Flexible intramedullary nails for fractures in children
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ASPECTS OF CURRENT MANAGEMENT
Flexible intramedullary
nails for fractures in children
M. Barry, Over the past few years there has been a metaphysis which made them suitable for con-
J. M. H. Paterson marked increase in the use of intramedullary sideration in paediatric fractures.
fixation in the management of fractures of long In the early 1980s, surgeons in Nancy,
From Royal London bones in children. To some extent this reflects a France, developed an elastic stable intra-
Hospital, London, more interventionist attitude among paediatric medullary nail based on a theoretical concept
England orthopaedic surgeons but is also due to techni- by Firica.7 Previous experience had suggested
cal developments, notably that of the elastic that elasticity and stability were not easily
stable intramedullary nail (ESIN). combined in one construct. However, work-
The use of intramedullary devices to stabi- ing from the concept of three-point fixation
lise fractures is not new. In the mid-19th cen- used with a single Rush nail, these surgeons
tury, ivory pins were used for this purpose and were able to improve stability significantly by
were then gradually supplanted by various using two pre-tensioned nails inserted from
metal devices.1 These were generally rigid opposite sides of the bone. Metazieau, Ligier
implants, although more flexible ones were and their colleagues7 were able to show that
introduced in in the 1930s. The school of rigid titanium nails which were accurately con-
intramedullary fixation was typified by the toured and properly inserted could impart
Küntscher nail, which achieved great stability excellent axial and lateral stability to diaphy-
in all planes by occupying the entire medullary seal fractures in long bones. Rotational stabil-
cross-sectional area of the bone.2 However, its ity was also better than had previously been
use in growing children was limited by the dif- experienced, although this was to remain the
ficulties encountered in trying to avoid the phy- weakest point of the technique. The use of
ses. titanium nails allowed greater elasticity than
The Rush nail was introduced at about the was available in the steel nails of the Ender
same time as the Küntscher nail.3 It was the system.
forerunner of modern elastic intramedullary Most contemporary work on flexible intra-
fixation in that the objective was to achieve medullary nailing in children’s fractures is
three-point fixation on the inner aspect of the based on the Nancy experience, although there
cortex. Unlike the stiff Küntscher nail, the remain pockets of Ender and Marchetti enthu-
Rush nail was slightly flexible and it was siasts. For the purposes of this review, flexible
intended that it should be pre-bent to the intramedullary nailing is taken to mean elastic
appropriate configuration before insertion.3 stable intramedullary nailing using the con-
Rotational stability was poor, however, and in cepts espoused by the Nancy group.
M. Barry, MS FRCS (Orth), most situations the flexibility was insufficient
Consultant Orthopaedic
Surgeon to allow insertion points in the metaphysis Principles of the technique
J. M. H. Paterson, FRCS, which were well away from the active physis in The ideal fracture for this technique is a trans-
Consultant Paediatric
Orthopaedic Surgeon children. verse or short oblique diaphyseal fracture with
Children’s Orthopaedic Unit, Others, such as Hackethal4 and Marchetti,5 minimal comminution in a long bone. How-
Royal London Hospital,
Whitechapel, London E1 used bundles of thinner wires which filled the ever, such is the versatility of the method that
1BB, UK. medullary cavity but with stabilisation the indications have widened considerably
Correspondence should be achieved by splaying the ends of the wires with time and personal experience.
sent to Mr J. M. H. Paterson.
within the bone well beyond the fracture. The essential prerequisite is accurate pre-
©2004 British Editorial Ender6 developed this further with his nails, bending of an elastic titanium nail so that the
Society of Bone and
Joint Surgery
which were the first to feature adaptations to apex of the bend will lie at the fracture site. A
doi:10.1302/0301-620X.86B7. both ends of the nail in order to improve both second nail of equal diameter is prepared to
15273 $2.00
J Bone Joint Surg [Br]
control of insertion and quality of fixation. provide a diametrically opposed curve at the
2004;86-B:947-53. These nails could be safely inserted into the fracture site. The diameter of the nail should be
VOL. 86-B, No. 7, SEPTEMBER 2004 947948 M. BARRY, J. M. H. PATERSON
Fig. 1a Fig. 1b Fig. 2a Fig. 2b
Radiographs of an angulated fracture of the mid-shaft of the femur in a Radiographs of the same fracture from Figure 1 following closed reduc-
boy aged six years a) anteroposterior (AP) and b) lateral views. tion and intramedullary stabilisation with two flexible nails a) AP and b)
lateral views. Note the symmetrical placement of the nails and their sep-
aration at the level of the fracture site.
