management of femoral diaphyseal fractures in the age group of 6-16 years is controversial. There has been a revival worldwide for operative arrested development .
Materials and Methods:
twenty-two children ( 18 boys, 4 girls ) aged 6-16 years with holocene ( > 3 days ) femoral diaphyseal fractures ( 20 closed, 2 open ) were stabilized with Titanium Elastic Nail ( TEN ). These fractures were in proximal third base ( n=3 ), center third ( n=15 ) and in the distal third ( n=4 ) 17 patients undergo operating room within seven days of their injury. The results were evaluated using Flynn ‘s scoring criteria. statistical analysis was done using Fischer ‘s exact trial .
All 22 patients were available for evaluation after a hateful of 26 months ( 14-36 months ) of follow-up. Radiological union in all cases were achieved in a mean time of 8.7 weeks. Full weight yield was possible in a mean time of 8.8 weeks. Mean duration of hospital persist was 9.8 days. The results were excellent in 13 patients ( 59.0 % ), successful in six ( 27.2 % ) and poor people in three patients ( 13.6 % ). All patients had early recurrence to school.
Intramedullary arrested development titanium elastic breeze through is an effective treatment of diaphyseal fractures of the femur in by rights selected patients of the 6-16 years senesce group. Keywords:
Elastic titanium nailing, intramedullary nail, pediatric femoral fractures
Femoral shot fracture is an incapacitating pediatric injury. 1, 2 The treatment has traditionally been age-related, influenced by the type of injury, associated injuries and the location and type of the fracture. To a great extent, the treatment options vary according to the surgeon ‘s preference. 3 Because of rapid curative and spontaneous correction of angulation most of the femoral diaphysis fractures in children younger than six years of old age can be treated conservatively. 4, 5 Above six years of age all such fractures, when treated nonoperatively could have, passing of reduction, malunion, intolerance and complications associated with poultice. Near the end of bony adulthood accurate reduction is necessary as angular deformity is no longer amendable by growth. 6 Availability of interlock intramedullary nail has made the discussion of femoral beam fractures in skeletally matured children well established. however, the best treatment between six and 16 years of age is a topic of debate. 7 Since the concluding two decades, there has been a growing tendency towards a more running access in patents over six years of age. 3, 6, 8 Titanium Elastic Nailing, which is variously known as Elastic Stable Intramedullary Nailing, has become the choice of stabilization in pediatric long cram fractures, particularly the femoral shot fractures. 9, 10 The perceive advantage of this technique includes early coupling due to repeated micromotion at fracture web site, deference for the physis, early mobilization, early weight hold, scratch toleration, easy implant removal and high gear affected role satisfaction pace. 1, 3, 9, 11 We report a prospective study with the objective of evaluating the function and efficacy of Titanium Elastic Nail in selected cases of femoral diaphyseal fractures in the 6-16 years age group .
