primary external fixation. The aim of this study was to compare the physiologic effects of external femoral fixation with those of intramedullary stabilization over the first 24 hours after femoral fracture using an established large animal (ovine) trauma model. Under terminal anesthesia, bilateral high-energy femoral fractures and hypovolemic shock were produced using a pneumatic actuator. Twenty-four sheep were randomized into 4 groups and monitored for 24 hours. Group 1--control, group 2--trauma only, group 3--trauma and external fixation, and group 4--trauma and reamed intramedullary nailing. Outcome measures included the following: pulmonary embolic load (transesophageal echocardiography), metabolic base excess, plasma coagulation markers, and polymorphonuclear cell counts obtained from bronchoalveolar lavage samples. The total embolic load was significantly higher (P < 0.001) in the intramedullary nailing group. All trauma groups had a significant increase (P < 0.05) in prothrombin times with a fall in antithrombin III and fibrinogen levels. However, the type of fracture stabilization used did not significantly affect any of the other outcome measurements. A higher pulmonary embolic load can be expected during early intramedullary femoral fracture stabilization compared with primary external fixation. However, the degree of stimulation to systemic coagulation and pulmonary inflammation by each type of surgery was comparable.

Comparison of Intramedullary Nailing Versus Plate-Screw Fixation of Extra-Articular Metacarpal Fractures

To compare the clinical and radiographic outcomes of intramedullary nail (IMN) fixation of metacarpal fractures with those of plate-screw (PS) fixation. Between 2004 and 2006, we treated 52 consecutive closed, displaced, extra-articular metacarpal fractures operatively using 1 of 2 fixation methods: IMN or PS. Patient characteristics, mechanism of injury, pattern of fracture, and preoperative radiographic parameters were similar in both groups. The outcome measures were collected and analyzed:total active motion of the digit and Disabilities of the Arm, Shoulder, and Hand score and radiographic parameters. Thirty-eight patients received IMN fixation and 14 patients received PS fixation. Mean follow-up time was 18 weeks in the IMN group and 19 weeks in the PS group. The mean and median total active motion were 237 degrees and 250 degrees for the IMN group, 228 degrees and 248 degrees for the PS group, with no statistically significant difference between the groups. The mean Disabilities of the Arm, Shoulder, and Hand score was 9.47 in the IMN group and 8.07 in the PS group. The association between hardware type and fracture location (middle or distal third of metacarpal) was not statistically significant. Time to radiographic healing also did not reach statistical significance between groups. Operative time was significantly shorter with use of the metacarpal nail. Five patients in the IMN group displayed loss of reduction; no failure was observed in the PS group. There were no significant differences in the clinical outcomes using either technique. Although operative time was shorter in the IMN group than in the PS group, the incidences of loss of reduction, penetration to the metacarpal-phalangeal joint, and secondary surgeries for hardware removal in the operating room were much higher in the IMN group. Therapeutic III.

Operative treatment of tibial shaft fractures: a comparison of different methods of primary stabilisation

Segmental fractures of the tibial shaft (AO type 42-C2) often occur after a high energy direct trauma with consecutive severe soft tissue injury and a high rate of open fractures. The blood supply of the intermediate bone fragment can be severely disturbed and therefore operative treatment is demanding. In this retrospective study, we compared three different methods of stabilisation. We reviewed the clinical charts and postoperative problems of 26 patients in a ten year period. Sixteen (62%) fractures were stabilised with an intramedullary nail, five (19%) fractures by plate osteosynthesis and five (19%) fractures with an external fixator. Bony consolidation was obtained in all patients after an average time of 11.4 months. In 17 patients (65.4%) a second operative procedure had to be performed. Pseudarthrosis was seen in 11 fractures (40%), three times in the proximal and eight times in the distal fracture. In the intramedullary nailing group, pseudarthrosis occurred in nine patients. In the group treated with an external fixator, pseudarthrosis was seen three times. After changing to a different implant bony consolidation was achieved in every patient. Conventional intramedullary nailing is not suitable for stabilisation of segmental fracture types with a short metaphyseal fracture fragment. New nails with proximal and distal interlocking in three different planes offer better stability. Bone vascularisation should not be endangered by the stabilisation procedure and optimal reduction of the fracture is an important prerequisite for uneventful fracture healing, especially in this difficult fracture configuration.

Is a Sliding Hip Screw or IM Nail the Preferred Implant for Intertrochanteric Fracture Fixation?