two-fifths of the internal diameter of the medullary canal. late the fracture. Insertion of the second nail in a similar
Its length should be selected on the basis of pre-operative fashion but from the opposite side of the bone will counter-
radiographs of known magnification, and confirmed on the act this moment with an equal and opposite force. For this
limb before insertion. reason, both nails should be inserted up to the fracture site,
In general, the insertion site will be in the metaphysis of the fracture reduced, and the nails tapped across the frac-
the bone. It is tempting to make a small stab incision to ture site in an alternating manner for perhaps 1 to 2 cm into
make the insertion, but it should be remembered that these the far segment. Both nails can then be knocked home, leav-
nails will also usually be removed, and it is difficult to ing sufficient nail exposed at the site of insertion to enable
explain to parents why the incision for removal is much subsequent removal.
longer than the original scar. Under fluoroscopic control, If the contouring of the nails has been accurate, they will
the cortex can be broached with an awl or drill according to come to rest with their maximum separation at the level of
individual preference. In younger children, in certain bones, the fracture, crossing in the medulla above and below this
and in cases of pathological fracture in osteopenic bone, it site. This so-called trifocal buttressing of each nail within
may be possible simply to use a curved haemostat. The the medullary cavity will impart the maximum stability to
selected nail is introduced and gently tapped along the the fixation. This will nonetheless be far from rigid, and
medulla with the tip angled away from the cortex. The healing is characterised by the early appearance of the exu-
temptation to rotate the nail back and forth should be berant callus associated with micromovement.8
resisted. If possible, the fracture should be reduced by
manipulation and the nail advanced across the fracture site. Fractures in the lower limb
This is the time when careful rotation of the nail can be very Shaft of the femur (Figs 1 and 2). In the past, the majority
useful in enabling the tip of the nail to gain access to the of fractures of the femur in children were treated conserva-
medulla on the far side of the fracture. tively, and the only point of discussion concerned which
The elastic deformation of the curved nail in a straight form of traction was to be employed. Nowadays, pressure
medulla creates a bending moment which will tend to angu- on hospital beds and the trend towards shorter stays in hos-
THE JOURNAL OF BONE AND JOINT SURGERYFLEXIBLE INTRAMEDULLARY NAILS FOR FRACTURES IN CHILDREN 949
Fig. 3a Fig. 3b Fig. 4a Fig. 4b
Radiographs of a fracture of the mid-shaft of the tibia in a boy aged ten Radiographs of the same fracture from Figure 3 at union fol-
years a) AP and b) lateral views. lowing intramedullary stabilisation with two flexible nails
a) AP and b) lateral views.
pital has led to an increase in the number of surgical inter- with or without a cast brace, depending on the weight and
ventions for these injuries. size of the child and the configuration of the fracture.11
There is no indication for the use of ESIN in these frac- The results in the age range of five to 14 years are
tures in children under the age of four to five years. These excellent11,12 and compare well with those of either external
can be treated very satisfactorily in hip spicas, with or with- fixation13 or treatment with a spica.14 The stay in hospital is
out preliminary traction. Thus, the lower age limit for ESIN generally for a few days only.14 The fracture heals typically
in femoral fractures is probably about five years of age. The within eight to ten weeks and the presence of the nails does
upper limit is more difficult to determine. Recent work has not appear to impair bone healing.15 Non or delayed union
shown increasing angulation at the fracture site after ESIN is very uncommon12 and when it occurs may be related to
stabilisation in older, heavier children.9 However, there is the use of nails of inadequate diameter.9 Otherwise, compli-
no ideal alternative. The risk of avascular necrosis of the cations seem to be limited to discomfort or skin tenting at
head of the femur from the insertion of rigid intramedullary the sites of insertion of the nail.9,15 These can be reduced by
nails in teenagers is well described,10 and this form of fixa- allowing the end of the nail to lie along the flare of the meta-
tion is best avoided while the proximal femoral physes physis; it should not be bent away from the bone. Growth
remain active. ESIN can be used in the older child, but addi- disturbance appears to be minimal with a mean femoral
tional support in the form of a cast brace may be indicated overgrowth of only 1.2 mm.12 The originators of the tech-
if there is concern about stability. Thus, it may be reasona- nique recommended removal of the nail at about six months.
