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Rakowski DR, Roper B, Purtell SR, Carry P, Sanders JS. Do Open Tibial Shaft Fractures Portend a Worse Outcome in the Pediatric Population? A Pilot Study Utilizing a Matched Cohort. JOURNAL OF THE PEDIATRIC ORTHOPAEDIC SOCIETY OF NORTH AMERICA 2025; 11:100167. [PMID: 40432863 PMCID: PMC12088292 DOI: 10.1016/j.jposna.2025.100167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2024] [Revised: 02/03/2025] [Accepted: 02/03/2025] [Indexed: 05/29/2025]
Abstract
Background Tibia fractures are the third most common pediatric long bone fractures and are associated with numerous complications such as compartment syndrome, angular deformity, and nonunion. This study sought to determine if complication rates were higher in open tibia fractures than in closed tibia fractures in the pediatric population, with the hypothesis that there would be no difference. Methods A single-center, retrospective cohort study was performed at a quaternary care academic pediatric hospital identifying all open tibia fractures treated from March 1, 2016, to November 30, 2021. These patients were matched by sex, age, and injury pattern, with patients treated for closed tibia fractures during this same time period. Data collected included demographics, clinical and radiographic information, and complications. Results Both fracture groups included 30 patients (24 males and 6 females). The average age at injury was 11.3 years in the open group, and 11.2 years in the closed group. The median follow-up duration was 7.7 months (1.2-67.8 months) and 9.3 months (1.4-62.9 months) for the open and closed groups, respectively, (P = .5749). One hundred percent of open fractures were treated operatively, versus 50% of the closed-group ones (P < .0001). There was no significant difference in any type of complications when comparing the open group to the closed tibia fracture group (odds ratio: 1.29, 95% confidence interval: 0.48 to 3.45, P = .6180). The most common complication was the development of a clinically significant angular deformity (26.7% in the open group and 10% in the closed group, P = .1806). There was a 10% rate of compartment syndrome in both groups and a nonunion rate of 6.7% for the open group and 3.3% for the closed group (P > .999). Conclusions This pilot study utilizing a matched cohort found no significant difference in complication rates between open and closed pediatric tibia fractures, though complications were prevalent in both groups. These findings emphasize the importance of maintaining a high clinical suspicion for compartment syndrome and thoroughly counseling patients on the risks of angular deformity. Key Concepts (1) A matched cohort study demonstrates complication rates are similarly high in both open and closed pediatric tibial shaft fractures.(2) Angular deformity is the most common complication overall.(3) Treatment algorithms may differ in open versus closed tibial shaft fractures, with open fractures fixated with different constructs and immobilized for longer. Level of Evidence Level III, case control study.
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Affiliation(s)
- Dylan R. Rakowski
- University of Colorado School of Medicine, Department of Orthopedics, Aurora, CO, USA
| | - Brennan Roper
- University of Texas, Department of Orthopedic Surgery, Houston, TX, USA
| | - Sarah R. Purtell
- Children's Hospital Colorado, Musculoskeletal Research Center, Aurora, CO, USA
| | - Patrick Carry
- Children's Hospital Colorado, Musculoskeletal Research Center, Aurora, CO, USA
| | - Julia S. Sanders
- University of Colorado School of Medicine, Department of Orthopedics, Aurora, CO, USA
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Marengo L, Enrietti E, Piccinno M, Ceroni L, Marre' Brunenghi G, Boero S, Colella A, Dibello D. Casting, elastic intramedullary nailing or external fixation in pediatric tibial shaft fractures: which is the most appropriate treatment? A multicenter study. J Pediatr Orthop B 2025; 34:27-32. [PMID: 38375856 DOI: 10.1097/bpb.0000000000001165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
The main objective of this study was to retrospectively evaluate and compare the outcomes and complications of displaced closed tibial fractures in children treated by CRC (closed reduction and casting), elastic stable intramedullary nailing (ESIN) or external fixation (EF). One hundred twenty-three consecutive children were treated for displaced closed tibia shaft fracture from July 2014 and January 2020 at two different institutions. Seventy-five of them met the inclusion criteria and were included in the study: 30 (40%) patients were treated with CRC, 33 (44%) with ESIN, and 12 with EF (16%). All clinical and radiographic outcomes and complications were registered and compared. The three groups did not differ with regard to gender, affected side, fracture site and associated fibula fracture. The age at the time of treatment in the CRC group was statistically lower than in ESIN and EF groups (8.43 ± 3.52 years vs. 10.39 ± 2.56 years vs. 11.08 ± 3.55 years, respectively). Immobilization time and time to partial and total weight bearing were significantly reduced in ESIN and EF groups compared to CRC group ( P < 0.05). Overall, no statistically significant differences were found between the three groups regarding complication rate and clinical and radiographic outcomes between the three groups. However, in CRC group, 3 patients (10%) had secondary fracture displacement and underwent ESIN. Surgical treatment is not contraindicated in children with displaced tibia shaft fractures. EF and ESIN provide earlier mobilization and weight-bearing recovery than CRC. However, apart from that, nonoperative treatment was as efficacious as surgical treatment.
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Affiliation(s)
- Lorenza Marengo
- Department of Orthopedic and Traumatology, IRCCS Istituto Giannina Gaslini, Genova
| | - Emilio Enrietti
- Department of Orthopedic and Traumatology, CTO Hospital, University of Turin, Turin
| | - Melissa Piccinno
- Department of Orthopedic and Traumatology, Ospedale Pediatrico Giovanni XXIII, Bari
| | - Luca Ceroni
- Department of Psychology, University of Turin, Turin, Italy
| | | | - Silvio Boero
- Department of Orthopedic and Traumatology, IRCCS Istituto Giannina Gaslini, Genova
| | - Antonio Colella
- Department of Orthopedic and Traumatology, Ospedale Pediatrico Giovanni XXIII, Bari
| | - Daniela Dibello
- Department of Orthopedic and Traumatology, Ospedale Pediatrico Giovanni XXIII, Bari
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Torres-Izquierdo B, Tippabhatla A, Pereira DE, Cummings JL, Rivera AE, Meyer ZI, Hosseinzadeh P. Patient-reported outcomes of adolescents with tibia shaft fractures: comparison of closed reduction and casting vs. elastic stable intramedullary nailing. J Pediatr Orthop B 2024; 33:462-467. [PMID: 37916465 DOI: 10.1097/bpb.0000000000001138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Tibial shaft fractures are the third most common pediatric long bone fractures. Closed reduction and casting (CRC) is considered initial treatment in this population, however, surgical management using elastic stable intramedullary nailing (ESIN) is also used in adolescents. This study compared patient-reported outcomes in a cohort of adolescents with tibia fractures treated with ESIN or CRC. This single-center retrospective study gathered adolescent patients 10-18 years of age with closed tibia shaft fractures between the years 2015 and 2021 treated by either CRC or ESIN. Measured outcomes include patient demographics, overall casting time, time to full weight bearing, time to full healing, radiographic healing, complications (loss of reduction, malunion >5° and >10°) and Patient-Reported Outcomes Measurement Information System (PROMIS) scores. A total of 141 patients (68% male) were included, with 31 receiving ESIN and 110 having CRC. Patient demographics were similar across groups. At follow-up, CRC had a significant shorter time to healing (11 vs. 15 weeks), but an increased casting duration (7 vs. 4 weeks). Finally, the ESIN group had significantly greater pre-intervention angulation, displacement, and shortening. In both interventions, mobility and pain interference scores showed significant improvements from baseline (2 weeks post-op) at 12, 16, and 24 weeks. No statistically significant differences were noted between CRC and ESIN groups across PROMIS domains of pain interference and mobility. CRC and ESIN are effective in improving pain and mobility in adolescent diaphyseal tibia fractures, but neither intervention is superior based on PROMIS scores at 12, 16 and 24+ weeks. From a patient standpoint, we demonstrate that neither treatment is superior in achieving better-perceived mobility or decreasing pain sooner. Level of Evidence: Level III.
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Affiliation(s)
- Beltran Torres-Izquierdo
- Department of Orthopedic Surgery, Washington University in St. Louis, Saint Louis, Missouri, USA
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Hui T, Wang J, Yu Y, Dong H, Lin W. External fixator versus Ilizarov external fixator for pediatric tibial shaft fractures: A retrospective comparative study. Injury 2024; 55:111376. [PMID: 38307778 DOI: 10.1016/j.injury.2024.111376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/19/2024] [Accepted: 01/20/2024] [Indexed: 02/04/2024]
Abstract
INTRODUCTION External fixators (EF) are widely employed for pediatric tibial shaft fractures, being a prevalent choice in clinical practice. However, they are associated with numerous complications, such as loss of reduction, delayed union, and nonunion. An alternative approach involves the use of Ilizarov external fixators (IEF), which have been documented in the treatment of tibial shaft fractures in various studies. This study endeavors to retrospectively compare the clinical outcomes of EF and IEF in the treatment of pediatric tibial shaft fractures. METHODS The study retrospectively examined patients aged 5-14 years who underwent treatment for tibial shaft fractures at our institute between January 2017 and January 2023. These individuals were subsequently classified into EF and IEF groups. Exclusions comprised patients presenting with pathological fracture, neuromuscular disorder, metabolic disease, prior tibial fracture or instrumentation, and polytrauma. Additionally, individuals with a follow-up duration of more than 12 months or incomplete medical records were excluded. RESULTS A total of 45 patients were divided into two groups: the EF group, comprising 24 patients (18 males, 6 females), and the IEF group, consisting of 21 patients (17 males, 4 females). The two groups exhibited no statistically significant differences in terms of sex, age, body weight, time from injury to surgery, AO classification, or concomitant injuries. There were two cases of nonunion in the EF group. Radiological union occurred more rapidly in the IEF group (7.8 ± 0.4 weeks) than in the EF group (9.3 ± 1.1 weeks) (P < 0.05). The mean hospitalization duration differed significantly between the EF group (6.7 ± 3.4 days) and the IEF group (7.5 ± 1.1 days) (P > 0.05). The mean duration of the operative procedure significantly differed between the IEF group (147.8 ± 24.5 min) and the EF group (77.2 ± 43.9 min) (P < 0.001). A significant difference (P < 0.001) in weight-bearing time was observed between the IEF group (2.6 ± 0.7 weeks) and the EF group (9.9 ± 1.4 weeks). According to the Johner-Wruhs criteria, no significant differences were found between the two groups. A significant difference (P < 0.001) in hospitalization costs was observed between the IEF group (7848.0 ± 262.4 $) and the EF group (5403.0 ± 233.3 $). CONCLUSION EF is cheaper, quicker and simpler and we need more randomized controlled studies and that this is a pilot study only. Both types of surgery are good choices for children. Nevertheless, the IEF group demonstrates advantages such as early weight-bearing capability and faster fracture healing.
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Affiliation(s)
- Taotao Hui
- Department of Pediatric Orthopedics, Wuxi No.9 People's Hospital Affiliated to Soochow University, Wuxi, 214000, Jiangsu Province, China
| | - Jun Wang
- Department of Pediatric Orthopedics, Wuxi No.9 People's Hospital Affiliated to Soochow University, Wuxi, 214000, Jiangsu Province, China
| | - Yinghao Yu
- Department of Pediatric Orthopedics, Wuxi No.9 People's Hospital Affiliated to Soochow University, Wuxi, 214000, Jiangsu Province, China
| | - Haojuan Dong
- Department of Pediatric Orthopedics, Wuxi No.9 People's Hospital Affiliated to Soochow University, Wuxi, 214000, Jiangsu Province, China
| | - Weifeng Lin
- Department of Pediatric Orthopedics, Wuxi No.9 People's Hospital Affiliated to Soochow University, Wuxi, 214000, Jiangsu Province, China.
