Flexible intramedullary nailing in paediatric femoral fractures. A report of 73 cases

Abstract

BackgroundFlexible intramedullary nailing has emerged as an accepted procedure for paediatric femoral fractures. Present indications include all patients with femoral shaft fractures and open physis. Despite its excellent reported results, orthopaedic surgeons remain divided in opinion regarding its usefulness and the best material used for nails. We thus undertook a retrospective study of paediatric femoral fractures treated with titanium or stainless steel flexible nails at our institute with a minimum of 5 years follow up.Material and methodsWe included 73 femoral shaft fractures in 69 patients treated with retrograde flexible intramedullary nailing with a minimum follow up of 5 years. Final limb length discrepancy and any angular or rotational deformities were determined.ResultsMean age at final follow up was 15.5 years (10-21 years). Mean follow up was 7.16 years (5.0-8.6 years). Titanium and stainless steel nails were used in 43 and 30 cases respectively. There were 51 midshaft, 17 proximal, and 5 distal fractures.All fractures united at an average of 11 weeks but asymptomatic malalignment and LLD were seen in 19% and 58% fractures respectively. LLD ranged from -3 cm to 1.5 cm. Other complications included superficial infection(2), proximal migration of nail(3), irritation at nail insertion site(5) and penetration of femoral neck with nail tip(1). There were 59 excellent, 10 satisfactory and 4 poor results.ConclusionFlexible intramedullary nailing is reliable and safe for treating paediatric femoral shaft fractures. It is relatively free of serious complications despite asymptomatic malalignment and LLD in significant percentage of fractures.

Treatment of pediatric femoral shaft fractures by stainless steel and titanium elastic nail system: A randomized comparative trial

“…In our study the number of patients with normal range of motion at hip and knee in Group 1 was 16 (94.12%), while in Group 2 the number was 17 (100%). Similar results were obtained by the studies of Khazzam et al 9 and Lohiya et al 10 where clinical evaluation revealed full range of motion of the hip and knee in all patients at final follow-up. The average duration of progressing to full weight bearing in our study was 11.6 weeks.…”

A paradigm shift of the conventional intramedullary devices to new biological osteosynthetic devices: Bone stents

“…Pain and skin irritation at the nail insertion site has been encountered, which causes limited movement of the knee, however the problem no longer exists once the nail is removed 13 . One study which consisted of 229 children with 234 diaphyseal fractures of the femur basically showed the most common complication was angulation 16 .…”

“…The entry point of flexible nails is the metaphysis and they are mainly used for paediatric shaft fractures, to avoid damage to the growth plates. In addition, flexible nails allow micromovement 13 and are associated with a lower risk of infection 25 . Previously, this technique was considered to be the appropriate treatment for femoral shaft fractures in patients of age of 6-16 years, but literature suggests that the technique works well for preschool children too, and has also produced exceptional union results.…”

Developments in the Treatment of Pediatric Long Bone Shaft Fractures

“…32,33 ESIN has rapidly become the treatment of choice for pediatric femur fractures because it leads to excellent results and allows rapid ambulation with little risk of osteonecrosis, physeal injury, or refracture. 34 However, excessive shortening leading to protruding nails and discrepancy of leg length as well as the need for unplanned surgical procedures have frequently been described in length-unstable fractures and/ or heavier patients (> 50 kg). 35 Because of its simplicity and ubiquitous application, the ESIN method has been optimized repeatedly to increase stability especially in the lower extremities.…”