OTA 1997 Posters - Pediatrics

Intramedullary Nailing of Adolescent Femur Fractures

Don A. Buford, Jr., MD, Kevin Christensen, MD, Paul Weatherall, MD

Dallas, Texas, USA

Purpose: We have prospectively followed adolescents with femur fractures treated with intramedullary nailing to identify the complications and evaluate outcomes of this method of treatment.

Methods: Sixty patients with femur fractures have been treated with intramedullary nailing. All patients with fracture patterns amenable to antegrade nailing and whose parents gave informed consent were included in the study. Six patients have been lost to follow-up, leaving fifty-four patients in the study group. We operated on patients on the day of admission unless there were other medical issues that prevented immediate surgical care. Solid titanium nails were used for MRI compatibility. No specific operative modifications were made other than an attempt to place the entry portal more lateral and posterior than the piriformis fossa to avoid disrupting the retinacular blood supply to the femoral head. We prospectively followed these patients both clinically and radiographically to assess complications and functional result. We also obtained MRI scans to evaluate for any evidence of avascular necrosis of the femoral head.

Results: Average patient age is twelve(range 6-15). All patients had open physes at the time of surgery. Average time to clinical and radiographic healing is six weeks. To date, we have removed implants in thirty-three patients with an average time of ten months after initial nailing. All but two patients in the study group show no signs of avascular necrosis, rotational or angular deformity, or nerve palsy. In patients who have had hardware removal, average follow-up is six months post nail removal. We have had very few complications to date. Two patients have had subclinical avascular necrosis documented by MRI. One patient developed AVN of both femoral heads one year after nail removal from the right femur. The second patient has asymptomatic marrow changes consistent with AVN but no femoral head collapse and no functional restriction. One additional patient refractured through his femoral nail and after exchange nailing has healed without any further complications.

Discussion: There has been much recent discussion about potential complications of intramedullary nailing in growing patients. There are concerns over effects on proximal femoral growth and blood supply and on the difficulty of hardware removal. Benefits of intramedullary nail fixation include decreased hospital stay, load sharing with early weight bearing, and rigid fixation with rotational control. We have found remarkably few intra-op or post-op complications. Fixation and fracture control with intramedullary nailing is better than with flexible intramedullary implants. We feel that nailing is also preferable to external fixation because of the benefit of early weight bearing, less school disruption, better fracture control, and increased patient and family satisfaction with care. Similarly, spica casting has greater complications with fracture malalignment, longer hospital stays, and decreased patient and family satisfaction with care. Plate fixation has the disadvantage of an extended open exposure and of stress shielding at the fracture site.

Conclusion: We feel that intramedullary nailing of adolescent femur fractures is a safe treatment option. We have found few post-operative complications and a small risk of avascular necrosis of the femoral head which must be followed for.