Management of compound fracture tibia in children with titanium elastic nails

$Page 1: Management of compound fracture tibia in children with titanium elastic nails$
Management of compound fracture tibia in children with

titanium elastic nails

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Original Article

Management of compound fracture tibia in childrenwith titanium elastic nails

Mohd Iftekar Ali

Consultant, Apollo Reach Hospital, Karimnager, India

a r t i c l e i n f o

Article history:

Received 30 October 2014

Accepted 19 February 2015

Available online xxx

Keywords:

Femur fracture

Children open

Titanium elastic nail

E-mail address: [email protected]://dx.doi.org/10.1016/j.apme.2015.02.0170976-0016/Copyright © 2015, Indraprastha M

Please cite this article in press as: Ali MI, MMedicine (2015), http://dx.doi.org/10.1016

a b s t r a c t

Introduction: Tibia fractures in the skeletally immature patient can usually be treated

without surgery. The purpose of this study was to assess the use of flexible titanium nails

in the open fracture tibia that requires operative stabilization.

Method: Over a 3-year period, retrospective study of 48 open tibia fractures which were

treated with flexible titanium intramedullary nails. All charts and radiographs were

reviewed. The average age was 10 years 4 months. There were 13 distal third open frac-

tures, 21 middle third fracture, 14 upper third.

Result: All fractures healed. Fracture obtained union by an average of 15 weeks. There were

no malunions. The average follow-up was 1 year 5 months. There were no instances of

growth arrest, remanipulations, or refracture, infection.

Conclusion: In the open pediatric tibia fracture, flexible titanium nails are an effective

treatment to obtain and maintain alignment and stability.

Copyright © 2015, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Open fractures are complex injuries of bone and soft tissue.

They refer to osseous disruption in which a break in the

skin and underlying soft tissue communicates directly with

the fracture and its hematoma. They are orthopedic emer-

gencies due to risk of infection secondary to contamination

and compromised soft tissues and sometimes vascular

supply and associated healing problems. Any wound

occurring on the same limb should be suspected as result of

open fracture until proven otherwise. The principles of

management of open fracture are initial evaluation and

exclusion of life threatening injuries, prevention of

o.uk.

edical Corporation Ltd. A

anagement of compou/j.apme.2015.02.017

infection, healing of fracture and restoration of function to

injured extremity.

Most tibial fractures in children can be successfully treated

with closed reduction and cast immobilization. Surgery is

indicated, however, when the fracture is irreducible, unstable,

open with soft tissue injury, or associated with multiple

injuries.

Surgical options include percutaneous pinning, external

fixation, plating, and increasingly, flexible intramedullary (IM)

nailing.

The advantages of elastic titanium nail include minimal

soft tissue disturbance with small scars, early mobilisation,

low infection rates and shorter hospital stays.1 Possible com-

plications such as malunion and refracture remain as they

ll rights reserved.

nd fracture tibia in childrenwith titanium elastic nails, Apollo

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http://dx.doi.org/10.1016/j.apme.2015.02.017




would with conservative treatment. The nails can be removed

once the fracture has united, depending on the patient and

surgeon preference.

2. Materials and methods

In this retrospective study between February 2010 to October

2013, 48 patients having open fractures (14 Gustilo grade I, 24

grade II, 5 gradeIIIA, 5 grade IIIB) were included. It is shown in

Pie Chart no2, There were 36 males and 12 females, Mal-

e:Female ratio being 3:1. Ratio ofmale and female shown in Pie

Chart no1. Age of the patients ranged from 8 years to 13 years

with mean age of 10 years 4 months. Wounds were classified

using Gustilo's classification system.2e4. Case I and case ii

were shown with x-rays and clinical pictures in Fig. 1 and

Fig. 2.

