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Children’s orthopaedics

Flexible intramedullary nails for unstable fractures of the tibia in children
AN EIGHT-YEAR EXPERIENCE

V. R. P. Vallamshetla, Flexible intramedullary nailing is gaining popularity as an effective method of treating longbone fractures in children. U. De Silva, We retrospectively reviewed the records and radiographs of 56 unstable fractures of the C. E. Bache, tibia in 54 children treated between March 1997 and May 2005. All were followed up for at P. J. Gibbons
From Birmingham Children’s Hospital, Birmingham, England
least two months after the removal of the nails. Of the 56 tibial fractures, 13 were open. There were no nonunions. The mean time to clinical and radiological union was ten weeks. Complications included residual angulation of the tibia, leg-length discrepancy, deep infection and failures of fixation. All achieved an excellent functional outcome. We conclude that flexible intramedullary fixation is an easy and effective method of management of both open and closed unstable fractures of the tibia in children.

V. R. P. Vallamshetla, MRCS, Orthopaedic Registrar University Hospitals of Coventry & Warwickshire NHS Trust, Stoney Stanton Road, Coventry CV1 4FH, UK. U. de Silva, MRCS, Registrar 22 Peach Ley Road, Selly Oak, Birmingham B29 4ES, UK. C. E. Bache, FRCS Orth, Consultant Orthopaedic Surgeon Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK. P. J. Gibbons, FRCS Orth, Senior Staff Specialist Department of Orthopaedic Surgery The Children’s Hospital at West Mead, Sydney, New South Wales 2145, Australia. Correspondence should be sent to Mr V. R. P. Vallamshetla; e-mail: vrpdr@yahoo.co.in ©2006 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.88B4. 17363 $2.00 J Bone Joint Surg [Br] 2006;88-B:536-40. Received 31 October 2005; Accepted after revision 6 January 2006

The standard treatment for fractures of the tibia in children is manipulation and casting.1,2 Surgical stabilisation has historically been reserved for fractures associated with polytrauma, neurovascular injury, open injury and following fasciotomy for compartment syndrome. In the early 1980s, Ligier, Metaizeau and Prevot3 reported the use of flexible intramedullary nails to allow early stabilisation of fractures in children with polytrauma, to facilitate wound care in open fractures and to avoid prolonged immobilisation. Stability was achieved by inserting two pretensioned nails from opposite cortices, thereby establishing a three-point fixation. Although this technique was initially intended for fractures of the femur, its use has been extended to other long-bone fractures. We report our experience and results using flexible titanium nails in the treatment of unstable fractures of the tibia in children.

Patients and Methods
We undertook a retrospective review of the notes, theatre records and radiographs of all patients with unstable tibial diaphyseal fractures treated by flexible titanium intramedullary nails (C-Nail, Evollutis, Briennan, France) at our institution between March 1997 and May 2005. During this period, 54 children (43 boys and 11 girls) with 56 unstable tibial diaphyseal fractures (27 right, 25 left, two bilateral) (Figs 1a and 1b) were treated by this

