|Year : 2013 | Volume
| Issue : 1 | Page : 70-73
Role of titanium elastic nailing in pediatric femoral shaft fractures
Ajit Saigal1, Alok C Agrawal2
1 D.L.W Railway Hospital, Mangalam Clinic and Trauma Center, Varanasi, Uttar Pradesh, India
2 Department of Orthopedics, NSCB Medical College, Jabalpur, Madhya Pradesh, India
|Date of Web Publication||23-Sep-2013|
D.L.W Railway Hospital, Mangalam Clinic and Trauma Center, Varanasi - 221 001, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Titanium elastic nailing has emerged as a treatment of choice for stabilization of paediatric diaphyseal femoral fractures. Materials and Methods: Between 2007 and 2012, we treated 18 fractures of the femur using closed titanium elastic nailing (TEN),in pediatric patients. This study was done as a retrospective study on 18 cases of fracture of the femoral diaphysis, operated between 2007 and 2010. An assessment of the available postoperative radiographs revealed 88.8% (16 of 18) of the fractures had nails, which formed a divergent C configuration; cortical contact by both nails was visible in 77.7% (14 of 18) and the nails crossed above and below the fracture site in 83.3% (15 of 18). Results: The final outcome was adjudged as excellent when there was anatomical or near anatomical alignment with no postoperative problems in 61.1% (11 of 18) of the patients, satisfactory when there was acceptable alignment and leg length, with resolution of postoperative problems in 22.2% (4 of 18) of the cases, and poor in the presence of unacceptable alignment or leg length, with unresolved postoperative problems in 16.6% (3 of 18) of the cases. Minor or major complications occurred in seven patients. Poor outcomes were due to limb length discrepancy> 2 cm in one1 patient (5.5%), rotational deformity in one patient (5.5%), and varus malunion in one patient (5.5%). Conclusion: We recommend TEN in pediatric patients.
Keywords: Femoral diaphyseal fractures, pediatric, titanium elastic nailing
|How to cite this article:|
Saigal A, Agrawal AC. Role of titanium elastic nailing in pediatric femoral shaft fractures. J Orthop Traumatol Rehabil 2013;6:70-3
|How to cite this URL:|
Saigal A, Agrawal AC. Role of titanium elastic nailing in pediatric femoral shaft fractures. J Orthop Traumatol Rehabil [serial online] 2013 [cited 2019 Jul 21];6:70-3. Available from: http://www.jotr.in/text.asp?2013/6/1/70/118745
| Introduction|| |
Fractures of the femoral shaft are common in children suffering with lower limb fractures.
The incidence of femoral shaft fractures is 20 to 25 per 100 000 children, per year, in the United States and Europe.  Between half and two-thirds of these fractures are reported to have a spiral configuration, which is difficult to manage by conservative methods of treatment.  Most pediatric femoral shaft fractures are treated conservatively, with Bryant's traction, in infants or by plaster hip spica (single/double) in early childhood. The results are usually satisfactory in the long term due to the great potential of remodeling in the pediatric age group. Operative methods of treatment are needed when there is a failure to obtain and maintain acceptable reduction of the fracture by conservative methods. ,
In pediatric femoral shaft fractures the aim of treatment is to stabilize the fracture, maintain the length, control the rotational alignment, promote healing, and minimize the morbidity and complications for the child. , Dr. Metaizeau and his team from the Children's Hospital of Nancy, France, developed the technique of flexible stable intramedullary nailing with titanium elastic nails, during 1979-1984, for forearm fractures.  At present, all tibial, femoral, radial, ulnar, and humeral shaft fractures in the pediatric age group can be fixed with TEN. The TEN fixation is commonly done between five and fifteen years of age, but in a few selected cases, a good result is obtainable even between the ages of two and five years.  According to the recent guidelines produced by the German Society of Pediatric Surgery, femoral fractures can be treated by elastic stable intramedullary nailing in children over three years of age. Even complex spiral fractures are amenable to nailing as long as sufficient stability can be achieved. TEN can be carried out in both closed and open fractures and at all levels between the subtrochanteric and supracondylar areas. It can be carried out after gaining experience in fracture patterns like transverse/oblique/spiral/comminuted and segmental also. This results in rapid recovery and rehabilitation and avoids prolonged immobilization. We did a retrospective analysis of our results on using TEN in diaphyseal fractures of the femur.