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Landau AJ, Oladeji AK, Cummings JL, Goldstein R, Lin A, Hosseinzadeh P. Outcomes of Elastic Stable Intramedullary Nailing for Surgical Treatment of Pediatric Tibial Shaft Fractures. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202312000-00004. [PMID: 38038594 PMCID: PMC10686583 DOI: 10.5435/jaaosglobal-d-23-00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND This retrospective study aimed to assess radiographic and clinical outcomes, characterize demographic, injury, and fracture characteristics, and elucidate the rate of postoperative complications and associated factors in a large cohort of children treated with elastic stable intramedullary nail for diaphyseal tibial fractures at two large pediatric referral centers. METHODS Medical records were reviewed for demographic clinical and radiographic parameters at injury, surgery, and all subsequent clinical visits until radiographic healing was observed and/or for a minimum of 6 months postoperatively. RESULTS A total of 146 patients (79.5% male) were included. The mean (SD) age was 11.8 (63.0) years. Radiographic union occurred by 3 months in 56.6% of patients. Nine patients had delayed union, and four had nonunion. By 3 months postoperatively, 97.2% of patients had progressed to full weight bearing and 92.5% had full range of motion of the knee and ankle. Subgroup analyses revealed that patients with open fractures were found to be more than eight times at increased risk of developing delayed union (.6 months, odds ratio = 8.71). CONCLUSION Elastic stable intramedullary nail remains a safe and effective treatment of open and closed pediatric diaphyseal tibial fractures. A small yet notable risk of residual angular deformity, delayed union, and nonunion remains, although rates may be better than previously reported.
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Affiliation(s)
- Andrew J. Landau
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
| | - Afolayan K. Oladeji
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
| | - Jason L. Cummings
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
| | - Rachel Goldstein
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
| | - Adrian Lin
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
| | - Pooya Hosseinzadeh
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
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Hanf-Osetek D, Bilski P, Łabądź D, Snela S. Tibial shaft fractures in children: flexible intramedullary nailing in growing children especially weighing 50 kg (110 lbs) or more. J Pediatr Orthop B 2023; 32:253-259. [PMID: 35502744 DOI: 10.1097/bpb.0000000000000986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Currently the gold standard in surgical treatment of displaced tibial shaft fractures in children with open growth cartilage is elastic stable intramedullary nailing (ESIN). The purpose of this study is the analysis of indications, complications, and duration of treatment using intramedullary flexible nails in children who are still growing but especially weighing 50 kg or more. Hospital records from 2017 to 2020 were retrospectively reviewed to identify the children from 4 to 17 years of age with displaced tibial shaft fractures admitted to the hospital. Only children with open growth cartilage, with a minimum of 6 months of follow-up and complete clinical data, were included. Studies of 91 children xwere analyzed. The average patient age at the time of the injury was 10.88 ± 2.82 years. In the entire group, 31.9% children weighed 50 kg or more, and 68.1% of the children were below this weight. All children were treated using ESIN. The mean time to nail removal was 8.4 ± 4.09 months in the whole group of children stabilized with ESIN. There were no differences in the two groups depending on the weight ( P = 0.637). Only two adverse events were observed. This study demonstrates that the use of ESIN in displaced tibial shaft fractures in growing children weighing 50 kg or more is acceptable and safe. The discussion to be made is whether it is still an acceptable method of treatment for this type of fracture due to the progressive obesity epidemic in children and adolescents.
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Affiliation(s)
- Dorota Hanf-Osetek
- Department of Pediatric Orthopedic, Clinical Regional Hospital No. 2
- Institute of Medicine, College for Medical Sciences of University of Rzeszow, Rzeszow, Poland
| | - Paweł Bilski
- Department of Pediatric Orthopedic, Clinical Regional Hospital No. 2
| | - Dawid Łabądź
- Department of Pediatric Orthopedic, Clinical Regional Hospital No. 2
| | - Sławomir Snela
- Department of Pediatric Orthopedic, Clinical Regional Hospital No. 2
- Institute of Medicine, College for Medical Sciences of University of Rzeszow, Rzeszow, Poland
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Displaced Tibia Fractures in Adolescents: Closed Reduction and Casting Versus Flexible Intramedullary Nails. J Pediatr Orthop 2023; 43:7-12. [PMID: 36167360 DOI: 10.1097/bpo.0000000000002273] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Although there has been a recent trend towards the operative intervention of pediatric diaphyseal tibial fractures, there is sparse literature that supports this trend. This study compares the outcomes in children between 10 and 18 years of age with diaphyseal tibial fractures who undergo nonoperative treatment with closed reduction and casting (CRC) to those who undergo operative treatment with flexible intramedullary nailing. METHODS A retrospective chart review was performed of all patients between 10 and 18 years of age who underwent treatment for tibia fractures at the authors home institution between 2005 and 2018. Radiographs and medical records were reviewed for the duration of immobilization, time to fracture healing and complications including delayed union, malunion, nonunion, and surgical site infection. All statistical analysis was performed using an αof 0.05. RESULTS One hundred forty one patients (81.8% males) were included in the final analysis. Patients treated with flexible nailing took an average of 7 weeks ( P <0.001) longer than patients treated with CRC to achieve radiographic healing. The average time to full weight-bearing activities was longer by 1 week in the patients treated nonoperatively with CRC ( P =0.001). There was no statistically significant difference in the malunion rates between the 2 groups ( P =0.067), but delayed union and nonunion were exclusively seen in the flexible nailing group. There was a total of 40 complications among 33 (23.4%) patients, most of whom were in the CRC cohort (60.6%, n=20), but there was no statistically significant difference in complication rates between the 2 cohorts. DISCUSSION Most adolescents presenting with closed diaphyseal tibial fractures of moderate severity can be successfully treated both nonoperatively with CRC and operatively with flexible intramedullary nailing. However, we recommend an initial attempt at nonoperative treatment be performed in these patients due to the association of more severe complications with flexible nailing. LEVEL OF EVIDENCE Level III.
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Outcomes and complications following flexible intramedullary nailing for the treatment of tibial fractures in children: a meta-analysis. Arch Orthop Trauma Surg 2022; 142:1469-1482. [PMID: 33635402 DOI: 10.1007/s00402-021-03839-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/15/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Tibial shaft fractures are common occurrence in children and surgical treatment is sometimes required, particularly in unstable or open fractures, and in polytrauma. The aim of this study was to investigate the available evidence on the efficacy and safety of flexible intramedullary nailing (FIN) for both open and closed tibia fractures in children, exploring the main surgical outcomes and rate of complications. MATERIALS AND METHODS Pubmed/Medline, Scopus and Cochrane Central databases were searched following the PRISMA guideline. Studies reporting on the outcomes of FIN for paediatric tibia shaft fractures were included. Weighted means were evaluated for surgical outcomes. Meta-analysis of proportion and odd ratios were used to analyse total complication rates and differences between open and closed fractures. RESULTS Twenty-eight studies (835 patients) were included; the mean age was 11.0 ± 3.0 years. The mean follow-up was 22.5 ± 13.5 months; the mean time to full weight-bearing was 7.5 ± 3.7 weeks. The total complication rate was 28.1% (minor = 20.7%, major = 6.3%); this was greater in open fractures (13.6% vs 5.1%, p = 0.007). The rate of union was 97.5%, with a mean time to union of 11.9 ± 7.2 weeks. Malunion was found in 8.5% cases, delayed union in 3.8%, non-union in 1.4%, symptomatic hardware in 5.1%, leg-length discrepancy in 5.0%, superficial infections in 2.3%, deep infections in 1.0%, compartment syndromes in 1.4%, and refracture in 0.2%. Almost all patients returned to unrestricted physical activity. CONCLUSIONS FIN offers excellent outcomes for the treatment of paediatric tibia shaft fractures. Patients presenting with an open fracture have a higher but acceptable complication rate. Comparative studies are needed to clarify if other treatments have superior outcomes.
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Elastic Stable Intramedullary Nailing for Treatment of Pediatric Tibial Fractures: A 20-Year Single Center Experience of 132 Cases. CHILDREN 2022; 9:children9060845. [PMID: 35740782 PMCID: PMC9221784 DOI: 10.3390/children9060845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/29/2022] [Accepted: 06/07/2022] [Indexed: 12/24/2022]
Abstract
Objective: The aim of this study was to analyze the outcomes and complications in children treated with elastic stable intramedullary nailing (ESIN) for tibial fractures. Methods: The study included 132 patients (92 males) with a median age of 11 years (IQR 10, 15) treated with ESIN for displaced tibial shaft fractures or dia-metaphyseal distal tibial fractures from March 2002 to March 2022. The median follow-up was 118.5 months (IQR 74.5, 170). The primary outcome was success rate, while secondary outcomes were the time of bone healing, length of hospital stay, and associated injuries. Demographic data, type and nature of fracture, indication for surgery, healing time, operative time, complications of treatment, and time to implant removal were recorded. Results: Complete radiographic healing was achieved at a median of 7 weeks (IQR 6, 9). Most of the patients (n = 111; 84.1%) had fractures localized in the shaft of the tibia. The most common injuries were acquired by road traffic accidents (n = 42) and by a fall in the same level (n = 29), followed by injuries from sport activities (n = 21) or motorbike accidents (n = 18). Associated injuries were reported in 37 (28%) children. Fractures were closed in the majority of the children (n = 100; 76%), while 32 (24%) children presented with an open fracture. Children with open fractures were significantly older than children with closed fractures (13.5 years (IQR 10, 15) vs. 11 years (IQR 8.5, 14.5); p = 0.031). Furthermore, children with open fractures had a significantly longer hospital stay (7 days (IQR 5, 9) vs. 3 days (IQR 3, 6); p = 0.001), a higher rate of associated injuries (n = 14 (43.7%) vs. n = 23 (23%); p = 0.022), and a higher rate of postoperative complications (n = 7 (21.9%) vs. n = 8 (8%); p = 0.031). No intraoperative complications were recorded. A total of 15 (11.4%) postoperative complications were recorded. Most complications (60%) were minor complications, mostly related to the wound at the nail insertion site and were managed conservatively. A total of six (4.5%) patients required reoperation due to angulation of the fragments (n = 5) or refracture (n = 1). Conclusion: ESIN is a minimally invasive bone surgery technique and is a highly effective treatment for pediatric tibial unstable fractures with a low rate of complications. Based on the given results, surgical stabilization of the tibial fractures using titanium intramedullary nailing can be safely performed without casting with early physiotherapy.
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Brandes LL, Nicolini LF, Greven J, Lichte P, Stopinski TT, Sattler M, Hildebrand F, Pishnamaz M. Biomechanical Performance of BoneHelix ® Compared with Elastic Stable Intramedullary Nailing (ESIN) in a Pediatric Tibia Fracture Model. Life (Basel) 2021; 11:life11111189. [PMID: 34833065 PMCID: PMC8622329 DOI: 10.3390/life11111189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/31/2021] [Accepted: 11/02/2021] [Indexed: 11/16/2022] Open
Abstract
Tibial shaft fractures are common injuries in the pediatric and adolescent populations. Elastic stable intramedullary nailing (ESIN) is the treatment of choice for cases that require surgical stabilization. A new intramedullary device, BoneHelix® (BH), may be an alternative for use with fractures that cannot be satisfactorily stabilized with ESIN. This study aimed to assess the biomechanical performance of BH compared with ESIN in a porcine tibia fracture model, observing cyclic fatigue and load to failure. Computed tomography was used to monitor the implant position and to rule out unintended damage. No implant or bone failure occurred during the fatigue testing. An increase in the cumulative plastic displacement was observed in both test groups over the loading cycles applied. Both implant–bone constructs displayed a trend toward closure of the osteotomy gap. During the load-to-failure test, the average loads at failure in specimens instrumented with ESIN and BH were 5364 N (±723) and 4350 N (±893), respectively, which were not statistically significant (p = 0.11). The values of both groups were two to three times higher than the estimated maximal load (2000 N) during physiological weight bearing. The biomechanical results thus indicate equivalent performance and stability by the implants tested.
