Vol 1 | Issue 1 | July - Sep 2013 | page 37-41 | Sachdeva G, Kamble S

Author: Gaurav Sachdeva¹, Suhas Kamble¹

Department of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune, Maharashtra, India.
Institute at which research was conducted: Padmashree Dr. D. Y. Patil Medical College, Pune, India.
University Affiliation of Thesis: D. Y. Patil University.
Year of Acceptance: 2012

Address of Correspondence
Dr. Gaurav Sachdeva
Department of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune, Maharashtra, India.
E mail: g_s2001in@yahoo.com

 Abstract

Background: Ideally, fixation of paediatric diaphyseal fractures should produce an “internal splint” that shares loads, maintains reduction until hard callus formation, and does not endanger the growth areas or blood supply. Results from several studies have shown that FIN / TENS fixation meets these requirements because it allows rapid mobilization, potentially no risk for osteonecrosis, low risk for physeal injury, and reduced risk for refracture. ESIN meets the requirements of this ideal device.
Materials and methods: 31 cases of Diaphyseal fractures in 30 Patients were included. Final outcome was graded excellent, satisfactory or poor based on criteria described by Flynn et al.
Result: The results according to Flynn et al were Excellent in 26 patients (86.67%) , Satisfactory in 3 patients (10%),and Poor in 1 patient (3.33%).
Conclusion: Enders nailing is a simple and useful technique for stabilization of Diaphyseal fractures in longbones in children as it permits adequate rotational stabilization.

Keywords: Diaphyseal fractures, titanium elastic nail, intramedullary nail, children

Introduction:

Recently there has been a growing trend towards surgical treatment of Diaphyseal fractures in children .To some extent this reflects a more interventionist attitude
among Orthopaedic Surgeons but is also due to technical development, notably that of ESIN(Barry & Paterson, 2004).The treatment for children between the ages of 6 and 10 years is the most controversial. Many such patients may be treated successfully with immediate closed reduction & casts. However, external fixation and flexible intramedullary rod fixation are being used more frequently, particularly in patients with multiple trauma.However, in older children and adolescents operative treatment should be considered to avoid complications such as delayed union, malunion, rotational deformity, refracture, knee stiffness, limb length discrepancy and psychosocial problems.Operative treatment results in shorter hospitalization and early mobilization, which has psychological, social, educational and economic advantages over conservative treatment. A variety of therapeutic alternatives mentioned above such as external fixator, compression plating, rigid Intramedullary nailing and elastic stable intramedullary nailing are being used for Diaphyseal fractures in children.
With the use of external fixator, there is a high incidence of pin tract infection, refracture after removal of external fixator. Also the external fixator is more uncomfortable and cumbersome for the child (Linhart & Roposch, 1999)Submuscular Compression plating needs two major operations - one for insertion and another one for the removal of the plate (Gonzalez et. al.1995).Rigid intramedullary nails have their own pros and cons. They not only increases risk of AVN of femoral head in children and adolescents (Thometz and Lamdan, 1995), but also there is a high incidence of abnormalities at the proximal end of the femur including coxa valga, arrest of growth of greater trochanter, thinning of the neck of the femur because of damage to trochantero-cervical region.
Ideally, fixation of paediatric diaphyseal fractures should produce an “internal splint” that shares loads, maintains reduction until hard callus formation, and does not endanger the growthareas or blood supply. Results from several studies have shown that FIN / TENS fixation meets these requirements because it allows rapid mobilization, potentially no risk for osteonecrosis, low risk for physeal injury, and reduced risk for refracture. ESIN meets the requirements of this ideal device (Flynn et al. 2001).
Upper age limit for ESIN in Pediatric Diaphyseal fracture is until the time of closure of the proximal growth plate after which conventional rigid locked intramedullary nailing can be used safely. Sanders J.O et al (2001) The choice of treatment may be influenced by the age of the child, the level and pattern of the fracture and to a great extent, by regional, institutional or surgeons preferences.

Materials and methods:

This is a Prospective Study based on patients admitted with Diaphyseal Fractures in Long Bones in the age group of 6 years - 16 years The study was done on 31 cases of Diaphyseal fractures in 30 Patients.all Recent Diaphyseal fracture of Transverse, short oblique, minimally comminuted type were included. Postoperative data collected was no. of nails, postoperative immobilization, period of hospital stay, period of radiological union , return to normal work, any complication , time to nail removal. Radiographs were evaluated for alignment, nail size, nail shape (C or S), callus formation, nail position, and measurement of fracture location . Final outcome was graded excellent, satisfactory or poor based on criteria described by Flynn et al.

Results:
The results according to Flynn et al were Excellent in 26 patients (86.67%) , Satisfactory in 3 patients (10%),and Poor in 1 patient (3.33%). Only 3 patients (10.03%) had complication in the form of skin erosion (superficial infection). 23 patients (76.67%) had radiological callus within 8 weeks of operation, while 7 patients (23.33%) had there
radiological callus by 12 weeks .24 patients (80%) had a hospital stay of upto 10days , while only 6 patients (20%) had a stay of more than 10 days. The geometry of fracture was Transverse (54.80%), Oblique (22.60%) and unicortical communition (12.90%).

Conclusion:
The following conclusion could be drawn from the present study:
1) Enders nailing is a simple and useful technique for stabilization of Diaphyseal fractures in long bones in children as it permits adequate rotational stabilization.
2)It is suitable for short oblique or transverse fractures and fractures with unicortical comminution. Unstable fractures with long obliquity or significant comminution are not suitable for
stabilization with Enders nailing on account of its relatively poor longitudinal stability.
3)Early callus formation and better healing time following use of Enders nail indicates advantages of undreamed nails over plating osteosynthesis and external fixator in fracture healing, specially
in fresh fractures.
4)Minimum of two Enders nails with use of both medial & lateral portals is desirable to provide adequate rotational stability and to counteract the angular stresses produced in humerus, femur and tibia. One nail is sufficient in radius & ulna.
5)Significant incidence of distal migration of the nail and knee pain at a later stage is one the limiting factor of Enders Nail in Diaphyseal fracture in long bones in children which can be prevented by use of a locking 4mm screw / K-wire through the eye of enders nail. However disappearance of symptoms with nail removal does neutralize these problems to some extent, though, one has to wait till sound bony union before the nails can be removed.

Elastic stable intramedullary nailing is an excellent method of managing most, but not all, pediatric diaphyseal fractures that need operative stabilization. It is by no means the only technique nor is there evidence yet that it is superior to other methods. Its advantages make it a valuable choice to consider in managing these fractures. Ultimately, the choice should reflect best evidence and also incorporate patient
preferences.

Key Words:
Diaphyseal fractures, titanium elastic nail, intramedullary nail, children

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