| Materials and Methods|| |
This study was done as a retrospective analysis of 18 cases of fractures of the femoral diaphysis, operated on by the senior author, between 2007 and 2012. The age group of the children varied between two to fifteen years. Three cases were operated between the age group of two and five years and 15 cases were between five and fifteen years. There was a bimodal distribution of cases between two and five years and nine and eleven years. All cases were operated within 48 hours in a closed manner. The cases were followed for a duration of two years, during which all the cases underwent routine implant removal about seven to eight months post injury.
| Surgical Technique|| |
Two retrograde titanium elastic nails were used in all pediatric femoral shaft fractures. A traction table with a 'C-arm' image intensifier was used for older children. In younger patients an ordinary operation table with a radiolucent top was used, especially in short oblique and comminuted fractures. A 1-2 cm longitudinal incision was made over the medial and lateral surface of the distal femur, starting 2 cm proximal to the distal femoral epiphyseal plate. The soft tissue was split down to the bone with a hemostat and the cortex was opened with a 3.2 drill bit, initially at a right angle and then at 10 degrees, inclined away from the distal femoral epiphysis. The nail diameter chosen was 40% of the narrowest canal diameter, determined preoperatively. Two nails of similar diameter in a symmetrical construct alignment, face to face with the maximum curvature of the fracture site, were used. The nails were put in a double 'C' construct to ensure a three-point fixation, so that early mobilization could be done with toe touching.
Two elastic nails were pre-contoured and introduced with a T-handle by rotatory movements of the wrist or with a hammer, across the fracture site, under image control. The alignment and anatomic reduction, with proper attention to length and rotation, was confirmed by the image intensifier. The second nail was introduced from the opposite cortex up to the proximal fragment. Traction was released during crossing of second nail at the fracture site, to avoid any distraction. Care was taken to see that the nails did not cross the epiphyseal growth plate proximally and that both nails were at the same level proximally. Attention was given to avoid short nails. There is no danger with regard to the blood supply to the epiphysis. [Example: [Figure 1] and [Figure 2]
Postoperatively the patients were kept in bed with knee flexion and extension permitted. Full weight-bearing was permitted only on fracture union, between six and eight weeks.
|Figure 1: Preoperative radiographs of a nine-year-old boy with fracture of the femur, proximal one-third of the right femur, (a) postoperative follow-up radiograph of his thigh (b), AP and lateral views at 12 weeks after surgery showing union and excellent alignment (c).|
Click here to view
|Figure 2: Preoperative radiographs of a four-year-old boy with oblique fracture of the femur middle one-third of the left femur, (a) postoperative follow-up radiograph of his thigh at 12 weeks after surgery showing union and excellent alignment (b).|
Click here to view
| Results|| |
The fracture occurred in the upper third of the femoral shaft in three cases (16.6%), the middle third in eleven (61.1%), and the lower third in four (22.2%). There were nine transverse (50%), two short oblique (11.1%), three spiral (16.6%), and three butterfly (16.6%). All the fractures were treated with two titanium elastic nails. Nails of the same diameter were used in all the fractures. All 18 patients showed fracture union, with maintained limb length in 17 out of 18, and also full range of movement at the knee and hip joints.
On an assessment of the available postoperative radiographs, 88.8% (16 of 18) of the fractures had nails that formed a divergent C configuration; cortical contact by both nails was visible in 77.7% (14 of 18), and the nails crossed above and below the fracture site in 83.3% (15 of 18). We classified the final outcome as excellent when there was anatomical or near anatomical alignment, with no postoperative problems in 66.6% (11 of 18) of the patients; satisfactory when there was acceptable alignment and leg length with resolution of postoperative problems in 22.2% (4 of 18) of the cases; and poor in the presence of unacceptable alignment or leg length with unresolved postoperative problems in 16% (3 of 18) of the cases. The mean time until removal of the nails was 7.2 months (7 to 8.5 months). The mean time between fixation and full weight-bearing was six weeks (4 to 10 weeks). The complications noted were: Soft tissue and skin problems in relation to nails at the entry points in three patients (16.6%), limb length discrepancy >2 cm in one patient (5.5%), rotational deformity in one patient (5.5%), varus malunion in one patient (5.5%), and a big size callus in one patient (5.5%). The soft tissue irritation at the entry point of the nails resolved after removal of the nails in three patients and the final result was classified as satisfactory. One patient was observed to have a large-sized callus, which decreased with the passage of time and the final result was classified as satisfactory.
