Pediatric long bone fractures treated by elastic intramedullary nailing

<p class="abstract"><strong>Background:</strong> Pediatric long bone fractures can have a high morbidity and long term disability among the survivors. The present study was aimed to study the clinical outcomes of children with long bone fractures managed by elastic intramedullary nail.</p><p class="abstract"><strong>Methods:</strong> We retrospectively reviewed the medical records of children (aged 2 to 15 years) who were admitted and treated for unilateral femoral, tibial or forearm fractures with elastic intramedullary nail from January 2018 till February 2020. All were managed with elastic intramedullary nailing. The union times and complications were noted from the medical records.<strong></strong></p><p class="abstract"><strong>Results:</strong> Femoral, tibial and forearm bones were involved in 15 patients each (33.3%). Road traffic accident was reported by 31%) and physical abuse by one case (2%). The mean time of union was 10 weeks, ranging from 6 to 12 weeks. The mean time for union of the femur and tibia was 11.54 and 11.34 weeks respectively. It was significantly lower for forearm (6.67 weeks, p value &lt;0.05). Two patients reported of bursitis and impingement, which were resolved after nail removal. One case had limb length discrepancy of about 0.5 cm in femur fracture, which was not impairing functional activity. Functional status was assessed based on Flynn criteria was found to be excellent in 36%, good in 44% and fair in 20%.</p><p class="abstract"><strong>Conclusions:</strong> The results of the present study show that titanium elastic nail (TEN) is an effective treatment modality for managing pediatric long bone fractures. We recommend the use of TEN in managing long bone fractures in children.</p>

Prospective Study of Surgical Management of Diaphyseal Fractures of Both Bones Forearm in Older Children Using Titanium Elastic Intramedullary Nailing at a Tertiary Care Hospital in Srikakulam

BACKGROUND Diaphyseal fractures of the forearm are one of the common fractures in the paediatric population. Closed reduction and cast immobilisation remain the standard treatment for paediatric diaphyseal forearm fractures owing to their unique remodelling potential. The main concern of conservative management is re-displacement of fracture in cast resulting in the unacceptable angular deformity in the forearm. Intramedullary fixation with titanium elastic nails for paediatric diaphyseal forearm fractures is becoming the trending surgical technique in those cases that warrant surgical intervention. The purpose of this study was to evaluate the functional outcome of the management of fracture of both bones forearm in the older children with titanium elastic nailing system. METHODS This was a prospective study done among thirty patients aged 5 to 16 years admitted to the Department of Orthopaedics at GEMS & Hospital, Ragolu, Srikakulam with diaphyseal fractures of both bones forearm from September 2017 to September 2019. We treated the patients by closed / open reduction and internal fixation with elastic stable intramedullary nailing. The patients were followed-up for six months. RESULTS We evaluated the patients clinically and radiologically after surgery. We assessed the outcome using modified Anderson’s AO criteria for forearm fractures extracted from the international journal of current pharmaceutical and clinical research functions. All fractures united at an average of 9.1 weeks without any delayed or non-union. The results were excellent in 86.6 % of patients and good in 13.3 % of patients without significant complications. There were minor complications in 6 patients (20 %). CONCLUSIONS Titanium elastic intramedullary nailing is a safe, effective and minimally invasive surgical method for treatment of displaced both bones forearm diaphyseal fractures in older children. This technique gives relative stability with a three-point fixation principle resulting in secondary bone healing by promoting early callus, ideal for early mobilisation. The technique offers several advantages, including minimal incision, preservation of fracture haematoma, dynamic axial stabilisation, and shorter hospitalisation. KEYWORDS Both Bone Fracture Forearm, Titanium Elastic Nailing System, Early Mobilisation

Comparative efficacy and safety profile for the treatment of humeral bone cysts in children: curettage and mixed bone grafting either with or without elastic intramedullary nailing

Purpose The primary aim of our study was to evaluate the comparative efficacy and safety profile of curettage and mixed bone grafting without instrument or with elastic intramedullary nailing in the treatment of humeral bone cyst in children. Methods Our retrospective study included a total of 48 children harboring humeral bone cyst in our hospital from August 2012 to February 2019. The patients enrolled were divided into elastic nailing group with the application of elastic intramedullary nailing (n = 25) and control group without using instrument (n = 23) during the management of curettage and mixed bone grafting. The following medical outcomes of the two groups were monitored and recorded: the amount of intraoperative blood loss, operation time and postoperative full weight-bearing time, in addition to postoperative clinical effects after 1 year, the function and pain level of shoulder joint before and 1, 3, 6, 9, 12, and 16 months after operation. Follow-up radiographic outcomes were reviewed to observe bone healing, local recurrence and internal fixation loosening, and other postoperative complications. Results The clinical curative effect of the elastic nailing group was higher than that of the control group 16 months after operation (96.00% > 73.91%, P < 0.05). The intraoperative blood loss and postoperative full weight-bearing time in the elastic nailing group were less than those in the control group (P < 0.05), but the operation time was statistically insignificant between the two groups (P > 0.05). Before operation, the shoulder joint function of the two groups was comparable (P > 0.05), while the function showed remarkably better outcome in the elastic nailing group than control group 1 to 16 months after operation (P < 0.05). Before operation, the pain level of the two groups was comparable (P > 0.05), while 1 to 16 months after operation, the pain level of the elastic nailing group was significantly lower than that of the control group (P < 0.05). Patients in both groups were followed up for 16 months. Mixed bone grafting fusion was indicated by imaging CT and X-ray during the follow-up period, with an average fusion time of 11.3 ± 1.2 months (range, 8–16 months). Three months after operation, there was 1 case of incomplete pathological fracture in the control group, while no related complications occurred in the elastic nailing group. Moreover, no tumor recurrence was observed in the two groups. The two groups were comparable in terms of the incidence of complications (P > 0.05). Conclusion Children with humeral cyst treated with curettage and mixed bone grafting with the additional use of elastic intramedullary nailing exerted superior results to those without using instrument as there are beneficial outcomes and safety profile and no complications.

