LMC journal Vol. 2.indd 98 Ender’s Nail fi xa on in paediatric femoral sha fractures. Dwivedi R, Shah S, Acharya P and Gurung S Department of orthopaedics, Lumbini Medical College Teaching Hospital, Palpa, Nepal Corresponding author: Dr Rajeev Dwivedi ,MS,Lecturer in Orthopaedics ,Lumbini Medical College Teaching Hospital Palpa, Nepal; e-mail rd172002@gmail.com ABSTRACT Introduc on: Femoral sha fractures are among the most common major pediatric injuries treated by orthopaedic surgeons. Treatment ranges from strictly nonsurgical methods to surgical stabiliza on. Opera ve treatment of femoral sha fractures in children with intramedullary nails (Ender’s and tanium elas c nails) is increasing because it has advantage of early mobiliza on, rapid healing and be er control of alignment. Objec ves: We evaluated the results of Ender’s nails fi xa on in femoral sha fractures in children. Method: We studied 40 children with 40 femoral sha fractures in age group 5-15 years. There were twenty four fractures in middle third, 7 in distal third and 9 in proximal third. Twenty fractures were transverse, 8 were oblique and 6 were spiral. Communi on was seen in 6 cases. They were treated by closed reduc on and Ender’s nail fi xa on. Retrograde fi xa on was done in 38 cases, in 2 cases antegrade fi xa on was done. Result: The mean follow up was 7.5 months. The average me to par al weight bearing was 3.8 weeks (2 to 6wks). The average me to full weight bearing was 8 weeks (6 to 12 wks). Union was achieved in all pa ents within a mean of 11 weeks (8 to 16 wks). Two pa ents had varus angula on of 8° and 6° each, whereas one had valgus angula on of 8°and one had anterior angula ons of 10°. Lengthening of 1.2 cm was observed in one pa ent. In one case skin irrita on due to nail was observed and that subsided without interven on. According to the Flynn criteria 34 had excellent and 6 had sa sfactory results. No poor results were seen. Conclusion: Ender’s nail fi xa on can be preferred method of treatment for femoral sha fractures in age group 5 -15 years as the results are excellent and sa sfactory. It is technically simple and can be done in a closed manner. It spares the vascularity and growth plate. Keywords: Ender’s nail, femoral sha fracture, children, Flynn criteria INTRODUCTION Femoral sha fractures are among the most common major pediatric injuries treated by orthopedic surgeons.1 Treatment ranges from strictly nonsurgical methods (e.g. closed reduction with spica casting or traction followed by spica casting) to surgical stabiliza on (using intramedullary devices, external fi xa on, or internal fi xa on with plate and screws).1 Cas ng with or without trac on is s ll the preferred treatment for isolated femur fractures in children of preschool age.1 For children above 5years of age op on of surgical treatment is increasing because it has advantage of early mobiliza on, reduced dura on of hospital stay and reduced psychological adverse impact . Flexible intramedullary nails (Ender’s and titanium elas c nails), external fi xa on, compression pla ng and locked rigid intramedullary rod are the available op ons for fi xing femoral fractures in children. In the present study, we evaluated the outcomes of use of Ender’s nails in trea ng pediatric femoral sha fractures. MATERIAL AND METHODS The present prospec ve study was conducted in the Department of Orthopedics at Nepalgunj Medical College Teaching Hospital, Kohalpur over a period of 2 years from November 2009 to November 2011. We included children between 5 to 15 years with femoral sha fractures from a point fi ve cen meter (cm) distal to lesser trochanter to 5 cm proximal to distal femoral physis. Children more than 15 years and less than fi ve years of age, children with pathological fracture and with open fracture were excluded from study. The results were evaluated using Flynn's scoring criteria.2 Major postoperative complication were defined as nonunion,delayed union, infection, r e f ra c t u r e , n a i l i r r i t a t i o n r e q u i r i n g h a rd w a r e removal, and nail breakage. Minor postoperative complications were defined as nail irritation that resolved without intervention, asymptomatic nail migration, and any perioperative problem that resolved without surgical intervention or early hardware removal. Original Article L M Coll J 2013; 1(2): 98-101 99 Preopera ve x-ray showing transverse fracture of sha of femur in 10 years old boy OPERATIVE TECHNIQUE Nail