Between 1996 and 2003 six institutions in the United States and France contributed a consecutive series of 234 fractures of the femur in 229 children which were treated by titanium elastic nailing. Minor or major complications occurred in 80 fractures. Full information was available concerning 230 fractures, of which the outcome was excellent in 150 (65%), satisfactory in 57 (25%), and poor in 23 (10%). Poor outcomes were due to leg-length discrepancy in five fractures, unacceptable angulation in 17, and failure of fixation in one. There was a statistically significant relationship (p = 0.003) between age and outcome, and the odds ratio for poor outcome was 3.86 for children aged 11 years and older compared with those below this age. The difference between the weight of children with a poor outcome and those with an excellent or satisfactory outcome was statistically significant (54 kg vs 39 kg; p = 0.003). A poor outcome was five times more likely in children who weighed more than 49 kg

Background:. In recent times there has been an increasing trend towards surgical intervention in paediatric femoral shaft fractures with widening indications. Titanium elastic nails and external fixation are two widely practiced procedures for such fractures. Materials & Methods:. We report a series of 48 children with 52 fractured femurs, 18 being managed by TENS and 34 in a linear external fixator. Children were aged between 3.5 to 12 years and the fractures were stabilised after an optimal closed reduction on a normal theatre table under image intensifier control. Fracture site distribution was nearly uniform in both the groups. Though most children were assigned to any of the groups at random, external fixators were applied on many younger children and those having financial constraints. Results:. The average age of children in the TENS group was 7.4 years and the average fracture healing time was 9.4 weeks. In the ex-fix group the figures were 5.6 years and 8.6 weeks respectively. Fixators were removed when good callus formation was seen on at least three cortices; average fixator time was 7.5 weeks. Fracture callus formation was slower in TENS group. Soft-tissue irritation at the nail entry points was the commonest complication for the TENS whereas pin-track infection was problem in the ex-fix group. Conclusion:. Management of paediatric femoral shaft fractures has changed to include more interventions. Flexible or elastic nailing like the TENS is a versatile and popular technique, however stabilisation in an external fixator also produce comparable results. External-fixation is an easier, cheaper and shorter procedure, and a mini ex-fix becomes a convenient external splint for smaller children who can be more conveniently nursed. Moreover ex-fix removal is an office procedure without anaesthesia

We reviewed eleven diaphyseal humerus fractures treated over an 18 month period, March 2004 to October 2005, using a single intramedullary Titanium Elastic Nail (TEN). The mean age of 6 boys and 5 girls was 7.6 years. The longest follow up was twelve months. The mean period of implant insertion was 6 months. Diaphyseal fractures were most commonly the result of a fall (45%), and 3 (27%) were the result of motor vehicle accidents (MVA) with other associated injuries. Two (18%) were pathological fractures. All were closed fractures. Nine of the eleven (81%) were treated by a closed reduction and a single retrograde TEN inserted percutaneously. Two required open reduction. There were no pre-operative or post-operative neurovascular complications. At mean follow up (6 months), there were ten satisfactory results (91%), with one complication of implant sepsis. The use of TENs for diaphyseal humerus fractures in children has not been widely described in the literature as compared to their use for diaphyseal femoral fractures. Traditional teaching advocates conservative treatment for these fractures. We believe that in 4–12 year old patients, a single TEN is a viable option in the treatment of these fractures in that it gives over-all good results with minimal morbidity. It is easy, quick, allows early return to activities, and avoids some of the complications of conservative treatment such as those associated with prolonged immobilization and malunion

Introduction. Pediatric femoral fracture including supracondylar and subtrochantric fracture constitutes 1.6% of all pediatrics fractures. 1. Elastic nails remain the standard treatment of choice in mid shaft transverse femoral fracture in children weighting less than 45kg. 2. But in subtrochantric and spiral femoral fracture, failure rate of TENS nails are quite high. 3. . Material and methods. We retrospectively reviewed 30 subtrochantric fracture in children (average age 9 years) treated with bridge plate by mini invasive approach. Result. All fracture united well in average 14 weeks. Single complication was 5mm limb lengthening due to fixation in traction on fracture table in one case. We strongly recommend bridge plate in complex femoral fracture in children

We report early major complications encountered following TEN fixation of femoral fractures in children.