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Affiliation(s)
- Laura Leonie Brandes
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany; (L.L.B.); (L.F.N.); (J.G.); (P.L.); (F.H.)
| | - Luis Fernando Nicolini
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany; (L.L.B.); (L.F.N.); (J.G.); (P.L.); (F.H.)
| | - Johannes Greven
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany; (L.L.B.); (L.F.N.); (J.G.); (P.L.); (F.H.)
| | - Philipp Lichte
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany; (L.L.B.); (L.F.N.); (J.G.); (P.L.); (F.H.)
| | - Thomas Thaddäus Stopinski
- Institut für Versuchstierkunde, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany;
| | - Martin Sattler
- Johannes Wesling Klinikum Minden, Hans-Nolte-Straße 1, 32429 Minden, Germany;
| | - Frank Hildebrand
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany; (L.L.B.); (L.F.N.); (J.G.); (P.L.); (F.H.)
| | - Miguel Pishnamaz
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany; (L.L.B.); (L.F.N.); (J.G.); (P.L.); (F.H.)
- Correspondence:
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Alberghina F, Andreacchio A, Cravino M, Dimeglio A, Canavese F. Displaced diaphyseal tibia fractures managed by elastic stable intramedullary nailing with or without the use of intraoperative traction table during nail insertion: a comparative analysis of 160 patients. J Pediatr Orthop B 2021; 30:431-437. [PMID: 32732800 DOI: 10.1097/bpb.0000000000000788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The use of an orthopedic traction table (OTT) during elastic stable intramedullary nailing (ESIN) in the management of displaced diaphyseal tibia fractures (DTFs) is controversial. The aim of this study was to evaluate the clinical and radiological outcome of children with displaced DTF managed by ESIN with and without the use of an OTT. Medical records were retrospectively reviewed for all pediatric patients sustaining DTF managed by ESIN from 2011 to 2019 at two different institutions. In all, 160 consecutive children with displaced DTF were recorded, of whom 80 underwent operative treatment by ESIN without OTT (group A), and 80 by ESIN with the use of an OTT and skeletal traction (group B). ESIN outcome measure scale, Beaty radiologic criteria and Radiographic Union Scale for Tibia fractures (RUST) score were used to evaluate the results. Average patient age at time of injury was 10.8 years (range 7-15). The mean follow-up was 55.8 months (range 12-96). All complications (2.5%) and poorer results according to ESIN outcome measure scale and Beaty radiological criteria were recorded among children managed with OTT. No complications related to pin insertion for skeletal traction were observed. Mean RUST score, length of surgery and cumulative time of radiation exposure were comparable between the two groups. Children with a displaced DTF treated by ESIN without the use of OTT showed superior results as there are no additional procedures (traction wire insertion and removal) decreased theater time and no complications with similar radiation dose.
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Affiliation(s)
- Flavia Alberghina
- Pediatric Orthopedic Surgery Department, 'Regina Margherita' Children's Hospital, Torino
| | - Antonio Andreacchio
- Pediatric Orthopedic Surgery Department, 'Vittore Buzzi' Children's Hospital, Milano, Italy
| | - Mattia Cravino
- Pediatric Orthopedic Surgery Department, 'Regina Margherita' Children's Hospital, Torino
| | - Alain Dimeglio
- Pediatric Surgery Department, Clinique St. Roch, Montpellier
| | - Federico Canavese
- Pediatric Surgery Department, University Hospital Estaing, Clermont Ferrand, France
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12
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Durga Prasad V, Sangeet G, Venkatadass K, Rajasekaran S. Ender's nailing of displaced tibia shaft fractures in children - A nine-year experience. Injury 2021; 52:837-843. [PMID: 33051079 DOI: 10.1016/j.injury.2020.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/09/2020] [Accepted: 10/06/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Displaced fractures of the tibial shaft in children can be effectively treated with minimal complications with flexible nails. Our aim is to evaluate the outcome of displaced paediatric tibia shaft fractures treated with Ender's nails. MATERIALS We retrospectively reviewed the records of all unstable tibial fractures treated between 2010 and 2018, in our institution. Only children with a minimum of six months follow-up and complete clinical data were considered for the study. RESULTS Of the 72 patients who fulfilled the inclusion-exclusion criteria, 8 were lost for follow-up and hence we had 64 patients included for the study. There were 54 boys and 10 girls, with an average age of 10.9 years(4 to 17 years). The average follow-up was 16.9 months (6 to 47 months). There were nine open fractures. Two nails were used in 52(81.25%) patients while a single nail was used in 6(9.37%) patients and three nails were used in 6(9.37%) patients. The union rate was 100% with an average union time of 10.6 weeks. There were 17 (26.5%) patients with delayed union but none required intervention. One (1.56%) child had a malunion >10° (recurvatum of 11.9° and varus of 8.1°). Radiographs at the final review demonstrated >5° of coronal plane malalignment in eight patients (12.5%) and >5° sagittal plane malalignment (recurvatum) in six patients (9.37%). There was an associated fibular fracture in 50 children and there was no significant association between the presence of fibular fracture and malalignment (p>0.05). All children who presented for implant removal had full range of movement at the knee and ankle joint and no limb length discrepancy. CONCLUSION We report the largest series of paediatric tibial shaft fractures treated with Ender's nails. Ender's nail is a simple and cost-effective option for treating these fractures with excellent union rates and minimal complications.
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Affiliation(s)
- V Durga Prasad
- Department of Orthoapedics & Spine Surgery, Ganga hospital, 313, Mettupalayam road, Coimbatore -641043, India
| | - G Sangeet
- Department of Orthoapedics & Spine Surgery, Ganga hospital, 313, Mettupalayam road, Coimbatore -641043, India
| | - K Venkatadass
- Department of Orthoapedics & Spine Surgery, Ganga hospital, 313, Mettupalayam road, Coimbatore -641043, India.
| | - S Rajasekaran
- Department of Orthoapedics & Spine Surgery, Ganga hospital, 313, Mettupalayam road, Coimbatore -641043, India
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Williams KA, Thier ZT, Mathews CG, Locke MD. Physeal-Sparing Rigid Intramedullary Nailing in Adolescent Tibial Shaft Fractures: A Pilot Study. Cureus 2021; 13:e13893. [PMID: 33880249 PMCID: PMC8046697 DOI: 10.7759/cureus.13893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Purpose: Elastic stable intramedullary nailing (ESIN) and open reduction internal fixation (ORIF) are literature-supported operative treatments for displaced tibial shaft fractures in skeletally immature patients. Very little is written about rigid intramedullary nails (RIMNs) in adolescents. Our purpose is to describe a physeal-sparing, reamed, locked RIMN technique for adolescent tibial shaft fractures and report its safety. Methods: Adolescent patients with tibial shaft fractures indicated for operative intervention at one institution were retrospectively identified from 2011-2018. Patients were classified based on method of fracture fixation. Primary outcomes included fracture union, reoperation, and complication rates. Results: Thirteen patients were included in the RIMN arm, with an average age of 13.8 years. Two patients in the observational group underwent ESIN and seven patients underwent ORIF, with an average age of 11.5 years. Significant differences were found between time of immobilization (28 days vs 121 days), time to touch down weight bearing release (1 day vs 34 days), and hardware pain (2/13 vs 7/9). The RIMN group sustained fewer reoperations (2/13 vs 5/9). No differences were found in rates of complications or fixation failure between groups. Conclusions: Based on our small pilot study, RIMNs in adolescents should be considered as a potential treatment option when a physeal-sparing distal start point is utilized. Additionally, short-term follow-up suggests safety. Patients who underwent the RIMN procedure required fewer reoperations compared with the observational group. Overall, fracture healing was similar across the two groups. The benefits of RIMN include early immobilization and improved weight-bearing profile. Level of Evidence: IV.
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Affiliation(s)
- Kevin A Williams
- Orthopaedic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, USA
| | - Zachary T Thier
- Medical Education, Lincoln Memorial University DeBusk College of Osteopathic Medicine, Knoxville, USA
| | - Candler G Mathews
- Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Mark D Locke
- Orthopaedic Surgery, Prisma Health - University of South Carolina, Columbia, USA
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Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures. Injury 2021; 52 Suppl 1:S67-S73. [PMID: 32081395 DOI: 10.1016/j.injury.2020.02.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 02/09/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The first-line treatment of paediatric tibial fractures is non-operative but the number of operatively treated patients is rising. Elastic intramedullary nailing and external fixation are widely used in children while solid intramedullary nailing, the standard procedure in adults, is usually not recommended due to the open physes. MATERIALS AND METHODS Between January 2007 and October 2017, unreamed locked solid intramedullary nailing was used in 16 cases of adolescent (mean age 13.7 ± 1.25 years) tibial diaphyseal fractures with open physes. An atypical, physeal-sparing method was used in all cases. Fourteen patients were managed by the standard implant used routinely in adult trauma care. Two patients were treated by a special nail, modified specifically for paediatric care. RESULTS Good functional healing was found in all cases treated by the atypical method. Partial weight bearing began immediately after surgery in 38% of the cases. Full weight bearing was allowed 7.3 ± 2.4 weeks postoperatively. The average time to fracture union was 11.5 ± 2.9 weeks. Superficial infection and wound healing complication occurred in 3 cases. Deep infection, compartment syndrome or other bone related complications did not arise. DISCUSSION The treatment of tibial fractures in adolescents is challenging due to larger body size and significant growth potential. The atypical intramedullary nailing method presented in this study can provide optimal functional healing, early mobilization and weight bearing while completely sparing the physis. This method can serve as an alternative in the operative treatment of adolescent tibial diaphyseal fractures.
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Weber B, Kalbitz M, Baur M, Braun CK, Zwingmann J, Pressmar J. Lower Leg Fractures in Children and Adolescents-Comparison of Conservative vs. ECMES Treatment. Front Pediatr 2021; 9:597870. [PMID: 33748039 PMCID: PMC7969713 DOI: 10.3389/fped.2021.597870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 02/11/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Lower leg fractures are one of the most common fractures in pediatric age. In general, treatment of lower leg fractures is predominantly non-operative, requiring clinical and radiological controls. Nevertheless, it can be observed that in recent years tibial shaft fractures have increasingly been treated surgically. The aim of the present study is to investigate treatment strategies in the context of different fracture types of the lower leg. Methods: In this retrospective chart review, we analyzed 168 children with a diaphyseal fracture of the lower leg admitted to a trauma center between 2005 and 2017. The fractures were classified according to the AO Pediatric Comprehensive Classification of Long Bone Fractures (AO-PCCF). Results: The frequency of fractures based on the AO-PCCF classification was as follows: Simple oblique fracture of the tibia (43.5%, n = 73), hereof 32 toddler's fractures, multifragmentary oblique fracture of the tibia in 14.3% (n = 24) and simple oblique fracture of both, tibia and fibula in 18 patients (10.7%). Most pediatric fractures were treated conservatively by cast (n = 125). Thirty-seven patients received an ECMES, whereas 3 patients were treated with an external fixator and also 3 fractures were stabilized by plate osteosynthesis. Conservatively treated patients were significantly younger (mean age 6.0) compared to patients treated with ECMES (mean age 10.2) or plate osteosynthesis (PO)/external fixator (EF) (mean age 11.3), even if toddler's fractures (mean age 2.0) are excluded (mean age 7.4). There was no difference in time to full weight-bearing, hospitalization of patients treated with ECMES compared to conservative therapy although ECMES-treated fractures show more instability. The consolidation time was significantly higher in ECMES treated patients compared to conservative therapy. Conclusion: Pediatric patients (≤4 years) with lower leg fractures most often showed simple oblique fractures of the tibia, half of them toddler's fractures, which were treated predominantly by conservative therapy. All in all, the consolidation time was longer in intramedullary nailing (ECMES) than in conservative therapy. Nevertheless, time to full weight bearing and duration of cast was the same in both groups, even though ECMES treated fractures show more instability.