diameter was theoretically chosen on the basis of 40% of the narrowest intracortical diameter but was ultimately determined intraoperatively by surgeon. Approximate length of the nail was determined by measuring on x-rays and on normal side from tip of greater trochanter to adductor tubercle. Nails were bent in an even curve. On a fracture table, close reduction was done under fluroscopic guideness. After incising the skin, insertion points were made one on medial and another on lateral side of distal femur, 2.5cm proximal to the distal epiphyseal plate. The nails were introduced right up to fracture site. Then, one of the nail was passed across the already reduced fracture site followed by second nail. The nails were directed in such a way that medial nail was introduced into the neck and lateral just below trochanteric apophysis in a fan shaped manner. Two divergent nails were used. RESULTS Forty children with forty femoral shaft fractures were treated with Ender’s nails. Ages of children ranged from 5 to 15 years (mean 9.87 years). There were 24 boys and 16 girls. Twenty two cases sustained right sided and 18 cases sustained left sided fractures. Eighteen patients had injury due to fall from height, 13 patients sustained road traffic accident while 9 patients had injury while playing. No cases with bilateral fractures were seen. Among all, 24 fractures were in middle third, 7 in distal third, and 9 in proximal third. Twenty cases had transverse fracture, 8 were in oblique and 6 were spiral in pattern. Six cases showed some comminution. Among them on Winquist 3 grading system, 3 were grade I, 2 were grade II and 1 was grade III. No case of Winquist grade IV was seen. The interval between injury and surgery varied from 2 days to 6 days (average 2.9days). The mean hospital stay was 6.9 days. The average duration of surgery was 50 minutes. In 2 cases antegrade nailing was done whereas in 38 cases nails were inserted in a retrograde manner. Postopera vely, no pa ent needed any protec ve splint. Knee bending and quadriceps strengthening exercises were begun as soon as pa ent was comfortable. The average time to partial weight bearing on axillary crutches was 3.8 weeks (2to 6wks). Full weight bearing could be commenced in about 2-4 weeks me more in most of the cases. The average me to full weight bearing was 8 weeks (6 to 12 week). Union was achieved in all pa ents within a mean of 11 weeks (8 to 16 weeks). Full movement of knee was achieved in 9 weeks (6 to 16 weeks). Intraopera ve Complica ons: In one case the opposite cortex got perforated but the nail was reintroduced. Follow up: The mean follow up was 7.5 month (6 to 16 months). By this time, all the patients had full- unrestricted ac vity. None of the pa ents had any pain, limp or gait abnormality. Six weeks post opera ve x-ray of same pa ent showing early callus R Dwivedi et al 100 Journal of Lumbini Medical College Angular deformity more than 5 degree was observed in only 4 pa ents. Two pa ents had varus angula on 8° and 6° each whereas one had valgus angula on of 8° and one had anterior angula on of 10°. On clinical examina on lengthening of more than 1cm (1.2 cm) was observed in one pa ent. In one case, skin irrita on due to nail was observed that subsided without interven on. On clinical examina on signifi cant malrota on was not seen in any pa ent. According to the Flynn criteria 2 (Table-1) 34 pa ents had excellent result, 6 had sa sfactory and no poor results were seen. Table-1: Flynn et al2(2001) criterion for assessment of results EXCELLENT SATISFACTORY POOR Limb length discrepancy <1 cm <2 cm >2 cm Malalignment < 5 degree 5-10 degree >10 degree Pain none none present Complica ons none minor major DISCUSSION There are a wide range of conserva ve and surgical op ons available for the treatment of children with femoral shaft fractures in age group 5-15 years. Conserva ve (spica) treatment has disadvantages such as prolonged hospital stay, shortening, angular and torsional deformity and the psychosocial implica ons. These are avoided in surgical treatment with Flexible intramedullary nails. 