Session VI - Pediatrics

Flexible Titanium Nailing of the Unstable Pediatric Tibia Fracture

Todd O'Brien, MD; Peter J. Ronchetti, MD; Christopher Piller, MD; Michael D. Maloney, MD; David S. Weisman, MD, University of Rochester Medical Center, Rochester, NY

Purpose: Tibia fractures in the skeletally immature patient most often can be treated nonoperatively. For the select fractures that cannot be maintained in satisfactory alignment with nonoperative methods, there are few options. External fixation is a common option, but has a significant complication rate. Flexible nails allow for immediate stabilization of the fracture, facilitate access to compromised soft tissues, and allow for early motion of the injured extremity. We assessed flexible titanium nails for the tibia fracture that requires operative stabilization.

Methods: Over a 5-year period, 16 unstable tibia fractures in 14 patients (12 boys and 2 girls) with an average age of 10 years (range, 7 to 14) were treated with flexible titanium intramedullary nails. Closed reduction had been attempted for all isolated closed fractures. The lateral and medial insertion site was distal to the proximal physis. Two equal-diameter flexible titanium nails were placed, depending on canal size. All charts and radiographs, including injury, preoperative, postoperative, and last follow-up were reviewed. Seven patients had assessment of limb-length discrepancy by lower extremity scanogram.

Results: There were nine high-energy injuries, which included three open fractures. Two open fractures had significant soft tissue injury. Ten injuries were isolated to the tibia. The average operative time for isolated injuries was 80 minutes (range, 67 to 112), including an intraoperative radiograph. On average, 2 minutes of fluoroscopy was used. Twelve of the fractures were placed in short leg immobilization for 2 to 4 weeks until callus appeared. Closed injuries obtained union by an average of 8 weeks (range, 4 to 10). Open fractures obtained union by an average of 15 weeks (range, 12 to 20). There were no re-operations prior to implant removal. All nails were removed at an average of 6 months (range, 3-11). The average duration of follow-up was 17 months (range, 3 to 36). There were no cases of implant failure or need for revision. No patient complained of knee pain with range of motion. There was one superficial infection in a closed fracture at the nail insertion site that resolved with the administration of oral antibiotics. Six patients had angulation in the coronal plane at follow-up, none greater than 6°. The average angulation at follow-up in the sagittal plane was 2.3° (range, 0° to 10°). The average tibial overgrowth was 4 mm (range, 2 mm to 7mm).

Conclusion: There are limited surgical treatment options for unstable pediatric tibia fractures. The use of flexible titanium nails in this population is an effective treatment to obtain and maintain alignment and stability. Advantages over other fixation techniques include lower infection rate, lower re-fracture rate, and ease of management.