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Affiliation(s)
- Birte Weber
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany.,Department of Trauma, Hand and Reconstructive Surgery, Goethe University of Frankfurt, Frankfurt, Germany
| | - Miriam Kalbitz
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Meike Baur
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Christian Karl Braun
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany.,Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Jörn Zwingmann
- Department of Orthopedic and Trauma Surgery, University of Freiburg Medical Center, Freiburg, Germany
| | - Jochen Pressmar
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
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Risk Factors for Adverse Radiographic Outcomes After Elastic Stable Intramedullary Nailing of Unstable Diaphyseal Tibia Fractures in Children. J Pediatr Orthop 2020; 40:481-486. [PMID: 32282621 DOI: 10.1097/bpo.0000000000001565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Elastic stable intramedullary nails (ESIN) are commonly utilized to treat unstable pediatric tibia fractures but have been associated with complications. The purpose of this study was to identify risk factors for adverse radiographic outcomes after ESIN of pediatric tibia fractures. METHODS A retrospective review of all patients who underwent diaphyseal tibia fracture stabilization with ESIN between 2010 and 2018 at 3 pediatric level 1 trauma centers was performed. Inclusion criteria were open growth plates, no intra-articular or physeal fracture involvement, and radiographic follow-up until union. Patient demographics, injury mechanism, fracture characteristics, and implant fill relative to the medullary canal were recorded. Radiographic outcome measures included achievement of and time to union, residual angular deformity, and additional procedures. RESULTS One hundred seventy-two patients met inclusion criteria and were followed for a mean of 1.2 years. Nonunions were observed in 3% of the patient cohort. Another 10% required >6 months to heal, but did not require further surgical intervention. Angular deformities were common with 57% having a residual deformity ≥5 degrees and 14% having a residual deformity ≥10 degrees. Of the patients with a residual deformity between 5 and 10 degrees, 3% were symptomatic, where as 26% of the patients with a residual deformity ≥10 degrees were symptomatic. Greater angular deformities were associated with open fractures, compartment syndrome, and longer time to union. Patient age, weight, tibial comminution, and canal fill were not associated with nonunions or malunions. CONCLUSIONS ESIN of pediatric tibia fractures results in reliable healing for a majority of patients, but poses risks for residual angular deformities and delayed healing. Open fractures and compartment syndrome were associated with adverse radiographic outcomes.
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17
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Quadruple Versus Double Flexible Intramedullary Nails to Treat Pediatric Distal-third Tibial Shaft Fractures: A Biomechanical Comparison. J Pediatr Orthop 2020; 40:487-491. [PMID: 32931690 DOI: 10.1097/bpo.0000000000001604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The vast majority of pediatric distal-third tibial shaft fractures can be treated with closed reduction and casting. If conservative measures fail, then these fractures are usually treated with 2 antegrade flexible intramedullary nails. A postoperative cast is usually applied because of the tenuous fixation of the 2 nails. Recent studies have described the use of 4 nails to increase the stability of the fixation, a technique that may preclude the need for postoperative casting. The purpose of this biomechanical study is to quantify the relative increase in stiffness and load to failure when using 4 versus 2 nails to surgically stabilize these fractures. METHODS Short, oblique osteotomies were created in the distal third of small fourth-generation tibial sawbones and stabilized with 2 (double) or 4 (quadruple) flexible intramedullary nails. After pilot testing, 5 models per fixation method were tested cyclically in axial compression, torsion, and 4-point bending in valgus and recurvatum. At the end of the study, each model was loaded to failure in valgus. Stiffness values were calculated, and yield points were recorded. The data were compared using Student's t tests. Results are presented as mean±SD. The level of significance was set at P≤0.05. RESULTS Stiffness in valgus 4-point bending was 624±231 and 336±162 N/mm in the quadruple-nail and double-nail groups, respectively (P=0.04). There were no statistically significant differences in any other mode of testing. CONCLUSIONS The quadruple-nail construct was almost 2 times as stiff as the double-nail construct in resisting valgus deformation. This provides biomechanical support for a previously published study describing the clinical success of this fixation construct.
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18
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Minimally Invasive Medial Plate Osteosynthesis of High-Energy Pediatric Tibia Fractures. J Orthop Trauma 2020; 34:e272-e281. [PMID: 32097234 DOI: 10.1097/bot.0000000000001751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We report on the largest series to date of minimally invasive medial plate osteosynthesis of high-energy tibia fractures in skeletally immature patients. DESIGN Retrospective. SETTING Level 1 trauma center. PATIENTS Skeletally immature patients with high-energy tibia fractures treated with minimally invasive medial plate osteosynthesis between 2006 and 2017. We identified 28 fractures in 26 patients. MAIN OUTCOME MEASURE We reviewed the record for patient, injury, and treatment factors as well as for complications and reoperation. We assessed the relationships between age, implant selection, and implant removal using χ and t test analyses. RESULTS Mean age was 12 years (4-15) with OTA/AO classifications including 42A (18), 42B (6), and 42C (4). There were 10 open fractures (1 type I, 2 type II, and 7 type III). Mean follow-up was 37.6 months (minimum 7). Mean time to full weight-bearing and union was 2 and 3 months, respectively. Plate stock (2.7, 3.5, and 4.5 mm) and length (6-20 holes) varied independent of age, P = 0.19. There were 2 superficial infections, one 15 mm leg length discrepancy, and one case of fasciotomy at the time of plate fixation for trauma-related compartment syndrome. Implant removal was more likely in younger patients (10.9 vs. 13.2 years, P = 0.04) and not associated with plate stock, P = 0.97. There were no neurovascular injuries, losses of reduction, or rotational deformities. Angulation was universally <5 degrees in the coronal plane and <10 degrees in the sagittal plane. CONCLUSIONS Minimally invasive medial plate osteosynthesis of high-energy pediatric tibia fractures may be performed with a low rate of complications and should be considered in this select patient population with multiple injuries, high-energy mechanisms, and significant soft-tissue trauma. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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19
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Weltsch D, Baldwin KD. Rigid locked nail fixation for pediatric tibia fractures - Where are the data? World J Orthop 2019; 10:299-303. [PMID: 31448204 PMCID: PMC6704350 DOI: 10.5312/wjo.v10.i8.299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/27/2019] [Accepted: 07/23/2019] [Indexed: 02/06/2023] Open
Abstract
Tibial shaft fractures are common injuries among the pediatric and adolescent population. Conservative treatment remains the preferred treatment. However, over the last two decades, there has been an increasing trend of operative fixation in pediatric tibia fractures, commonly with intramedullary nail fixation (IMN). Elastic stable intramedullary nails (ESIN) are heavily used especially in skeletally immature patients as they are physeal respecting and the technique for insertion is familiar. Alternatively, reamed locked intramedullary nails (RIMN) have gained traction in adolescents and skeletally immature pre-adolescents. When identifying publications germane to intramedullary fixation of pediatric tibia fractures, the majority investigated clinical and radiographic outcomes associated with ESIN. We were able to identify only one study specifically examining RIMN in this population, albeit other studies included patients treated with RIMN. In parallel, there has been considerable progress in the field of skeletal maturity estimation with criteria based on different anatomic regions. However, little data exists for trauma purposes as no gold standard system had been accepted and proven to be precise for determination of potential growth remaining around the knee or for quantifying the risk of damage to the proximal tibial physis. Systems devised have been either unvalidated or unnecessarily complex or both. In order to achieve more informed treatment choices and optimal patient outcomes when using IMN fixation in pediatrics, simple to use, validated plain film-based methodology is needed to define skeletal maturity for the proximal tibia. Additionally, further examination of outcomes and the role of RIMN in this population are warranted.
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Affiliation(s)
- Daniel Weltsch
- Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, United States
- Department of Orthopaedic Surgery, The Chaim Sheba Medical Center at Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Ramat Gan 52620, Israel
| | - Keith D Baldwin
- Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, United States
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA 19104, United States
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20
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Kleiner JE, Raducha JE, Cruz, Jr. AI. Increasing rates of surgical treatment for paediatric tibial shaft fractures: a national database study from between 2000 and 2012. J Child Orthop 2019; 13:213-219. [PMID: 30996747 PMCID: PMC6442513 DOI: 10.1302/1863-2548.13.180163] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 01/31/2019] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Tibia fractures are the third most common long bone fracture in children. Because of the remodelling potential of the tibial diaphysis, nonoperative treatment has historically been advocated for most tibial shaft fractures in children. The purpose of this study was to estimate the rate of surgical treatment of tibial shaft fractures over time and identify demographic factors associated with surgical treatment, utilizing a large, publicly available, national database. METHODS The Healthcare Cost and Utilization Project Kids' Inpatient Database was evaluated for the years between 2000 and 2012. Tibial shaft fractures and surgically treated patients were identified using International Classification of Diseases, 9th Revision, Clinical Modification codes. Univariable and multivariable logistic regression were used to determine variables associated with a greater proportion of surgical treatment. Statistical analyses were performed utilizing SAS statistical software v.9.4. Statistical significance was set at p < 0.05. RESULTS In all, 24 166 tibial shaft fracture admissions were identified, with 15 621 (64.7%) treated surgically. The percentage of patients receiving surgery to treat tibial shaft fractures increased from 57.3% in 2000 to 74.3% in 2012 (p < 0.001). Multivariable regression showed that increasing age was associated with increased rate of surgical treatment (p < 0.001). The greatest increase in surgical treatment was seen in children aged five to nine years, increasing from 23.0% in 2000 to 46.2% in 2012. CONCLUSION The rate of operative treatment of paediatric tibial shaft fractures increased over time. The largest increase was seen in children aged five to nine years. Increased proportion of surgical treatment was associated with older age, concurrent femur fracture and non-Medicaid insurance status. LEVEL OF EVIDENCE Level III - Retrospective comparative study.
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Affiliation(s)
- J E. Kleiner
- Department of Orthopaedics, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - J E. Raducha
- Department of Orthopaedics, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - A. I. Cruz, Jr.
- Department of Orthopaedics Division of Pediatric Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island, USA
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21
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Cruz AI, Raducha JE, Swarup I, Schachne JM, Fabricant PD. Evidence-based update on the surgical treatment of pediatric tibial shaft fractures. Curr Opin Pediatr 2019; 31:92-102. [PMID: 30461511 DOI: 10.1097/mop.0000000000000704] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To describe surgical treatment options for pediatric tibial shaft fractures which are the third most common pediatric long bone fracture. Management of these injuries is dictated by fracture location, fracture pattern, associated injuries, skeletal maturity, and other patient-specific factors. Although most pediatric tibial shaft fractures can be treated nonoperatively, this review provides an update on surgical treatment options when operative intervention is indicated. RECENT FINDINGS Advances in surgical implants and techniques affords a wide range of options for the surgical treatment of pediatric tibial shaft fractures. Flexible intramedullary nailing is gaining wide adoption for acute surgical treatment. Recent studies support cross-sectional imaging for further evaluation and scrutiny of fracture patterns suspicious for intraphyseal or intra-articular extension. Grade I open tibial shaft fractures may be safely treated with irrigation and debridement in the emergency department; however, no high-level comparative studies have been performed to make any definitive conclusions regarding the effectiveness of this treatment strategy. SUMMARY Tibial shaft fractures are common injuries in pediatric patients. Management is dictated by fracture location, fracture pattern, associated injuries, patient age, and other patient-specific factors. Surgical intervention is indicated for fractures that are open, irreducible, have failed nonoperative management, are associated with compartment syndrome, or in the multiply injured patient. Surgical treatment options include flexible intramedullary nailing, plate osteosynthesis, external fixation, and rigid intramedullary nailing. Recent literature has shown increased rates of flexible intramedullary nailing. All operative and nonoperative management options can result in complications including compartment syndrome, infection, delayed union, nonunion, malunion, limb length discrepancy, and symptomatic hardware. Most pediatric patients go on to uneventful union with excellent final outcomes and return to full activities.
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Affiliation(s)
- Aristides I Cruz
- Department of Orthopaedic Surgery, Hasbro Children's Hospital, Warren Alpert Medical School of Brown University
| | - Jeremy E Raducha
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Ishaan Swarup
- Pediatric Orthopaedic Surgery Service, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Jonathan M Schachne
- Pediatric Orthopaedic Surgery Service, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Peter D Fabricant
- Pediatric Orthopaedic Surgery Service, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA
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Raducha JE, Swarup I, Schachne JM, Cruz AI, Fabricant PD. Tibial Shaft Fractures in Children and Adolescents. JBJS Rev 2019; 7:e4. [DOI: 10.2106/jbjs.rvw.18.00047] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Metaizeau JD, Denis D. Update on leg fractures in paediatric patients. Orthop Traumatol Surg Res 2019; 105:S143-S151. [PMID: 29601968 DOI: 10.1016/j.otsr.2018.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/06/2018] [Accepted: 02/13/2018] [Indexed: 02/07/2023]
Abstract
Leg fractures are common and further increasing in prevalence in paediatric patients. The diagnosis is readily made in most cases. Choosing the best treatment is the main issue. Non-operative treatment is the reference standard for non-displaced or reducible and stable fractures but requires considerable expertise and close monitoring, as well as an immobilisation period that far exceeds 3 months in many cases. Some surgical teams therefore offer elastic stable intra-medullary nailing (ESIN) as an alternative to children who do not want to be immobilised for several months. Internal fixation is required for unstable or irreducible leg fractures. ESIN is often used as the first-line method, based on its very good risk/benefit ratio. For fractures that do not lend themselves to ESIN, optimal stabilisation can be achieved by choosing among the other available options (screw-plate fixation, rigid intra-medullary nailing or external fixation) on a case-by-case basis. Close monitoring during the first few days is crucial to ensure the early detection of compartment syndrome. The other complications and sequelae are non-specific.
