Flexible intramedullary nailing for distal femoral fractures in patients with myopathies

Abstract

Purpose Distal femoral fractures are quite common in nonambulating patients with myopathies, as they present marked osteoporosis. The deterioration of preexisting knee flexion contracture is a known problem, as these fractures are usually angulated posteriorly. The goals of treatment are to reduce immobilization and bed rest to a minimum, prevent function loss, and prevent refracture. The aim of our work was to investigate if these goals can be achieved by an operative treatment with closed reduction and flexible intramedullary nailing (FIN). Methods Six distal femoral fractures in four nonambulating patients with myopathies (three Duchenne muscular dystrophy and one nemaline myopathy) were treated with FIN between 2005 and 2011. Patient charts and radiographs were reviewed to determine if intra-or postoperative complications occurred and to detect the interval to wheelchair mobilization and hospital discharge. Pre-and postoperative knee flexion contracture was noted from the patient charts of our reeducation unit, where patients were already known preoperatively. Results Wheelchair mobilization without further immobilization after an interval of 2-3 days was possible. No aggravation of knee flexion contracture was detected in our patient series. No complications associated to the operative treatment itself and no refractures in the follow up occurred. Conclusion Our experience showed that FIN is a low invasive and sufficiently stable osteosynthesis in such fractures. Left in place, nails will reinforce mechanical stability.

Flexible intramedullary nailing for supracondylar femoral fractures in children with Duchenne muscular dystrophy

“…Significant displacement requiring open reduction is rarely found [ 3 , 5 , 13 ] in these cases, and the distal fragment is usually angulated in flexion. Pre-existing mild flexion contractures of the knee may facilitate this displacement and if the angulation is not completely reduced, it can be augmented after consolidation [ 3 ].…”

“…The latter is limited to the thigh, to allow hip movements and facilitate patient management; yet, this greater mobility can cause increased pain especially during the first few days until initial healing has occurred. In both circumstances, there is a high risk of skin breakdown (facilitated by the reduced mobility of the child, and steroid-induced skin fragility) [ 3 ] and secondary displacement [ 14 ].…”

“…An image intensifier was used. The FIN [ 3 ] was realized in a descending construct with the 2 nails entering the medullary cavity from the lateral cortex below the greater trochanter. The first nail was advanced up to the fracture site, then the second nail was inserted and advanced.…”

“…They represent a critical moment in the natural history of a progressive loss of functional abilities. These fractures commonly affect children who are progressively losing their ability of unsupported walking and standing [ 1 ] and the immobilization required for fracture healing commonly leads to further muscle weakening and the loss of these residual skills [ 2 , 3 ]. When the ambulatory ability is tenuous, even minor bruises, ankle sprains or bed rest as short as 2 weeks can cause the end of the walking ability [ 2 , 3 ].…”

Orthopedic and Surgical Management of the Patient With Duchenne Muscular Dystrophy

“…Early mobilization can be enhanced if internal or external fixation is used instead of casting or splinting. 12 Consultation with cardiology and pulmonary specialists is required before placing the child under anesthesia. Postoperative referral to a physical therapist facilitates a focused approach to resuming ambulation quickly and safely.…”