ABSTRACT- Background: Femoral shaft fractures are most common fractures in paediatric orthopaedic age group. There are distinct methodologies to treat them. Elastic stable intramedullary nailing is one in every of them and a longtime and reliable methodology for treating these fractures.
Aims: To evaluate the clinical, functional and radiological outcome of intramedullary fixation of displaced fracture shaft femur in skeletally immature children using titanium elastic intramedullary nails.
Material and Methods: 65 Femoral shaft fracture in 60 children aged 6-14 years were fixed with titanium intramedullary elastic nail under image intensifier control between July 2013 and June 2017.Two nails of proper and equal diameter were used for fracture fixation. No external splint was used after surgery. Outcomes assessed on the basis of Flynn et al scoring criterion.
Results: All patients achieved complete healing at a mean of 9.5 weeks. 51 fracture reduced by closed means but 14 needs open reduction. Common size of elastic nail used was 3mm. no major complication was recorded all were minor and can be taken care off. Most common was entry site skin irritation recorded in 10 patients. 90% had excellent result and 10% had satisfactory.
Conclusion: Elastic stable intramedullary nailing is the method of choice for the Femoral shaft fracture in paediatric patients, because it is minimally invasive and provide six point fixation and shows very good functional and cosmetic result. It allows early ambulation and shorter hospital stay and higher parent satisfaction. ESIN also provide flexural, translational and rotational stability as well.
Key-words- Elastic stable intramedullary nailing (ESIN), Titanium elastic nail (TEN), Femoral shaft fracture, Paediatric
INTRODUCTION
Surgical treatment of long bones fractures in children must first consider the fact that excellent results can be achieved with non operative treatment, with reported union rates of more than 90% and 100% full functional recovery. [1] Occasionally reduction cannot be maintained due to excessive shortening, angulations, or malrotation at the fracture site, making operative intervention necessary. [2] Fracture treatment in children relies on rapid healing and spontaneous correction of angulated fractures; therefore most of the diaphyseal fractures can be treated by plaster alone. Operative treatment of childrens fracture is often looked at critically. [3]
Conservative treatment of long bone shaft fractures in children is by traction followed by plaster, hip spica or a Thomas splint. Conventional treatment gives good results in children under 6 years of age. But above that age, all long bone fractures in children cannot be treated by conservative methods. There is possibility of loss of reduction, shortening, angulations and malunion. Plaster immobilization has its own complications like pressure sores, nerve palsies, soiling of the skin and the plaster, breakage of plaster, joint stiffness. The child is immobilised and needs an attendant for personal care.
Various methods are used to treat paediatric long bone fractures and these include traction, [4] splints/orthotics, plaster casts, [5] external fixation, [6] open reduction and internal fixation using plates and screws [7] or intramedullary stabilization with a rod. [8] These modalities are not without complications. [9-11] In addition some require prolonged hospital stay, periods of inactivity and aesthetically unsatisfactory scars.
Reeves et al. [12] was reported that the cost of non operative treatment is 40% higher than operative treatment. Over recent years the use of elastic stable intramedullary nails has dramatically increased with the introduction of a variety of nails for paediatric fractures. [13]
Over the past two decades the advantages of fixation and rapid mobilization has been increasingly recognized health care cost containment and a desire for early discharge from the hospital have become important factors in treatment of long bones shaft fracture. As a result newer techniques have become popular. An ideal fixation device for paediatric long bones fracture would be a load sharing internal splint maintaining reduction for a few weeks until callus forms. Most importantly implant should endanger neither the physis nor the blood supply. Titanium implants are increasingly being used for elastic stable intramedullary nailing. The material properties of titanium confer advantages for an implant used to stabilise paediatric long bones fractures. Titanium elasticity limits the amount that the nail is permanently deformed during insertion. More importantly elasticity promotes callus formation by limiting stress shielding. Titanium also has excellent biocompatibility.
The biomechanical principal of the TENs is based on the symmetrical bracing action of two elastic nails inserted into the metaphysic, each of which bears against the inner bone at three points. [14-15] This produces the following four properties that are essential for achieving optimal results; flexural, axial, translational and rotational stability. [14] The ESIN has the benefits of early immediate stability to the involved bone segment, which permits early mobilization and return to the normal activities of the patients, with very low complication rate. [16-17]
MATERIALS AND METHODS
It is a prospective study, which was conducted in the department of orthopaedic, Hind Institute of Medical Sciences, Lucknow, Uttar Pradesh, India between July 2013 and June 2017; between 60 paediatric patients (40 male and 20 female) with 65 femoral diaphyseal fractures were treated by internal fixation with intramedullary titanium elastic nails.