The injuries were caused by road traffic accidents in 38

patients (79.16%), crush injuries in 10 (20.83%), among them

are 12 cases of pedestrian, 14 are motor cycle, 22 are car pas-

sengers. Associated injuries included ipsilateral and contra-

lateral lower extremity fracture (n ¼ 10), fracture of the upper

extremity (n ¼ 11), clavicle fracture (n ¼ 8), thoracic injuries

(n ¼ 7) and pelvic injuries (n ¼ 6).

Fig. 1 e Clinical picture/preoperative

Please cite this article in press as: Ali MI, Management of compouMedicine (2015), http://dx.doi.org/10.1016/j.apme.2015.02.017

The different fracture patterns noted in our series were

transverse fractures (n ¼ 20), oblique and spiral fractures

(n ¼ 10), comminuted fractures (n ¼ 12), segmental fractures

(n ¼ 62).

3. Immediate management on presentationto accident and emergency department

Patients with open tibial fractures must be assessed and

managed appropriately following the Advanced Trauma Life

Support (ATLS) guidelines.

A history suggestive of exposure to foreign material such

as farmyard soil is likely to involve virulent pathogens, for

example Clostridium perfringens.3,5e8 Examination should

commence with the skin to help exclude crush or burst

wounds, large or multiple wounds and closed de-gloving

injuries.5All patient received tetanus prophylaxis. In the

emergency room before splinting the extremity, gentle wound

toilet with copious amount (3e5 L) of sterile saline was done

and the wound was covered with sterile dressing. All patients

received third generation Cephalosporin (1 g stat, then 500mg

every twelfth-hourly) and Amikacin (5e7 mg/kg stat, then

15 mg/kg/day in divided doses) for three days.

/post operative/follow-up x-ray.




Fig. 2 e Clinical picture/preoperative/post operative/follow-up x-ray.

a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1e6 3

4. Principles of wound debridement

Early thorough debridement is the most important surgical

procedure for open lower limb fractures.3,4 Debridement in-

volves the excision of all devitalized tissue apart from the

neurovascular bundles.2e4 It should be donemeticulously and

dissection should be sharp. All debris, devitalized tissue, loose

cortical bone fragments should be removed. Dissection is

continued to viable tissues edges identified by colour, con-

sistency and contractility. The recommended time for

debridementwithin 6 h has for long been considered critical in

prevention of infection. This 6 h rule has been questioned by

literature.9 Knowledge of perforators and angiosomes is use-

ful for proper placement of incisions. Before we have

conclusive evidence against 6 h time before debridement,

debridement should be done as soon as possible if all re-

quirements and expertise are available. Where necessary, a

repeat debridement should be done within 24e48 h. Irrigation

is very important principle in open fracture management, but

the method of delivery, optimal amount or irrigation solution


still remain controversial. Antibiotic solutions appear more

effective than saline but literature support is lacking. De-

tergents help remove bacteria and in one studywere similar in

reducing risk of infection to antibiotics.10 Antiseptics should

be avoided as they are toxic to tissues. The pressure required

remains controversial, high pressure improves removal of

bacterial but damages soft tissues and bone. Low pressure like

bulb syringe and suction is adequate.11 No difference was

noted between use water and saline in wound cleaning.12

Most surgeons still use saline. Based on current evidence,

normal saline should be used routinely, use of additives

should be limited until we have enough supporting evidence,

low pressure lavage is advocated, if high pressure is used it

should be limited to 50psi25.

5. Stabilisation of open tibial fractures

Under fluoroscopy, the fracture site and proximal tibial physis

are marked. The entry point for nail insertion is 1.5e2.0 cm




36males

12females

Pie Chart 1 e Showing number of male to female cases.


distal to the physis, sufficiently posterior in the sagittal plane

to avoid injury to the tibial tubercle apophysis. A longitudinal

2 cm incision is made on both the lateral and medial side of

the tibia metaphysis just proximal to the desired bony entry

point. Using a hemostat, the soft tissues are bluntly dissected

down to bone. Based on preoperative measurements, an

appropriately sized implant is selected so that the nail diam-

eter is 40% of the diameter of the narrowest portion of the

medullary canal. A drill roughly 0.5 cm larger than the

selected nail is then used to open the cortex at the nail entry

site; angling the drill distally down the shaft facilitates nail

entry. Prior to insertion, the nails are prebent by hand into a

gentle “C” shape which helps achieve three-point fixation.

