Elastic Stable Intramedullary Nailing of Femoral Shaft Fracture-Experience in 48 Children

Document Type: RESEARCH PAPER

Authors

1 V.M.M.C.Karaikal, Pondicherry, India

2 Saveetha Medical College, Chennai, India

Abstract

Background: Femoral shaft fractures are an incapacitating pediatric injury accounting for 1.6% of all pediatric bony
injuries. Management of these fractures is largely directed by age, fracture pattern, associated injuries, built of the child
and socioeconomic status of the family. We retrospectively evaluated the use of elastic stable intramedullary nail (ESIN)
in surgical management of femoral shaft fractures in children and its complications.
Methods: Fifty two children were treated with titanium elastic nails (TEN) from June 2009 to June 2014 at our
institution. At the end of the study there were 48 children. Fractures were classified according to Winquest and
Hansen’s as Grade I (n=32), Grade II (n=10), Grade III (n=6) and compound fractures by Gustilo and Anderson’s
classification, Grade I (n=5), Grade II (n=3 ). There were 36 mid-shaft fractures, 7 proximal third shaft fractures, 5
distal third shaft fractures. The final results were clinically evaluated by using Flynn’s criteria and radiologically by
Anthony et al’s criteria.
Results: The mean duration of follow-up was 20 months (range 12 – 40 months). All fractures healed radiologically
with grade III callus formation at 9 – 12 weeks (mean 9.7 weeks). The results were analyzed using Flynn’s criteria
and were excellent in 40 children (83%) and satisfactory in 8 children (17%). The soft tissue discomfort near the knee
produced by nail ends was the most common problem in our study (25%). Other complications include limb shortening
(n=5), Varus malunion (n=4), Nail protruding site infection (n=4) and nail migration (n=2). There was no delayed union,
non-union or refractures.
Conclusion: TEN is minimally invasive, safe, relatively easy to use and an effective treatment for fracture shaft of
femur in properly selected children.