A case series of four children aged 8– 16 years who had primary TEN fixation of isolated femoral diaphyseal fractures.

Three of the four patients had major complications. These were: significant knee stiffness requiring manipulation, haemarthrosis requiring washout and nail removal, loss of position and refracture. Two required revision to locked intramedullary nails without early complication.

In the skeletally immature child TEN fixation of femoral fractures has a significant major complication rate. This needs to be recognised when comparing TEN fixation with other treatment options.

Aims. Osteopetrosis (OP) is a rare hereditary disease that causes reduced bone resorption and increased bone density as a result of osteoclastic function defect. Our aim is to review the difficulties, mid-term follow-up results, and literature encountered during the treatment of OP. Methods. This is a retrospective and observational study containing data from nine patients with a mean age of 14.1 years (9 to 25; three female, six male) with OP who were treated in our hospital between April 2008 and October 2018 with 20 surgical procedures due to 17 different fractures. Patient data included age, sex, operating time, length of stay, genetic type of the disease, previous surgery, fractures, complications, and comorbidity. Results. The mean follow-up period was 92.5 months (25 to 140). Bony union was observed in all of our patients. Osteomyelitis developed in two patients with femoral shaft fractures, and two patients had peri-implant stress fractures. Conclusion. Treatment of fractures in OP patients is difficult, healing is protracted, and the risk of postoperative infection is high. In children and young adults with OP who have open medullary canal and the epiphyses are not closed, fractures can be treated with surgical techniques such as intramedullary titanium elastic nail (TENS) technique or fixation with Kirschner (K)-wire. Cite this article: Bone Joint J 2020;102-B(8):1082–1087

To analyse the management of open paediatric tibial fractures treated at a children's Major Trauma Centre (MTC), comparing fixation methods, union and complications. We retrospectively identified all patients admitted to RMCH with an open tibia fracture between 2008 – 2016. Demographics, mechanism, inpatient stay and follow-up management were reviewed. There were a total of 44 patients, with an average age = 10 years (3–15). 93% of cases were caused by road traffic accidents, commonly pedestrian versus car. Older children were more likely to sustain higher grade injuries, requiring increased length of stay. 35 patients had primary / delayed wound closure, 1 patient required fasciotomies and 4/44 needed skin grafts and/or flap. 7 patients were treated in plaster, 9 by elastic nailing, 15 had mono-lateral fixators and 12 with circular frame. The average number of surgeries = 3 (1–7) with older children having increased risk of revision surgery. Monolateral fixators were the most common primary fixation method (n=15), however 60% required revision to ring fixator due to displacement or delayed union. The main risk factor for displacement was inadequate fracture reduction in theatre, as well as those fracture patterns involving butterfly fragments. Union (defined as RUST score = 3 on >3 cortices) was achieved in all patients (ave 6 months). Delayed union was associated with higher grade injuries, those treated with elastic nails demonstrated the longest union time (ave 7.3 months). 21/44 (47.7%) patients had complications, with pin site infection being the most commonly seen. 18% patients suffered a major complications needing further surgery. Various fixation methods can be successfully used to treat these fractures. They demonstrate a high complication rate and often require multiple surgeries, with union taking an average of 6 months. Mono-lateral fixators demonstrate a high revision rate, particularly if the fracture is not well reduced

The August 2015 Children’s orthopaedics Roundup. 360 . looks at: Learning the Pavlik; MRI and patellar instability; Cerebral palsy and hip dysplasia; ‘Pick your poison’: elastic nailing under the spotlight; Club feet and surgery; Donor site morbidity in vascularised fibular grafting; Cartilage biochemistry with hip dysplasia; SUFE and hip decompression: a good option?