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Affiliation(s)
- Jean-Damien Metaizeau
- Pediatric orthopedic department, university hospital F. Mitterrand, 21079 Dijon, France.
| | - Delphy Denis
- Pediatric orthopedic department, university hospital F. Mitterrand, 21079 Dijon, France
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Marengo L, Nasto LA, Michelis MB, Boero S. Elastic stable intramedullary nailing (ESIN) in paediatric femur and tibia shaft fractures: Comparison between titanium and stainless steel nails. Injury 2018; 49 Suppl 3:S8-S11. [PMID: 30415674 DOI: 10.1016/j.injury.2018.09.049] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 09/25/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Elastic stable intramedullary nailing (ESIN) is currently considered the gold standard in surgical treatment of femur and tibial shaft fractures in school age paediatric patients. Although elastic intramedullary nails are available in both titanium (Ti) and stainless steel (SS) alloy, titanium nails are most commonly used. Nevertheless, there is still contrasting evidence as to whether the use of Ti nails can offer better outcomes in terms of fracture healing and stability over SS nails. The aim of this study was to compare outcomes and complications of Ti and SS ESIN for femur and tibia shaft fractures in a population of school age paediatric patients. MATERIALS AND METHODS All consecutive patients who underwent ESIN for femoral or tibial shaft fracture from June 2012 to May 2015 at our centre were retrospectively reviewed. Standard demographic data were collected. Pre-operative and post-operative X-rays were reviewed, complications were collected from patients charts. Patients were divided in two groups, titanium nails (Ti group) and stainless steel nails (SS group) and outcomes compared between the two. RESULTS A total of 34 patients were included (17 patients Ti group, 17 patients SS group) with a total of 14 femur and 21 tibia fractures. Average age at surgery was 9.4 ± 2.5 years in Ti group and 10.4 ± 2.4 years in SS group (p = 0.21). The average time to bone healing was 3 months in Ti group, and 2.8 months in SS group (p = 0.63). At final follow-up (12 months), no patient showed a coronal plane or sagittal plane deformity >10° and >15°, respectively. Complication rate was similar between the two groups (24% Ti group, 22% SS group). CONCLUSIONS We did not observe any significant difference in terms of bone healing, fracture mechanical stability, return to full activity, and complication rate between Ti and SS ESIN for paediatric femoral and tibial shaft fractures. While Ti nails remain a better choice for patients with metal allergy, SS nails may offer safe, effective, and cheaper alternative to Ti nails in school age femur and tibial shaft fractures.
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Affiliation(s)
- Lorenza Marengo
- Department of Paediatric Orthopaedics, IRCCS Istituto Giannina Gaslini, via Gerolamo Gaslini 5, 16147, Genoa, Italy.
| | - Luigi Aurelio Nasto
- Department of Paediatric Orthopaedics, IRCCS Istituto Giannina Gaslini, via Gerolamo Gaslini 5, 16147, Genoa, Italy
| | - Maria Beatrice Michelis
- Department of Paediatric Orthopaedics, IRCCS Istituto Giannina Gaslini, via Gerolamo Gaslini 5, 16147, Genoa, Italy
| | - Silvio Boero
- Department of Paediatric Orthopaedics, IRCCS Istituto Giannina Gaslini, via Gerolamo Gaslini 5, 16147, Genoa, Italy
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Chen H, Chen S, Shi Y, Lu Y, Yu B. Children with open tibial fractures show significantly lower infection rates than adults: clinical comparative study. INTERNATIONAL ORTHOPAEDICS 2018; 43:713-718. [DOI: 10.1007/s00264-018-3996-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 05/18/2018] [Indexed: 01/03/2023]
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Simon AL, Apostolou N, Vidal C, Ferrero E, Mazda K, Ilharreborde B. Paediatric tibial shaft fractures treated by open reduction and stabilization with monolateral external fixation. J Child Orthop 2018; 12:20-28. [PMID: 29456750 PMCID: PMC5813121 DOI: 10.1302/1863-2548.12.170056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Elastic stable intramedullary nailing is increasingly used for surgical treatment of tibial shaft fractures, but frequently requires immobilization and delayed full weight-bearing. Therefore, external fixation remains interesting. The aim was to report clinico-radiological outcomes of monolateral external fixation for displaced and unstable tibial shaft fractures in children. METHODS All tibial fractures consecutively treated by monolateral external fixation between 2008 and 2013 were followed. Inclusion criteria included skeletal immaturity and closed and open Gustilo I fractures caused by a direct impact. Patients were seen until two years postoperatively. Demographics, mechanism of injury, surgical data and complications were recorded. Anteroposterior and lateral side radiographs were performed at each visit. Full-limb 3D reconstructions using biplanar stereroradiography was performed for final limb length and alignment measures. RESULTS A total of 45 patients (mean age 9.7 years ± 0.5) were included. In all, 17 were Gustilo I fractures, with no difference between open and closed fractures for any data. Mean time to full weight bearing was 18.2 days ± 0.7. After 15 days, 39 patients returned to school. Hardware removal (mean time to union 15.6 weeks ± 0.8) was performed during consultation under analgesic gas. There were no cases of nonunion. No fracture healed with > 10° of angulation (mean 5.1° ± 0.4°). Leg-length discrepancy > 10 mm was found for six patients. CONCLUSIONS This procedure can be a safe and simple surgical treatment for children with tibial shaft fractures. Few complications and early return to school were reported, with the limitations of non-comparative study. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- A.-L. Simon
- Pediatric Orthopedic Department, Robert Debré Hospital, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris Diderot University, Paris, France,
Correspondence should be sent to A-L. Simon, Pediatric Orthopedic Department, Robert Debré Hospital, AP-HP, Paris Diderot University, 48 Bd Sérurier, 75019 Paris, France. E-mail:
| | - N. Apostolou
- Pediatric Orthopedic Department, Robert Debré Hospital, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris Diderot University, Paris, France
| | - C. Vidal
- Pediatric Orthopedic Department, Robert Debré Hospital, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris Diderot University, Paris, France
| | - E. Ferrero
- Pediatric Orthopedic Department, Robert Debré Hospital, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris Diderot University, Paris, France
| | - K. Mazda
- Pediatric Orthopedic Department, Robert Debré Hospital, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris Diderot University, Paris, France
| | - B. Ilharreborde
- Pediatric Orthopedic Department, Robert Debré Hospital, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris Diderot University, Paris, France
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Comparison of the outcomes of pediatric tibial shaft fractures treated by different types of orthopedists: A prospective cohort study. Int J Surg 2018; 51:140-144. [PMID: 29407250 DOI: 10.1016/j.ijsu.2018.01.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 01/19/2018] [Accepted: 01/24/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND The objective of this study was to compare the outcomes of pediatric tibial shaft fractures treated with titanium elastic nail (TEN) by pediatric orthopedists and non-pediatric orthopedists. MATERIALS AND METHODS We conducted a prospective cohort study of 90 children of tibial shaft fractures, who were randomized to operative stabilization either by pediatric orthopedists (Group A, 45 cases) or by non-pediatric orthopedists (Group B, 45 cases) from April 2010 to May 2015. Demographic data and clinical characteristics (age, sex, weight, fracture side and type, cause of injury, number of fibula fracture and time from injury to operation) were comparable between the two groups before surgery. Clinical data, complications and functional outcomes between the two groups were recorded. RESULTS A total of 10 patients were lost to follow-up for various reasons and each group remained 40 cases. The mean follow-up period was 14.9 ± 1.9 months for Group A and 15.3 ± 2.2 months for Group B (P = 0.451). There was no significant difference in length of hospitalization, full weight-bearing time, fracture union time and TEN outcome scores between the two groups (P = 0.917, P = 0.352, P = 0.404, P = 506, respectively). However, Group A exhibited significantly shorter operation duration and less fluoroscopy times than Group B (P < 0.001 and P < 0.001, respectively). Also, there was a trend for patients of Group A to have lower rate of open reduction than Group B (P = 0.019). When comparing the total complications, no significant difference existed between the groups (P = 0.764). CONCLUSIONS Our results indicated that pediatric tibial shaft fractures treated surgically by pediatric orthopedists offered potential advantages including a shorter operating time, less times of fluoroscopy and a lower rate of open reduction. However, both pediatric and non-pediatric orthopedists could achieve satisfactory clinical results in treatment of these injuries.
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Huang YC, Renn JH, Tarng YW. The titanium elastic nail serves as an alternative treatment for adult proximal radial shaft fractures: a cohort study. J Orthop Surg Res 2018; 13:10. [PMID: 29334971 PMCID: PMC5769387 DOI: 10.1186/s13018-017-0704-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 12/26/2017] [Indexed: 11/10/2022] Open
Abstract
Background To investigate whether closed reduction and internal fixation (CRIF) with titanium elastic nails (TENs) is a viable alternative treatment in proximal radial fractures. Methods In Kaohsiung Veterans General Hospital, from November 2013 to April 2015, five adult male patients with forearm injuries (average age 43 years; range 35–64 years) were treated for proximal radial shaft fractures. CRIF with TENs for radial shaft fractures was performed in these five patients. Radiographs; range of motions; visual analog scale (VAS); quick disabilities of the arm, shoulder, and hand (Quick DASH) questionnaire; and time to union were evaluated in our study. Results Mean follow-up period was 30 months (range 28–36 months). Average time of radius union was 7.3 months (range 6–10 months). Functional outcomes 1 year after operation revealed an average Quick DASH score of 7.92 (range 4.5–25), an average VAS of 1.5 (range 1–3), and average forearm supination and pronation of 69.2° (range 45°–75°) and 82.5° (range 80°–85°). No major complication was noted. Conclusions CRIF with TEN for adult proximal radial fractures is a method to avoid extensive exposure or nerve injury during ORIF, especially in multiple trauma patients who require short operative time, uremia patients with ipsilateral forearm AV shunt, severe soft tissue swelling due to direct muscle contusion or strong muscularity before surgery, extensive radial fracture, and those in pursuit of cosmetic outcomes.
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Affiliation(s)
- Ying-Cheng Huang
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung 1st Rd, Kaohsiung, 81346, Taiwan, Republic of China
| | - Jenn-Huei Renn
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung 1st Rd, Kaohsiung, 81346, Taiwan, Republic of China.,National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Yih-Wen Tarng
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung 1st Rd, Kaohsiung, 81346, Taiwan, Republic of China. .,National Defense Medical Center, Taipei, Taiwan, Republic of China.
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Abstract
Open fractures in children differ from adults owing to their better healing potential. Management strategies for open fracture in children are changing with improvement in our understanding of soft-tissue reconstruction and fracture fixation. A literature review was performed for articles covering management of open fractures in children. The cornerstones of management include prevention of infection, debridement, and skeletal stabilization with soft-tissue coverage. The injury should be categorized according to the established trauma classification systems. Timely administration of appropriate antibiotics is important for preventing infections. Soft-tissue management includes copious irrigation and debridement of the wound. Fractures can be stabilized by a variety of nonoperative and operative means, taking into consideration the special needs of the growing skeleton and the role of a thick and active periosteum in the healing of fractures. The soft-tissue coverage required depends on the grade of injury.
