elastic stable intramedullary nailing of femoral ... - Semantic Scholar

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.

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elastischen

E, Hovelius

Erikkson the

femur.

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Condylennageln.

L. Ender

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nailing in fractures Srug [Am] 1979:61-A

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Firica A, Popescu R, Scarlet M, et al. L’ost#{243}esynth#{232}se stable #{233}lastique, nouveau reunion II :82-91.

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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

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tram

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RT, Gerdes

MH,

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in

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RE. Early J

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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

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Metaizeau

longs

JP, Ligier JN. Le traitement ches l’enfant : interferences

chirurgical

processus physiologiques de consolidation ques. J Chir (Paris) 1984;l21 :527-37.

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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

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