ble to use ESIN up until the time of closure of the proximal However, at least one author has questioned the necessity of
growth plate, after which conventional rigid locked removal in the absence of symptoms in the child.16
intramedullary nailing can be used safely. Shaft of the tibia (Figs 3 and 4). The tibia does not lend
The technique is as outlined above. Early intervention itself well to the potential benefits of ESIN stabilisation.
and the use of a fracture table make closed reduction much The triangular cross-section makes it difficult to place nails
easier. In most cases, it is possible to allow the child to in the symmetrically opposed configuration necessary for
mobilise immediately with light partial weight-bearing, the technique to work properly. The marked proximal
VOL. 86-B, No. 7, SEPTEMBER 2004950 M. BARRY, J. M. H. PATERSON
Fig. 5a Fig. 5b
Radiographs of a seemingly innocuous fracture of the mid-shaft of the forearm which angulated during treatment by a cast a) AP and b) lateral views.
Fig. 6a Fig. 6b
Radiographs of the insertion of flexible intramedullary nails same fracture from Figure 5, one week later resulted in virtually anatomical union at six
weeks a) AP and b) lateral views.
metaphyseal flare and the presence of the tibiofibular artic- or in the poly-traumatised child with multiple fractures of
ulation make antegrade nail insertion awkward. Additional long bones.17 Again, two nails are used. The entry point for
protection with a cast is probably indicated, and under the nails is dependent on the level of the fracture. Fractures
these circumstances, surgeons might consider the benefits of the proximal and middle thirds can be stabilised with a
of nailing to be marginal. Enthusiasts for the ESIN tech- pair of retrograde nails, as described above. Fractures of the
nique report good results, although casting of the limb distal third are stabilised with two antegrade nails. Both
appears to play a major role in management.11 nails are inserted through a lateral entry point at about the
level of the insertion at the deltoid. Separate holes are made
Upper limb in the lateral cortex, one above the other.
Humerus. In children, most fractures of the humeral shaft Paediatric orthopaedic surgeons are acutely aware of the
can be managed conservatively and do not require treat- challenges of the supracondylar fracture of the humerus,
ment with an ESIN. and many feel that the use of an ESIN in this situation adds
Fractures of the proximal humerus often involve the further unnecessary challenges. Nevertheless, elastic nails
proximal physis and are generally Salter and Harris type-II can be used to stabilise supracondylar fractures.18 Two ante-
injuries. The potential for remodelling is significant and grade nails are used, with the aim of passing a nail down
some displacement is acceptable. In unstable fractures or in each column, across the fracture site and into the metaphy-
those which are significantly displaced, additional stability sis. There is a steep learning curve to this technique, and for
may be required. This may be afforded by K-wires inserted most surgeons the displaced supracondylar fracture will
through the deltoid and across the fracture site or by the use continue to be treated by reduction and K-wire stabilisation.
of elastic nails. Two nails are inserted into the lateral Radius and ulna. It is in the forearm that treatment with the
column of the humerus at the elbow and passed distally to ESIN has probably had the greatest impact on management
proximally. The physis and fracture site is crossed and the of fractures. Most orthopaedic units dealing with signifi-
tips of the nails impacted into the head of the humerus. cant numbers of paediatric fractures now regard flexible
Both nails are inserted through a lateral point of entry, just intramedullary nails as the treatment of choice when inter-
proximal to the distal physis. Separate holes are made in the nal stabilisation of these injuries is required.
lateral column, one above the other. Once the fracture is A wide variety of intramedullary devices has been used.
stabilised, early mobilisation can be started as there is no As well as titanium elastic nails,19-21 K-wires,22-24 Stein-
muscle transfixation at the shoulder. mann pins25 and reamed square nails26 have been used for
Fractures of the shaft of the humerus may require stabi- the fixation of these fractures. Elastic nails and K-wires
lisation with ESIN when conservative measures have failed seem to be equally effective.27
THE JOURNAL OF BONE AND JOINT SURGERYFLEXIBLE INTRAMEDULLARY NAILS FOR FRACTURES IN CHILDREN 951
Fig. 7a Fig. 7b
Radiographs of a Monteggia injury treated by intramedullary fixation, in this case, a K-wire.