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Affiliation(s)
- Akshat Sharma
- Department of Paediatric Orthopaedics, KUMC GURO Hospital, Seoul, Korea,Address for correspondence: Dr. Akshat Sharma, 15, Nav Vikas Apartments, Sector – 15, Rohini, New Delhi - 110 089, India. E-mail:
| | - Vikas Gupta
- Central Institute of Orthopaedics, Safdarjung Hospital, New Delhi, India
| | - Kumar Shashikant
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
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Abstract
BACKGROUND Elastic nailing is a common method of fixation for tibial shaft fractures in skeletally immature individuals. Poor outcomes of titanium elastic nails for femoral shaft fractures have been associated with increasing patient age and weight, especially patients weighing >50 kg. Our objective is to determine if there is an upper weight or age limit to the safe and effective use of titanium elastic nails for tibial shaft fractures in the pediatric population. METHODS This is a retrospective cohort study of patients who underwent stabilization of a tibial shaft fracture with titanium elastic nails at a large tertiary-care pediatric trauma center. Data collected included patient demographics, injury characteristics, and radiographic data. Weight groups were stratified as ≥ or <50 kg, and age groups as 14 years or older or less than 14 years old. Malunion was defined as 10 degrees of angulation in either the sagittal or coronal plane. Union was defined as bridging of ≥3 cortices on orthogonal radiographs. A significant difference in time to union was considered to be 3 weeks. RESULTS Ninety-five patients were included with a mean age of 12.1 years (range, 6 to 16 y) and a mean weight of 50.2 kg (range, 21 to 122 kg). Malunion rate was similar between weight cohorts: 13.3% (6/45) in the ≥50-kg group and 10% (5/50) in the <50-kg group (P=0.61). Malunion rate was similarly comparable between age groups: 17.6% (6/34) in the 14 years and older group and 8.2% (5/61) in the less than 14-year-old group (P=0.17). There was no statistically significant difference in time to union between weight or age cohorts. In sum, we did not find a significant difference in the rate of malunion or time to healing between younger and older patients or between lighter and heavier patients. CONCLUSION The use of titanium elastic nails for tibial shaft fractures, unlike for other long bone fractures, seems not to be precluded in older and heavier patients. LEVEL OF EVIDENCE Level III.
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Nandra RS, Wu F, Gaffey A, Bache CE. The management of open tibial fractures in children. Bone Joint J 2017; 99-B:544-553. [DOI: 10.1302/0301-620x.99b4.37855] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 12/06/2016] [Indexed: 11/05/2022]
Abstract
Aims Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union. Patients and Methods A retrospective review was performed on 61 children who between 2007 and 2015 presented with an open tibia fracture. Their mean age was nine years (2 to 16) and the median follow-up was ten months (interquartile range 5 to 18). Management involved IV antibiotics, early debridement and combined treatment of the skeletal and soft-tissue injuries in line with standards proposed by the British Orthopaedic Association. Results There were 36 diaphyseal fractures and 25 distal tibial fractures. Of the distal fractures, eight involved the physis. Motor vehicle collisions accounted for two thirds of the injuries and 38 patients (62%) arrived outside of normal working hours. The initial method of stabilisation comprised: casting in nine cases (15%); elastic nailing in 19 (31%); Kirschner (K)-wiring in 13 (21%); intramedullary nailing in one (2%); open reduction and plate fixation in four (7%); and external fixation in 15 (25%). Wound management comprised: primary wound closure in 24 (39%), delayed primary closure in 11 (18%), split skin graft (SSG) in eight (13%), local flap with SSG in 17 (28%) and a free flap in one. A total of 43 fractures (70%) were Gustilo-Anderson grade III. There were four superficial (6.6%) and three (4.9%) deep infections. Two deep infections occurred following open reduction and plate fixation and the third after K-wire fixation of a distal fracture. No patient who underwent primary wound closure developed an infection. All the fractures united, although nine patients required revision of a mono-lateral to circular frame for delayed union (two) or for altered alignment or length (seven). The mean time to union was two weeks longer in diaphyseal fractures than in distal fractures (13 weeks versus 10.8 weeks, p = 0.016). Children aged > 12 years had a significantly longer time to union than those aged < 12 years (16.3 weeks versus 11.4 weeks, p = 0.045). The length of stay in hospital for patients with a Gustilo-Anderson grade IIIB fracture was twice as long as for less severe injuries. Conclusion Fractures in children heal better than those in adults. Based on our experience of deep infection we discourage the use of internal fixation with a plate for open tibial fractures in children. We advocate aggressive initial wound debridement in theatre with early definitive combined orthopaedic and plastic surgery in order to obtain skeletal stabilisation and soft-tissue cover. Cite this article: Bone Joint J 2017;99-B:544–53.
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Affiliation(s)
- R. S. Nandra
- Birmingham Children’s Hospital, Steelhouse
Lane, Birmingham, B4 6NH, UK
| | - F. Wu
- Birmingham Children’s Hospital, Steelhouse
Lane, Birmingham, B4 6NH, UK
| | - A. Gaffey
- Birmingham Children’s Hospital, Steelhouse
Lane, Birmingham, B4 6NH, UK
| | - C. E. Bache
- Birmingham Children’s Hospital, Steelhouse
Lane, Birmingham, B4 6NH, UK
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Canavese F, Botnari A, Andreacchio A, Marengo L, Samba A, Dimeglio A, Pereira B, Mansour M, Rousset M. Displaced Tibial Shaft Fractures With Intact Fibula in Children: Nonoperative Management Versus Operative Treatment With Elastic Stable Intramedullary Nailing. J Pediatr Orthop 2016; 36:667-672. [PMID: 26151246 DOI: 10.1097/bpo.0000000000000528] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The main objective of this study was to retrospectively evaluate the clinical and radiographic outcomes of displaced tibial shaft fractures with intact fibula in children after nonoperative management and operative treatment by elastic stable intramedullary nailing. METHODS A study was performed on 80 consecutive children, 56 males, 24 females from 2 Institutions, with displaced and closed tibial shaft fracture with intact fibula. All patients underwent regular clinical and radiographic follow-up visits for at least 2 years after injury. RESULTS In total, 26 patients (group A-Institution I) were treated surgically by elastic stable intramedullary nailing and 54 patients (18 patients from group B-Institution I and 36 patients from group C-Institution II) were treated nonoperatively with closed reduction and casting. groups A, B, and C did not significantly differ on sex (P=0.37), side (P=0.54), and fracture site (P=0.14).Valgus deformity was significantly controlled in group A patients only (P=0.001); during follow-up in group B patients (P=0.017), and showed no significant change between pretreatment images and last follow-up in group C patients (P=0.71). Procurvatum deformity was significantly controlled in group A patients only (P=0.001); it showed no significant improvement after conservative treatment in group B (P=0.73) and C patients (P=0.8). Recurvatum was significantly improved in group A (P<0.001) and C patients (P<0.001) but remained unchanged in group B patients (P=0.15). Varus deformity improved significantly in all patient groups.Immobilization time was significantly shorter in group A compared with group B and C patients (P<0.001).However, numerical differences, although statistically significant, were not clinically relevant for all variables but immobilization time. CONCLUSIONS This study showed good functional and radiologic outcomes in the pediatric population who had sustained closed, traumatic, displaced fracture of tibial diaphysis without associated fibula fracture.On the basis of the findings reported here, it is not contraindicated to operate skeletally immature patients with displaced fracture of tibial diaphysis without associated fibula fracture. However, results were essentially the same and either method is a satisfactory choice for pediatric tibia shaft fractures with an intact fibula. In particular, we found that conservative treatment was as efficacious as surgical treatment apart from the length of time for immobilization. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Federico Canavese
- *Pediatric Orthopedic Department, Estaing University Hospital §Biostatistics Unit, DRCI, Estaing University Hospital, Clermont-Ferrand ‡Faculty of Medicine, Montpellier University, Montpellier, France †Pediatric Orthopedic Department, Regina Margherita Children's Hospital, Turin, Italy
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Ramasubbu RA, Ramasubbu BM. Surgical stabilization for open tibial fractures in children: External fixation or elastic stable intramedullary nail - which method is optimal? Indian J Orthop 2016; 50:455-463. [PMID: 27746486 PMCID: PMC5017165 DOI: 10.4103/0019-5413.189613] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Management of open tibial fractures is well documented in adults, with existing protocols outlining detailed treatment strategies. No clear guidelines exist for children. Surgical stabilization of tibial fractures in the pediatric population requires implants that do not disrupt the open epiphyses (growth plate). Both elastic stable intramedullary nails and external fixation can be used. The objective of this study was to identify the optimal method of surgical stabilization in the treatment of open tibial fractures in children. MATERIALS AND METHODS MEDLINE and Embase were searched from their inception to March 2014 using the following advanced search terms (Key words): "open tibia fracture," "fracture fixation," "external fixation," "intramedullary," and "bone nail." Only studies in English and pertaining to children with open fractures treated with elastic stable intramedullary nails or external fixation between 1994 and 2014 were included. Twelve clinical studies were critically appraised. RESULTS Due to a paucity in the literature coupled with a nonsystematic presentation of results, it proved to be very difficult in extracting relevant results from the studies. This was further added by a variation in outcome measures. Consequently, the results we obtained were difficult to draw conclusions from. CONCLUSION There is no conclusive evidence or best practice guidelines for their management. Thus, as is highlighted in this study, more research is needed to determine the optimum treatment strategy for this common pediatric injury. The existing literature is of poor quality; consisting mainly of retrospective reviews of patients' medical records, charts, and radiographs. Carefully designed, high-quality prospective cohort studies utilizing a nationalized multi-hospital approach are needed to improve understanding before protocols and guidelines can be developed and implemented.
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Affiliation(s)
- Rohan A Ramasubbu
- Department of Clinical Anatomy, School of Medicine, University of St. Andrews, Fife, Scotland,Address for correspondence: Mr. Rohan A Ramasubbu, 13/2 Gilmore Place, Edinburgh, EH3 9NE, Scotland. E-mail:
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Canavese F, Marengo L, Samba A, Rousset M, Mansour M, Andreacchio A, Dimeglio A. Evaluation of upper extremity function of displaced diaphyseal humeral fractures in children treated by elastic stable intramedullary nailing: preliminary results. J Pediatr Orthop B 2016; 25:399-405. [PMID: 27058818 DOI: 10.1097/bpb.0000000000000318] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
The aim of this study was to retrospectively evaluate the outcome of displaced humeral shaft fractures in children and adolescents treated by elastic stable intramedullary nailing (ESIN) and to evaluate upper extremity function using the Quick-DASH questionnaire. Correction was maintained over time in 14 of 16 patients. All patients were pain free at last follow-up. Shoulder and elbow ranges of motion were comparable with the noninjured side. The mean Quick-DASH score was 1. This study reports good functional outcomes in children with displaced humeral shaft fractures surgically treated with ESIN, even in the presence of residual deformity. ESIN enables stable reduction, good rotational control, and good functional outcome.
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Affiliation(s)
- Federico Canavese
- aDepartment of Pediatric Surgery, University Hospital Estaing, Clermont Ferrand bFaculty of Medicine, University of Montpellier, Montpellier, France cDepartment of Pediatric Orthopedic Surgery, Regina Margherita Children's Hospital, Torino, Italy
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Abstract
Open fractures in children are rare and are typically associated with better prognoses compared with their adult equivalents. Regardless, open fractures pose a challenge because of the risk of healing complications and infection, leading to significant morbidity even in the pediatric population. Therefore, the management of pediatric open fractures requires special consideration. This article comprehensively reviews the initial evaluation, classification, treatment, outcomes, and controversies of open fractures in children.