method (Figs 1c and 1d). Our indications for the procedure were polytrauma, open fracture, or failure to achieve a satisfactory closed reduction. The mean age on the day of surgery was 12 years (4 to 16). All the patients were followed up for at least two months after the removal of the nail. We classified each fracture according to the AO classification (Table I),4 as well as the mechanism of injury, associated injuries, intra-operative reduction, post-operative immobilisation, time to assisted and unassisted weight-bearing, time to union, functional outcome and complications. We also calculated the Injury Severity Score5 for all children with polytrauma. Technique. All patients were operated upon under general anaesthesia. The affected limb was cleaned and draped. The appropriate size of nail was determined using the image intensifier. The fracture site and entry point at the level of the metaphysis were marked, taking care to avoid the physis. A 2 cm to 3 cm incision was made on either side of the tibia, proximal to the marked entry point. Under fluoroscopic control, the cortex was broached with a drill of larger diameter than the nail to be inserted. Two nails of equal diameter were pre-bent so that the apex of the bend would lie at the fracture site on opposite cortices. The tips of the nails were bent to 45˚ in order to facilitate passage along the opposite cortex and to aid in fracture reduction. The nails were
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lateral view. Of the 56 fractures. c) postoperatively. with deep infections. The fracture was reduced and the nails advanced into the opposite metaphysis. 1a Fig. multi-fragmentary in 20 (36%). all the patients were placed in a short-leg cast and mobilised. one had a grade II open fracture. The mean Injury Severity Score5 in the children with multiple injuries was 13 (4 to 50) (Table II). which were classified according to Gustilo and Anderson. Severity of fractures in our patients. fractured at a level different to the fracture of the tibia in 15 (27%) but at the same level in 24 (43%). A total of 16 (30%) patients had associated injuries. lateral view. Weight-bearing in a walking plaster was permitted VOL. Results Of the 54 children. anteroposterior view. 4. the fibula was intact in 17 (30%). In three distal third fractures. We considered that it was important to leave sufficient nail for subsequent removal.FLEXIBLE INTRAMEDULLARY NAILS FOR UNSTABLE FRACTURES OF THE TIBIA IN CHILDREN 537 Fig. Table I. The fracture pattern was spiral in 12 (21%) fractures. Both healed Table II. non-weight-bearing for four to six weeks. The fractures were located in the upper third of the tibia in three (5%). a) pre-operatively. 2) for fractures of the distal third of the tibia in three (6%) patients. There were four patients who had simultaneous fasciotomy and nailing for suspected compartment syndrome. oblique in 19 (34%) and transverse in four (7%). while the other had a closed fracture that required open reduction after failed conservative management. There were two patients. 1c Fig. Associated injuries in our patients Type of injury Head injury Ipsilateral femoral fracture Contralateral femoral fracture Ipsilateral humeral fracture Contralateral humeral fracture Ipsilateral forearm fracture Bilateral tibial fractures Number of children 9 6 1 3 1 1 2 then introduced under fluoroscopic control. The first nail was advanced to the fracture site and the second introduced from the opposite cortex. the middle third in 38 (68%) and the lower third in 15 (27%) children. After surgery. The associated fracture of the fibula was left alone. 88-B. 1b Fig. APRIL 2006 . No.6 Eight (62%) were grade I. and multi-fragmentary with bone loss in one (2%). No patient demonstrated evidence of growth arrest after nail insertion. b) pre-operatively. Care was taken to avoid the growth plates. 1d Radiographs of the fractured right tibia and fibula of a 14-year-old boy. the mechanism of injury in 35 (65%) was high energy trauma and low energy trauma in 19 (35%). two (15%) were grade II and three (23%) were grade III. both 13 years of age. and d) post-operatively. There were 13 (23%) open fractures. Fractures were considered to be united when tri-cortical callus was visible on the radiographs and there was no tenderness at the fracture site on clinical examination. Retrograde nails were inserted (Fig. the surgeons preferred to use retrograde nailing. A 15-year-old boy with a grade I open fracture developed cellulitis following nailing. which settled with antibiotics. classified using the AO system4 AO classification A1 A2 A3 B1 B2 B3 C2 Number of fractures 12 19 4 9 10 1 1 when adequate callus was seen at the fracture site. Of these. anteroposterior view.

anteroposterior view. J. b) lateral view at two weeks post-operatively and. with removal of the nails and intravenous antibiotics. In the majority of cases. and d) healed tibia. Radiographs at final review demonstrated malunion in two patients (Table III). VALLAMSHETLA. lateral view six months after surgery. C. The mean follow-up was 11 months (8 to 17). 2b Fig. 2d Radiographs of the fractured left tibia of a 13-year-old boy. R.538 V. one with a proximal oblique fracture and the other with a long oblique lower-third fracture of the tibia. BACHE.5 cm and 2 cm following nailing of multifragmentary tibial fractures occurred in two (4%) patients and were treated by epiphysiodesis of the contralateral leg. U. uneventfully after debridement and wash-out. we noted that the alignment achieved intra-operatively was THE JOURNAL OF BONE AND JOINT SURGERY . We were able to remove the nails in 52 (96%) children but removal failed in two (4%) children. E. The nails were removed between six and nine months after insertion as a day-case procedure. The mean time to clinical and radiological union was ten weeks (7 to 18). There was one (2%) patient who had delayed union but required no intervention. Leg-length discrepancies of between 1. P. GIBBONS Fig. anteroposterior view. c) healed tibia. In two (4%) patients. a) with retrograde nailing. DE SILVA. 2a Fig. there was a need for revision to plate fixation after failed fixation at the one-week follow-up. as the nail heads were broken. P. 2c Fig. Both cases of deep infection occurred during a period when patients with burns were nursed in the same area as trauma cases.

