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ORIGINAL ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 2  |  Page : 401-406

Management of diaphysealtibial fracture in pediatrics by elastic stable intramedullary nails


Orthopedic Surgery Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission17-Jul-2013
Date of Acceptance20-Oct-2013
Date of Web Publication26-Sep-2014

Correspondence Address:
K F Elsayed Ahmed
BSc, Nasr City Medical Insurance Hospital, 5 Emtedad Ramses Street, Nasr City, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.141715

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  Abstract 

Objectives
The objectives of this study were to investigate the safety and the efficacy of elastic stable intramedullary nailing in the treatment of pediatric tibial shaft fractures.
Background
Use of the intramedullary nailing technique in the treatment of one of the common injuries involving the lower extremities in children and adolescents.
Patients and methods
A prospective study of 20 children with tibial shaft fracture, who had been admitted to the Menoufia University Hospital and the Nasr City Medical Insurance Hospital between March 2012 and June 2013; all patients had diaphysealtibial fracture. The average age of the patients in this series was 11.3 years (range 5-15 years), and the mean follow-up was 8.1 months (range 6-15 months). Patient charts and radiographs were reviewed prospectively. Outcomes were classified as excellent, satisfactory, or poor according to Flynn's classification for flexible nail fixation; functional assessment and radiological assessment using the Radiographic Union Scale of the Tibial Fracture scoring system was carried out in the 4th and the 12th weeks.
Results
All patients achieved full weight bearing at a mean of 9.7 weeks (range 8-16 weeks). The results were excellent in 15 (75%) patients and satisfactory in five (25%) patients; two cases showed 5-10΀ of angular malalignment, and the other three cases were complicated with nail-end protrusion and a limb-length discrepancy of 2 cm of less. No patient was with poor result.
Conclusion
On the basis of these results, elastic stable intramedullary nailing with titanium elastic nails is an effective surgical technique that allows rapid healing of tibial shaft fractures with an acceptable rate of complications.

Keywords: Pediatric, tibial fractures, titanium elastic intramedullary nails


How to cite this article:
Elsayed Ahmed K F, Zakaria B, Hadhood M, Shaheen A. Management of diaphysealtibial fracture in pediatrics by elastic stable intramedullary nails. Menoufia Med J 2014;27:401-6

How to cite this URL:
Elsayed Ahmed K F, Zakaria B, Hadhood M, Shaheen A. Management of diaphysealtibial fracture in pediatrics by elastic stable intramedullary nails. Menoufia Med J [serial online] 2014 [cited 2019 Dec 16];27:401-6. Available from: http://www.mmj.eg.net/text.asp?2014/27/2/401/141715


  Introduction Top


Tibial fractures are the third most common pediatric fracture type and represent about 10-15% of these fractures [1]. Fractures of the tibia and the fibula may be the result of direct as well as indirect forces [2]. These types of fractures require operative treatment only when they cannot be reduced, when they are open, or occasionally when they occur in the proximal or the distal tibial physis [3]. Uncomplicated pediatric tibial and fibular shaft fractures can be treated by manipulation and cast application in most of the patients [4]. Elastic stable intramedullary nailing of long-bone fractures in the skeletally immature has gained widespread popularity because of its clinical effectiveness and low risk of complications. Many advantages support the use of this technique in the femur and the tibia, which include closed insertion, preservation of the fracture hematoma, and a physeal sparing entry point [5]. The biomechanical principal of elastic stable intramedullary nails (ESINs) is based on the symmetrical bracing action of two elastic nails inserted into the metaphysis, each of which bears against the inner bone at three points. This produces optimal results, that is, axial, translational, and rotational stability. ESINs have the benefits of immediate stability to the involved bone segment, which permits early mobilization and early return of the child to normal activities [6]. In contrast to rigid fixation, elastic internal fixation needs some degree of relative movement to promote the formation of the external callus, which is the physiological callus that forms most rapidly, and has the highest biomechanical strength [7].