This study compares the initial outcomes of minimally invasive techniques for single-event multi-level surgery with conventional single-event multi-level surgery. The minimally invasive techniques included derotation osteotomies using closed corticotomy and fixation with titanium elastic nails and percutaneous lengthening of muscles where possible. A prospective cohort study of two matched groups was undertaken. Ten children with diplegic cerebral palsy with a mean age of ten years six months (7.11 to 13.9) had multi-level minimally invasive surgery and were matched for ambulatory level and compared with ten children with a mean age of 11 years four months (7.9 to 14.4) who had conventional single-event multi-level surgery. Gait kinematics, the Gillette Gait Index, isometric muscle strength and gross motor function were assessed before and 12 months after operation. The minimally invasive group had significantly reduced operation time and blood loss with a significantly improved time to mobilisation. There were no complications intra-operatively or during hospitalisation in either group. There was significant improvement in gait kinematics and the Gillette Gait Index in both groups with no difference between them. There was a trend to improved muscle strength in the multi-level group. There was no significant difference in gross motor function between the groups. We consider that minimally invasive single-event multi-level surgery can be achieved safely and effectively with significant advantages over conventional techniques in children with diplegic cerebral palsy

The purpose of this study was to evaluate the subjective and objective functional outcome after osteosynthesis of the forearm bone fractures with plates and screws (ORIF) or elastic nailing (CRIF). We evaluated 55 patients (45 men and 10 women) who underwent internal fixation of both forearm bones with CRIF or ORIF, concerning the range of motion of the forearm, wrist and elbow (pronation, supination, flexion and extension), grip strength and a validated outcome measure (DASH score). The mean duration of follow-up was 3 years, and standardized radiographs of the forearm were evaluated. The mean age was 41.6. We used the Student's t test to compare means and chi-square test to compare proportions. The mean (confidence interval 95%) of the DASH scale was 29.6 (22.6 to 36.5), significantly higher (p<0.001) than the normative value in the U.S. (10.1). There was a statistically significant reduction of forearm supination (86.4 vs. 64.6, p<0.001) and grip strength (0.63 vs. 0.48, p<0.001) in relation to the opposite member; grip strength decrease correlated with worse subjective outcome (p<0.02). There were no significant differences between groups undergoing ORIF or CRIF. The risk of nonunion and reintervention was not different between groups (p=0214). Forearm bones fractures are associated with high rates of consolidation and satisfactory mobility of the forearm since we obtain an anatomic reduction of the fracture, as is most easily achieved by plate fixation. However, elastic nailing is a less invasive technique that allows restoring function more quickly with less pain and no increased risk of complications. Given the scant scientific evidence currently available we will require a more comprehensive study to compare the anatomical and functional outcome after ORIF and CRIF

Aim: The purpose of the study was to report the outcome of Flexible elastic nailing for femoral shaft fractures in children. Materials and Methods: Sixty-three femoral shaft fractures in 62 children treated with titanium flexible elastic nailing over a 10 year period (1998–2007). There were 44 boys and 18 girls aged 7.4 to 15.6 yrs (mean 11.2 yrs). Their body weight ranged from 22 to 64.80 kg (mean 40.99 kg). The right side was involved in 36 and the left in 27 children (including 1 bilateral fracture). The mechanism of injury varied from Road traffic accidents (RTA) in 42, Sports in 2 and Falls in 18 children. The proximal third shaft was involved in 3, middle third in 50 and distal third in 10 children. The fracture pattern varied from Transverse in 28, Oblique in 21, Spiral in 12 and Comminuted in 2 children. Results: All fractures united with a mean union time of 15 weeks (range 6 to 30 weeks). The average follow-up was 72 weeks (range 52–104 weeks). Outcome assessment using the Titanium Elastic Nailing (TEN) Score showed 63% excellent, 32% satisfactory and 5% poor results. The minor complications varied from transient knee stiffness in 8 children, prominent nail ends in 7 children, extensor lag in 2 children, and acceptable facture angulation in 2 children. The major complications were fracture malunion, non-union, delayed union in 1 child each and re-fracture at different level in one child. The mean leg length discrepancy after union was 8mm (range 0–13 mm). There were no cases of infection. This method of treatment provided stable fixation, early mobilization and discharge. Conclusion: We found that good surgical technique with attention to surgical details resulted in 95% excellent to satisfactory outcome

