stable intramedullary naffing. (ESIN) in 123 fractures of the femoral shaft in .... Radiographs of an. I 1-year-old boy with a comminuted spiral fracture. Figure. 4.
ELASTIC
STABLE
OF FEMORAL
SHAFT
J. N. LIGIER,
From
We report
INTRAMEDULLARY
the use of elastic
FRACTURES
J. P. METAIZEAU,
the Department
of Paediatric
stable
NAILING
intramedullary
IN CHILDREN
J. PREVOT,
Surgery,
P. LASCOMBES
Children’s
naffing
(ESIN)
Compared
In children,
fractures
by
ESIN
obviates
of the femoral shaft are commonly types of traction for about three
various
weeks, followed form of treatment
treatment, children.
for treating
by plaster cast immobilisation. has two major drawbacks.
This safe The first is
that prolonged bed rest separates the child from his normal environment; the second is the cost of such periods in hospital and the use of beds which might serve
other
patients. During the past five years we have used elastic stable intramedullary nailing (ESIN) for such cases. This closed surgical procedure allows early weightbearing and walking; it aims to develop early bridging callus and contributes to rapid restoration of bone continuity. In the series we report, the results were at least equal to those of more conventional methods.
PATIENTS Between with 1 23 Nancy Infantile pitalier ESIN.
AND
the
patients
were
Complications
the need for prolonged
children
over
favourable
trauma
selected
from
among
and Paediatric
Orthopaedic
Surgery
P. Lascombes, Cedex,
Paediatric Hospital,
Paediatric
H#{244}pital Belle-Isle,
©
for
reprints
54045
5451
Orthopaedic
1 Vandoeuvre-Nancy-
should
be
sent
to Professor
of Bone
and
minimal,
the
in
most
J. Pr#{233}vot. Joint
Surgery
but
also
had
later,
because
children and head
over
of
seven
a few even injury or
the
years
younger multiple
ESIN.
ages of the children ranged from 5 to 16 years (mean 10 years ± 2 months). There were 80 boys and 38 girls who had sustained 64 right-sided and 59 left-sided The
fractures
(five
had
bilateral
injuries).
In all,
42 fractures
were in the proximal third, 35 in the middle third and 36 in the distal third ; there were also six pertrochanteric fractures and four double fractures. Of the 63 transverse fractures (Figs 1 to 3) 16 presented with comminution of one cortex. Twenty-eight fractures were spiral, nine of which had a large butterfly fragment (Figs 4 and 5). There were 22 oblique fractures, six had comminution of four were double fractures injuries were present in
patients injury,
: 35 had a head injury, four and I 1 had other lower-limb patient had a posterior hip dislocation femoral shaft fracture. Three children had a lumbosacral cele, two were affected by poliomyelitis form
of cerebral technique.The
(Figs 6 42% of
had
an abdominal fractures. One with an ipsilateral myelomeningoand three
had
palsy. patient
is placed
on
an ortho-
paedic table and the fracture partially reduced by traction guided by fluoroscopy. Blunt-ended nails of the finest quality steel (cold-hammered at 140#{176}) or titanium were used. The nails were 45 cm long with diameters of 3, 3.5 or 4 mm depending should be noted that
Surgeon 1 , France.
Metz-Cedex
1988 British Editorial Society 030l-620X/88/1015 $2.00 J Bone Joint Surg [Br] l988;70-B:74-7
74
Surgeon
Morvan,
France.
J. P. Metaizeau, Requests
Orthopaedic
All#{233}edu
old, results,
treated in this way, with an associated
Operative
Children’s
bridging
were
10 years
preliminary
old were children
some J. N. Ligier, Senior Hospital Fellow J. Pr#{233}vot, Professor of Paediatric Surgery
shaft
is to develop
bed rest and is thus particularly
both cortices, and to 8). Associated
METHODS
September 1979 and June 1985 1 18 children femoral shaft fractures were admitted to the Children’s Hospital (Service de Chirurgie Orthop#{233}dique, H#{244}pitald’Enfants, Centre HosUniversitaire de Nancy) and treated with
Initially,
of the femoral
and the aim
area,
caused by the ends of the rods. A surprising feature was the low incidence lengthening of only 1.2 mm after an average follow-up of 22 months.
ulceration a mean
with conservative
advantageous
treated
skin with
Nancy
in 123 fractures
children. Flexible rods are introduced through the distal metaphyseal callus. Early weight-bearing is possible and is recommended. There was one case of bone infection and no delayed union. common being minor of growth changes,
Hospital,
for treating straightening
on the child’s weight and age. It Ender nails are not elastic enough
children and that they often lead of the normal curves of the bone.
An important the surgeon. These THE
step is the preparation are angled at 45#{176} about JOURNAL
OF BONE
AND
to
of the nails by 2 cm from one JOINT
SURGERY
ELASTIC
Fig.