A Novel Surgical Method for Treating Symptomatic Incomplete Atypical Femoral Fracture using Percutaneous Elastic Intramedullary Nailing

Purpose: To introduce the principles and procedure of percutaneous elastic intramedullary nailing (PEIN) as a treatment for symptomatic incomplete atypical femoral fracture (SIAFF). Methods: From October 2014 to April 2019, 6 cases of SIAFF were treated with PEIN. Two pre-bent 4-mm stainless-steel nails were used to apply compressive force to the fracture site. The antegrade method was used for proximal fractures and the retrograde method for middle and distal femoral fractures. The femoral bowing angle in the coronal and sagittal planes, and the time required for callus formation and union, were evaluated on plain radiographs in both planes. Thigh pain, tenderness, and complications were also assessed. Results: The mean operating time was 65.00 ± 22.64 min. No case progressed to complete atypical fracture. In one case, fracture occurred around the point of nail entry after the patient fell from a chair on postoperative day 7. The incomplete fracture lines were united in 5 cases, after excluding one case with a complication. The time taken to confirm endocortical callus formation, fracture line disappearance, and clinical union was 2.11 ± 0.53, 6.45 ± 4.10, and 6.45 ± 3.65 months, respectively. Conclusions: PEIN is a quick, simple but effective treatment for SIAFF that considers the fracture mechanism and is applicable to cases with severe femoral bowing. Level of evidence: Level IV, case series.

Elastic intramedullary nailing combined with methylprednisolone acetate injection for treatment of unicameral bone cysts in children: a retrospective study

Purpose The aetiology of unicameral bone cysts (UBCs) is unclear. This study aims to evaluate the feasibility of elastic intramedullary nailing (EIN) combined with injections of methylprednisolone acetate (MPA) for the treatment of UBCs in children. Methods We retrospectively analyzed 53 children with UBCs in our hospital between January 2010 and April 2016. A total of 24 patients (Group A) were treated by EIN and MPA, whilst 29 patients (Group B) were treated by curettage, bone grafts and EIN fixation. The radiographs of the UBCs were evaluated following the Capanna criteria. All patients were followed-up on the third, sixth, 12th, 24th and 36th months. Fixation time, hospitalization time and complications were evaluated. Results In Group A, the mean number of MPA injections was 1.8 (1 to 3). Based on radiographic evaluation, eight patients were healed (Capanna grade I), 14 were healed with residual cysts (Capanna grade II), one showed recurrence (Capanna grade III) and one showed no response to the treatment (Capanna grade IV). In Group B, 11 patients were evaluated as Capanna grade I, 12 as Capanna grade II, three as Capanna grade III and three as Capanna grade IV. There was significant difference in the early postoperative function activity (p < 0.001), hospitalization time (p = 0.028), blood loss during surgery (p < 0.001) and surgery time (p < 0.001). Conclusion The combination of EIN and MPA for the treatment of UBCs in children is feasible, has little operative trauma, short surgery time, short hospitalization time, less blood loss and a low risk of incision infection. Level of evidence: III

Intramedullary Nailing of Paediatric Tibial Fractures: Comparison between Flexible and Rigid Nails

Purpose: To describe patient characteristics and to compare outcomes of children undergoing rigid intramedullary nailing of tibial fractures as compared with those operated on using elastic intramedullary nailing. Methods: A retrospective review of 26 children who have undergone flexible intramedullary nailing of tibial fractures and 30 children with rigid nailing at our university hospital between 2008 and 2017. The patient charts and radiographs were evaluated to identify demographic characteristics and several variables were measured preoperatively, as well as 6–12 weeks postoperatively in addition to final follow-up radiographs. Results: Twenty-six patients (26/26, 100%) treated with a flexible nail and 14 patients (14/30, 46.7%) treated with a rigid nail had open proximal tibial physis (p < 0.001). An acceptable postoperative alignment was obtained in 20 patients (20/26, 76.9%) in the elastic stable intramedullary nail group and in 29 patients (29/30, 96.7%) in the rigid group (p = 0.026). Some complications occurred in four patients (4/26, 15%) in the elastic stable intramedullary nail population and seven patients (7/30, 23%) in the rigid intramedullary nail population (p = 0.46). Malunion occurred in six patients (6/26, 23%) in the elastic stable intramedullary nail group and in none of the patients treated with a rigid intramedullary nail (p = 0.005). Conclusion: Younger children with tibial fractures who weight 50 kg or less and with proximal tibial growth plates wide open can be treated with elastic stable intramedullary nail while more mature adolescents benefit from rigid intramedullary nailing.