An excellent functional outcome was reported.8 The operation is performed through small incisions. compartment syndrome and for older children. This was a retrospective review of clinical and radiographical outcomes for 31 children with fractures of the tibia. Although cast immobilisation remains the standard treatment for appropriate fractures of the tibia. fracture of the ipsilateral femur and segmental fractures. whilst there was one bony complication in the ESIN group.3. The ideal device to treat paediatric fractures of the tibia would be a simple load-sharing device. 4.16-18 Wiss et al16 reported that 48 of 52 fractures of the tibia healed at a mean of 17 weeks. The mean time to union was 18 weeks in the external fixation group but only seven weeks in the ESIN group. fixation is particularly beneficial for children who have sustained multiple injuries from high energy trauma. which would maintain alignment. It should also be easy to insert and remove after bony union. with all patients mobilising independently by three to five months. open fractures. assuming that weight-bearing is not allowed until there is evidence of callus. Kubiak et al11 allowed immediate partial weight-bearing post-operatively if there was > 50% bone contact. Flexible intramedullary nails provide fixation that is stable as well as elastic. we now permit patients with stable (transverse or short oblique) fracture patterns to partially weightbear as soon as comfort allows. There were seven bony complications in the external fixation group (two delayed unions.5 cm Delayed union * > 10˚ recurvatum † > 10˚ varus Number of children 1 1 1 2 2 1 maintained at the time of the final review. 16 had Elastic Stable Intramedullary Nailing (ESIN) and 15 had external fixation. In the external fixation group there were eight children (53%) with an open fracture. away from the fracture site. otherwise differential loading of opposite cortices may lead to an angular deformity. three nonunions and two malalignments). was in contrast to our series where the mean time to union was ten weeks.2 cm. of which 36 involved the tibia. VOL. Qidawi13 described a retrospective review of 84 fractures of the tibia treated with intramedullary Kirschner wires with a mean time to union of 9. while our patients were nonweight-bearing for a period of four to six weeks. APRIL 2006 There are few articles in the literature on the management of diaphyseal fractures of the tibia in children with intramedullary fixation. They reported one superficial infection. There was one death as a result of polytrauma. It is important that both nails are of equal diameter.FLEXIBLE INTRAMEDULLARY NAILS FOR UNSTABLE FRACTURES OF THE TIBIA IN CHILDREN 539 Table III. One child had a leg-length discrepancy of over 1. which satisfy most of these criteria. six coronal and seven sagittal angulations.3. minimising the potential for infection. 88-B. Three patients developed angular malformation > 7˚ and five had shortening > 1. in a similar way to the percutaneous technique. fixed internally with intramedullary fixation. has allowed an increasing number of surgeons to use this type of nail for treating paediatric long-bone fractures. compared with five (31%) in the ESIN group. Complications arising in our patients Complication Sagittal plane angulation* Coronal plane angulation† Infection Superficial Deep Shortening > 1. Discussion For the past two decades. paediatric orthopaedic surgeons have used a variety of methods to minimise the prolonged immobilisation necessary after traditional closed treatment of fractures of the tibia. Kubiak et al11 compared flexible nailing with external fixation. When nearing skeletal maturity. but no functional compromise. including open fractures without segmental bone loss and limited comminution. There are several advantages of this technique. The authors recommended that ESIN should be used for the treatment of fractures of the tibia in skeletally immature patients in need of surgical stabilisation. The reported union at a mean of seven weeks in the ESIN group. The development of flexible intramedullary nails. had some progression of deformity. Vrsansky. The technique allows early weight-bearing in a Sarmiento-type9 cast or functional brace. O’Brien et al10 reported 16 fractures of the tibia. This may be explained by the time to weight-bearing.7 those with head injuries.5 cm. Bourdelat and Al Faour15 reviewed 308 children with fractured long bones fixed with flexible intramedullary nails. across the physis. nails can be passed through the tip of the medial malleolus. This encourages abundant bridging callus formation and facilitates early union. Nails are generally inserted via two proximal entry points but can be inserted retrogradely for more distal fractures. allow mobilisation until bridging callus forms and would not cross the physis. which achieved a very good functional outcome. Of these. but no func- . Three-point fixation within the medullary canal allows maintenance of both alignment and rotation for most fractures. No. In light of our experience. Because there is no reaming of the medullary canal. the endosteal blood supply is not compromised.14 In the past. allowing micromotion at the fracture site when load is applied.10-13 Some authors suggest that the marked proximal metaphyseal flare and the triangular cross-section of the tibia pose a challenge to achieving the symmetrically-opposed nail configuration required for the technique to work effectively.5 weeks. this method of fixation was restricted to failure of conservative treatment. More recently. No patient had any rotational deformity. two patients with significant communition. However. as a method of treating fractures of the tibia in children. We also feel that ESIN provides adequate stability in all but the most severe comminuted or segmental patterns. Several studies involving flexible intramedullary nailing of the tibia in adults are documented.

