|Year : 2021 | Volume
| Issue : 2 | Page : 117-120
Results of flexible nails for fixation of tibial diaphysis fractures in children
Mariwan Saleem Mohammed1, Othman Sami Yousif2, Omer Ali Rafiq Barawi3
1 Department of Orthopedics, Erbil, Kurdistan Region, Iraq
2 Department of Emergency, Erbil, Kurdistan Region, Iraq
3 Department of Emergency, Surgeon College of Medicine, University of Slemani, Kurdistan Region, Iraq
|Date of Submission||29-Dec-2020|
|Date of Acceptance||09-Jan-2021|
|Date of Web Publication||26-Jun-2021|
Othman Sami Yousif
Department of Emergency, East Hospital, Erbil, Kurdistan Region
Source of Support: None, Conflict of Interest: None
Background: Fracture tibia is one of the most common fractures in the pediatric age group. It accounts about 15% of cases. In majority of cases, close reduction and plaster application is the mainstay of treatment. Objectives: The objective was to assess the outcome of flexible nails in the treatment of tibial diaphysis fractures in children and to evaluate the results regarding the union rate and complications including limb length discrepancy, angular deformities, and pain. Materials and Methods: This prospective descriptive case–control study which included 30 children with 30 unilateral tibial diaphysis fractures in which the physis were open, all were closed, and open (type 1 and type 2) fractures, and with displaced transverse, short oblique, and spiral fractures, in which the trial of close reduction was failed. All patients are admitted and operated at West Erbil Emergency Hospital. Alignment of fractures, any infection, delayed union, nonunion, limb length discrepancy, motion of knee joint, time of complete union, and skin irritation were assessed with minimum follow-up period of 6 months. Results: In the current study, the complete union was achieved in 9–11 weeks in 20 (66.7%) patients, while in 6 (20%) patients, achieved in 12 weeks, and in 4 (13.3) patients, achieved in 13–16 weeks that were regarded as a delayed union. In 6 (20%) patients, there were nail protrusion and skin irritation, no shortening more than 0.5 cm was recorded, shortening <0.5 cm recorded in 12 (40%) patients, and no lengthening was recorded. In 3 (10%) patients, the angulations in coronal and sagittal views were 5°–10°. There was no case of nonunion. Conclusion: Elastic nails are an effective way for the treatment of the pediatric tibial diaphysis fractures. It is a simple and easy method but with radiation risk, although elastic nails have complications, all are avoidable and minor that will be managed with minimal intervention.
Keywords: Children, flexible nails, tibial diaphysis fracture, treatment
|How to cite this article:|
Mohammed MS, Yousif OS, Barawi OA. Results of flexible nails for fixation of tibial diaphysis fractures in children. Med J Babylon 2021;18:117-20
| Introduction|| |
Fracture tibia is one of the most common fractures in the pediatric age group. It accounts about 15% of cases. The prevalence of tibia fractures in both boys and girls has increased since 1950. The average age of occurrence is 8 years, and the frequency of occurrence does not change significantly with age. Seventy percent of pediatric tibial fractures are isolated injuries; ipsilateral fibular fractures occur with 30% of tibial fractures. Fifty percent to 70% of tibial fractures occur in the distal third and 19%–39% in the middle third. The least commonly affected is the proximal third. Thirty-five percent of pediatric tibial fractures are oblique, 32% comminuted, 20% transverse, and 13% spiral.
Rotational forces produce an oblique or a spiral fracture and are responsible for approximately 81% of all tibial fractures. Most tibial fractures in children are the result of traffic accidents. The tibia is the second most commonly fractured long bone in abused children.
In majority of cases, close reduction and plaster application is the mainstay of treatment. Surgical treatment is indicated in case of failed close reduction, open fracture, fracture with neurovascular injuries, and polytrauma patients.
In large series of tibial shaft fractures treated with above-knee casts, the initial shortening of 10 mm was compensated wholly or partially by growth acceleration, mild varus deformities corrected spontaneously, valgus deformities, and posterior angulation persist to some degree and rotational deformities persisted, especially internal rotation. Spontaneous correction of angular deformity after tibial fractures has been reported to occur in boys up to age 10 years and in girls up to 8 years, however other reports indicate that little spontaneous correction occurs regardless of the age of the child.
Treatment of pediatric fractures dramatically changed in 1982, when Metaizeau et al. from Nancy, France, developed the technique of flexible stable intramedullary pinning using titanium pins. In the last two decades, there was increased interest in the operative treatment of pediatric fractures, although debate persisted over its indication.
Flexible intramedullary nailing in long bone fractures in pediatric age groups has become popular because of its effectiveness and less complications. Flexible intramedullary nails achieved biomechanical stability from its C configuration, which produce three points of fixation and acts as internal splint.