  Patients and methods Top


This study is a prospective study of 20 children with tibial shaft fracture; 14 cases had closed fracture and six cases had open fracture. According to the level of the fracture, 11 cases were mid-diaphyseal, eight cases were lower diaphyseal, and a single case was upper diaphyseal. According to the AO classification of tibial fractures, there were 16 cases of class A (simple type), three cases of class B (wedge type), and a single case of class C (complex type). All cases had been admitted to the Menoufia University Hospital and the Nasr City Medical Insurance Hospital between March 2012 and June 2013; all cases that fulfilled the inclusion criteria had been treated by ESINs [Figure 1]. Preoperative assessment was performed by obtaining the history and performing physical examination, radiologic evaluation, and laboratory evaluation of the patients. This was followed by selection of the appropriate type of anesthesia in the proper supine position using an image intensifier. The surgical technique started with closed reduction, achieved by applying axial traction to the leg. The surgical approach consisted of two longitudinal incisions, about 20-mm long, made in the medial and the lateral aspects of the leg, ~10-30 mm distal to the proximal physis. This was followed by implant selection by using the appropriate nail diameter, which was determined by measuring the diameter of the narrowest part of the medullary canal on the radiograph, and then using Flynn's equation: nail diameter = 0.4 × the diameter of the medullary canal; then, nail contouring was carried out according to the type and the location of the fracture. Contouring was performed by hand. The apex of the bow was at the level of the fracture. This shape allowed the nail to generate optimal resistance to deforming forces. The bow in each nail was similar for a balanced effect.
Figure 1:

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Then, through the medial approach, blunt-scissor dissection is performed down to the cortical surface of the tibia, posterior to the midsection the medial proximal metaphysis, close to the posteromedial border, 10-30 mm distal to the physis. The entry hole is made with an awl into the medial cortex of the proximal metaphysis. Then, the medial nail is attached to a T-handle (or inserter) and inserted through the entry hole: the curved tip is inserted perpendicular to the medial cortex; as soon as it makes contact with the far cortex, the inserter is rotated to direct the nail toward the medullary canal. The nail is advanced down to the fracture site using quick oscillatory rotary motions (clockwise and counter clockwise) to prevent jamming in the cancellous bone trabeculae at the metadiaphyseal junction [Figure 2].
Figure 2:

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After insertion of the medial nail, lateral nail insertion started through the lateral approach. This was started by blunt-scissor dissection, along the superficial fascia, which is retracted posteriorly together with the anterior compartment muscles. When the tips of the scissors reach the lateral cortex, they are held flush against the cortex and advanced posteriorly to the midsection of the bone. The entry hole is created with an awl, and the lateral nail is inserted and advanced using the same technique as previously [Figure 3].
Figure 3:

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Both nails are advanced down to the fracture site, and the fracture is reduced again using the same maneuvers. Adequate reduction is achieved when the tip of the lateral nail points laterally and the tip of the medial nail points medially. Then, each nail is carefully pushed across the fracture site using a mallet or a slotted hammer so as to avoid any motion at the fracture site or breakout of the cortex. In case of incomplete reduction, the direction of one of the nails must be changed so that its tip points toward the opposite fragment. It may be directed medially or laterally, anteriorly or posteriorly, or in combined directions as appropriate. The correct position of the nail tip is checked with image intensification in both the frontal and the sagittal planes. Then, the nail is pushed using gentle hammer blows as described previously.

The final construct is technically perfect: two nails with opposing curves, the apexes of which are located at the fracture site. Should mild displacement persist after both nails have entered the distal fragment, contouring can still be used to complete the reduction.

Assessment and evaluation of our cases were performed as follows:

  1. Functional assessment was carried out according to the postoperative immobilization period, the time to full weight bearing, and the range of motion of the knee and the ankle.
  2. Radiological assessment was carried out according to the Radiographic Union Scale of the Tibial Fracture (RUST) scoring system [8] in the 4th and the 12th week. Individual cortical scores (anterior, posterior, medial, and lateral) are added to provide a score value for a set of radiographs of 4 (definitely not healed) to 12 (definitely healed) [Table 1].
  3. The presence of complications (minor and solved or major with residual morbidity) was assessed.
Table 1: Score of the Radiographic Union Scale of Tibial Fracture

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The final assessment of the results was carried out and classified as excellent, satisfactory, or poor on the basis of the scoring system for femoral ESINs described by Flynn [9].