Both nails are then inserted through the entry holes and

advanced distal to the fracture site.13

14

24

5

5

GRADE I

GRADE II

GRADE IIIA

GRDE IIIB

Pie Chart 2 e Showing number of cases according to

gustillos classification toward the triradiate cartilage. This

situation is the ideal indication for the use of

ultrasonography to follow the reduction. When the

harness is used in this situation, the infant should be

checked at 7e10 days to determine whether the reduction

is being accomplished.


6. Post operative protocol

All children were initially non-weight-bearing, and were

mobilized with physical therapy on postoperative day 1.

Postoperatively patients were nursed in supine position with

the operated leg elevated on a pillow. Long knee brace was

used in three cases of distal third fractures, where fixation

was not adequate. Patients were mobilized without weight

bearing on the fifth to seventh day postoperatively. Partial

weight bearing was started at three weeks and full weight

bearing by six to eight weeks depending on the fracture

configuration, callus response and associated injuries.

7. Soft tissue reconstruction

Adequate soft tissue cover is vital to ensure infection-free

fracture union.

Most wounds in open fractures are closed with delayed

primary closure. Surgical incisions performed during initial

debridement can be closed primarily and original open frac-

ture wound left open. Early experienced debridement to

clearly healthy tissues and early rotational or free muscle flap

cover may be better in experienced hands than sequential

debridement and delayed closure.14 Early closure has shown

to prevent nosocomial infections. The aim should be to ach-

ieve closure in 72 h.

8. Results

This retrospective study included 48 patients who were

treated for the open tibial fractures between 2010 and 2013.

Site of injury in tibia was upper 1/3 rd in 14,middle 1/3 rd in 21,

lower 1/3 rd in 13 cases. All patients in our series achieved

complete radiographic healing (evidence of tricortical bridging

callus) at a mean of 15.0 weeks (range 7e24 weeks). All pa-

tients had their elastic nails removed at an average of

23.1weeks after the initial surgery.

At final follow-up, the mean angulation was 2� in the

sagittal plane and 3� in the coronal plane.

Irritation at the nail entry site was the most common

complications following nail insertion, occurring in five pa-

tients (10.4%). One child required early removal of the nails for

this complaint. No patients developed obvious rotational ab-

normalities, leg length discrepancies, or physeal arrests as a

result of treatment. We had no postoperative deep infections

or neurovascular injuries in our series except one case of su-

perficial infection. A primary closure done in all cases, and

split-thickness skin graft (n ¼ 12) was done in 12 cases after

onemonth of primary fixation. A localmusculo cutaneous flap

for coverage of open tibial fractures in 3 cases after 45 days of

primary fixation.

We had no leg length discrepancies in our series due to

shortening at the fracture site.

The mean weight of the patients in our series was 28.6 kg

(range 20.0e37.2 kg). We found no significant difference be-

tween patients, <28,6 kg (twenty patients) and patients

�28.6 kg (twenty eight patients) in terms of coronal or sagittal




a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1e6 5

plane angulation (p ¼ 1, p ¼ 0.39). We also had no leg length

discrepancies in our series due to shortening at the fracture

site.

When classifying our treatment outcomes based on the

TEN outcome scoring system by Flynn et al i found 32 excel-

lent results, 16 satisfactory results, and no poor result (Table

1).15 Satisfactory results were due to either irritation at the

nail entry site or angulation at fracture site.

9. Discussion

The management of open fractures of the tibia in a pediatric

population remains a complex and challenging problem.

Traditionally, open tibia fractures in children have been

managed with closed reduction and casting techniques

following irrigation and debridement. With increasing ad-

vances in pediatric sedation and anesthesia, wound care and

antibiotics and a large armamentarium available for both in-

ternal and external fixation of these fractures, one would

think that the approach to treatment of these fractures would

have trended towards fixation in more recent years.