This study is based on 286 consecutive fractures of the shaft of the humerus surgically treated in the Orthopaedic Department Spedali Civili, Brescia, from November 1996 to December 2001. Fractures were classified accordingly to AO System. A peculiar group was represented by 33 (11.5%) complex and multifragmental fractures, where the fracture involved either the shaft and the proximal metaphysis and epiphysis. Fractures were always treated by plate and screws when a deficit of the radial nerve was present, in order to allow neurolysis or nervous graft. Fractures without radial nerve lesion were treated either by plate or by endomedullary nail. In the latter group two typed of nail were used:. rigid, reamed, Kuntscher nail inserted through the proximal epiphysis. elastic nail, type Marchetti-Vicenzi, inserted through a posterior, distal humeral approach. Patients were evaluated with a follow-up of a least 1 year. The rate of fracture consolidation, was similar in the group 1 rigid nail (96.5%) and plate (96.9%), while lower in the group of elastic nail (89.1%). Also time of consolidation and functional recovery was similar in the first two groups. Particular problems presented by the group of complex fractures required a differentiated post-surgical treatment, with plaster cast or orthopaedic devices used as adjuvant mode of immobilization. All except one of these cased consolidated in a larger lapse of time (mean 4.5 months) with the following functional results: 36.5% very good; 18.1% good; 9.1% fear; 36.3% poor. A selection of the technical solution adopted is presented

Introduction: The traditional methods for the treatment of femoral shaft fractures of children consists of closed reduction and either spica casting or fixation by external fixator. There are also reports on the treatment of such injuries by open reduction and internal fixation by plate. In the last years the method of minimal invasive fixation of such fractures with elastic nails became popular in children over 6–7 year old. The purpose of this paper is to present our experience with elastic nail fixation of femoral shaft fractures of children. Material and Methods: We present a series of 43 children aged 3–13 year old, mean age: 6.5y, follow-up 2–4 years, mean 2.5 years) with shaft fractures of the femur. 12 children were under 5 year of age. Seven of them were poly-trauma patients. There were no open fractures. Each patient was treated by closed reduction and percutaneous nail insertion under C-arm imaging intensifier control. Fixation was accomplished by a knee immobilizer alone. Early non-weight-bearing mobilization was encouraged until appearance of callus formation. Subsequently, weight-bearing was encouraged. Results: The results of all cases were excellent. All fractures were united within 7–14 weeks, with an average of 9 weeks. There were not any cases of femoral fractures through nail insertion. There was no decrease in the range of hip and knee motion. None of the patients had complications such as infection, malalignment or neurovascular injury. There was two cases of bursitis around the tip of the nail in the supracondylar region, which was resolved by early pin removal. Removal of the pins was done 6–9 months following operations. Conclusions: Closed reduction and minimal invasive fixation of femoral shaft fractures by use of Nancy Nails is safe, simple and useful in children with femoral shaft fractures, even in young children under the age of 5 years, and especially in cases of poly-trauma. This minimally invasive procedure allows for early mobilization with no loss of range of motion or associated complications