This study was performed to determine whether patients who sustain an intertrochanteric fracture have better outcomes when stabilized using a sliding hip screw or an intramedullary nail. A 20% sample of Part A and B entitled Medicare beneficiaries 65 years or older was used to generate a cohort of patients who sustained intertrochanteric femur fractures between 1999 and 2001. Two fracture implant groups, intramedullary nail and sliding hip screw, were identified using Current Procedural Terminology and International Classification of Diseases, 9th Revision codes. The cohort consisted of 43,659 patients. Patients treated with an intramedullary nail had higher rates of revision surgery during the first year than those treated with a sliding hip screw (7.2% intramedullary nail versus 5.5% sliding hip screw). Mortality rates at 30 days (14.2% intramedullary nail versus 15.8% sliding hip screw) and 1 year (30.7% intramedullary nail versus 32.5% sliding hip screw) were similar. Adjusted secondary outcome measures showed significant increases in the intramedullary nail group relative to the sliding hip screw group for index hospital length of stay, days of rehabilitation services in the first 6 months after discharge, and total expenditures for doctor and hospital services. Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Dynamische Analyse von Osteosynthesen am Olecranon: ein in-vitro Vergleich zweier Osteosynthesesysteme / Dynamic analysis of olecranon osteosyntheses – an in vitro comparison of two osteosynthesis systems

The aim of the present study was to develop a test setup with continuous angle alteration to imitate elbow joint motion for the mechanical evaluation of tension band wiring and a newly designed intramedullary nail. The servo-pneumatical test stand worked with a rotational angle-adjusted and a linear force-adjusted engine. The fracture model was dynamically tested under cyclic loading imitating elbow joint motion. In total, 14 fresh cadaver upper extremities underwent olecranon fracture by means of transverse osteotomy and were assigned to two groups: tension band wiring and intramedullary nailing. There was a continuous angle alteration between 0 and 1000 of flexion, with continuous changing pull force between 25 N and 150 N. Two steel pins were placed in the proximal, two in the distal olecranon fragment for video analysis of the motion between the two pairs of pins. Displacement in the fracture gap was determined after 4 and 300 cycles. After 300 cycles, the displacement in the fracture fixation model was significantly higher in the tension band wiring group than in the intramedullary nailing group. Other studies evaluating biomechanical properties of olecranon osteosyntheses with joint involvement did not change the force direction dynamically. We introduced a test setup with continuous angle alteration to imitate joint motion. This is an important step for accurate biomechanical evaluation of the treatment of different fixation methods in olecranon fractures. The tested nailing system showed significant advantages in loosening under cyclic loading compared to tension band wiring.

Estabilização primária da diáfise umeral: estudo experimental de diferentes métodos de osteossíntese

OBJETIVO: Estudo experimental idealizado com o objetivo de se avaliar a estabilização primária das fraturas da diáfise umeral com três diferentes métodos de osteossíntese, representados por uma placa tipo DCP aplicada com técnica em ponte, uma síntese incomum, denominada SPS®, ainda sem similar na literatura, aplicada pela técnica em ponte, e um terceiro método constituído de uma haste intramedular com um método de bloqueio também incomum proporcionado por um parafuso cortical distalmente e por um fio do tipo Ender proximalmente. MATERIAL E MÉTODO: Vinte e um pares de úmeros humanos foram divididos em três grupos, utilizando-se um tipo de material para cada grupo, os quais foram submetidos a osteotomias, aos procedimentos de fixação e a ensaios não destrutivos de flexo-compressão e de torção, com limites de carga de 200N e de 100N, respectivamente e, num mecanismo de "crossing", foram submetidos secundariamente a novos ensaios de torção e de flexo-compressão, amparados por análise estatística. RESULTADOS: O grupo da placa DCP em ponte mostrou boa resistência às cargas aplicadas, o que também ocorreu no grupo do SPS®, que apesar de mostrar maiores índices de deflexão, apresentou grande capacidade elástica. O grupo da haste intramedular mostrou bons resultados nos ensaios de flexo-compressão, devido ao seu mecanismo de tutor, mas não demonstrou resistência às cargas de torção.

Intramedullary Nailing versus Fixed Angle Blade Plating for Subtrochanteric Femoral Fractures: A Prospective Randomised Controlled Trial

To compare closed intramedullary nailing to open reduction and internal fixation using a fixed angle blade plate for the management of subtrochanteric femoral fractures. 58 patients were equally randomised to undergo either an intramedullary nailing (IN) or fixed angle blade plating (BP). There were no significant differences between the 2 groups with regard to age, time to surgery, operating time, receipt of blood transfusions, duration of hospital stay, or fracture classification. The revision rate was 28% (8/29) in the BP group and none in the IN group; the difference was statistically significant. Internal fixation using a fixed angle blade plate for subtrochanteric femoral fractures has higher implant failure and revision rates, compared to closed intramedullary nailing.

