Session VI - Pediatrics

Intramedullary Tibial Nailing of Adolescents with Open Epiphyses

George J. McLauchlan, MD; Tiernan Byrnes, MD; Charles M. Court-Brown, MD, Royal Infirmary of Edinburgh, Edinburgh, Scotland

Introduction: Intramedullary nailing is the treatment of choice for adult tibial diaphyseal fractures. There are no reports in the literature describing its use for patients with open growth plates. We examined the technique of locked intramedullary nailing for tibial diaphyseal fracture in a group of adolescents with open proximal and distal epiphyseal growth plates.

Methods: From 1988 to 1997, 36 adolescent patients with a tibial diaphyseal fracture were treated with locked intramedullary nailing using a Grosse Kempf nail. There were 29 boys with a mean age of 15 years (range, 12 to 16) and 7 girls with a mean age of 14 years (range, 13 to 15). Thirty-one (86%) cases presented as an isolated injury, four patients (11%) had another musculoskeletal injury, and one patient (3%) was multiply injured with an ISS score of >15. Thirty-two fractures (89%) were closed and four (11%) were open. The most common mechanisms of injury were sports activities (50%) and pedestrian involvement in a motor vehicle accident (28%). The commonest AO fracture type was the A2.1 with an intact fibula. Overall, 20 (56%) patients had an intact fibula. The operative technique used was that previously described for an adult population, although in some cases an attempt was made to avoid the proximal physis, and a lower than normal entry point was used. Twenty-five patients were followed prospectively for a year by a research physical therapist, as the patients were also involved in other studies being conducted within the unit. The remaining 11 patients were contacted and questioned about their postoperative progress. Radiographs were made of all patients after physeal closure to examine the effect of intramedullary nailing on epiphyseal growth.

Results: All fractures united without the requirement for secondary surgery. The mean time to union was 11.5 weeks, with 10.8 weeks in the closed group and 16.5 in the open. The mean time to walking was 6 weeks (range, 4 to 18) and return to running was 12 weeks (range, 5 to 32). There were no malunions, but there were two infections, both successfully treated with high-dose antibiotics and retention of the nail. Six (17%) patients developed a compartment syndrome. Five of these were successfully treated by four-compartment fasciotomy. Fourteen patients (39%) complained of knee pain. All patients had evidence at the time of operation that the proximal tibial growth plate had been breached to a varying degree. In the subsequent follow-up at skeletal maturity, however, there was no radiological evidence of tibial shortening or partial growth arrest of the proximal tibial diaphysis.

Conclusion: Overall, reamed intramedullary nailing gives excellent results in the management of tibial diaphyseal fractures in an adolescent population. Tscherne C0 and C1 fractures in this age group unite significantly quicker than in a standard adult population. Breaching of the proximal tibial growth plate does not lead to any obvious longitudinal or angular growth abnormalities. Surgeons should be aware of the high incidence of compartment syndrome in this population.