The traditional treatment method of pediatric femoral shaft fracture has been traction and spica casting.This method is safe but prolonged immobilization, frequent X-ray , pin tract infections are some of the disadvantages. Internal fixation has become an alternative treatment in especially children between 6-10 years. Surgical treatment has been advocated for children who have multiple injuries or severe head injury. Compression plate fixation provides rigid and stable fixation but requires extensive dissection. Fixation of the fractures with flex-ible intramedullary nailing is another alternative treatment method and is safe and effective especially in simple transverse and short oblique fractures.In the current study we tried to evaluate the results of flexible intramedullary nailing and compare them with compression plate fixation. Thirty four patients with 36 femoral segments were included to the study. Clinical and radiological records of the patients were evaluated retrospectively. Patient’s demographic data, mechanism of injury, type of treatment , duration of the operation ,age ,side were obtained from the files. 19 femoral segments were treated with compression plating .There were 13 male and 5 female patients in this group. The mean age was 7.7 (6-10).The mean operation time was 100 minutes.(75-160 minutes- time between entering and leaving the operation room )Average time to healing was calculated as 7.7 (4-10 ) months.In this group, four femoral segment non-unions and implant failures occured in 6-10 months time .These patients were managed with titanium elastic nail.17 femoral segments were treated with titanium elastic nail ( TEN ).There were 10 male and 6 female patients in this group.The mean age of the patients were 7.9 years ( 7-10 ) .There were four patients managed with plate fixation previously . Revision surgery was done with implant removal and open reduction.The remaining 12 patients were operated with closed reduction and nailing. The mean operation time for this group was 86 ( 45-135) minutes . No immobilization method was used and partial weigth bearing permitted after the surgery.The mean healing time was 4 ( 3-7 ) months for this group. As we compare the both groups , the results were similiar. Average operation time was shorter in the nailing group but there were no statistically significant difference between the two groups. ( p> 0.05) . Average healing time was statistically significantly shorter in the nailing group. ( p= 0.038). It is generally accepted that plating is a traditionally safe and effective method; this study demonstrates that flexible intramedullary nailing maintains shorter operation time and shorter time to healing . The lack of need of post-operative immobilization , and small incisions for the insertion of the nail which is cosmetically more acceptable are the other advantages of this method. Conclusion: Internal fixation with flexible intramedul-lary nailing of the femoral fractures in pediatric age group is an advocatable solution

The type and the location of the fractures of the long bones in children that can be treated by elastic intra-medullary nailing are described in this study. Fourty-one patients (aged from 5–18 years old) were treated in our department with fractures of the long bones located on the metaphysis or diaphysis (5 on the distal third of radious and ulna ,8 diaphyseal fractures of the forearm ,7 diaphyseal fractures of the tibia ,5 of the distal end of tibia ,6 of the femoral diaphysis,7 on the distal end of femur and 3 on the diaphysis of the humerus). All operations were performed under radiological control ,to avoid any damage of the growth plates. Tibial , femoral and humeral fractures were fixed with 2 nails whereas forearm fractures were reducted with one nail. Postoperative immobilization with a long cast was applied in forearm fractures at least for 4 weeks. The follow-up time ranged from 1–3 years. The following clinical findings were noticed at the examination : skin infection at the point of the nail insertion area (3 patients), limitation of the range of movements at the carpal joint (2 patients). Radiological findings showed satisfactory callus formation at an early stage in all cases and rotational deformity in 2 femoral obligue fractures due to insufficient stabilization. According to our clinical and radiological findings the results were excellent in 34 cases and good in 7 cases. Fractures of the diaphysis or metaphysis of the long bones in children are fully indicated for intramedullary nailing with elastic nails and the postoperative complications are minor when the fractures are not close to the growth plates. The method is not indicated for comminuted or oblique fractures and fractures – separations