Treatment of Open Femur Fractures in Children

Open femur fractures in children are uncommon and usually associated with other injuries. In adults, there is a current trend to treat open fractures with intramedullary (IM) devices. The goal of this study was to compare external fixator (EF) to IM devices in the treatment of open femur fractures in children. Diaphyseal femur fractures without growth plate involvement were included. Thirty-five patients (12 IM; 23 EF) were identified. Age, hospital stay, polytrauma, mechanism of injury, and Gustilo-Anderson grade were recorded. Follow-up was at least until the fracture was clinically and radiographically healed. Patients with EFs were 5.2 times more likely (95% confidence interval, 1.05-25.5) to have any complication. Excluding pin track infections, patients with EFs were 2.7 times as likely (95% confidence interval, 0.567-13.2) to have a complication. Refractures occurred only in the EF group (6/23, 26%) and not in the IM nailing group (P = 0.062, Fischer exact test). These were associated with varus malunions-all 3 of the EF group with more than 15 degrees of varus at fracture union suffered a refracture. Treatment of open femur fractures in children is a challenging problem. Treatment with IM devices had fewer complications than the EF. We think that whenever possible, the use of IM devices for the treatment of open femur fracture in children should be considered, especially grade 1 open injuries. If EFs are used, avoiding varus malunion may decrease the refracture rate, and secondary change to an IM device should be considered. Comparative cohort study. Grade 3 level of evidence.

Comment on Changulani et al. “Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomised controlled study”

Dear Editor, We read with great interest the article by Changulani et al. [3]. There is still a wide debate on whether nailing or plating is the preferred method of fixation for humeral fractures treated by surgery [1]. However, we have a few comments to make: Radial nerve-related complications have been quoted as approaching 3% in humeral dynamic compression plating (DCP) [2]. In their study the authors reported nerve-related complications as being 4.1% and 4.7% in DCP and intramedullary nailing (IMN) [3]. Thus, we feel that the nerve-related complications are not a point against plating. The authors mention implant removal, usually at 12 months, in their Methods section [3]. We would like to know whether implants were removed from all the patients or only from a selected group. If implant removal was done only in a small group of patients, the indication for the same should be mentioned for the DCP and IMN groups. This may highlight an added advantage or disadvantage of the two procedures. The authors mention that 12 out of 23 patients in the IMN group (>50%) underwent bone grafting [3]. However, there is no mention of the criteria for bone grafting. The requirement for bone grafting in more than 50% of patients in the IMN group offsets the advantage of IMN’s being a less invasive surgery. Also, if bone grafting was done at the time of initial surgery, the biological advantage of retained fracture haematoma in IMN is lost. And, if the bone grafting was done at a later date, there are increased chances of delayed union with IMN. Additionally, plate fixation gives a lower relative risk of reoperation than does intramedullary nailing [1]. Lastly, the authors mention that the American Shoulder and Elbow Surgeons’ scores were similar in the two groups. They also mention that four patients had restriction of full abduction. This, we feel, needs further clarification. It has been stated that shoulder pain and reduction in shoulder range of motion were significant associations with IMN. Whereas, plate fixation reduces the risk of shoulder problems in comparison with intramedullary nails [1].

Grafting may effect the outcome in diaphyseal fractures of the humerus

Dear Editor, We have read the article entitled “Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomised controlled study.” with great interest [1]. In their study, the authors compared the results of the humerus intramedullary nail (IMN) in 23 patients and the dynamic compression plate (DCP) in 24 patients for the management of diaphyseal fractures of the humerus. The patients were randomised into 2 groups prospectively and treated by open reduction and internal fixation technique. In their study, inclusion criteria were grade 1 or 2a compound fractures, polytrauma, early failure of conservative treatment and unstable fractures. Exclusion criteria were patients with pathological fractures, grade 3 open fractures, refractures and old neglected fractures. We would like to ask some questions of the authors regarding their study. Why was it necessary to use autograft for the treatment of these fresh fractures according to the inclusion criteria? Did using autograft (7 patients in DCP group, 12 patients in IMN group) affect the result? How did they randomise the patients, because some fractures need autograft others not? Were there any patients treated by using autograft in the nonunion group, because grafting may change the final outcome (fracture healing)? In the Results section, there were 3 patients with nonunion in both groups, but in the Discussion section, there were 2 patients with different percentages of nonunion compared to the Results section. Which is the correct one? In the Discussion, McCormack RG et al. was cited as Reference 15. But in the Reference list McCormack RG et al. was cited as Reference 11. Thus the References and citation numbers were different from each other. Why did the authors need to open reduction in all the fractures treated by using IMN? We wish to thank the authors for their invaluable contribution to the current literature. And we hope that the authors will answer our questions.