Session IX - Pediatrics and Spine

Treatment of High-Energy Tibial Fractures in Children: Are Flexible Nails an Improvement over External Fixation?

Erik N. Kubiak, MD; Kenneth A. Egol, MD; David Scher, MD; David S. Feldman, MD; Kenneth J. Koval, MD; Hospital for Joint Diseases, New York University, New York, New York, USA

Purpose: In this Institutional Review Board-approved study, we wished to determine whether external fixation or flexible intramedullary nailing is the optimal implant choice for the treatment of high-energy tibial fractures in children. Locked intramedullary rods used to treat adult fractures are precluded in the skeletally immature patient because of the high risk of growth disturbance. Pediatric tibial fractures are routinely treated with closed reduction and casting. A small number of high-energy fractures with or without associated injury require external fixation or flexible intramedullary fixation to avoid physeal violation if surgery is chosen. Both implants can be placed without violating physes, provide for early immobilization, and provide a biologically favorable healing environment.

Methods: In our trauma database, we identified 45 consecutive skeletally immature patients who had 46 high-energy tibial fractures treated operatively. All were the result of motor vehicle accidents or a significant fall from a height. Indications for surgery included open fracture, polytrauma, inability to maintain reduction in a cast, fracture with associated vascular injury, fracture associated with compartment syndrome, severely comminuted fracture, and those with associated femoral fracture. Patients were examined by the treating surgeon and radiographs were obtained. The patients' parents completed the Pediatric Orthopedic Society of North America functional outcome assessment questionnaire.

Results: Thirty-eight patients were available for evaluation with complete medical records. Fifteen patients with 16 extremity fractures, five of which were open, were treated with external fixation; one patient had a fasciotomy for compartment syndrome. Twenty-three patients were treated with flexible intramedullary nails, 3 of these patients had open injuries, only one of which required fasciotomy for compartment syndrome. Deformity, sex, and mechanism of injury were similar for both groups.

	Age (years)	Months to  hardware removal	Follow-up (months)
External fixator	10.17 ± 3.71	2.32 ± 1.27*	17.61 ± 13.01
Flexible nail	11.1 ± 2.25	6.7 ± 5.66*	11.17 ± 6.45

* P <0.05

Deformity at Latest Follow-up Examination

	Angulation on AP radiograph	Displacement	Angulation on lateral radiograph	Displacement	Shortening
External fixator	2.9 ± 3.07	1.3 ± 2.11	2.5 ± 3.62	0	0
Flexible nails	2.6 ± 5.06	2.7 ± 4.11	3.1 ± 4.04	0.8 ± 1.4	0.1 ± 0.31

There were three nonunions that required an additional operation and three delayed unions in the external fixation group. However, there were no healing complications in the flexible nail group (P = 0.015.) No differences were seen in the POSNA functional score.

Conclusion: There were no significant differences among any of the deformity measurements between the two treatment groups. There were six healing complications (three nonunions and three delayed unions) in the external fixator group, representing a significant difference compared with the flexible nail group. All other parameters assessed were equivalent except time to second surgery.

Significance: Treatment of tibial fractures in skeletally immature patients remains for the most part nonoperative. We recommend the use of flexible nailing in the surgical treatment of high-energy tibial fractures in the skeletally immature patient because of the lower rate of healing complications and no difference in residual deformity.