1
Fig.
2
STABLE
Fig.
INTRAMEDULLARY
3
Radiographs of an eight-year old boy with a simple transverse femoral shaft fracture. Figure 1 - On admission. Figure 2 . An anteroposterior radiograph taken 21 days after the fracture shows external callus. Figure 3 The lateral radiograph shows restoration of the normal anterior bowing of the shaft.
Fig. Radiographs of an fracture. Figure 4 taken 21 days after
Radiographs of a nine-year-old boy with a double fracture admission. Figure 7 Two months after nailing. Figure 8 no overgrowth of the femur.
VOL.
70-B.
No.
1. JANUARY
1988
NAILING
of the femoral One year after
75
4
Fig. I 1-year-old boy On admission. the injury shows
shaft. injury,
-
5
with a comminuted spiral Figure 5 The radiograph some external callus.
Figure 6 On there had been
76
J. N. LIGIER.
end are
to facilitate also
bent
penetration into
an even
of the curve
J. P. METAIZEAU,
medullary
over
their
canal entire
23 mm), 15, and
and
length.
The. nails .‘
are introduced through a hole made in the distal femoral metaphysis just above the growth cartilage. They are carefully pushed up the medullary canal to the already-reduced bend at the tip satisfactorily. adequate to angulation
allows
fracture the
site. Under nail to pass
Two nails, one lateral stabilise the fracture.
it is important
that
fluoroscopy, the fracture
the site
and one medial, are To avoid residual
the nails
are introduced
at
the same level and that they have identical curvatures. After operation the limb is simply rested on a pillow. Mobilisation using crutches but without weight-bearing is allowed beginning
as soon as of the third
possible, and This coincides callus. third
this is soon followed with the appearance
The nails are postoperative
antibiotics
the fracture week partial
after
removed month.
is painfree. weight-bearing
At
the is
of the required
operation.
RESULTS
Distal
if
knee
movement was begun soon after operation. There were 1 3 cases of skin ulceration or local inflammatory reaction due to nail protrusion : three ofthese required reintroduction of the nail while in the remaining 10 the
nails
were
trimmed
under
local
tract infection. fracture site after
was
Removal required
immobilisation
occurred with
six
urinary
of the nail and drainage and the fracture then
of the healed
In 20 patients measure femoral was found in only
children an average
and 10 months. Clinically, plained of disability and noted.
have been followed period of one year
none of the patients no gait abnormalities
Lengthening and shortening. All 62 children radiographically, and a mean lengthening
comwere
were assessed of 1 .2 mm
was
noted. An attempt was made to discover whether this mean figure resulted from the algebraic sum of lengthening in transverse fractures without overlap and shortening in spiral fractures. Within narrow limits this hypothesis was confirmed. In 29 simple transverse fractures cases
the mean of lengthening
lengthening of more
was 2.06 than
10 mm
was
biplanar anteversion. one patient
neck
mm,
with
four
(1 1 , 1 5, 1 7 and
(15, the
used
later
to treat
as
radiography was used A rotational deformity with 10#{176} of retroversion
5#{176} of anteversion
against
to of
on
the
normal side. Cost oftreatment.
This is essentially the cost of hospital bed rest. We reviewed two comparable series of patients aged between 7 and 1 5 years, one treated by skin traction 1977,
the
second
Conservative of 25.5 days,
(Holmes,
treated
treatment
by ESIN
involved
comparable
Sedgwick
and
to that Scobie
during
1983.
a mean hospital reported elsewhere
1983
;
Henderson
et al.
1984). The ESIN series had a mean hospital stay 7.5 days including the removal of the nails. reduction of 70% is thus another advantage technique.
of only A cost of this
DISCUSSION
from
Simon-Weidner ques, ESIN and stability.
In contrast
Stability. fixation,
Ender’s
elastic
stability
provide
internal
preventing adjustment nailing
with
is not only elastic
other
techniques ensured
support,
(Ender
fixation of elastic
1970); fractures
shaft
Pankovich,
the
Goldflies
stability
involving
fixation
Pearson
also
The nails forces
and
automatic ascending (Ender and
this has been confirmed (Eriksson and Hovelius and
rigid but
soft tissues. channelling
of the
and technimobility
by the nails,
excessive displacement by the of the bone fragments. The double
increases
femoral
nail
1970), and from provides a combination
Simon-Weidner
in plaster.
Long-term results. Sixty-two up for over one year with
epiphysiodesis
by the bone and the surrounding
anaesthesia.
