Rigid Nail Research Articles

Complications in operatively managed pediatric femoral shaft fractures

Objectives: Despite being the strongest long bone in the body, femur shaft fractures (FSFs) remain steadily prevalent in Saudi Arabia and globally. The goal of treatment is to achieve fracture healing with the least complications. Therefore, this study intended to determine the complications in pediatric FSFs, which were operatively managed. Methods: This study is a retrospective analysis of 76 pediatric FSFs. The inclusion criteria included age ≤14 years, FSFs operatively treated in the study center, at least one-year follow-up, and admission between January 1, 2012, and January 1, 2020. Pathological fractures and patients with neuromuscular or syndromic conditions were excluded from the study. Results: Seventy-two patients (81.9% boys, mean age 8.1 years) with 76 FSFs were analyzed. Most injuries were from motor vehicle accidents (41.6%), falls (29.1%), and pedestrian trauma (15.2%). Titanium was used in 47 (61.8%). Plating was used in 16 (21%), rigid nails in eight (10.5%), and hip spica under general anesthesia in five (6.5%). Out of those 76 fractures, 17 had developed complications. These complications varied in their significance, including limb length discrepancy (LLD) (five), non-union (three), 15° angulation (three), skin irritation due to cast soiling (two), skin swelling due to prominent flexible nail (one), surgical site infection (one), osteomyelitis (one). LLD was significantly associated with increased weight, fracture pattern, non-union, and definitive fixation time. Conclusion: Overall complications in operatively treated pediatric FSFs were low and not disabling. LLD was the most common with a significant association with increased weight, unstable fracture pattern, non-union, and definitive fixation time.

Antibiotic cement-coated rigid locked nails in infected femoral and tibial nonunion. Reoperation rates of commercial versus custom-made nails

IntroductionThe objective of this study is to assess bone union, infection control, and reoperation rates in a series of patients with infected femoral or tibial nonunion treated with antibiotic-cement-coated rigid nails and to compare the results obtained with custom-made nails versus commercial nails. MethodsWe retrospectively analyzed a series of consecutive patients with infected nonunion of the femur or the tibia treated with antibiotic-cement-coated rigid nails between January 2010 and 2020. We assessed patients’ distinctive characteristics, initial injury, type of nail used (custom-made nail with vancomycin or commercial nail with gentamicin), success rate (bone union + infection control), reoperation rate, and failure rate. Comparative analyses were conducted between reoperated and non-reoperated patients regarding the type of nail used. A multivariate regression analysis was performed to assess the risk variables that impacted reoperation rates. ResultsWe included 54 patients with 22 (40.74%) infected femoral nonunions and 32 (59.25%) tibial nonunions, who were treated with 38 (70.37%) custom-made antibiotic-cement coated nails and 16 (29.62%) commercial nails. Bone union and infection control were achieved in 51 (94.44%) cases. The reoperation rate was 40.74% (n = 22), and the failure rate was 5.55% (n = 3). The use of custom-made nails was associated with a higher risk of reoperation (Odds Ratio 4.71; 95% Confidence Interval 1.10 - 20.17; p = 0.036). ConclusionAntibiotic-cement-coated nails reached a 94.44% success rate. Nails manufactured in the OR coated with vancomycin cement were associated with a higher risk of reoperation than commercial nails loaded with gentamicin cement. Level of evidenceIII comparative, observational, non-randomized.

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.

Flexible Intramedullary Nailing of Pediatric Femoral Fractures.