The aim of this study was to assess the outcome of flexible nails in the treatment of tibial diaphysis fractures in children and to evaluate the results regarding the union rate.
| Materials and Methods|| |
This is a prospective descriptive case–control study which included 30 children with 30 unilateral tibial diaphysis fractures collected over the period between June 1, 2016 and June 1, 2017 with a minimum follow-up period of 6 months. All patients were admitted and underwent closed elastic nailing at West Erbil Emergency Teaching Hospital. A written consent was obtained from the parents of patients who were enrolled in this study. All patients had sustained trauma either due to road traffic accidents (RTAs) or fall from height (FFH).
- Children and adolescent patients with tibial diaphysis fractures in which the physis were open
- All closed and open (type 1 and type 2) fractures
- Patients with displaced transverse, short oblique, and spiral fractures, in which the trial of close reduction was failed
- Patients with multiple injuries.
- Obese child more than 40 kg.
- Vascular injuries which include segmental fractures, fractures near the knee or ankle joint, and patients with compartment syndrome of the leg.
All data were analyzed in a prospective manner from the preoperative period, intraoperative till the postoperative period including the outcome of the surgery regarding the union rate and complications.
After admission, all patients were assessed clinically and associated injuries were identified and treated accordingly; a brief history was taken from the patients and they receive adequate analgesia, IV fluid, and adequate temporary splintage. AP and lateral radiograph of the leg including knee and ankle joint were taken and all were operated within 1 day after doing all necessary preoperative investigations including CBC and viral screen and blood group.
The study was conducted in accordance with the ethical principles that have their origin. It was carried out with patients' verbal approval before the sample was taken. The ethical approval of the present study was taken from the ethical clearance by the Ethical and Research Committee of the Iraq Board of medical specialties.
| Results|| |
All 30 patients that sustained tibial diaphysis fractures were identified. Demographic data of the patients, fracture pattern, level of fracture, type of fracture, and associated injuries are mentioned in [Table 1]. All patients were skeletally immature; the average age was 7.6 years.
The gender incidences were 20 (66.7%) males and 10 (33.3%) females. The fractures were on the right side in 20 (66.7%) patients and 10 (33.3%) patients were on the left side.
The most common mechanism of the injury was RTAs in 22 (73.3%) patients and FFH in 8 (26.7%) patients.
In 20 (66.7) patients, the fractures were short oblique, in 6 (20%) were transverse, and in 4 (13.3%) patients were spiral. The fractures were closed in 24 (80%) patients, in 5 (16.7%) patients were type 1 open fracture, and in 1 (3.3%) patient was type 2 open fracture. In the current study, the associated injuries include (two patients with head injuries, one patient with fracture clavicle, one patient with fracture 1st metatarsal bone, and another one patient with fracture distal radius) were present in 5 (16.7%) patients.
All patients that undergo operation, the operation time were taken to account, in which four (13.3%) patients with duration of operation were between 20 and 29 min, and in 26 (86.7%) patients, the duration of operation were 30–60 min, and average was 38.53 min as shown in [Table 2]. All fractures reduced closely.
In the current study, all patients were immobilized with back slab postoperatively, in which 14 (46.7%) patients were immobilized for 2–3 weeks, and 9 (30%) patients were immobilized for 4 weeks and 7 (23.3%) patients were immobilized for 5–6 weeks as shown in [Table 3].
Regarding the complications that occur in our study, all were minor and treated accordingly; in 6 (20%) patients, there were nail protrusion and skin irritation that were treated in two of them by cutting the tip of nails because of severe pain and irritation as shown in [Table 4].
In 9 (30%) patients, the results were satisfactory due to skin irritation (in 6 of them) or malalignment (in 3 of them), and in 21 (70%) patients, the results were excellent and there were no poor results.
| Discussion|| |
Tibial diaphysis fractures are common among the pediatric age groups, and still, it can be managed by cast immobilization as the first line of treatment, however sometimes, there are certain indications for surgical stabilization such as multiple injuries, unstable fractures, head injuries, open fractures, and failure of conservative treatment.
In the past, most of them even unstable fractures were treated by manipulation and cast immobilization had certain complications including malunion, limb length discrepancy, or they use traditional fixations like external fixations which sometimes lead to pin tract infection. But with the development of elastic nails, most of these complications have been minimized as these nails provide a load-sharing biocompatible internal splint, allow early mobilization, and avoid any growth disturbance by preventing damage to the epiphyseal plate and with minimal risk of infection and soft tissue damage.
In the current study, the right side was more common than the left side, 66.7% were right and 33.3% were left, regarding the mechanism of injury in the current study. RTA was more common than FFH in which 73.3% were due to RTA, while in 26.7% were due to FFH. These results are compatible to study was conducted by Dr. Rshid Anjum showed that the right side was more common than the left, 60% were right and 40% were left, also the RTA was the most common one, 80% were due to RTA and 20% due to FFH.
The current study showed that the fractures were more common in the middle third about 20 (66.7%) patients, while 8 (26.7%) patients occurred in the lower third and 2 (6.6%) patients with upper third fractures, although the most common one is the distal one, the current study showed that the middle was the most common which might be due to excluding fractures near the joints in the current study; these results are compatible to study done by Sankar and Kristofer which included 19 patients, in 15 of them occurred in the middle third, in two of them occurred on upper third, and in the other two patients occurred in the lower third which was due to the same reason.