One case of deep wound infection weeks after operation in a paraplegic child
greater than 10 mm 1 2 spiral fractures
was 0.7 mm : the range in this group in length of 1 2 mm to an increase of
femoral
Derived
distal ends of the nails sometimes at the knee ; this occurred most often
in
the two cases which presented the greatest difference in leg length (23 mm and 20 mm). Angulation and rotation. At follow-up, residual angulation never exceeded 10#{176}. In 14 patients, angulation of more than 5#{176} was observed ; this was varus in eight, valgus in two, anterior in three and posterior in one.
stay
There were no surgical failures and because the operation is rapid and uses only small incisions, blood loss is minimal. Early in the series, four patients had spica casts after operation and five had skin traction ; by the end ofthe study period, the average hospital stay had been reduced to 4.5 days. Sound union was achieved in every case and there were no fractures after removal of the nails. The
and three ofshortening 13 mm). By contrast,
mean shortening was from a loss 17 mm.
during
Complications. caused discomfort
P. LASCOMBES
the femoral
by full weight-bearing. of calcified external at the beginning No patient
J. PREVOT,
in adult 1979;
1979).
The bone provides axial stability provided that there is no overlap at the fracture site. This is ensured either by cortical contact in end-to-end reduction or by anchoring the bone of children
nails in the metaphysis. is very dense, so that
The
cancellous seen
the nail-drop
in the elderly patient The soft tissues muscles, in particular,
explain slight
the angular
is less common. also have an important role. The serve as guy-ropes. This helps to spontaneous postoperative correction of deviation, the rarity of excessive callus and
the retention of the normal shaft (Figs 1 to 3). THE JOURNAL
anterior
OF BONE
bow
of the
AND JOINT
femoral
SURGERY
ELASTIC
Stability rapid
return
ofsecondary
The
value
provided
mainly
by
living
STABLE
tissue
INTRAMEDULLARY
allows
the
of function and weight-bearing without fear displacement, even in hyperactive children. of this technique for the agitated, comatose or
multiply-injured child is considerable. Elastic mobility. ESIN allows a certain amount of movement at the fracture site, thus ensuring optimal development of the external callus by reducing shear and converting et al. results weeks
it into
compression
and
causes
no increase
leaves
the fracture
is minimal,
being
introduction minimum
treatment. reduction. in muscle haematoma
(Firica
limited
at right Because
healing and minimal may be considered
angles of
No.
1. JANUARY
technique
to small
scars can
at the be kept of modern
to each other. early weight-bearing,
can
sites
of
to the lowrapid
growth, ESIN method of
be adapted to all cases, in spica cast technique recommendand Chung (1976); it gives better and rotation, and can be adapted long-bone fractures in the child method is also being adapted for
1988
of certain
Pr#{233}votand
metaphyseal
Schmitt
1980;
fractures Metaizeau
(Metaiand
Ligier
1984). REFERENCES Ender J, Simon-Weidner runden, 1:40-2.
R. Die Fixierung
elastischen
E, Hovelius
Erikkson the
femur.
der trochanteren Bruche mit Acta Chir Austriaca 1970;
Condylennageln.
L. Ender
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Joint
nailing in fractures Srug [Am] 1979:61-A
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concept annuelle,
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of ESIN
or periosteal damage and intact. Cosmetic damage
disturbance of bone to be a physiological
treatment. The technique contrast with the early ed by Irani, Nicholson control of axial length to treat other diaphyseal (Ligier et al. 1985). The
treatment
zeau,
77
biom#{233}canique Nov 1980.
Henderson OL, Morrissy
The
of the nails. Irradiation by the use of two intensifiers
dosage type Conclusions.
70-B,
forces
1981). The early development of bridging callus in early consolidation ; this takes from four to six depending on the child’s age, almost twice as fast
as with conventional Advantages of closed
VOL.
traction
NAILING
shaft
Holmes SJK, Sedgwick for femoral shaft and advantages.
tram
RN,
JN,
RT, Gerdes
MH,
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in
McCarthy children.
RE. Early J
Pediatr
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casting Ort hop traction safety
JT, Chung SMK. Long-term results in the of femoral-shaft fractures in young children by spica immobilisation. J Bone Joint Surg [Am] :945-51.
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Metaizeau
intramedullary Kinderchir
JP,
Pr#{233}votJ,
pinning of long 1985 ;40 :209-12.
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Lascombes shaft
P.
fractures
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stable Z
Metaizeau
JP, Pr#{233}vot J, Schmitt M. R#{233}ducation et fixation des fractures et d#{233}collements #{233}piphysaires de la t#{234}te radial par broche centro-m#{233}dullaire. Rev Chir Orthop 1980;66:47-9. (Eng. abstr.)
Metaizeau
longs
JP, Ligier JN. Le traitement ches l’enfant : interferences
chirurgical
processus physiologiques de consolidation ques. J Chir (Paris) 1984;l21 :527-37.
entre
des fractures
des os
l’ost#{233}osynthe et les : indications th#{233}rapeuti-
Pankovich AM, Goldflies ML, Pearson RL, Closed Ender femoral-shaft fractures. J Bone Joint Sur [Am] l979;61-A
nailing of :222-32.