M ATERIALS AND M ETHODS
twenty-two children ( 18 boys, four girls ) in the old age range of 6-16 years ( average 10.8 years ) with holocene ( > 3 days ) femoral shot fractures ( 20 closed, one Grade- I and one Grade- II compound ) were stabilized with Titanium Elastic Nail ( TEN ), between January 2003 and February 2006. Most of the fractures were due to road traffic accidents ( n=14, 63.6 % ). Right-sided affair was seen in 12 cases ( 54.5 % ) and associated injuries were seen in five cases ( 22.7 % ). Three fractures were in the proximal one-third, 15 in the middle third and four were in the distal one-third. Twelve fractures were cross, seven minimally comminuted ( Winquist I ) and three were short-circuit oblique [ ]. Majority of the patients ( n=17 ) undergo surgery within seven days of their wound. The operation was performed under general anesthesia with the affected role on the fracture table in resistless side. Two Titanium Elastic Nails of identical diameter were used ( 18 of INOR and six of Synthes ). Three cases required insertion of nails with different diameter because of the intraoperative difficulty in driving the second pinpoint into the proximal fragment. The diameter of the individual nail was selected as per Flynn et aluminum ‘s formula 1 ( Diameter of collar = Width of the narrowest point of the medullary canal on Anteroposterior and Lateral view × 0.4 millimeter ) and intraoperative appraisal. The diameter of the pinpoint was chosen thus that each nail occupies at least one-third to 40 % of the medullary cavity. Fractures were reduced using fluoroscopic guidance. Fractures were inserted in regress fashion with median and lateral incision 2.5-3.5 curium above the physis. The nails were prebent sufficiently so that apex of the bowed nails rested at the lapp level on the fracture site to ensure a good adequate bounce push. open reduction was required in three cases ascribable to gentle tissue interjection and failure to negotiate one nail to the proximal break up. The nails were driven proximally then that both were divergent and the tips got anchor minimum 1 centimeter distal to the physis. postoperatively patients were nursed in resistless position with the operate stage elevated on a pillow. Long knee brace was used in three cases of distal third fractures, where arrested development was not adequate. Patients were mobilized without weight carriage on the fifth to seventh day postoperatively. partial derivative weight bearing was started at three weeks and full slant bear by six to eight weeks depending on the fault shape, callosity reply and consort injuries .Open in a separate window All patients were followed radiologically american samoa well as clinically until fractures healed and for any complication. statistical analysis was done using Fischer ‘s exact test to evaluate
- The meaning of association between the occurrence of hide locate irritations and by long, untrimmed nail ends
- Association of angulation of fracture with smaller and mismatch nail diameter
- result between patients < 10 years and > 10 years .
The results were evaluated using Flynn et alabama ‘s score criteria for TEN 12 [ ]. Nails were removed six to eight months post operation when the fracture line was no longer visible radiologically [, ] .
|Limb length discrepancy||Excellent <1.0 cm||Successful <2.0 cm||Poor >2.0 cm|
|Complication||Absent||Mild||Major complication and/or extended period for resolvable morbidity|
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The median duration of surgery was 70 minute ( 50-120 minute ). The mean hospital quell was 9.8 days ( 8-21 days ). A patient with head injury had to stay for a longer menstruation ( 21 days ). The hospital bide was dictated by consociate injuries and the sufficiency of fixation. All 22 patients were available for evaluation after a average of 26 months ( 14-36 months ) of follow-up. Radiological coupling was achieved in all cases in a average prison term of 8.7 weeks ( 6-12 weeks ). Full weight wear was possible in a entail time of 8.8 weeks ( 6-12 weeks ). The results were excellent in 13 patients ( 59.0 % ), successful in six ( 27.2 % ) and poor in three patients ( 13.6 % ) as per the seduce criteria for TEN by Flynn et aluminum. 12 Two patients had varus angulation ( 12° and 6° each ) whereas one had valgus angulation ( 15° ). Entry site pique occurred in four patients [ ]. Two patients had skin breakdown at introduction site which led to superficial contagion. The infection resolved with seven days oral course of cephalosporin. Limb lengthen of less than 1.5 curium was found in three cases both clinically american samoa well as radiologically, which was clinically insignificant [ ]. One case required nail removal at fifth calendar month due to wound dislocation at entry locate. Results were better for children less than 10 years of historic period ( P value-.0003 ). Leaving nail end long ( > 2 centimeter ) and untrimmed was importantly associated with entry locate annoyance ( P value.0001 ). functional range of drift of stifle was achieved in an average of 8.3 weeks ( 6-32 weeks ) .