Keywords

Main Subjects


1. Flynn JM, Skaggs D, Sponseller PD, Ganley TJ, Kay RM,
Leitch KK. The operative management of paediatric
fractures of the lower extremity. J Bone Joint Surg Am.
2002; 84(12):2288-300.
2. Agarwal-Harding KJ, Meara JG, Greenberg SL,
Hagander LE, Zurakowski D, Dyer GS. Estimating the
global incidence of femoral fracture from road traffic
collisions: a literature review. J Bone Joint Surg Am.
2015; 97(6):e31.
3. Ligier JN, Metaizeau JP, Prevot J, Lascombes P. Elastic
stable intermedullary nailing of femoral shaft
fractures in children. J bone joint surg Br. 1988:
70(1):74-7.
4. Caglar O, Aksoy MC, Yazici M, Surat A. Comparison of
compression plate and flexible intramedullary nail
fixation in pediatric femoral shaft fractures. J Pediatr
Orthop B. 2006; 15(3):210-4
5. Beaty JH, Austin SM, Warner WC, Canale ST, Nichols L.
Interlocking intramedullary nailing of femoral-shaft
fractures in adolescents: preliminary results and
complications. J Pediatr Orthop. 1994; 14(2):178-83.
6. Kong H, Sabharwal S. External fixation for closed
pediatric femoral shaft fractures: where are we now?
Clin Orthop Relat Res. 2014; 472(12):3814-22.
7. Crawford AH, Wall EJ, Mehlman CT, ET Al. Titanium vs
stainless steel elastic nail fixation of femur fractures:
is there a difference? Annual meeting of pediatric
orthopaedic society of north America, Ottawa,
Canada: 2005.
8. Flynn JM, Hresko T, Reynolds RA, Blasier RD, Davidson
R, Kassar J. Titanium elastic nails for pediatric femur
fractures: a multicenter study of early results with
analysis of complications. J Pediatr orthop. 2001;
21(1):4-8.
9. Kasser JR, Beaty JH. Femoral shaft fractures. In: Beaty
JH, Beaty JH, editors, Rockwood and Wilkins fractures
in children. 5th ed. Philadelphia: Lippincott Williams
and Wilkins; 2001. P. 941-80.
10. Stans AA, Morrissy RT, Renwick SE. femoral shaft
fracture treatment in patients age 6-16 years. J Pediatr
orthop. 1999; 19(2):222-8.
11. Luhmann SJ, Schootman M, Schoenecker PL, Dobbs
MB, Gordon JE. Complications of titanium elastic nails
for pediatric femoral shaft fractures. J pediatr Orthop.
2003; 23(4):443-7.
12. Wall EJ, Jain V, Vora V, Mehlman CT, Crawford AH.
Complications of titanium and stainless steel elastic
nail fixation of pediatric femoral fractures. J Bone
Joint Surg Am. 2008; 90(6):1305-13.
13. Thompson JD, Buehler KC, Sponseller PD, Gray DW,
Black BE, Buckley SL et al. Shortening in femoral
shaft fractures in children treated with spica cast. Clin
Orthop Relat Res. 1997; 338:74-8.
14. Greisberg J, Bliss MJ, Eberson CP, Solga P, d’Amato C.
Social and economic benefits of flexible intramedullary
nails in treatment of pediatric femoral shaft fractures.
Orthopedics. 2002; 25(10):1067-70
15. Khazzam M, Tassone C, Liu XC, Lyon R, Freeto B,
Schwab J, et al. Use of flexible intramedullary nail
fixation in treating femur fractures in children. Am J
Orthop (Belle Mead NJ). 2009; 38(3):E49-55.
16. Saikia K, Bhuyan S, Bhattacharya T, Saikia S. Titanium
elastic nailing in femoral diaphyseal fractures of
children in 6 - 16 years of age. Indian J Orthop. 2007;
41(4):381-5.
17. Oh CW, Park BC, Kim PT, Kyung HS, Kim SJ, Ihn JC.
Retograde flexible intramedulary nailing in children’s
femoral fractures. Int Orthop. 2002; 26(1):52-5.
18. Buechsenschuetz KE, Mehlman CT, Shaw KJ, Crawford
AH, Immerman EB. femoral shaft fracture in children:
traction and casting versus casting versus elastic
stable intramedullary nailing. J Trauma. 2002;
53(5):914-21.
19. Kapil Mani KC, Dirgha Raj RC, Parimal A. ediatric
femoral shaft fractures treated by flexible
intramedullary nailing. Chin J Traumatol. 2015;
18(5):284-7.
20. Bhaskar A. Treatment of long bone fractures in
children by flexible titanium nails. Indian J Orthop.
2005; 39(3):166-8.
21. Lascombes P, Haumont T, Journeau P. Use and abuse
of flexible intramedullary nailing in children and
adolescents. J pediatr Orthop. 2006; 26(6):827-34.
22. Narayanan UG, Hyman JE, Wainwright AM, Rang
M, Alman BA. Complications of elastic stable
intramedullary nail fixation of pediatric femoral
fractures, and how to avoid them. J Pediatr orthop.
2004; 24(4):363-9.
23. Ligier JN, Metaizeau JP, Prévot J, Lascombes P.Elastic
stable intramedullary nailing of femoral shaft fracture
in children. J Bone Joint Surg. 1988; 70(1):74-7.
24. Karaoğlu S, Baktir A, Tuncel M, Karakaş ES, Sakir
TM. Closed ender nailing of adolescent femoral shaft
fracture. Injury. 1994; 25(8):501-6.
25. Anastasopoulos J, Petratos D, Konstantoulakis C,
Plakogiannis C, Matsinos G. Flexible intramedullary
nailing in pediatric femoral shaft fractures. Injury.
2010; 41(6):578-82.
26. Baldwin K, Hsu JE, Wenger DR, Hosalkar HS.
Treatment of femur fractures in school-aged children
using elastic stable intramedullary nailing: a systemic
review. J Pediatr orthop B. 2011; 20(5):303-8.
27. Houshian S, Gothgen CB, Pedersen NW, Harving S.
Femoral shaft fractures in children: elastic stable
intramedullary nailing in 31 cases. Acta orthop Scand.
2004; 75(3):249-51.