  Results Top


Functional results

The mean time to full weight bearing was 9.7 weeks (range 8-16 weeks). According to the knee and ankle range of motion, all cases showed full range of motion, except two case with limited knee flexion with range 110° or less. Both cases improved in the last visit after physiotherapy and nail removal.

Radiological results

Individual cortical scores (anterior, posterior, medial, and lateral) are added to provide the RUST score at the 4th and the 12th week. At the 4th week, the score range was 4-9 (mean 6.2), and at the 12th week, the score range was 8-12 (mean 11) [Table 2] and [Figure 4].
Figure 4:

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Table 2: Mean value and range of different parameters

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Complications

Three cases were complicated with nail-end protrusion because the nail ends were not cut enough, which cause entry site irritation. According to limb-length discrepancies, shortening of 1-2 cm occurred in two cases and malalignment (angulations) of 5-10° in the other two cases [Table 3].
Table 3: Distribution of complications

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According to the scoring criteria for ESINs by Flynn, 15 (75%) cases had excellent results; these cases achieved complete union without pain, no leg-length discrepancy or malalignment, or complication. Five (25%) cases had satisfactory results due to leg-length discrepancy of less than 2 cm or malalignment (angular deformity) 5-10° or nail-end protrusion and skin irritation [Figure 5]. This study showed no poor results.
Figure 5:

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Case 1

A 11-year-old female patient had RTA; the affected limb was on the right side; the fracture was closed at the middle of the shaft and transverse in shape. Through lateral and medial proximal tibial approaches, two antegrade ESINs were used. In the postoperative evaluation, the time of partial weight bearing was 3 weeks and full weight bearing was 9 weeks. The RUST score at the 4th week was 8 and at the 12th week was 9. There were no postoperative complications, with excellent result, according to the scoring criteria for ESINs by Flynn [Figure 6].
Figure 6:

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Case 2

A 12-year-old male patient had RTA, with the affected limb on the left side; the fracture was closed at the middle of the shaft and transverse in shape through lateral and medial proximal tibial approaches; two antegrade ESINs were used. In the postoperative evaluation, the time of partial weight bearing was 3 weeks and full weight bearing was 8 weeks. The RUST score at the 4th week was 6 and that at the 12th weeks was 12. There were no postoperative complications, with excellent result, according to the scoring criteria for ESINs by Flynn [Figure 7].
Figure 7:

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  Discussion Top


The tibia is the most commonly fractured bone of the lower limb in children. Tibial shaft fractures can generally be managed with closed reduction and casting, which is an effective form of treatment and remains the gold standard of care. Less than 10° of angulation should be the goal in older children. Varus angulation remodels better than valgus or posterior angulation. Occasionally, reduction cannot be maintained due to excessive shortening, angulation, or malrotation at the fracture site, making operative intervention necessary [10],[11].

Surgical treatment is also indicated in case of open fracture, polytrauma, compartment syndrome, or severe soft tissue compromise. External fixation or plate and screw fixation were the treatment options available for unstable tibial shaft fractures that required operative fixation. Complications associated with these techniques include infection, overgrowth, and refracture [12].

Elastic stable intramedullary nailing of long-bone fractures in the skeletally immature has gained widespread popularity because of its clinical effectiveness and low risk of complications. Many studies have supported the use of this technique in the femur, citing advantages that include closed insertion, preservation of the fracture hematoma, and a physeal sparing entry point [13]. Titanium elastic nails achieve biomechanical stability from the divergent 'C' configuration, which creates three points of fixation and allows the construct to act as an internal splint [14]. This is in contrast to enders nails that achieve stability from nail stacking and canal fill. Titanium nails provide stable and elastic fixation, allowing for controlled motion at the fracture site, which results in healing by external callus [15].

O'Brien et al. [16] reported a series of 16 children with tibial shaft fractures treated with ESINs, with a mean follow-up of 17 months. All patients in their series went on to radiographic healing by an average of 9 weeks. No patients had greater than 10° of angular deformity at the final follow-up, and no clinically significant leg-length discrepancies resulted from treatment. The incidence of soft tissue irritation at the insertion site was not reported [16].

