Flexible intramedullary nails with supplemental external fixator in treating length unstable pediatric femur fractures

Flexible intramedullary nails with supplemental external fixator in treating length unstable pediatric femur fractures
Pediatric femoral fractures are common injuries, accounting for approximately 1.6% of all skeletal injuries in children. The treatment of pediatric femoral shaft fractures still bears some controversy, especially if they are unstable. Many options for treatment are available, including different conservative and operative treatment. Many factors like patient age, weight, fracture pattern, associated injuries, surgeon and family preferences, and socioeconomic factors tailor the appropriate treatment option (1).
Length unstable fractures have been defined as spiral, long oblique, or comminuted, with a fracture line length more than twice the diameter of the femoral shaft at the level of the fracture. This fracture is often associated with >2 cm of shortening. The length unstable diaphyseal femoral fracture is problematic in children due to the long recovery time, skeletal immaturity, heightened risk of post-operative complications, and a lack of consensus as to the proper fixation modality (2).

1. Flexible intramedullary nails with supplemental external fixator in treating length unstable pediatric femur fractures Thesis Submitted for partial fulfillment of Master Degree in Orthopedic Surgery By Mohamed Fouad Abd Elsalam

2. Under supervision of Prof. Dr. / Mohamed Goda Montaser Professor of Orthopedic Surgery Faculty of Medicine - Benha University Prof. Dr. / Sherief Abd Almonaem Assistant Professor of Orthopedic Surgery Faculty of Medicine - Benha University Dr. / Ahmed Taha Mohamed Lecturer of Orthopedic Surgery Faculty of Medicine - Benha University   Faculty of medicine Benha University 2023

3. General Principles About 15% of injuries in children are skeletal Out of all skeletal injuries in children Radial shaft fractures 6.4 % Tibial shaft fractures 6.2 % Femoral shaft fractures 2.1 % Proximal & shaft humerus fractures 1.4 %

4. Treatment options of femoral shaft fractures Immediate hip spica Delayed hip spica Plate osteosynthesis Conventional IMN Stainless steel K-wires Titanium elastic nailing External fixation

5. Rigid intramedullary nail In older children and adolescents Placement through the lateral aspect of GT 1. Safe technique 2. Effective 3. Well tolerated Growth arrest of the greater trochanter Beware Rotational Malalignment

6. External Fixation Used Less Frequently Indications: Open Fractures Multiply Injured Patient? Floating Knee? Severe Comminution ? Downsides: High Re-Fracture Rate Pin Site Infection Delayed Union

7. Open Plating AO Principles Good Option For: Proximal Fractures Some Open Fractures Downsides: Extensive Dissection Blood Loss Plate Removal Stress Risers

8. Sub-Muscular Plating Increasingly Popular Good Option For: Comminuted Fractures Distal Fractures Downsides: Learning Curve Stress Risers Plate Removal Valgus Deformity?

9. Elastic stable intramedullary nailing (ESIN) Advantages No need for postoperative cast Primary bone union Avoidance of growth plate injury Minimum invasive surgery Excellent functional and cosmetic results

10. Complications Nonunion ?? Osteomyelitis (rate is 2%) Overgrowth ( <10 mm before age of 10 years) Cortical perforation Re-fractures ? Skin irritation Length Unstable FXS: Limb Length Difference

11. Length unstable fracture pattern Comminuted fractures Long oblique or spiral if: Length twice as long as width of shaft 67% of fractures

12. Aim of the work The purpose of this study is to show the results and complications of flexible intramedullary nails (FIMN) with a supplemental external fixator in treating length unstable pediatric femur fractures, in children aged between 5 and 15 years.

13. Patients & Methods Study Design: - Randomized Clinical Trial Patients and methods:   Population of study: Children (aged 5–15 years) with length unstable shaft femur fracture Study location: Banha University Hospitals, Al- helal Hospital, and Health Insurance Hospitals

14. Inclusion criteria: Age between 5 and 15 years Both male and female sexes Site of the fracture: mid shaft, supracondylar, and subtrochanteric Gustilo type I open fractures and closed femoral shaft fractures Shape of the fracture: spiral, long oblique, and comminuted fractures Exclusion criteria: Age above 15 or below 5 years Gustilo types II and III open fractures High velocity gunshot injuries Pathological fractures Polytrauma necessitating intensive care unit care and/or extensive management of other injuries Length stable femoral fractures (simple transverse or short oblique) Intra-articular fractures

15. Methodology Preoperative assessment: Surgical technique: Post-operative assessment Flynn’s Titanium Elastic Nail (TEN) grading system will be used to assess the clinical outcome.

16. Results The recorded data will include patient characteristics (sex, age, weight, fracture type, follow-up duration, operative time, fluoroscopic time and time to weight bearing) and complications (rotational or angular deformity, shortening, symptomatic hardware, union and wound complications, and decreased range of motion). The results obtained will be tabulated and statistically analyzed.

17. Thank you