| Discussion|| |
The advantages of TEN in pediatric fractures are that these nails are not very expensive, they are available in different diameters, they do not disturb the blood supply of the femoral epiphysis, with proper bending they provide a three-point fixation, no plaster is required, and removal of the nails can be done very easily. Biomechanical testing of flexible intramedullary nails, using synthetic bone models, has shown that retrograde nail fixation has significantly less axial range of motion and more torsional stiffness than antegrade fixation in comminuted and transverse fracture models. There is no significant difference between the mechanical properties of three different retrograde nail constructions (two C-shaped, two S-shaped, and two straight flexible nails were tested), suggesting that any of the three constructs could be used to treat femoral fractures in children. Length and rotation control, with two divergent flexible nails, of comminuted mid-shaft femur fractures may be sufficient for early mobilization. Most femoral shaft fractures in children can be stabilized using retrograde fixation. Three points of fixation, established around the fracture or the medullary canal, must be 'stacked' with multiple nails at the fracture site, to prevent angulations. Usually, medial and lateral insertion sites are used, but a single insertion site, either medial or lateral, can be used in the distal femoral metaphysis. Two divergent C-configuration nails or one C-configuration and one S-configuration nail (bent by the surgeon at a point approximately 5 cm distal to the eyelet) are routine; additional nails can be added if necessary. Special expertise is needed to stabilize the sub-trochanteric fractures and fractures of the distal third of the femur. Antegrade insertion is commonly used for the latter. Most agree that fixation of some proximal and distal long spiral fractures may lack stability as far as rotation is concerned, hence, angulations and testing for stability after nailing at surgery is indicated. If instability is present, a long-leg cast with a pelvic band is used.
A prospective comparison of TEN fixation and spica casting for the treatment of femoral shaft fractures in children found that children treated with flexible nails achieved recovery milestones significantly faster than those treated with traction and spica casting alone. Hospital charges for the two methods were similar, and the complication rate after flexible nailing (21%) was lower than after traction and spica casting (34%). 
Although mechanical studies have demonstrated equal or superior fixation with titanium nails compared to stainless steel nails, and the biomechanical properties of titanium have been suggested to be superior to those of stainless steel for intramedullary fixation, a comparison of the two devices found a malunion rate nearly four times higher with the use of titanium nails (23%) than with stainless steel nails (6%).  Overall, major complications were more frequent with titanium nails (36%) than with stainless steel nails (17%).  In our series, however, we did not find any complications related to fracture union, maybe because we permitted weight-bearing only after the union.
| Conclusion|| |
Titanium elastic nailing can provide adequate fixation for most pediatric femoral shaft fractures if technical principles are followed. Comminuted and spiral fracture patterns need careful follow up and can be supplemented by cast immobilization, to decrease postoperative complications.
| References|| |
|1.||Poolman RW, Kocher MS, Bhandari M. Pediatric femoral fractures: A systematic review of 2422 cases. J Orthop Trauma 2006;20:648-54. |
|2.||Von Laer L, Kraus R, Linhardt W. Pediatric fractures and dislocations. 5th ed. Thieme: New York; 2007. p. 281-97. |
|3.||Anastasopoulos J, Petratos D, Konstantoulakis C, Plakogiannis C, Matsinos G. Flexible intramedullary nailing in paediatric femoral shaft fractures. Injury 2010;41:578-82. |
|4.||Baldwin K, Hsu JE, Wenger DR, Hosalkar HS. Treatment of femur fractures in school-aged children using elastic stable intramedullary nailing: A systematic review. J Pediatr Orthop B 2011;20:303-8. |
|5.||Ligier JN, Metaizeau JP, Prevot J, Lascombe P. Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 1988;70:74-7. |
|6.||Buechsenschuetz KE, Mehlman CT, Shaw KJ, Crawford AH, Immerman EB. Femoral shaft fractures in children: Traction and casting versus elastic stable intramedullary nailing. J Trauma 2002;53:914-21. |
|7.||Fricka KB, Mahar AT, Lee SS, Newton PO. Biomechanical analysis of antegrade and retrograde flexible intramedullary nail fixation of pediatric femoral fractures using a synthetic bone model. J Pediatr Orthop 2004;24:167-71. |
|8.||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;90:1305-13. |
[Figure 1], [Figure 2]