Elastic Stable Intramedullary Nailing for Treatment of Pediatric Tibial Fractures: A 20-Year Single Center Experience of 132 Cases

Abstract

Objective: The aim of this study was to analyze the outcomes and complications in children treated with elastic stable intramedullary nailing (ESIN) for tibial fractures. Methods: The study included 132 patients (92 males) with a median age of 11 years (IQR 10, 15) treated with ESIN for displaced tibial shaft fractures or dia-metaphyseal distal tibial fractures from March 2002 to March 2022. The median follow-up was 118.5 months (IQR 74.5, 170). The primary outcome was success rate, while secondary outcomes were the time of bone healing, length of hospital stay, and associated injuries. Demographic data, type and nature of fracture, indication for surgery, healing time, operative time, complications of treatment, and time to implant removal were recorded. Results: Complete radiographic healing was achieved at a median of 7 weeks (IQR 6, 9). Most of the patients (n = 111; 84.1%) had fractures localized in the shaft of the tibia. The most common injuries were acquired by road traffic accidents (n = 42) and by a fall in the same level (n = 29), followed by injuries from sport activities (n = 21) or motorbike accidents (n = 18). Associated injuries were reported in 37 (28%) children. Fractures were closed in the majority of the children (n = 100; 76%), while 32 (24%) children presented with an open fracture. Children with open fractures were significantly older than children with closed fractures (13.5 years (IQR 10, 15) vs. 11 years (IQR 8.5, 14.5); p = 0.031). Furthermore, children with open fractures had a significantly longer hospital stay (7 days (IQR 5, 9) vs. 3 days (IQR 3, 6); p = 0.001), a higher rate of associated injuries (n = 14 (43.7%) vs. n = 23 (23%); p = 0.022), and a higher rate of postoperative complications (n = 7 (21.9%) vs. n = 8 (8%); p = 0.031). No intraoperative complications were recorded. A total of 15 (11.4%) postoperative complications were recorded. Most complications (60%) were minor complications, mostly related to the wound at the nail insertion site and were managed conservatively. A total of six (4.5%) patients required reoperation due to angulation of the fragments (n = 5) or refracture (n = 1). Conclusion: ESIN is a minimally invasive bone surgery technique and is a highly effective treatment for pediatric tibial unstable fractures with a low rate of complications. Based on the given results, surgical stabilization of the tibial fractures using titanium intramedullary nailing can be safely performed without casting with early physiotherapy.

Flexible nailing: Pushing the indications for diametaphyseal lower-extremity fractures

“…[10,17,25] However, as casting has been shown to be associated with poor radiographic outcomes, redisplacement in cast, and delayed return to activities, [12,26] ESIN and other options for surgical management, such as compression plating, have been proposed. Recent literature has provided evidence that ESIN can be used safely and effectively in distal and proximal diametaphyseal fractures of the and femur, [2,3,6,12,[15][16][17][18] but these studies have been limited by small sample sizes and have left unanswered the question of whether this technique can be used in the most distal and proximal fractures. The results of our study demonstrate that although radiographic outcomes after ESIN in short-segment fractures were inferior to those in distal or proximal third shaft fractures, clinical outcomes were no different, suggesting that ESIN can be considered as a management option in these difficult-to-treat fractures.…”

“…[14] In recent years, several studies have examined the use of ESIN in distal diametaphyseal fractures in the lower extremities. [2,3,6,12,[15][16][17][18] Although they have had small sample sizes, the studies have demonstrated that ESIN is a safe and effective surgical management option for these fractures. [2,3,6,12,[15][16][17][18] However, they have primarily included patients with fractures in the more proximal portions of the diametaphyseal region, and controversy remains over whether ESIN can be used for fixation of the most distal and proximal diametaphyseal fractures.…”

Validation of TWIST score in the diagnosis of testicular torsion in children: A Prospective study

“…In two studies [11,19] taking the diagnostic cut-off of 7 points will give 100% of the PPV, in our study, when changing the cut-off point to 6 points, it also gives 100% of the PPV. However, the recommendations still suggest that exploratory surgery is appropriate for suspected cases [2,3], so we still choose the cut-off point of 5 to avoid missing TT cases. Several factors need to be considered including the qualifications of the staff applying the points, population characteristics, context and available resources.…”

“…As a result, TT requires early diagnosis and emergency surgical treatment. The salvage rates depend on the duration of pain, it can reach 97% if the operation is performed within 6 hours after symptoms onset and decrease to 60% if the time exceeds 12 hours [2,3].…”

Advances in Pediatric Fracture Diagnosis and Treatment Are Numerous but Great Challenges Remain

“…Furthermore, a large Croatian study describes the results of an impressive number of 132 pediatric tibial fractures treated with elastic stable intramedullary fixation during a period of 20 years [ 21 ]. Fifteen complications occurred, of which six required reoperation due to the secondary angulation of the fracture.…”