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

Sub muscular bridge plating for pediatric femur fractures – Review of 12 patients

Introduction: The treatment of paediatric femoral fractures has been evolving from nonoperative modalities to operative intervention, especially in older children. Different methods of fixation include flexible intramedullary nailing, modified locked intramedullary nailing, external fixation, open compression plating, and sub muscular bridge plating. Treatment of complex paediatric femur diaphyseal fractures is difficult by conventional methods. External ?xation can lead to malalignment and refractures, casting is difficult for polytrauma patients and larger children, elastic nails do not provide adequate stability to unstable fractures and metaphyseal areas, and lateral trochanteric entry rigid nails are unsuitable for very proximal and distal fragments and are ideal for older children for the want of larger medullary canal. Sub muscular bridge plating has emerged as a viable alternative procedure. We present our results of sub muscular bridge plating in 12 patients. Materials and Methods: We retrospectively reviewed 12 patients with pediatric diaphyseal femoral fractures treated with SBP from 2014 to 2016. The average age was 9 years with follow up of 1yr. Results: All the children had complete union and could return to full activity. Two patients had superficial infections. There were no cases of significant malalignment or leg length discrepancy. Implant removal was performed in 8 patients without complications. Conclusion: We find sub muscular plating of paediatric femoral fractures to be an effective and reliable procedure. SBP is a minimally invasive technique that allows early mobilization with minimal complications. Keywords: Paediatric femur fractures, Submuscular plating.

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

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

A study of 30 cases of titanium elastic nailing system (TENS) for long bones, and its clinical outcome

Elastic stable intramedullary nails (ESIN) was popularized in 1980s in Nancy, France. Titanium is twice as elastic as steel and hence it resists permanent deformation of the nail which occurs during nail insertion. The versatility of the principle has widened the indications with time and experience. Conservative treatment had disadvantages like longer period of immobility, longer hospital stays, delayed rehabilitation, more malunions etc. Aggressive surgery in the form of plating and rigid nailing were not essential in children. Elastic nails have become the preferred treatment in children between five to sixteen years. ESIN can also be used in adults for clavicle fractures, forearm fractures. ESIN is also preferred in Polytrauma/Multiple injuries as they are minimally invasive and have shorter surgical time. In Damage control orthopaedics, the principle of minimally invasive surgery is followed. Other advantages of ESIN are it is postop cast immobilization may not be required, shorter hospital stay, early return to daily activity, biological union, no growth plate injury, easy and safer implant removal. This technique should be part of the armamentarium of any orthopaedic surgeon. TENS is now being used for all long bones. Hence we decided to do a study of Titanium Elastic Nailing System (TENS) for long bone fractures.

Rigid Intramedullary Nailing of Femoral Shaft Fractures for Patients Age 12 and Younger: Indications and Technique.

Femoral shaft fractures are common injuries in the pediatric and adolescent age groups. Rigid intramedullary nailing is an excellent treatment option for older children and adolescents, particularly for length-unstable fractures and larger patients (>49 kg). Appropriate indications, contraindications, and preoperative assessment are described. The rigid nailing surgical technique is detailed including positioning, operative steps, pearls, and pitfalls. Complications and the reported outcomes of lateral trochanteric entry nailing are reviewed from the published series.

Treatment Outcome of Intramedullary Fixation with a Locked Rigid Nail in Humeral Shaft Fractures.

The aim of this study was to determine the treatment outcome of humeral shaft fractures with a locked rigid intramedullary nail in patients indicated for surgical treatment. In this descriptive-cross sectional study, all patients were followed up for one, six, and 18 months post operatively. The Short Form Questionnaire (SF-36) and Constant Shoulder Score were applied. Of 78 included patients (mean age: 35), one patient had a soft tissue infection, one had secondary radial nerve palsy, eight had non-union, one had elbow limited range of motion in extension, and three patients had decreased shoulder range of motion. The Constant Shoulder Score and Short Form Questionnaire Score (SF-36) increased in all patients, although aged women showed lower improvement. Intramedullary nail fixation in the humeral shaft fracture may be associated with high rates of non-union.

Luau Limbo and the Age for Rigid Nailing of Pediatric Femoral Fractures: How Low Can You Go? Commentary on an article by Samuel N. Crosby Jr., MD, et al.: "Twenty-Year Experience with Rigid Intramedullary Nailing of Femoral Shaft Fractures in Skeletally Immature Patients".