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Affiliation(s)
- Arianna Trionfo
- Department of Orthopaedic Surgery, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA.
| | - Priscilla K Cavanaugh
- Department of Orthopaedic Surgery, St. Christopher's Hospital for Children, Drexel University College of Medicine, 160 East Erie Avenue, Philadelphia, PA 19134, USA
| | - Martin J Herman
- Department of Orthopaedic Surgery, St. Christopher's Hospital for Children, Drexel University College of Medicine, 160 East Erie Avenue, Philadelphia, PA 19134, USA
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Abstract
OBJECTIVES The aim of this study is to investigate the effectiveness and reliability of limited-contact locking plates in minimally invasive percutaneous osteosynthesis (MIPO) of the lateral tibia. DESIGN A retrospective study. PATIENTS AND METHODS The retrospective study included 14 patients who were operatively treated with an MIPO technique due to open tibial fractures between 2006 and 2012. The patients were 11 males and 3 females with a mean age of 13.2 (range, 9 to 16) years. The patients were followed up for a mean period of 2.4 (range, 1 to 5) years. The mechanism of the injuries included a motor vehicle accident (n=11), a shotgun injury (n=2), and a fall from height (n=1). According to the Gustilo-Anderson classification, 10 patients had type I (72%), 2 had type II (14%), and 2 had type III (14%) open fractures. RESULTS The mean time to radiologic union was 18 (range, 11 to 32) weeks. No infection was detected that would require implant removal. No complications such as early epiphyseal closure, angulation, or limb-length inequality were observed. CONCLUSIONS Limited-contact locking plates in MIPO of the lateral tibia is an effective alternative method in the treatment of open pediatric tibial fractures. LEVEL OF EVIDENCE Level IV-therapeutic.
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Tibia Shaft Fractures in Adolescents: How and When Can They be Managed Successfully With Cast Treatment? J Pediatr Orthop 2016; 36 Suppl 1:S15-8. [PMID: 27078230 DOI: 10.1097/bpo.0000000000000762] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite the increasing popularity of operative treatment in adolescent tibia fractures, casting remains a viable first-line treatment. Because the selection bias in published reports does not allow direct comparison between casting and flexible nail treatment of closed pediatric tibia fractures, it is unclear whether flexible nailing offers any advantages over casting. This overview discusses parameters of acceptable alignment, indications, techniques for successful reduction and casting, subsequent inpatient and outpatient management including wedging of casted tibia fractures, expected outcomes, and comparison of casting with flexible nailing. As with any orthopaedic procedure, careful attention to patient selection, indications, and detail facilitates successful cast treatment in this older pediatric population.
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Flexible Intramedullary Nailing of Unstable and/or Open Tibia Shaft Fractures in the Pediatric Population. J Pediatr Orthop 2016; 36 Suppl 1:S19-23. [PMID: 27078231 DOI: 10.1097/bpo.0000000000000754] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Tibial shaft fractures are common injuries in the pediatric population, and can be treated conservatively the vast majority of the time. Yet, it is important to recognize that open and/or unstable tibial shaft fractures represent a different entity. Rigid intramedullary devices are generally contraindicated because of the skeletal immaturity of these patients, and external fixation is associated with a high complication rate. As a result, flexible nailing is being utilized with increasing frequency. It is essential for the clinician to understand the pearls and pitfalls associated with the utilization of these flexible nails; particularly in regards to their immediate use in the context of open fractures and the risk of compartment syndrome postoperatively after fixation.
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Marengo L, Paonessa M, Andreacchio A, Dimeglio A, Potenza A, Canavese F. Displaced tibia shaft fractures in children treated by elastic stable intramedullary nailing: results and complications in children weighing 50 kg (110 lb) or more. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2016; 26:311-317. [PMID: 26662289 DOI: 10.1007/s00590-015-1729-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 12/06/2015] [Indexed: 11/28/2022]
Abstract
The main objective of this study was to retrospectively evaluate the clinical and radiographic outcomes of displaced tibia shaft fractures in children weighing 50 kg (110 lb) or more treated by elastic stable intramedullary nailing (ESIN). Translation, sagittal and coronal angulations were assessed on plain radiographs in all the patients. Twenty-six out of 106 patients met the inclusion criteria. The average patient age at the time of injury was 13.5 ± 1.3 years (range 11.3-16.1). The mean patient weight was 57 ± 8 kg (range 50-80). This study demonstrates that the use of ESIN for displaced tibia shaft fractures in children and adolescents weighing 50 kg (110 lb) or more, or older than 13 years of age, is not contraindicated. In contrast to data in femoral shaft fractures, we did not find poorer outcomes in older or heavier patients. No correlation between nail size/medullary canal diameter ratio and outcome was observed.
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Affiliation(s)
- Lorenza Marengo
- Pediatric Surgery Department, University Hospital Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand, France
| | - Matteo Paonessa
- Pediatric Orthopedic Surgery Department, Regina Margherita Children's Hospital, Piazza Polonia 94, 10100, Turin, Italy
| | - Antonio Andreacchio
- Pediatric Orthopedic Surgery Department, Regina Margherita Children's Hospital, Piazza Polonia 94, 10100, Turin, Italy
| | - Alain Dimeglio
- Faculty of Medicine, University of Montpellier, 2 Rue de l'Ecole de Medicine, 34090, Montpellier, France
| | - Alberto Potenza
- Pediatric Orthopedic Surgery Department, Regina Margherita Children's Hospital, Piazza Polonia 94, 10100, Turin, Italy
| | - Federico Canavese
- Pediatric Surgery Department, University Hospital Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand, France.
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Elastic nailing of tibia shaft fractures in young children up to 10 years of age. Injury 2016; 47:832-6. [PMID: 26606988 DOI: 10.1016/j.injury.2015.10.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 09/03/2015] [Accepted: 10/13/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Although tibia shaft fractures in children usually have satisfactory results after closed reduction and casting, there are several surgical indications, including associated fractures and soft tissue injuries such as open fractures. Titanium elastic nails (TENs) are often used for pediatric tibia fractures, and have the advantage of preserving the open physis. However, complications such as delayed union or nonunion are not uncommon in older children or open fractures. In the present study, we evaluated children up to 10 years of age with closed or open tibial shaft fractures treated with elastic nailing technique. METHODS A total of 16 tibia shaft fractures treated by elastic nailing from 2001 to 2013 were reviewed. The mean patient age at operation was 7 years (range: 5-10 years). Thirteen of 16 cases were open fractures (grade I: 4, grade II: 6, grade IIIA: 3 cases); the other cases had associated fractures that necessitated operative treatments. Closed, antegrade intramedullary nailing was used to insert two nails through the proximal tibial metaphysis. All patients were followed up for at least one year after the injury. Outcomes were evaluated using modified Flynn's criteria, including union, alignment, leg length discrepancies, and complications. RESULTS All fractures achieved union a mean of 16.1 weeks after surgery (range: 11-26 weeks). No patient reported knee pain or experienced any loss of knee or ankle motion. There was a case of superficial infection in a patient with grade III open fracture. Three patients reported soft tissue discomfort due to prominent TEN tips at the proximal insertion site, which required cutting the tip before union or removing the nail after union. At the last follow-up, there were no angular or rotational deformities over 10° in either the sagittal or coronal planes. With the exception of one case with an overgrowth of 15 mm, no patient showed shortening or overgrowth exceeding 10mm. Among final outcomes, 15 were excellent and 1 was satisfactory. SUMMARY Even with open fractures or soft tissue injuries, elastic nailing can achieve satisfactory results in young children, with minimal complications of delayed bone healing, or infection.
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Malhotra K, Pai S, Radcliffe G. Do minimally displaced, closed tibial fractures in children need monitoring for compartment syndrome? Injury 2015; 46:254-8. [PMID: 24972494 DOI: 10.1016/j.injury.2014.04.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 02/15/2014] [Accepted: 04/26/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Acute compartment syndrome (ACS) may be seen following tibial fractures in adults. Although the risk of this complication is thought to be lower in children (especially in those under the age of 12 years) it is routine practice in many units to admit all children with this injury for observation. The aim of this study was to ascertain whether all children under the age of 12 presenting with fractures of the tibia merited admission and to provide recommendations on how to manage these patients based on our experience with this injury. PATIENTS AND METHODS We retrospectively studied the clinical and radiographic progress of consecutive patients presenting to our institution with tibial fractures over a 5-year period. RESULTS A total of 159 tibial fractures were seen in the study period. The mean age of patients treated was 5.8 years. 81% of the injuries occurred in the diaphyseal region and 60% involved the tibia only. A total of 9% of injuries were open and overall 66% of fractures were managed non-operatively. No cases of ACS were seen. DISCUSSION Based on our experience we provide a treatment algorithm detailing how children in the under 12 age group presenting with tibial fractures may be managed. Patients with minimally displaced fractures involving the tibia only, whose pain is adequately controlled and who can safely mobilise with suitable parental supervision may be safely discharged from the emergency department in a back slab with early follow up. Although no children under the age of 12 in the present study developed ACS following a fracture of the tibia, certain features such as a history of a high energy injury, displaced fractures or co-existing fibular fractures should raise suspicion that this complication may ensue. In these cases admission and observation may be warranted.
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Affiliation(s)
- Karan Malhotra
- Department of Trauma & Orthopaedics, Bradford Royal Infirmary, Duckworth Lane, Bradford BD9 6RJ, UK.
| | - Sunil Pai
- Department of Trauma & Orthopaedics, Bradford Royal Infirmary, Duckworth Lane, Bradford BD9 6RJ, UK
| | - Graham Radcliffe
- Department of Trauma & Orthopaedics, Bradford Royal Infirmary, Duckworth Lane, Bradford BD9 6RJ, UK
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Palmu SA, Auro S, Lohman M, Paukku RT, Peltonen JI, Nietosvaara Y. Tibial fractures in children. A retrospective 27-year follow-up study. Acta Orthop 2014; 85:513-7. [PMID: 24786903 PMCID: PMC4164870 DOI: 10.3109/17453674.2014.916489] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Tibial fracture is the third most common long-bone fracture in children. Traditionally, most tibial fractures in children have been treated non-operatively, but there are no long-term results. METHODS 94 children (64 boys) were treated for a tibial fracture in Aurora City Hospital during the period 1980-89 but 20 could not be included in the study. 58 of the remaining 74 patients returned a written questionnaire and 45 attended a follow-up examination at mean 27 (23-32) years after the fracture. RESULTS 89 children had been treated by manipulation under anesthesia and cast-immobilization, 4 by skeletal traction, and 1 with pin fixation. 41 fractures had been re-manipulated. The mean length of hospital stay was 5 (1-26) days. Primary complications were recorded in 5 children. The childrens' memories of treatment were positive in two-thirds of cases. The mean subjective VAS score (range 0-10) for function appearance was 9. Leg-length discrepancy (5-10 mm) was found clinically in 10 of 45 subjects and rotational deformities exceeding 20° in 4. None of the subjects walked with a limp. None had axial malalignment exceeding 10°. Osteoarthritis of the hip and/or knee was seen in radiographs from 2 subjects. INTERPRETATION The long-term outcome of tibial fractures in children treated non-operatively is generally good.
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Affiliation(s)
- Sauli A Palmu
- Children’s Hospital, Helsinki University Central Hospital, Helsinki,Orton Orthopaedic Hospital, Orton Foundation, Helsinki,Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere
| | - Sampo Auro
- Children’s Hospital, Helsinki University Central Hospital, Helsinki
| | | | - Reijo T Paukku
- Children’s Hospital, Helsinki University Central Hospital, Helsinki,Orto-Lääkärit, Medical Center, Helsinki, Finland
| | - Jari I Peltonen
- Children’s Hospital, Helsinki University Central Hospital, Helsinki,Orton Orthopaedic Hospital, Orton Foundation, Helsinki
| | - Yrjänä Nietosvaara
- Children’s Hospital, Helsinki University Central Hospital, Helsinki,Orto-Lääkärit, Medical Center, Helsinki, Finland
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Economedes DM, Abzug JM, Paryavi E, Herman MJ. Outcomes using titanium elastic nails for open and closed pediatric tibia fractures. Orthopedics 2014; 37:e619-24. [PMID: 24992056 DOI: 10.3928/01477447-20140626-52] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 12/27/2013] [Indexed: 02/03/2023]
Abstract
The authors conducted a retrospective review at their level I trauma center to assess the outcomes of closed vs open pediatric tibial fractures treated with titanium elastic nails. The study group included 38 pediatric patients (median age, 12 years) treated with titanium elastic nails for tibial fractures during a 5-year period. Patient demographics, closed or open injury, Gustilo-Anderson type for open fractures, fracture location, skeletal maturity, time to union, hospital length of stay, number of procedures performed per patient, and complications were recorded. The main outcome measures were time to union and complications. Average follow-up duration was 13 months. Mean time to union was 4 months for closed and 9 months for open fractures (P<.001). Average time to union for type IIIA and IIIB fractures was significantly increased (11 and 12 months, respectively; P=.02). Delayed union (>6 months postoperatively) occurred in 1 (6%) of 17 closed fractures compared with 11 (52%) of 21 open fractures. The average number of surgical procedures for closed fractures was fewer than for open fractures (2 vs 3 procedures, respectively; P=.03). Mean hospital length of stay was shorter for closed than open fractures (3 vs 6 days, respectively; P=.03). Two infections occurred in the open fracture group. Closed and open pediatric tibial shaft fractures can be successfully treated with titanium elastic nails. Open fractures treated with titanium elastic nails have a significantly longer time to union, require additional operative procedures, and result in longer hospital stays.
