Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Aug 18, 2019; 10(8): 299-303
Published online Aug 18, 2019. doi: 10.5312/wjo.v10.i8.299
Rigid locked nail fixation for pediatric tibia fractures - Where are the data?
Daniel Weltsch, Keith D Baldwin
Daniel Weltsch, Keith D Baldwin, Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, United States
Daniel Weltsch, 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, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA 19104, United States
Author contributions: Weltsch D and Baldwin KD contributed to data collection, statistical analysis, development of manuscript structure, initial manuscript drafting, and final manuscript editing.
Conflict-of-interest statement: The authors declare personal fees from JBJS reviews, personal fees from Synthes, other from Pfizer, Inc., and other from Simple Therapy, outside the submitted work.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Keith D Baldwin, MD, MPH, MSPT, Assistant Professor, Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States. baldwink@email.chop.edu
Telephone: +1-215-5901527 Fax: +1-215-5901501
Received: March 12, 2019
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.

Keywords: Pediatric, Trauma, Skeletal maturity, Reamed nail, Intramedullary, Fixation

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.