Pediatric femoral fractures are typically treated with age-dependent protocols that consider both the growth and remodeling potential of the femur and patient characteristics such as weight and socioeconomic environment of the child. Although it is generally agreed that children five years of age or younger can be adequately managed with a spica cast for length-stable femoral fractures, the range of treatment options for patients between the ages of five years to skeletal maturity span the gamut of flexible nailing, submuscular plating, external fixation, and trochanteric entry rigid intramedullary nailing. Piriformis entry rigid nails are generally shunned in pediatric practice because of a clear association with osteonecrosis1. Trochanteric entry rigid intramedullary nailing is advantageous in treating pediatric femoral shaft fractures in several respects. First, when compared with flexible nails, proximal and distal interlocking allows unmatched length and rotational control of complex injuries. Second, this load-sharing device does not fear the obese child2. Finally, the average orthopaedic surgeon is well trained in this technique and can offer reproducible results. For a femoral fracture in a child nearing skeletal maturity, the choice of rigid intramedullary nail fixation generates no particular debate. However, great concern exists for children with the …

Antegrade rigid nailing through the tip of the greater trochanter for pediatric femoral shaft fractures

The aim of this work was to evaluate the results of rigid nailing of pediatric femoral shaft fractures inserted antegrade through the tip of the greater trochanter. Twenty-three femoral shaft fractures in 23 children were fixed with rigid interlocking nails inserted through the tip of the greater trochanter at Mansoura Emergency Hospital in the period between June 2009 and August 2011. The average age of the patients at the time of injury was 12.6 years (range 9.2-15 years). The final follow-up radiographs were assessed for evidence of avascular necrosis (AVN) of the femoral head and any deformity of the proximal femur, the neck-shaft angle, the articulotrochanteric distance, and the femoral neck diameter. Patients were followed to a mean period of 31 months (range from 25 to 36 months) postoperatively. All fractures united in a range of 9 weeks (from 8 to 13 weeks) with no limb length discrepancy more than 2 cm and no clinically evident rotation in either direction; no case had a vascular necrosis of the femoral head or significant proximal femoral deformity by the final follow-up. Fixation of fractures of the shaft of the femur in children with rigid interlocking nails inserted through the tip of the greater trochanter is a rigid way for fixation controlling rotation and length. It is a safe technique without causing AVN of the femoral head or proximal femoral deformity.

Rigid intramedullary nail fixation of femoral fractures in adolescents: what evidence is available?

BackgroundFemoral fracture in adolescents is a significant injury. It is generally agreed that operative fixation is the treatment of choice, and rigid intramedullary nail fixation is a treatment option. However, numerous types of rigid nails to fix adolescent femoral fractures have been described. Hence, the aim of this paper was to collate and evaluate the available evidence for managing diaphyseal femoral fractures in adolescents using rigid intramedullary nails.Materials and methodsA literature search was undertaken using the healthcare database website (http://www.library.nhs.uk/hdas). Medline, CINAHL, Embase, and the Cochrane Library databases were searched to identify prospective and retrospective studies of rigid intramedullary nail fixation in the adolescent population.ResultsThe literature search returned 1,849 articles, among which 51 relevant articles were identified. Of these 51 articles, 23 duplicates were excluded, so a total of 28 articles were reviewed. First-generation nails had a high incidence of limb length discrepancy (Küntscher 5.8 %, Grosse–Kempf 9 %), whilst second-generation nails had a lower incidence (Russell–Taylor 1.7 %, AO 2.6 %). Avascular necrosis was noted with solid Ti nails (2.6 %), AO femoral nails (1.3 %) and Russell–Taylor nails (0.85 %). These complications have not been reported with the current generation of nails.ConclusionsRigid intramedullary nail fixation of femoral fractures in adolescents is a useful procedure with good clinical results. A multiplanar design and lateral trochanteric entry are key to a successful outcome of titanium alloy nail fixation.

