Paediatric tibial shaft fractures treated by open reduction and stabilization with monolateral external fixation

Abstract

PurposeElastic stable intramedullary nailing is increasingly used for surgical treatment of tibial shaft fractures, but frequently requires immobilization and delayed full weight-bearing. Therefore, external fixation remains interesting. The aim was to report clinico-radiological outcomes of monolateral external fixation for displaced and unstable tibial shaft fractures in children.MethodsAll tibial fractures consecutively treated by monolateral external fixation between 2008 and 2013 were followed. Inclusion criteria included skeletal immaturity and closed and open Gustilo I fractures caused by a direct impact. Patients were seen until two years postoperatively. Demographics, mechanism of injury, surgical data and complications were recorded. Anteroposterior and lateral side radiographs were performed at each visit. Full-limb 3D reconstructions using biplanar stereroradiography was performed for final limb length and alignment measures.ResultsA total of 45 patients (mean age 9.7 years ± 0.5) were included. In all, 17 were Gustilo I fractures, with no difference between open and closed fractures for any data. Mean time to full weight bearing was 18.2 days ± 0.7. After 15 days, 39 patients returned to school. Hardware removal (mean time to union 15.6 weeks ± 0.8) was performed during consultation under analgesic gas. There were no cases of nonunion. No fracture healed with > 10° of angulation (mean 5.1° ± 0.4°). Leg-length discrepancy > 10 mm was found for six patients.ConclusionsThis procedure can be a safe and simple surgical treatment for children with tibial shaft fractures. Few complications and early return to school were reported, with the limitations of non-comparative study.Level of EvidenceIV

Role of Ilizarov ring fixator as a definitive treatment in management of compound comminuted paediatric tibia fractures

“…No premature frame removal, Limb length discrepancy, osteomyelitis, compartment syndrome, delayed union, neurovascular injury was seen in any case No case required bone grafting or corrective osteotomy. No refracture was seenin any case following fixator removal [6,11,17] however high energy fractures are associated with soft tissue injury so selection of treatment modality becomes difficult [1,11] Unlike adults there are no clear cut guide lines for management of open tibial fractures in skeletally immature patient [1,12,13] As per literature open fractures with more than 10 yrs of age are associated with outcomes and complications like adults as compared to children less than 10 yrs of age [1] . Remodelling potential decreases with age more than 10 years [1] which may lead to residual deformity, therefore aim of treatment should be fracture union with minimal deformity in children more than 10 years [1,11] Many treatment modalities are available from conservative to operative.…”

“…Remodelling potential decreases with age more than 10 years [1] which may lead to residual deformity, therefore aim of treatment should be fracture union with minimal deformity in children more than 10 years [1,11] Many treatment modalities are available from conservative to operative. Operative treatment ranges from elastic nails, rigid nails, plates, monolataeral external fixator & ilizarov ring fixator, Taylors special frame, Supracutaneous platting [2,4,5,6,11,17] Tibia has relatively poor soft tissue envelop & variable blood supply which can be affected by initial trauma and further internal fixation may even reduce tissue viability leading to impairment in fracture healing [3,4] Risk of infection can be more in open fractures fixed internally [4,7] Elastic nails are minimally invasive and most favoured method by orthopaedic surgeons, but they are less stable in comminuted fractures [6,15] . Internal fixation by them also needs immobilization and support with splint for certain duration of time [15,16] .…”

“…Ilizarov ring fixator has stable construct with rotational stability due to its three dimensional design [1,6] , it permits early weight bearing, dynamic deformity correction by means of gradual compression -distraction cycles [14] This also prevents occurrence of residual deformity [1,14] .Tensioned wires fixed with rings and rods provides stable construct with trampoline like effect which promotes axial micro motion of fractures fragments permitting union [1] . Early reduction & stable fixation with ilizarov ring fixator is very useful & reliable method of treatment for compound paediatric tibia fractures [1] .…”

“…Early reduction & stable fixation with ilizarov ring fixator is very useful & reliable method of treatment for compound paediatric tibia fractures [1] . This method often proceeds to rapid union with few complications in comparison to other methods [1,6] passing of juxtra physeal wires also doesn't disturb growth plate. Early mobilization and rehabilitation of patientspromotes early functional recovery [1,3] .…”

Treatment of Closed Tibia Shaft Fractures in Children: A Systematic Review and Meta-Analysis

“…Of the excluded full texts, the most common reason for exclusion was that open fractures could not be separated (10 studies) [19][20][21][22][23][24][25][26][27][28] followed by studies with too small population (7 studies). [29][30][31][32][33][34][35] In two studies, 36,37 distal tibia fractures were no distinguishable from diaphyseal fractures, and two studies 38,39 reported only the incidence of compartment syndrome.…”