Fig. 8a Fig. 8b
Radiographs of a displaced fracture of the head of the radius reduced and stabilised using the curved tip of the Nancy flexible intramedullary nail.
Treatment with an ESIN is indicated for unstable, irre- with local discomfort on extension of the wrist post-opera-
ducible or open fractures, when non-operative manage- tively. The nail in the ulna is inserted just distal to the physis
ment fails (Figs 5 and 6) and in specific circumstances such on the radial border. The point of entry is easily palpable
as Monteggia injuries (Fig. 7) and fractures of the head and and is proximal to the annular ligament and the head of the
neck of the radius (Fig. 8). These are situations where sur- radius. Lascombes et al19 advocate that the two nails are
gical management might otherwise involve fixation with a pre-contoured although we have found that straight nails
compression plate and screws. Although such internal fixa- are equally effective.
tion is a mechanically sound form of surgical stabilisa- The question arises as to whether both bones should be
tion,28 it is associated with significant complications.29,30 nailed. Clearly if only one bone is fractured, only one nail is
Fixation with plates in children has given acceptable results required. If both bones are fractured and both of the frac-
but there are definite advantages in using the ESIN. The tures displaced then almost certainly two nails will be
operating time is shorter, there is minimal soft-tissue dissec- required. If one fracture is displaced and the other is not,
tion even if open reduction is required, cosmesis is excellent then the displaced fracture should be reduced and the sta-
and the implant is easier and safer to remove.31 bility of the forearm reassessed. A second nail may not
Technique. A single nail is used for each forearm bone. Gen- always be necessary.32
erally, a nail of 2.0 to 2.5 mm diameter is used, with the Displaced, unstable fractures of the neck of the radius
larger diameter employed if possible. The nail in the radius can be elegantly treated with an elastic nail inserted at the
is inserted just proximal to the physis on the radial border. distal radius. The curved tip of the nail can be used as an aid
Care should be taken to avoid injury to the superficial to reduction of the fracture.33,34
radial nerve. An alternate point of entry is dorsally, adja- In most cases, Monteggia fractures can be managed con-
cent to Lister’s tubercle. Use of this site can be associated servatively with closed manipulation and application of a
VOL. 86-B, No. 7, SEPTEMBER 2004952 M. BARRY, J. M. H. PATERSON
plaster cast. On occasion, the fracture may be unstable and plications, does not interfere with growth, and is associated
maintaining reduction of the radial head can be difficult with short hospital stays and a rapid return to daily activity.
with a plaster cast alone. An elastic nail can then be used. However, these are also the features of a well-executed
The nail is inserted at the tip of the olecranon and passed closed reduction and immobilisation in a well-moulded
distally down the shaft of the ulna. The nail can be slightly cast. Flynn et al,40 while reporting with enthusiasm on the
contoured to assist in maintaining reduction of the head of result of flexible intramedullary nailing, pointed out that
the radius. This point of entry will result in the nail passing the majority of paediatric fractures of the lower limb can,
across the proximal physis of the ulna. We have not seen and should, continue to be treated with closed reduction
any cases of arrest of physeal growth. and immobilisation. While welcoming the undoubted ben-
efits of flexible intramedullary nailing, we must ensure that
Pathological fractures the skills of manipulation of fractures and immobilisation
Elastic nails have a useful role in the management of benign in a cast are not lost.
pathological fractures of long bones. The pathological frac- Some questions remain: what is the upper age or weight
ture may be as a result of local bone weakness or more gen- limit for lower limb nailing? Is it necessary to remove nails,
eralised pathology. and if so, when? Is the theory of ESIN borne out in prac-
Local. Asymptomatic defects such as fibrous cortical defects tice? It is by no means certain that the ESIN devices offer
or unicameral bone cysts can present as a fracture.35,36 In any significant advantage in the forearm over simple K-
general, these fractures will unite and often the cyst itself wires. In general, however, flexible intramedullary nailing
will heal. The fracture can be treated by conservative has deservedly become established as a front-line treatment
methods but use of elastic nails has some advantages. As for certain fractures of long bones in children. This tech-
well as the stabilisation of the fracture, the nails will nique should be part of the armamentarium of any ortho-
decompress the cyst,37-39 which will promote healing of the paedic surgeon who deals with paediatric trauma.
defect as the fracture unites.
Generalised. The most common cause of generalised bone References
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