Fixation of supracondylar femoral fractures following total knee arthroplasty: is there any difference comparing angular stable plate fixation versus rigid interlocking nail fixation?

Literature does not provide any reliable comparison between angular stable plate fixation and rigid nail fixation for stabilization of supracondylar periprosthetic femoral fractures. Thus, the purpose of this study was to compare these two implants in clinical practice relating to fracture healing, functional results and treatment-related complications. In this retrospective study (level IV), clinical and radiographic records of 86 patients (62 female and 24 male, average age: 75.6) with supracondylar periprosthetic femoral fractures between 1996 and 2010 were analyzed. 48 patients underwent lateral plate fixation by an angular stable plate system (LISS), whereas 38 patients were stabilized by a rigid interlocking nail device. Sixty-four (76 %) patients returned to their pre-injury activity level and were satisfied with their clinical outcome. We had an overall Oxford outcome score of 2.21, with patients following angular stable plate fixation of 2.22, and patients after rigid nail fixation of 2.20. Successful fracture healing within 6 months was achieved in 74 (88 %) patients. Comparing between plate fixation and nail fixation, statistical analysis did not reveal any significant differences. Overall, we had a relatively high rate of fracture healing and a satisfactory functional outcome with both implants. Both methods of fixation showed similar results relating to the functional outcome and individual satisfaction of the patients. However, with regards to fracture healing and treatment-related complications, intramedullary nail fixation showed slight advantages.

Submuscular Bridge Plating for Complex Pediatric Femur Fractures Is Reliable

Complex, high-energy pediatric femur diaphyseal fractures cannot be treated reliably by conventional methods: casting is not suitable for polytrauma and large children, external fixation is associated with a high rate of malalignment and refractures, elastic nails are unsuitable for unstable fractures and metaphyseal areas, and lateral trochanteric entry rigid nails cannot address proximal and distal fragments and need relatively large medullary canals. A few centers have reported that submuscular bridge plating (SBP) is associated with minimal complications, but these findings require confirmation. We asked whether SBP (1) reproducibly leads to union in unstable fractures with a low complication rate, (2) leads to reasonable alignment and leg length equality (3), is unaffected by age, weight, or location of fracture, and (4) is associated with no or minimal refracture after hardware removal. We retrospectively reviewed 60 fractures in 58 patients with pediatric diaphyseal femoral fractures treated with SBP from 1999 to 2011. The average age was 9 years. Forty (67%) of the fractures were unstable. Minimum followup was 2.4 months (average, 15.5 months; range, 2.4-50.6 months). All fractures healed well and all patients returned to full activity. Two of the 58 patients (3%) had major complications leading to unplanned surgeries: one implant failure and one deep infection in an old open fracture. None of the patients developed clinically important malalignment or leg length discrepancy. Implant removal was performed in 49 patients without complications. SBP provided reliable fixation and healing for complex pediatric femur fractures and can have a broader application in the orthopaedic community. SBP is our preferred method for unstable fractures or fractures of the proximal and distal shaft.

A Comparative Study Of Surgical Management Of Subtrochanteric Fractures In Children

Introduction: Subtrochateric femoral fracture is a major cause of morbidity and mortality in patients with lower extremity injuries. There have been no studies that have specifically looked at the management of subtrochanteric femoral fractures in skeletally immature adolescents. It was the purpose of this study to investigate the treatment of this injury in this unique patient population. Methods: This study was conducted in the Department of Orthopaedic surgery in M. M. Medical College from July 2006 to November 2008. Thirty-four patients were recruited from Emergency and out patient department having closed subtrochanteric femoral fracture. All patients were operated under general or spinal anesthesia. All patients were followed for twelve months. Results: All children achieved union in a mean time of 10 weeks (range from 6 - 16 weeks) depending on the type of long bone. Full weight bearing was possible in a mean time of 8.8 weeks. Mean duration of hospital stay was 9.8 days. The mean follow-up period was 28 months (17-48 months). Complications were recorded in 4 (11.77%) patients and included: two entry site skin irritations, one protrusion of the wires through the skin and one delayed union. The results were excellent in 97.06% and good in 2.97% patients. Conclusions: We conclude that Rigid and close interlocking nailing between the age of 9-16 years offered excellent fracture stability allowing early mobilization (early weight bearing) and joint motion in comparisons to the other groups and between the age of 6-8 years titanium elastic nail and bridging plate offered excellent result. DOI: http://dx.doi.org/10.3329/bjms.v11i3.11718 Bangladesh Journal of Medical Science Vol. 11 No. 03 July’12