Inclusion Criteria
The diameter of TENs nail was determine by formula as stated by Kaser and Beaty. [18]
Operative technique: Under general or spinal anaesthesia, the patient was placed supine on an orthopaedic table with traction by assistant or by using traction table ensuring correct linear and rotational alignment clinically and radiologically using an image intensifier.
The essential prerequisite is accurate pre-bending of an elastic titanium nail so that the apex of the bend will lie at the fracture site. Its length should be selected on the basis of pre-operative radiograph of known magnification, and confirmed on the limb before insertion.
In general, the entry site of nail will be in the metaphysis of the bone. It is tempting to make a small stab incision to make insertion. Under image intensifier, the cortex can be breached with an awl or drill according to individual, TENs nail of proper diameter and length tapped along the medulla with the tip angled away from the cortex. The temptation to rotate the nail back and forth should be resisted. If possible, the fracture should be reduced by manipulation and the nail advanced across the fracture site.
Insertion of the later nail in a similar fashion but from the opposite side of the bone. All nails should be inserted up to the fracture site, the fracture reduced, and the nails tapped across the fracture site in an alternating manner for perhaps 1 to 2 cm into the far segment. All nails can then be knocked home, leaving sufficient nail exposed at the site of insertion to enable subsequent removal.
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Fig. 1: Pre-Operative X-ray of Right Femur of 11 yr Boy
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Fig. 2: Post-Operative X-ray of Right Femur of 11 yr Boy
AP = Antero Posterior
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Fig. 3: Post-Operative X-ray of Right Femur of 11 yr Boy after 9 Weeks
AP = Antero Posterior
Post operative rehabilitation: No external splints were used. The children were started on non weight bearing crutch walking and knee physiotherapy 2-3 days after the surgery and were ready for discharge 3-4 days after surgery. The children with polytrauma stayed on for a longer period in the hospital because of associated injuries. The children were encouraged to attend school 3-4 weeks after surgery avoiding sports and physical training. The school authorities consented to this and allowed an attendant for the children.
Full weight bearing was allowed after clinic-radiological fracture union. Union was defined clinically by the absence of bony tenderness and abnormal mobility at the fracture site and no pain at the fracture site on weight bearing. Radiological fracture union was defined by the presence of callus bridging the fracture and partial obliteration of the fracture lines in 2 views perpendicular to each other. The children were assessed for any malunion both linear and rotational, and for any limb length disparity. The wires were removed without anaesthesia in the outdoor with the help of pliers andt-handle.
RESULTS
Among the 60 children of 6-14 yrs of age, maximum 30 children (50%) were in the age group 9-11year. Out of 65 diaphyseal fracture femurs 43 were of right side. Mostly children were hurted by road traffic accident 35 and 25 by sports related injuries. On the basis of pattern 26 were transverse, 20 oblique, 15 spiral and 4 were communited. Most of them 49 children were not associated with any other injuries but 6 had clavicle fracture, 2 had pelvic injury and 3 were associated with head injury. 34 fractures were closed and 20 of grade I, 11 were grade II open fracture.
All patients underwent surgery under general anaesthesia and titanium nails were used in each patient. Most of the children (35) were operated within a week of injury. Cases operated late included that were associated with head injury or wound. The average operative time was 45 min (range 20-75 minutes). 51 (78.4%) patients the fracture was reduced by closed means; whilst in the other 14 (21.6%) open reduction was required. Open reduction needed a minimum exposure with minimum blood loss, minimum handling of periosteum and, no increase in the morbidity or alteration in the post operative rehabilitation. The commonest titanium nail size used was 3mm. 80% (48) patient were discharged within 3 days of operation on oral drugs which was one of the big advantage in comparison to conservative management but one child who develops infection post-operatively had stay for 20 days till the infection controlled.
All patients achieved complete clinic-radiological healing at a mean of 9.5 weeks (range 6-15 weeks). Closed fractures healed more quickly (mean 8.3 weeks) than open fractures (mean 12.6 weeks). In a subjective measure of outcome at follow-up, 70% of the patients were very satisfied and 30% satisfied; no patients or parents reported their outcomes as not satisfied. Routine removal of the nails was undertaken in all patients. At follow up patients went on to osseous union and regained a full range of movement after rehabilitation. There were no cases of delayed union, non-union or malunion. After removal of the nails all patients regained full function and all complications resolved.
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Complications: Most common complication found was entry site skin irritation in 10 patients which was subsided after nail removal. Exurbent callus formed in children with head injury, but this did not affect the final outcome. Others were protrusion of nail in one patient, infection develops in one patient, who was controlled with antibiotics and nail removed early and subsequently settles. Joint stiffness develops in two patients as they were not doing exercise, recovered with proper physiotherapy. There was no instance of loss of reduction, or nail migration during post-operative period. No clinically significant deformities and any limb length discrepancy were observed.