Vallamshetla et al. [17] studied 54 children, 43 male and 11 female, with 56 unstable fractures treated with flexible intramedullary nails. The mean age was 12 years (range 4-16 years); 35 fractures had been caused by high-energy trauma, and 13 were exposed. Most of the fractures (68%) were located in the middle-third. The mean consolidation time was 10 weeks (range 7-18 weeks) and the mean follow-up period was 11 months (range 8-17 months). Complications observed by them included leg-length discrepancies of between 1.5 and 2 cm after nailing of multifragmentary tibial fractures occurred in two (4%) patients and were treated by epiphysiodesis of the contralateral leg. Deep infection occurred in two cases during a period while patients with burns were nursed in the same area as trauma cases. Two patients with significant comminution had some progression of angular deformity. No patient had any rotational deformity. There was one death as a result of polytrauma [17].

El-Adl et al. [18] prospectively evaluated 48 femoral fractures and 25 tibial fractures, treated with flexible intramedullary nails. Despite complications such as discrepancy of the lower limbs and irritation in the soft parts related to the entrance points of the nails, all the cases obtained good or satisfactory results [18].

The main purpose of this study was to investigate the safety and the efficacy of fixation of pediatric tibial shaft fractures using ESINs. The mean age of the patients in this study was 11.3 years (range 5-15 years), with a mean of full weight bearing period of 9.7 weeks, nearly similar to both O'Brien et al.'s [16] and Vallamshetla et al.'s [17] studies, and the mean follow-up was 8.1 months (range 6-15 months).

Some intraoperative or postoperative complications developed in this study:

  1. Difficulties in closed reduction in three cases: open reduction was performed for them.
  2. Difficulties in 2nd nail insertion, especially in distal tibial shaft fractures as remanipulation was needed and adjustment of nail diameter.
  3. Three cases were complicated with nail-end protrusion causing entry site irritation. Only two of them showed limited knee flexion with maximum range 110° or less, which improved after nail removal and physiotherapy.
  4. According to limb-length discrepancies, shortening less than 2 cm occurred in two cases, very similar to Vallamshetla and colleagues' results, and less than 10° malalignment (angulations) occurred in two other cases, very similar to O'Brien and colleagues' results.


Radiological evaluation was performed according to the RUST [8] at the 4th and the 12th week. Individual cortical scores (anterior, posterior, medial, and lateral) were added to provide a RUST value for a set of radiographs of 4 (definitely not healed) to 12 (definitely healed).The range of RUST scores in this series was 4-9 points at the 4th week, with a mean value of 6.2, whereas the range at the 12th week was 8-12 points, with a mean value of 11.

According to the scoring criteria for ESINs by Flynn, all the cases in this study obtained good or satisfactory results: 15 excellent results, five satisfactory results, and no poor results, similar to the results obtained by El-Adl and colleagues. Satisfactory results were due to either irritation at the nail entry site due to nail-end protrusion or 5-10° of malalignment. Nail removal was performed only in seven cases (35% of the cases), which was arranged in the 6th month postoperatively.


  Conclusion Top


ESIN is now commonly used for the treatment of pediatric tibial shaft bone fractures. ESINs provide stable and elastic fixation, allowing for controlled motion at the fracture site, which results in healing by the external callus. The ESIN is not without the possibility of complication. Complications are usually a result of mistakes concerning the indications or technical errors. One of the common reported complications associated with these techniques is entry-site skin irritation and nail-end protrusion, which could be avoided by leaving no more than 2 cm at the nail ends outside the bone. We have not observed any major complications. ESIN shows very good functional and cosmetic results. ESIN for shaft fractures is a minimally invasive, simple technique with a steep learning curve.

