Published online Aug 18, 2019. doi: 10.5312/wjo.v10.i8.299
Peer-review started: March 15, 2019
First decision: June 12, 2019
Revised: June 27, 2019
Accepted: July 23, 2019
Article in press: July 23, 2019
Published online: August 18, 2019
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.
Core tip: Little data exists to support the use of reamed intramedullary nails (RIMN) in adolescents and skeletally immature pre-adolescents. However, RIMN is used as the cornerstone of fixation for skeletally mature patients and older skeletally immature patients. Although we are not aware of any papers or case reports of RIMN use which resulted in growth arrest or recurvatum deformity in the pediatric population, surgeons are reluctant to use this nail design in younger patients. Clinical data regarding RIMN and a reliable and easy to apply skeletal maturity measure for the proximal tibia are needed for better decision making in such cases.