|Age yrs/sex||Nail diameter (mm)||Radiological union (wks)||Full weight bearing and return to school (wks)||Hospital days||Followup month||Remarks|
|6M||3.0||6||6||8||28||Limb lengthening-1.2 cm|
|14M||3.5||10||12||14||26||# Both bone forearm|
|7F||3.0||8||10||8||16||Limb lengthening-1.4 cm|
|13M||3.5||8||8||10||28||Varus angulation -12°|
|6F||2.5||8||8||8||18||Limb lengthening-1.3 cm|
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Although femoral shaft fractures constitute fewer than 2 % of all pediatric fractures, the choice of discussion has remained a constant challenge to the orthopedics brotherhood. Until recently cautious discussion was the prefer method acting for the discussion of diaphyseal fractures in children and new adolescents. however, to avoid the effects of prolong immobilization, to reduce the loss of school days and for better harbor care, the surgical approach has been gaining popularity for the final two decades. Plate osteosynthesis is placid wide used. It is associated with a large exposure, relatively longer duration of immobilization and the risks of delayed union, infection and a big dissection for plate removal. 13, 14 The external fixator provides good stability and early mobilization, but is associated with the gamble of personal identification number tract infections and it takes a longer clock for weight hold. 15, 16 Intramedullary K-wire arrested development has besides been used for pediatric femoral fracture. But stability and fracture angulation is a disadvantage to be taken care of. Interlocking pinpoint is ideal for skeletally matured children. Reports of avascular necrosis of femoral head, hip valga have been reported with interlocking pinpoint when attempted in skeletally immature patients. 18, 19 however there have been proponents for using interlocking nail in the 11-16 years of age group, avoiding the pyriformis fossa as entrance web site, with good results. 20 Titanium elastic smash seems advantageous over other surgical methods particularly in this age group because it is simple, is a load-sharing internal splint that does n’t violate open physis, allows early mobilization and maintains alliance. Micromotion conferred by the elasticity of the arrested development promotes faster external bridge callus formation. The periosteum is not interrupt and being a close procedure there is no perturbation of the fracture hematoma, thereby less risk of infection. Flynn et alabama. found TEN advantageous over hip spica in treatment of femoral cock fractures in children. 7 Buechsenschuetz et aluminum, documented titanium nail superior in terms of union, scar acceptance and overall patient satisfaction compared to grip and roll. 21 Ligier et aluminum. treated 123 femoral beam fractures with elastic stable intramedullary nail. All fractures united. thirteen children developed entry web site annoyance. 22 similarly, Narayanan et alabama. found full consequence in 79 femoral fractures stabilized with TEN. 3 There is no relative study regarding the efficacy of Ender Nail, Rush Nail or Titanium Elastic Nail. All the nails give good results. Ender Nail and Rush Nail have poor rotational stability and ask multiple nails to achieve commodity fixation. furthermore, Ender Nail is not elastic and flexible enough for pediatric fractures as stated by Ligier. 22 Heinrich et alabama. observed good results in 78 femoral fractures treated with Ender Nail. 23 fracture geometry and the placement is an authoritative deciding for survival of surgical techniques. Transverse, short oblique and minimally comminuted fractures are suitable for TEN as stated by Flynn et alabama. 1 Narayanan et aluminum. 3 stated that cross, inadequate oblique, short spiral fractures with minimum comminution in the 5-12 years long time group were the best indications for TEN. Lascombes et alabama. 24 stated that TEN could be indicated in all femoral diaphyseal fractures of children above six years of old age till epiphysis closed except dangerous Type III open fractures. Titanium elastic collar does not provide adequate stability in grind, long external oblique muscle or corkscrew fractures. even if it is contemplated, postoperative immobilization becomes essential. Appropriate alternatives other than titanium rubber band nail should be considered in such circumstances. The most common complication of Titanium elastic pinpoint is entrance site aggravation and pain. 3, 12 other complications include limb length discrepancy, angulation of fracture, refractures and infection. Entry site irritation in our series was seen in four cases. We found that introduction site excitation was significantly associated with long and outstanding complete end ( > 2 centimeter ). similarly smaller and mismatch smash diameter that was by the way used in three cases was associated with increase incidence of varus/valgus angulation, which conforms to the finding by Narayanan et aluminum in their series. All these findings were statistically meaning .
The titanium elastic nail is an effective and viable treatment option in selected cases of femoral diaphyseal fractures in the 6-16 years age group .
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Source of Support: Nil Conflict of Interest: none .