This technique has many merits over the more traditional plating technique including a minimally invasive technique, a less time-consuming procedure, easier metal work removal, decreased infections rate, better cosmoses, and no need for long hospital stay or long postoperative care. Use of elastic stable intramedullary nailing in tibia shaft fractures that require surgical stabilization results in rapid healing with an acceptable rate of complications.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.Santili C, Gomes C, Waisberg G, Braga S, Lino JW, Santos FG. Tibial diaphyseal fractures in children. Acta Ortop Bras 2010; 18:44-48.  Back to cited text no. 1
    
2. Neil EG, Marc FS. In: editor. Fractures of tibia and fibula (chapter 15). Skeletal trauma in children. 3rd ed. 2003. 559-560.  Back to cited text no. 2
    
3. Canale ST, Beaty JH, editors. Fractures and dislocations in children, tibial and fibular fractures (chapter 33). Campbell′s operative orthopaedics. 11th ed. 2008.  Back to cited text no. 3
    
4. Stephen DH, James FM. In: editor. Fractures of the shaft of the tibia and fibula, diaphyseal fracture of tibia and fibula, treatment (chapter 25). Rockwood & Willkin′s fractures in children. 6th ed. Lippincott Williams & Wilkins; 2006. 1045-1046.  Back to cited text no. 4
    
5. Carey TP, Galpin RD. Flexible intramedullary nail fixation of pediatric femoral fractures. Clin Orthop 1996; 332:110-118.  Back to cited text no. 5
    
6. Furlan D, Pogorelic Z, Biocic M, et al. Elastic stable intramedullary nailing for pediatric long bone fractures: experience with 175 fractures. Scand J Surg 2011; 100:208-215.  Back to cited text no. 6
    
7. Ligier J-N. Flexible intramedullary nailing in children: part 1. Biomechanics of FIN. Stainless steel or titanium 2010; 21-28.  Back to cited text no. 7
    
8. Kooistra BW, Dijkman BG, Busse W, Sprague S, Schemitsch EH, Bhandari M. The radiographic union scale in tibial fractures: reliability and validity. J Orthop Trauma 2010; 24:S81-S86.  Back to cited text no. 8
    
9. Saikia KC, Bhuyan SK, Bhattacharya TD, Saikia SP. Titanium elastic nailing in femoral diaphyseal fractures of children in 6-16 years of age: Indian J Orthop 2007; 41:381-385.  Back to cited text no. 9
    
10.Sankar WN, Jones KJ, David Horn B. Titanium elastic nails for pediatric tibial shaft fractures. J Child Orthop 2007; 1:281-286.  Back to cited text no. 10
    
11.Ubel A, Andermahr J, Isenberg J. Experience with elastic stable intramedullary nailing (ESIN) of shaft fractures in children. Orthopade 2004; 33:928-935.  Back to cited text no. 11
    
12.Tolo VT. External skeletal fixation in children′s fractures. J Pediatr Orthop 1983; 3:435-442.  Back to cited text no. 12
    
13.Metaizeau J. Stable elastic intramedullary nailing of fractures of the femur in children. J Bone Joint Surg Br 2004; 86:954-957.  Back to cited text no. 13
    
14.Ligier JN, Metaizeau JP, Prevot J, Lascombes P. Elastic stable intramedullary pinning of long bone fractures in children. Z Kinderchir 1985; 40:209-212.  Back to cited text no. 14
    
15.Goodwin RC, Gaynor T, Mahar A, Oka R, Lalonde FD. Intramedullary flexible nail fixation of unstable pediatric tibial diaphyseal fractures. J Pediatr Orthop 2005; 25:570-576.  Back to cited text no. 15
    
16.O′Brien T, Weisman DS, Ronchetti P, Piller CP, Maloney M. Flexible titanium elastic nailing for the treatment of the unstable pediatric tibial fracture. J Pediatr Orthop 2004; 24:601-609.  Back to cited text no. 16
    
17.Vallamshetla P, De Silva U, Bache CE, Gibbons PJ. Flexible intramedullary nails for unstable fractures of the tibia in children. An eight-year experience. J Bone Joint Surg Br 2006; 88:536-540.  Back to cited text no. 17
    
18.El-Adl G, Mostafa MF, Khalil MA, Enan A. Titanium elastic nail fixation for paediatric femoral and tibial fractures. Acta Orthop Belg 2009; 75:512-520.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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