Pediatric femur fractures, epidemiology and treatment

Femur fractures in children most often occur as a consequence of traffic accidents, during play and sport activities, and due to different pathological states. Diagnosis is rather simple and it includes physical and radiographical examination. Femur fractures treatment in children can be operative and unoperative, depending on several facts: age, localisation and type of fracture, joint injuries of soft tissues, the presence of other injuries (in polytrauma), economical and social aspects, ect. The aim of this study was to present epidemiological characteristics of pediatric femur fractures, that is in the stage of development, including a special analysis of the used treatment techniques, as well as the comparison of the obtained data with those from the literature. The evaluation included following parameters: age, gender, cause, localisation and type of femur fracture, applied treatment and hospitalisation duration. Among the presented 143 patients with femur fracture, 109 were boys and 34 were girls (3.2:1 ratio; p = 0.0001). Average age for both genders was 8.6 years, and no difference between boys and girls were found for the age (p = 0.758). In total, the most common fracture was diaphyseal fracture of femur in 93 (65.03%) patients. The second was proximal fracture in 30 (20.98%) patients, and the last distal fracture of the femur in 20 (13.99%) patients (p = 0.0001). Three main causes of femur fracture can be distinguished: during play and sport activities in 67 (46.8%) children, in traffic accidents in 64 (44.8%) children, and pathological fractures in 12 (8.4%) children. Inoperative treatment was applied in 82 (57.3%) patients, and operative one in 61 (42.7%) patients. The most common treatment was traction, in 71 (49.6%) patients, followed by immobilization by hip spica cast mostly in young children. Intramedullar elastic nailing was applied in 16 (11.2%) cases, and intra-medullar rigid nailing (Küntscher) in 19 (13.3%) cases. Significantly longer hospitalization period was detected after traction (21 days) comparing to other ways of treatment, mainly operative or hip spica cast (5 to 10 days). In young children the standard treatment was hip spica cast after traction. Intramedullar elastic nailing is a modern trend accepted as standard in our approach to femur fracture treatment in children.

Fracturas diafisarias del fémur en el niño: actualización en el tratamiento

The treatment of diaphyseal femur fractures in children is a subject of great controversy due to the procedures employed in adults not being applicable during the growth period. However, there appears to be some consensus in that the method we choose must lead to shortening the hospital stay, is comfortable for the patient, provides suitable stability to the fracture and has less complications and after effects. There is some unanimity in that the methods of choice should be conservative in children less than 5 years-old (Pavlik harness, early cast), except in complex situations. It is from 6 years to 13 years, the period in which one method or the other that should be discussed more. Nowadays, elastic intramedullary nailing is the method preferred by many authors, particularly for transverse fractures and those located in the middle third, except in cases of great instability. In these situations of comminuted or oblique fractures with monolateral external fixation, the rigid nails introduced from the trochanteric region and percutaneous plating can be a good option. There is currently no method that could be applied to all the different types of fracture. The chosen therapeutic option should be based on the clinical stability of the patient, the characteristics of the fracture, diameter of the medullary cavity and weight of the patient.

