Session VI - Pediatrics

Flexible Titanium Intramedullary Nailing of the Pediatric Femur Fracture

David S. Weisman, MD, Jason Snibbe, MD, Michael D. Maloney, MD, University of Rochester Medical Center, Rochester, NY

Purpose: The use of flexible titanium intramedullary nails is an effective method for treating femur fractures in the skeletally immature patient. They allow for immediate stabilization of the fracture, earlier mobilization, and ease of nursing care and avoid the need for prolonged traction and casting. There is also a lower complication rate when compared with other treatment options.

Methods: Forty-six patients with 48 femur fractures were treated with flexible titanium intramedullary nailing. The surgical management included a medial and lateral distal insertion point proximal to the physis. Two 2-mm, 3-mm or 4-mm diameter solid titanium nails were contoured and placed, depending on canal size. Follow-up evaluation included clinical and radiographic assessment of lower extremity alignment and healing.

Results: There were 34 boys and 12 girls with an average age of 9 years (range, 3 years 8 months to 14 years 3 months) with 48 fractures. Twenty-three of the fractures were caused by a motor vehicle accident; 24 were due to a low-energy injury. All fractures but one were closed injuries. The average surgical time, including intraoperative final radiographs for an isolated femoral nailing (n = 41), was 85 minutes (range, 50 to 180), and the estimated blood loss was 42 cc (range, 10 to 200). The average postoperative length of stay was 2 days. All patients were discharged with crutches and non-weight bearing with the availability of a wheelchair for school use. Two patients were placed in long leg casts postoperatively. All other patients were allowed progressive weight-bearing status at 2 to 4 weeks as callus progressed. All fractures healed within 6 to 12 weeks. Ten patients had initial angulation greater than 5° in the coronal plane (range, 5 to 13°). No patient had angulation greater than 10° in the sagittal plane. One patient had a rotational deformity of 12°. Two patients had a proximal nail penetration of 2 mm, but no further complications. In two cases, long spiral fractures shortened on the nails, and, in one case, required surgical modification for skin penetration. In no cases did the hardware back out. There have been no refractures to date. One patient undergoing chemotherapy sustained a second fracture distal to the original injury at the 1-year follow-up. This fracture was also nailed and, at 2-year follow-up, there were no further problems. The average limb-length discrepancy was 2.8 mm (+16 to -22). There have been no instances of growth arrest or avascular necrosis. All patients returned to school between 2 and 6 weeks after injury. All nails were removed at an average of 5 months after fracture. The average follow-up of all patients was 15 months with a minimum of 6 months.

Discussion: These results show that flexible titanium intramedullary nailing is an effective treatment option for the management of femur fractures in the skeletally immature patient. The short-term advantages include ease of care, lower re-manipulation rate, shorter hospitalizations, and lower social burden. Long-term advantages include a lower infection rate and a lower re-fracture rate over other operative methods. As long-term follow-up continues, the overgrowth phenomenon can be more thoroughly compared to other techniques.