Aims: The purpose of this retrospective review was to analyze our results with the use of the Marchetti-Vicenzi elastic locked nail in femoral shaft fractures. Methods: Between Jan.1994 and Dec.1997, 75 femoral fractures in 73 patients were treated in our department. There were 51 men and 22 women with a mean age of 29 years. All patients were followed to fracture union. In 67 cases (89%) the cause of injury was a R.T.A. According to Winquist and Hansen, there were 8 fractures of type 0 (no comminution), 5 of type I, 22 of type II, 29 of type III and 11 of type IV. Six fractures were open grade II and two were grade IIIa. Multiple injuries were seen in 22 patients (30%). Results: Certain intraoperative complications were encountered in 25 cases (33%). Open nailing was required in 21 fractures (28%) mainly because of the loss of reduction (absence of guide wire) or because the distal pins jammed at the fracture site. Distal locking mechanism problems (bending of protruding locking wire or breakage of safety loops) occurred in 11cases (15%). In 3 patients the distal pins protruded from the anterior cortex and in another 4 breakage of one or more pins occurred during the postoperative period. Delayed union was seen in 7 patients (9%). Five fractures (7%) progressed to non-union. All the non-united fractures were type III or IV. The remaining fractures united after a mean period of 15 weeks. Four fractures (5%) which were located in the distal third, united with signiþcant varus deformity (≥10¡). Shortening (≥2 cm) were seen in 4 patients (5%). There was one deep infection that led to nonunion. Conclusions: Because of the high complication rate in this series, we do not recommend this type of elastic nail for the treatment of femoral shaft fractures

Introduction. Locking plates have been especially useful in the treatment of osteoporotic fractures. This study aimed to investigate the role of locking plate in femoral fractures in patients with osteogenesis imperfecta. Material & Methods. 6 male patients with osteogenesis imperfecta were operated for femoral fractures using locking compression plate. Their age ranged between 4 and 14 years. They were kept non weight bearing till the fracture united. Results. 5 patients out of 6 patients had refracture, as soon as they started walking. All 5 patients were reoperated using intramedullary titanium elastic nails. All of them united later on and were walking full weight bearing at the end of one year. Conclusion. Our study indicates that locking plates should not be used in the treatment of fractures in patients with osteogenesis imperfecta

The December 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: A comprehensive nonoperative treatment protocol for developmental dysplasia of the hip in infants; How common are refractures in childhood?; Femoral nailing for paediatric femoral shaft fracture in children aged eight to ten years; Who benefits from allowing the physis to grow in slipped capital femoral epiphysis?; Paediatric patients with an extremity bone tumour: a secondary analysis of the PARITY trial data; Split tibial tendon transfers in cerebral palsy equinovarus foot deformities; Liposomal bupivacaine nerve block: an answer to opioid use?; Correction with distal femoral transphyseal screws in hemiepiphysiodesis for coronal-plane knee deformity.

Purpose of Study:. To review the outcome of paediatric patients with radius and ulna fractures treated with titanium elastic nails. Description of methods:. Paediatric patients with radius and ulna fractures who fulfilled the criteria for TENS nailing were used. The criteria included failed closed reduction, instability (>15°angulation, >5°rotation) and open fractures. The patients were treated with retrograde TENS nailing of the radius and ulna. The patients were followed up at a paediatric orthopaedic outpatient clinic at 1, 3, 6 and 12 weeks with a final visit at 6 months. Data was collected at every visit looking at range of motion (pronation and supination), clinical and radiological signs of union and complications. Summary of results:. Over a 16 month period, 214 paediatric patients with radius and ulna fractures were seen and managed. Eleven of these patients were treated with TENS nails. The average age of the patient was 8.3 years. The average time to union was 8.5 weeks. The average range of motion at 6 months was pronation of 80°and supination of 73°. Two patients developed a compartment syndrome in the immediate post-operative period and were treated with a fasciotomy and skin grafting. No other complications were noted. Conclusion:. TENS nailing of paediatric radius and ulna fractures in unstable, irreducible and open fractures is a good treatment modality with good, early union of fractures and acceptable range of motion. It provides an excellent alternative to plating these fractures

Congenital pseudarthrosis of the tibia remains difficult to treat. With variable success, children are subjected to many surgical procedures. We review our experience using titanium elastic nails in this condition. We have treated 10 patients, six boys and four girls. Five had associated neurofibromatosis and pseudarthrosis of the fibula. In seven children, a mean of four previous operations had been done. The mean follow-up time was 4 years. In our patients, union occurred at a mean of 18 weeks, with a mean limb length discrepancy of 3 cm. The range of movement in the knee and ankle was good. Our early results are encouraging