Current Concepts in Pediatric Femur Fracture Treatment

Femoral neck fractures require urgent evacuation of intracapsular hematoma, anatomic reduction, and secure fixation with screws and cast immobilization. Extracapsular trochanteric and subtrochanteric fractures are best treated by fixed angle devices (locked plates or dynamic screw and side plate). "Length stable" low energy shaft fractures with minimal displacement or < 2 cm of shortening on presentation, are treated with one-leg spica casting (if the patient weighs < or = 50 lb. "transportable"). Unstable, complex (multifragmentary) and significantly displaced high energy shaft fractures are treated operatively. Transverse or short oblique shaft fractures in patients < 12 years may be treated with elastic intramedullary nails. Bridge plating will provide better stability in complex fractures. Children > 12 years have less risk of vascular disturbance to the proximal physis, and should have lateral transtrochanateric entry locked rigid nails. Fractures with severe soft tissue injuries could be temporized with external fixation. Distal physis and epiphyseal injuries require anatomical reduction and smooth wires and/or screw fixation (placed in such a way as to minimize further damage to the physis) and need to be augmented with a brace. Leg-length discrepancy is not a significant clinical problem in operatively treated patients. We recommend hardware removal after complete fracture healing, usually in 6 to 12 months. Implants left in the growing child could become buried deep inside of the bone, or cause "periprosthetic" fractures and/or eventually impede adult reconstruction. Minimal risks are reported for hardware removal in healthy patients with healed fractures (4 cortices bridged).

Unusual Complications during Removal of Intramedullary Nails after Lower Leg Fractures Tibial Shaft Fissure and Inability to Remove the Nail

Patients and Methods: Between January 1995 and December 1999, 279 fractures of the lower leg were stabilized by crural intramedullary nailing (ACE® interlocking nails, DePuy). Only under certain circumstances was the medullary cavity reamed. This paper reports on ten patients with whom unusual complications arose during nail removal. Results: In two cases, the nail jammed in the fracture callus during its removal, so that the nail had to be left in place. In eight further cases, the nail could only be removed with extreme difficulty and the use of special instruments; in six of the cases, however, a long fissure in the dorsal tibial shaft was visible under intraoperative X-ray fluoroscopy. Postoperative patient mobilization was achieved using either a brace (allowing full weight bearing on the leg) or crutches (partial weight bearing on the leg). The tibial medullary canal was reamed in nine of the ten patients, and a nail relatively wide in diameter (11–14 mm) was inserted. Conclusions: The ACE® interlocking nail employed is bent 5° ventrally over the final 50 mm to the tip. This does not only facilitate nail insertion, but the nail also adapts to the physiological anteversion of the distal tibia. As a result of its bent shape and large diameter and in the case of considerable endosteal callus formation with associated narrowing of the medullary cavity the rigid titanium nail can no longer pass through. This may lead to a fissure when removing the nail, or even result in the total inability to remove the nail. Another reason is the dorsal groove in nails ≥ 11 mm in diameter, into which bone grows at the site of callus formation. When removing the nail, the distal end of the nail (with no groove) has to slide over this dorsal bony ridge, thus narrowing the available lumen of the medullary canal by about 20% in the anteroposterior direction. The manufacturer has announced a change in the nail design.

Surgical Treatment of Pediatric Femoral Shaft Fractures

Summary: Closed reduction and treatment by immediate spica cast is the preferred method of treatment of femoral shaft fractures in children as old as 4 years of age. Elastic stable intramedullary nailing has proven to be the most advantageous procedure in children between 4 and 14 years of age. Traction methods have a long hospital stay, discomfort, and the risk of overgrowth and malalignment. Plate fixation requires extensive dissection and produces a large scar. Rigid nailing is associated with a small but troublesome risk of avascular head necrosis and valgus deformity as a result of growth plate arrest. External fixation is the preferred method for the rare open and comminuted fractures. Elastic intramedullary fixation with elastic stable intramedullary nailing and Ender nails has a short learning curve for surgeons and a low complication rate. Short hospital stays and low costs of the implants are further advantages. Overgrowth in late controls is lower than that in other types of treatment, with an average of 5 mm.