In the current study, the average of time of complete union was 11.33 weeks which is compatible to study done by O'Brien; it showed that the time of complete union was 9 weeks; in other study done by Zarad, the average time of complete union was 10 weeks which is compatible to the current study. In a study done by Mark G. Swindells, the average of time of complete union was 10 weeks and in a study done by Atul Bhaskar, the average of time of complete union was 11 weeks which are all compatible.
In the current study, there was no any case of nonunion as they were all reduced closely which is compatible to the study done by Basil Kamran which also did not have any case of nonunion. In the current study, there were four cases of the delayed union in which complete healing took more than 12 weeks which was due to type of fracture which was open, this is compatible to study done by Kapil Mani in which there were four cases of the delayed union from a total of 45 cases and no cases of nonunion.
Regarding the complications that occurred in the current study, most were minor, including nail protrusion that happened in six patients which was due to improper cutting of the nails and angulation 5°–10° in three patients which was due to in adequate reduction. This is compatible to a study done by Elseyd Ahmed in which there were three patients of a total of 20 patients with nail protrusion and skin irritation, and only two patients with angulation 5°–10°.
Regarding limb length discrepancy, in the current study, not more than 5 mm discrepancy was recorded and this little discrepancy might be due to overlapping, especially in spiral fractures, compatible results were recorded by a study done by Jeong Heo, in 16 patients with tibial diaphysis fracture no more than 10 mm discrepancy was recorded.
| Conclusion|| |
Elastic nails are an effective way for the treatment of pediatric tibial diaphysis fractures; they control the length, angulations, and rotation as they provide stability through three points of fixations for each nail. It is a simple and easy method but with radiation risk. Although elastic nails had complications, all are avoidable and minor that managed with minimal intervention.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Moony JF, Hennrikus WL. Fractures of the shaft of the tibia and fibula. In: Flynn JM, Skaggs DL, Waters PM, editors. Rockwood and Wilkins Fractures in Children. 8th
ed. Philadelphia USA: Wolters Kluwer; 2015. p. 1136-8.
Prabhakar V, Nagendra Srinivas G, Siddarth M. A prospective study of surgical management of diaphyseal fractures of tibia in children aged between 5 to 16 years using elastic stable intra medullary nailing. Int J Med Appl Sci 2015;4:194.
Canale ST, Beaty JH. Campbell's Operative Orthopaedics. 12th
ed. Philadelphia: Elsevier Mosby; 2013. p. 1492.
Onta PR, Thapa P, Sapkota K. Outcome of Diaphyseal Fracture of Tibia Treated with Flexible Intramedullary Nailing in Paediatrics' Age Group; A Prospective Study P. Am J Public Health Res 2015;3:65-8.
Kc KM, Acharya P, Sigdel A. Titanium Elastic Nailing System (TENS) for Tibia Fractures in Children: Functional Outcomes and Complications. JNMA J Nepal Med Assoc 2016;55:55-60.
Choudhari P, Chhabra S, Kiyawat V. Evaluation of results of titanium elastic nailing system in paediatric lower extremity fractures of long bones. J Evol Med Dent Sci 2014;3:15303-9.
Anjum R, Raina P, Singh S. Fixation of Paediatric tibial fractures with TENS; A prospective study. Int J Adv Res 2015;3:251-4.
Sankar WN, Kristofer J. Titanium elastic nails for pediatric tibial shaft fractures. J Child Orthop 2007;1:281-6.
O'Brien T, Weisman DS, Ronchetti P, Piller CP, Maloney M. Flexible titanium nailing for the treatment of the unstable pediatric tibial fracture. J Pediatr Orthop 2004;24:601-9.
Zarad AL. Flexible intramedullary nails for unstable fractures of the tibia in children: A retrospective evaluation of effectiveness. Egypt Orthop J 2014;4:281-5. [Full text]
Swindells MG. Elastic intramedullary nailing in unstable fractures of the paediatric tibial diaphysis: A systematic review. J Child Orthop 2010;4:45-51.
Bhaskar A. Treatment of long bone fractures in children by flexible titanium elastic nails. Indian J Orthop 2005;39:166-8. [Full text]
Kamran B, Iqba MZ. Outcome of closed titanium elastic nailing in paediatric tibial diaphyseal fractures. JSZMC 2016;7:1074-7.
Elsayed Ahmed KF, Zakaria B, Hadhood M, Shaheen A. Management of diaphyseal fracture in pediatrics by elastic stable intramedullary nails. Menoufia Med J 2014;27:401-6.
Heo J, Oh CW, Park KH, Kim JW, Kim HJ, Lee JC, et al
. Elastic nailing of tibia shaft fractures in young children up to 10 years of age. Injury 2016;47:832-6.
[Table 1], [Table 2], [Table 3], [Table 4]