Elastic stabile intramedullary nailing (ESIN) of diaphyseal femur fractures in children and adolescents

Abstract

Elastic stabile intramedullary nailing (ESIN) is a well-established method to stabilize diaphyseal fracture of the femur (DFF) in children. We aimed to evaluate the minimal medullary canal diameter (MMCD) of the fractured femur relative to the diameter of the nails. We also analyzed the real anteversion angle (AVA) of the affected femur in comparison to the healthy femur. We retrospectively reviewed the medical records and plain X-ray images of children aged 2–15 years treated with ESIN for unstable femoral shaft fractures between 2004 and 2012. We measured MMCD on preoperative plain X-ray images. Nail diameter (ND) and any postoperative complications were extracted from the medical records. At follow-up conducted at a median of 40 months (range: 4–103 months) after the operation, we obtained Dunn X-ray images of both hips. Particular emphasis was placed on postoperative torsional differences in relation to age, weight, and maturity of the growth plate. We analyzed the relationship between postoperative rotational malalignment and the ratio of ND to MMCD. Median age of the 22 children at the time of injury was 7.5 years (range: 2–15 years). Median body weight was 25 kg (range: 13–57 kg). Median MMCD amounted to 8.6 mm (range: 5.5–11.0 mm). Median ND/MMCD was 36.9% (range: 27.3%–47.4%). Radiological analyses revealed a median of 27.0° (range: −22.0° to +49.0°) of real AVA in the affected leg and 32.5° (range: 18.0°–48.0°) in the healthy leg. Three children (13.6%) experienced a grade III complication (Clavien–Dindo classification of surgical complications; CDCSC). Two of these children suffered retrotorsion of the femoral neck, while the third child experienced diminished anteversion. Overall, 3 of 22 children (13.6%) suffered a CDCSC-grade III complication (i.e., retrotorsion of the femoral neck in two children and diminished anteversion of the femoral neck in one child). We recommend obtaining Dunn images at the end of the operation to confirm correct rotational alignment after stabilization with ESIN. Further prospective studies are required to confirm our findings.

Elastic Stable Intramedullary Nailing Femoral Shaft Fractures in Children from Six to Ten Years Age

“…This is similar to Akinyoola et al [11] whose study included 134 patients and reported that the fracture line was transverse in 38.4%, oblique in 26.1%, spiral in 24.6%, comminuted in 10.1% and greenstick in 0.7%. Also, our present study is in agreement with Frei et al [8] who observed 9 transverse (40.9%), 6 spirals (27.3%), 4 comminuted (18.2%) and 3 long oblique (13.6%) fractures.…”

“…A third patient complained about pain in his thigh. In contrast to our study, Frei et al [8] reported that out of 22 children, there were excellent result in 6 (27.3%), satisfactory result in 10 (45.5%) and poor result in 6 (27.3%).…”

“…Regarding the affected side, 61.1% of the studied group were right sided affected and 38.9% of them were left sided that might be explained by leg dominance. This is in contrast with Frei et al [8] who found that in15 children, 68.2% the left femurs were fractured. One child (4.5%) sustained multiple traumas in a railway incidence.…”

“…The same age was reported in a study of Govindasamy et al [9] in a total of 52 children were included in their retrospective analysis, the average age of the studied group was 9.5 years (range 6 -16) at the time of injury, there were 30 boys (57.6%) and 18 girls (42.4%) in their study. In addition, Frei et al [8] reported the same age and sex composition as there were 22 children (14 boys [63.6%], 8 girls [36.4%]).…”

“…Also, Govindasamy et al [9] found that the most common problem encountered in their study was skin irritation and impingement due to the distal nail ends in 12 cases (25%). Finally, in Frei et al [8] study, two of 22 children (9%) experienced reactive bursitis, one child (4.5%) suffered from subcutaneous nerve irritation due to a protruding distal nail end, and one child (4.5%) experienced proximal cortical perforation of the nail end.…”