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Abstract
UNLABELLED Fractures of the tibia and fibula are among the most common injuries involving the lower extremities in children and adolescents. Although most can be treated nonoperatively, with satisfactory long-term results, some fractures require surgical stabilization. The increasing experience in adults with minimally invasive plate osteosynthesis for the treatment of complex fractures of the lower extremity has supported the treatment of selected distal tibia fractures in older children and adolescents. This article details the surgical technique for plating of the distal tibia using the percutaneous approach and assesses the results and complications in a pediatric series. We retrospectively reviewed 11 consecutive patients with open physes who had undergone percutaneous plating of a distal tibial fracture between January 2008 and January 2012. All patients were monitored clinically and radiographically until fracture union. Complications related to treatment, such as malunion, delayed union, nonunion, infection, and the need for subsequent surgical treatment, were recorded. Eleven patients (11 tibial fractures) were treated with minimally invasive plate osteosynthesis. The average follow-up period was 22 months (range, 12-48 months). Fractures healed with an average time to union of 9.4 weeks (range, 8-16 weeks). There were no cases of delayed union or nonunion. No clinically evident neurovascular complications were observed. One patient had a superficial infection, treated successfully by oral antibiotics. There were no cases of rotational deformity or leg-length discrepancy at the final follow-up. Because of its biologic advantages and stable fixation that allows early mobilization, percutaneous plating seems a reasonable treatment option for selected distal tibial fractures in children and adolescents. LEVEL OF EVIDENCE Level IV therapeutic study - Case series.
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Mid-term results of the elastic intramedullary nailing in paediatric long bone shaft fractures: a prospective study of 102 cases. J Pediatr Orthop B 2014; 23:212-20. [PMID: 24584033 DOI: 10.1097/01.bpb.0000444460.95927.05] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The aim of this study was to evaluate the mid-term results of a large series of paediatric patients with long bone shaft fractures who were treated with elastic intramedullary nailing. Between November 2009 and November 2010, 108 long bone shaft fractures in 102 patients were treated with elastic intramedullary nails. The number of nails used, admission time, nail diameter/medullary canal diameter ratio of the nontraumatized extremity, weeks until radiological consolidation, weeks until full weight bearing for the femur and tibia shaft fractures, weeks until the nails were removed, number of radiographs from the diagnosis time to the removal time of nail(s), clinical complications and radiological results were recorded; the union rate, time to union, nonunion, delayed union, malrotation, malalignment, follow-up time and functional outcomes (Flynn outcome scoring) were also recorded. The mean follow-up time was 22.2 (14-30) months. The mean age of the patients was 9.6 (6-15) years for all cases. The mean nail removal time for all cases was 19.2 (17-29) weeks. Eighteen patients developed complications: six had insufficient reductions; two had refractures; four developed a deep infection; one had delayed union that needed revision; two had lower extremity length discrepancies of more than 15 mm; and three had skin impingements. The mean admission time was 19 (6-32) h; the mean number of radiographs from the diagnosis time to the removal time of nail(s) was 14 (8-20) for each fracture. All patients showed excellent or satisfactory results according to Flynn's criteria. The mean time to full weight bearing for the femur and tibia shaft fractures was 62.4 (52-88) days. A nail diameter/medullary canal diameter ratio of over 0.4 showed good results; short union time, less lower extremity length discrepancy and less malalignment were recorded. When patients were informed about possible complications as well as the advantages, almost all chose the operative approach. According to our experience and opinion, elastic intramedullary nailing is the best choice for diaphyseal fractures in children with skeletal immaturity compared with other surgical choices such as osteosynthesis with a plate.
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Abstract
OBJECTIVES The aim of this study was to assess the use of the Taylor Spatial Frame (TSF) in the treatment of unstable tibial fractures in skeletally immature patients. DESIGN Retrospective review. PATIENTS/PARTICIPANTS Twelve consecutive skeletally immature patients with unstable tibial fracture treated at our centre with a TSF. INTERVENTION A TSF was applied by a single surgeon for the stabilization of unstable tibial fractures. MAIN OUTCOME MEASURES Time to union, nonunion, malunion, reoperations, leg length discrepancy, and complications such as infections and compartment syndrome in both closed and open tibial fractures. RESULTS Over a 4-year period, 8 patients with closed unstable tibial fractures and 4 patients with grade IIIB open fractures were treated with a TSF by a single surgeon. Union was achieved in all cases with no residual angulation and no leg length discrepancy. The mean time of the TSF treatment for the 8 closed fractures was 12.6 (range: 8-22) and for the 4 grade IIIB open fractures was 24.25 weeks (range: 13-36). There was 1 patient who developed compartment syndrome after application of the TSF and 2 who developed superficial pin site infections treated with oral antibiotics. CONCLUSIONS This study supports the use of TSF in experienced users for the treatment of unstable closed and open fractures in skeletally immature patients.
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Abstract
BACKGROUND Postoperative axial deviations and delayed unions are possible complications after flexible intramedullary nailing (FIN). The goals of this study were to determine if a correlation exists between occurrence of the above complications and the ratio of the diameter between nail and medullary canal [nail diameter (ND)/MCD ratio], to study the interobserver variability in the measurement of MCD, and to define a threshold to be respected to optimize the results. METHODS Eighty-one consecutive diaphyseal fractures treated by means of FIN were evaluated. The ND/MCD ratios were determined by 2 independent observers. Axial deviations were defined as 5-degree angulation or more observed before bone union. Absence of bone union at 3 months was considered as delayed union. Statistical analysis was made for interobserver variability of MCD, dependency between occurrence of complications and ND/MCD ratio and eventual confounding variables (age, weight, sex, and fracture location). RESULTS Of the 81 fractures, 14 presented with an axial deviation and 3 with a delayed union. Interobserver variability of MCD diameter was excellent (intraclass correlation: 0.96). Occurrence of the above complications was significantly associated with a low ND/MCD ratio (P=0.0002) but with none of the examined confounding variables. Receiver operating characteristic analysis showed absence of complications with a ND/MCD ratio >35% with a sensitivity of 100% and specificity of 89%. Related with the MCD measurements variability, a safe threshold of 40% can be suggested. CONCLUSIONS In FIN, ND>40% to the MCD should be chosen to avoid complications, besides respecting the technical principles. Measuring the medullary canal diameter in order to choose correct nail size is reproducible between different observers. In adolescents with a medullary canal diameter of >10 mm in femur or tibia fractures, alternative methods of osteosynthesis than FIN should be considered. SIGNIFICANCE This work statistically confirms that a ND/MCD ratio of >40% must be respected to avoid some complications in FIN. LEVEL OF EVIDENCE Level III.
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Nisar A, Bhosale A, Madan SS, Flowers MJ, Fernandes JA, Jones S. Complications of Elastic Stable Intramedullary Nailing for treating paediatric long bone fractures. J Orthop 2013; 10:17-24. [PMID: 24403743 DOI: 10.1016/j.jor.2013.01.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 01/01/2013] [Indexed: 12/27/2022] Open
Abstract
This study reports the complications observed in children with long bone fractures treated using Elastic Stable Intramedullary Nailing (ESIN). One hundred and sixty-four (n = 164) fractures in 160 patients under the age of 16 years formed the basis of our review. This included 108 boys and 52 girls with the median age of 11 years and median follow up of 7.5 months. The analysis included fractures of the radius/ulna, humerus, femur and tibia. All pathological fractures were excluded. In this series 54 patients (34%) had complications however majority of these were minor complications with irritation due to prominent nail ends being the commonest complication. No long-term sequelae were encountered in our patients.
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Affiliation(s)
- Aamer Nisar
- Specialist Registrar, Sheffield Children's Hospital, Western Bank, Sheffield, United Kingdom
| | - Abhijit Bhosale
- Specialist Registrar, Sheffield Children's Hospital, Western Bank, Sheffield, United Kingdom
| | - Sanjeev S Madan
- Consultant Orthopaedic Surgeon, Sheffield Children's Hospital, Western Bank, Sheffield, United Kingdom
| | - Mark J Flowers
- Consultant Orthopaedic Surgeon, Sheffield Children's Hospital, Western Bank, Sheffield, United Kingdom
| | - James A Fernandes
- Consultant Orthopaedic Surgeon, Sheffield Children's Hospital, Western Bank, Sheffield, United Kingdom
| | - Stanley Jones
- Consultant Orthopaedic Surgeon, Sheffield Children's Hospital, Western Bank, Sheffield, United Kingdom
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Abstract
BACKGROUND Flexible nailing has become the preferred implant for pediatric patients with tibial shaft fractures that require operative fixation. Immediate definitive fracture fixation with flexible nails in patients with high-energy, open fractures has not been examined. The purpose of our study was to determine if immediate flexible nailing of open pediatric tibial shaft fractures is safe and efficacious from a bone healing, wound, and infectious standpoint. METHODS A retrospective review of 26 tibial shaft fractures consecutively treated with flexible nailing at our institution from 2003 to 2010 was performed. Age, mechanism of injury, associated injuries, presence of compartment syndrome, antibiotic administration, systemic insults, time to union, as well as bone healing (nonunion, delayed union, malunion, leg length discrepancy, growth arrest), wound, and infectious complications were collected. Comparisons were made between patients with open fractures and those with closed fractures. RESULTS We identified 14 patients with open fractures and a control group of 12 patients with closed injuries who underwent flexible nailing. Patients with open fractures were more likely to have polytraumatic injuries (71.0% vs. 25.0%, P = 0.04). There was no difference (P = 1.0) in the rates of compartment syndrome (open = 14.0%, closed = 17.0%) between the 2 groups. Systemic complications (pulmonary compromise and increased intracranial pressure) were noted in 2 patients who underwent immediate nailing of their open fractures; both of whom had closed head injuries. There was no difference (P = 1.0) in the rates of wound/infectious complications between the open (7.0%) and closed (4.0%) fractures groups, with no cases of wound breakdown or osteomyelitis. There was an increased rate (P = 0.02) of bone healing complications in the open fracture group (21.0% vs. 4.0%); all in patients with Gustilo type 2 or 3 injuries. All patients achieved radiographic union at final follow-up. CONCLUSIONS Immediate flexible nailing of open pediatric tibial shaft fractures can be safely performed with minimal risk of wound or infectious complications. Clinicians should understand that prolonged bone healing (particularly in Gustilo type 2 or 3 injuries) should be expected in patients who undergo immediate flexible nailing of their open fractures. Open tibial shaft fractures are high-energy injuries, and should be seen as surrogate markers of polytrauma in the pediatric population. The risk of compartment syndrome is high regardless of whether a patient has a closed or open tibia fracture, and caution should be used in performing flexible nailing in patients who may have closed head injury due to a risk of systemic complications. LEVEL OF EVIDENCE Level III, therapeutic study, retrospective cohort.
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Abstract
Open fractures in the pediatric population are rare. As such, recommendations for care based on high-level studies are scarce. Furthermore, most level I and II recommendations come from studies involving open fractures in adults. Although it is generally accepted that open pediatric fractures have better outcomes than open fractures in adults, the lack of quality studies provide ample opportunities to answer questions regarding care of these injuries. This review explores the available literature and gives corresponding recommendations based on the level of evidence.
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