Hampton (1955) emphasised the important role played by

adequate reduction of the fracture in the prevention of wound

infection.16 Titanium elastic nails achieve biomechanical

stability from the divergent “C” configuration which creates

six points of fixation and allows the construct to act as an

internal splint.17 This is in contrast to Enders nails that ach-

ieve stability from nail stacking and canal fill. Titanium nails

provide stable and elastic fixation, allowing for controlled

motion at the fracture site which results in healing by external

callus.

O'Brien et al previously reported a series of 16 childrenwith

tibial shaft fractures treated with TENs, with a mean follow-

up of 17 months.18

External fixation was the mainstay of treatment in severe

open fracture like IIIA and IIIB, and has the advantage of

allowing easy access to management of soft tissues injuries

and bone transport, and can be exchanged for an intra-

medullary nail. The main problem of External fixator is pin

tract infections, loosening and delayed or nonunion. Plate and

screw fixation has higher infection rates open fractures.

Reamed locked intramedullary nails, while shown to be

effective in the skeletallymature, pose unnecessary risk to the

proximal tibial physis, and have limited indications in those

children with growth remaining.19

In a recent study directly comparing external fixation with

elastic intramedullary nailing for pediatric tibial shaft frac-

tures, Kubiak et al reported superior functional outcomes and

patient satisfaction in the cohort treated with TENs.17

Table 1 e TEN outcome scoring.

Excellent result

Leg length inequality <1.0 cm

Malalignment 5�

Pain None

Complications None

Patient results (n ¼ 48) 32


9.1. Early vs delayed treatment

The Delayed [7e30 days] treatment group is considered to be

“infected” at the time of surgery (cellulitis, inflammation, or

drain-age). The techniques of debridement are different for

early [0e7 days] and delayed treatment wounds; extensive

bony debridement is necessary in the latter. All devitalized

bone should be removed to bleeding or previously unexposed

surfaces, and the medullary canal should be opened in saucer

fashion to accept the flap and obliterate dead space.

9.2. Early vs. delayed fixation

Multiply injured patient with injury severity score >18 run

high risk of pulmonary complications and benefit significantly

from early fracture stabilization. Fracture fixation should be

within 24 h of injury which improved survival results from

lower incidence of sepsis due to a decreased rate of pulmonary

and cardiovascular insufficiency.

9.3. Risk of infection vs operative timing

The longer wound remains open, greater chance for wound

contamination. Brumback, et al (1989) concluded that imme-

diate IM nailing of open femoral frx was contraindicated if

debridement procedure was delayed >8 h.20 Kindsfater and

Jonassen found increased infection rates if debridement was

delayed more than 5 h post-injury.21

9.4. Risk of infection vs timing of administration ofantibiotics

The time from injury to administration of antibiotics is also a

critical time frame and has been examined. Patazakis and

Wilkins4 examined 77 infections in 1104 open fracture

wounds and looked at factors that reduced the infection

rate.22 They found that for fractures treated with antibiotics

within 3 h of injury, 4.7% were infected, compared to a 7.4%

infection rate in those that started antibiotic treatment after

3 h. They concluded that the single most important factor in

reducing infection rate was early administration of

antibiotics.

10. Conclusion

The management of open fractures presents a challenge due

to risk of infection, healing problems and subsequent

morbidity. Adequate debridement and copious lavage re-

mains one of the cornerstones of management of open

Satisfactory result Poor result

<2.0 cm >2.0 cm

10� >10�

None Present

Minor and resolved Major/lasting morbidity

16 0





fractures. Early internal fixation and soft tissue closure is

advocated. Elastic stable intramedullary nailing provides an

acceptable option.

Conflicts of interest

The author has none to declare.

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Health & Medicine

Management of compound fracture tibia in children with titanium elastic nails