Marcus RE.24:383-5 (in French). Prevot J. Al Faour A. GIBBONS tional restriction was noted. Barry M. J Pediatr Orthop 1988. Internal fixation of fractures in children and adolescents: a comparative analysis. J Pediatr Orthop 2001. 13. Tibial fractures in children: follow up study.16 of intramedullary nailing for grade II to grade III open fractures in adults documented deep infection rates of one in 38 patients and none in 20. 12.49-A:855-75. Flexible titanium nailing for the treatment of the unstable paediatric tibial fracture. Vrsansky P.8: 306-10. We conclude that. flexible intramedullary nailing is a relatively simple and effective way to stabilise open and closed fractures of the tibia in children with few complications. Closed nailing of tibial shaft fractures. J Pediatr Orthop 2001. Gumbs VL. O’Neill B. 9. J Bone Joint Surg [Am] 1981. References 1. 1990. Koch P. Segal D. J Pediatr Orthop 2004. Ronchetti P. Hasenhuttl19 reviewed 235 cases and reported good healing in 93% of closed fractures and 66% of open fractures.5 cm to 2 cm following multifragmentary fractures. 17. Keller HW. Pankovich AM. P. VALLAMSHETLA. Operative treatment of tibial fractures in children: are elastic stable intramedullary nails an improvement over external fixation? J Bone Joint Surg [Am] 2005. Gad HF. Abul Kheir IH. All the patients were able to start protected weightbearing by four to six weeks and all but two (who had open fractures and other associated injuries) were able to fully weight-bear independently six weeks later. Müller ME. Flynn JM. Hasenhuttl K. DE SILVA. J Pediatr Orthop 2000. Kubiak EN. THE JOURNAL OF BONE AND JOINT SURGERY . Berlin: Springer-Verlag. J Trauma 1974. where indicated. Tolo VT.86-B:947-53.87-A:1761-8. The comprehensive classification of fractures of long bones. Flexible intramedullary nails for fractures in children. Chir Pediatr 1983.141:187-96.58-A:453-8. Booz MK. Salter D. The nonunion rate was 4. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. Metaizeau JP.62 12:1106-12. 15.24:601-9.20:23-7. Sarmiento A. A functional below-the-knee cast for tibial fractures. Baker SP.4%. BACHE. as was the rate of deep infection with osteomyelitis.3: 435-42. Flexible intramedullary nailing of tibialshaft fractures. P. Flexible stable intramedullary pinning technique in the treatment of paediatric fractures.188:10-20. 7. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Nazarian S. Thompson GH. Shannak AO. Reynolds RA. 14. Egol KA.160:185-95. Titanium elastic nails for paediatric femur fractures: a multi-centre study of early results with analysis of complications. fixed with flexible intramedullary nails. 5. 11. Ligier JN. 63-A:921-31. 16. U. Intramedullary Kirschner wiring for tibia fractures in children. The mean time to radiological union was ten weeks. 3. Qidawi SA. R. Paterson JM. et al. Scher D. Injury 1990 21:4:217-19. C. Weisman DS. Two patients developed shortening of the affected leg of no more than 1. Tarabishy IE. Maloney M. Rehm KE. J Trauma 1986. Long WB. Huber RI. Anderson JT. Clin Orthop 1984.16:602-5. Haddon W Jr. 6. J Pediatr Orthop 1996. Yelda S. Flexible nailing of tibial shaft fractures. 19. Hresko T. Clin Orthop 1981. There were two deep infections and two angular deformities which did not compromise function. 8. The treatment of unstable fractures of the tibia with flexible medullary wires: a review of two hundred and thirty-five fractures. 18. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. 10. Two reports8.21:4-8. Closed flexible medullary nailing in pediatric traumatology. Wiss D. Flexible intramedullary nailing as fracture treatment in children. J Paediatr Orthop 1983. J Bone Joint Surg [Am] 1976. We have reviewed 56 fractures of the tibia in 54 children. There were no cases of nail erosion through the skin and all the wounds healed uneventfully. Gustilo RB.21:294-7. allowing early mobilisation and an excellent functional outcome. O’Brien T. 2.540 V. Piller CP. External skeletal fixation in children’s fractures. J Bone Joint Surg [Br] 2004. J Bone Joint Surg [Am] 1967. Huber PM. J. et al. E. Wilber JH. 4. Bourdelat D.