Table 1: Complications of Intramedullary Fixation of Fracture Shaft Femur by Elastic Nail
| S. No | Complications | No. of cases (n=60) |
|---|---|---|
| 1 | Entry site irritation | 10 |
| 2 | Superficial infection | 1 |
| 3 | Deep infection | None |
| 4 | Limb length discrepancy | None |
| 5 | Refracture | None |
Classifying our treatment outcomes based on the ten outcome scoring system by Flynn et al. [17], we found 90% excellent result, 10% satisfactory result and 0% poor result.
Table 2: Flynn et al. [17] scoring criteria for TENS
| Excellent | Satisfactory | Poor | |
|---|---|---|---|
| Limblength inequality | < 1.0 cm | 1.0-2.0cm | >2.0 cm |
| Malalignment | <5° | 5-10° | >10° |
| Pain | None | None | Present |
| Complications | None | Minor & resolved | Major & lasting morbidity |
| No. of patients (60) | 54 | 6 | 0 |
DISCUSSION
The majority of emergency in most trauma centres are fractures of long bones. Although the majority of long bones shaft fractures in children can be treated with closed reduction and casting, occasionally surgical stabilization is required. Historically, external fixation has been the treatment of choice; however, risk includes pin track infections, non-union, and refracture [2,16]. Reamed locked intramedullary nails, while shown to be effective in the skeletally mature, pose unnecessary risk to the long bones physis, and have limited indications in those children with growth remaining. For femoral fractures may increase risk of avascular necrosis if fossa pyriformis is used as an entry point. [2] The elastic stable intramedullary nailing (ESIN) is now commonly used for the treatment of paediatric long bones fractures and their use has minimized the surgical scarring previously caused by open reduction and plating. [13] This method achieves biomechanical stability from the divergent C configuration which creates six points of fixation and allows the construct to act as an internal splint. [2,19] The ESIN provide stable and elastic fixation, allowing for controlled motion at the fracture site which results in healing by external callus. Several studies have demonstrated the safety and efficacy of this technique [1,17,20-23]. The ESIN is not without the possibility of complication. Complications usually are based on mistakes concerning the indication or technical errors [24-25]. The most common reported complications associated with these techniques include infection, over growth, entry site skin irritation and re-fracture. [2,13,22] The most common complication was irritation of skin at the entry site. We have not observed any major complications. This is similar with complication rate reported by previous studies [2,13,24-25].
Age, fracture pattern, fracture location, soft tissue injury, presence of other fractures, physician and family preference, and the social situation all affect the treatment of a child with femoral shaft fracture. Treatment modalities include traction, immediate spica casting, traction followed by spica casting, external fixation, plating, flexible nailing, and intramedullary nailing. [17,26] Fixation by flexible nails is appropriate for patients over the age of six years. [17,26-27] Usually, femoral shaft fractures in children younger the age of six years are treated conservatively.
Khazzam et al. [28] evaluated use of TENs in the treatment of femoral fractures in 135 children. They recorded very good functional results, low complication rate and concluded that use of TENs in the treatment of femoral shaft fractures in children is successful regardless of patient age, fracture location, or fracture pattern.
The aim is to encourage the formation of bridging periosteal callus. The elastic nail, the bone and the muscles provide the stability. The muscle act as guy ropes, so even in an irritable child or the hyperactive child, the muscle activity just complements the fixation. Muscle action also causes spontaneous correction of any angular deformities. Micromotion allowed by the elasticity of the fixation promotes external bridging callus. The periosteum is not disturbed and being closed procedure there is no evacuation of fracture hematoma or risk of infection. Callus formation is twice as fast as with conventional methods. [15]
CONCLUSIONS
Titanium elastic nailing seems to be more physiological and effective method of treatment of femoral shaft fractures in 6-14 years old children. It is simple, rapid and safe procedure with advantages of early union, early mobilization and early return to function with minimal complications. Elastic medullary nailing advantages make it a valuable choice to consider in managing children shaft femur fractures.
REFERENCES
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| How to cite this article: Srivastav D, Kumar M, Mohan A: Evaluation of Results of Intramedullary Fixation of Paediatric Fracture Shaft Femur by Titanium Elastic Nail. Int. J. Life. Sci. Scienti. Res., 2017; 3(5):1360-1364. DOI:10.21276/ijlssr.2017.3.5.16 Source of Financial Support:Nil, Conflict of interest: Nil |