Rigid locked nail fixation for pediatric tibia fractures - Where are the data?

Abstract

Tibial shaft fractures are common injuries among the pediatric and adolescent population. Conservative treatment remains the preferred treatment. However, over the last two decades, there has been an increasing trend of operative fixation in pediatric tibia fractures, commonly with intramedullary nail fixation (IMN). Elastic stable intramedullary nails (ESIN) are heavily used especially in skeletally immature patients as they are physeal respecting and the technique for insertion is familiar. Alternatively, reamed locked intramedullary nails (RIMN) have gained traction in adolescents and skeletally immature pre-adolescents. When identifying publications germane to intramedullary fixation of pediatric tibia fractures, the majority investigated clinical and radiographic outcomes associated with ESIN. We were able to identify only one study specifically examining RIMN in this population, albeit other studies included patients treated with RIMN. In parallel, there has been considerable progress in the field of skeletal maturity estimation with criteria based on different anatomic regions. However, little data exists for trauma purposes as no gold standard system had been accepted and proven to be precise for determination of potential growth remaining around the knee or for quantifying the risk of damage to the proximal tibial physis. Systems devised have been either unvalidated or unnecessarily complex or both. In order to achieve more informed treatment choices and optimal patient outcomes when using IMN fixation in pediatrics, simple to use, validated plain film-based methodology is needed to define skeletal maturity for the proximal tibia. Additionally, further examination of outcomes and the role of RIMN in this population are warranted.

Physeal-Sparing Rigid Intramedullary Nailing in Adolescent Tibial Shaft Fractures: A Pilot Study

“…Very little is written about rigid intramedullary nailing (RIMN) in adolescents, given the transphyseal nature of a traditional tibial nail starting point. This obviates the need for consideration of other techniques given the potential for subsequent physeal arrest with the transphyseal technique [ 19 ]. One group studied the use of RIMN in adolescents and did not show an increased incidence of growth arrest, but their technique was not physeal-sparing [ 20 ].…”

Length Unstable Pediatric Tibial Shaft Fracture Treated With Cerclage Augmented Elastic Intramedullary Nails: A Novel Technique

“…This technique could be used and alleviate the difficult decision in determining the borderline "too young" adolescent patient with open physis to receive a reamed intramedullary nail, where the risk of physis arrest still is uncertain. 19 The technique would allow for relative stability with a load-sharing construct and minimally invasive aspects of EIN while decreasing the morbidity associated with open plating. 1 Recent studies have shown that elective hardware removal risks may not outweigh the benefit but is required in pediatric patients for continued growth.…”

“…Pediatric long bone fractures do not require reamed locked intramedullary fixation, such as what is required in the adult population. This technique could be used and alleviate the difficult decision in determining the borderline “too young” adolescent patient with open physis to receive a reamed intramedullary nail, where the risk of physis arrest still is uncertain 19. The technique would allow for relative stability with a load-sharing construct and minimally invasive aspects of EIN while decreasing the morbidity associated with open plating 1.…”