4,5 Many orthopedician reserve surgical management only for mul ply injured pa ents. This study aimed to treat isolated femoral sha fractures surgically by Ender’s nails. External fi xa on although is associated with minimal so ssue dissec on but it causes pa ent apprehension on account of external device, high rate of pin track infec on and real danger of refracture a er removal of fi xator.6 Compression pla ng is associated with large so ssue dissec on opening of fracture site and major opera on for removal. Rigid intramedullary nailing may damage the blood supply to the femoral head resul ng in avascular necrosis of femoral head or causing growth arrest at the greater trochanter resul ng in coxa valga. Enders nailing is technically simple, me saving and can be done in a closed manner.4 Two divergent Ender’s nails provide adequate fi xa on and stability.7 The major advantages of Ender’s nail is in healing with abundant callus, a ributed to non rigid fi xa on.8 It spares the vascularity and growthplate. It allows early mobiliza on, rapid external callus forma on and rapid restora on of con nuity of bones. This results in rapid fracture union and early return to full weight bearing while reducing hospital stay and treatment cost. Fourteen weeks post opera ve x-ray showing union According to criterias given by Flynn2 the fi nal results in our study were excellent in 34 (85%) cases, and sa sfactory in 6 (15%) cases. Outcome of our study matched with several other studies. Our study matched with Mann et al9 (1986), they demonstrated excellent results with 100% union rate without any angular malunions or leg length discrepancies, however, this study was conducted in older children 9-15 years of age. Karaoglu S and colleagues10 (1994) reported excellent results in their study, however, this study was conducted in children between the ages of 10 and 16 years. Ozturkmen Y et al 11 (2002) reported on Twenty six children (mean age 8.9 years, range 5.9 to 12.3 years) they also demonstrated excellent results with Ender’s nail in approximately 85% of patients. Union was achieved in all pa ents within a mean of 6.6 weeks (range 5 to 12 weeks) and no observa on regarding delayed union, infec on, nonunion, growth arrest and refracture a er nail removal was seen. Laghvendu Shekhar et al12 (2006) reported in 34 femoral fractures treated by Ender’s nail, 20 pa ents (83.3%) had excellent results , 4 (16.3%) had sa sfactory and none had poor result. Kumar S et al 13 (2011) reported on Sixty-two femoral sha fractures treated by elas c intramedullary nailing ( tanium elas c and Ender nails) with mean age of the pa ents being 9.2 years. The result demonstrates 100% union rate irrespec ve of the age, weight and height 101 R Dwivedi et al of the pa ent. They did not fi nd any mismatch in the results of fractures stabilized with tanium elas c nails with that of Ender’s nails. Lohiya et al14 (2011) reported outcomes of fl exible intramedullary nailing in 73 femoral sha fractures. Titanium and Ender nails were used in 43 and 30 cases respec vely. There were overall 59 excellent, 10 sa sfactory and 4 poor results however among Ender’s group only one poor result was observed. To conclude, Ender’s nailing can be preferred surgical op on for the treatment of children with femoral sha fractures in age group 5-15 years, as it can be done by closed method, outcomes are excellent and sa sfactory, associated with few complica ons and it spares the vascularity and growth plate. REFERENCES 1. Flynn JM, Schwend RM. Management of pediatric femoral sha fractures. J Am Acad Orthop Surg. 2004; 12(5): 347-59. 2. Flynn JM, Hresko T, Reynolds RA, Blasier RD, Davidson R, Kasser J. Titanium elas c nails for pediatric femur fractures: a mul center study of early results with analysis of complica ons. J Pediatr Orthop 2001; 21(1): 4- 8. 3. Winquist RA, Hansen ST Jr. Comminuted fractures of the femoral sha treated by intramedullary nailing. Orthop Clin Nort Am 1980; 11:633-48. 4. Mazda K, Khairouni A, Pennecot GF et al. Closed fl exible intramedullary nailing of the femoral sha fractures in children. J Pediatr Orthop 1997; 6: 198-202. 5. Gregory P, Sullivan JA, Hernodon WA. Adolescent femoral sha fractures: rigid versus fl exible nails. Orthopedics 1995; 18: 645-9. 6. Gregory P, Pevny T, Teaque D. Early complica ons with external fi xa on of paediatric femoral sha fractures. J Orthop Trauma 1996; 10:191-198 7. Lee S, Mahar AT, Newton PO. Ender nail fixation of pediatric femur fractures a biomechanical analysis. J Pediatr Orthop. 2001; 21(4): 442-5. 8. Yamaji T, Anodo K, Nakamura T, Washimi O, Terada N, Yamada H. Femoral sha fracture callus forma on a er intramedullary nailing a comparison of interlocking and Ender nailing. J Orthop Sci 2002; 7 (4):472-6. 9. Mann DC, Weddington J, Davenport K. Closed Ender nailing of femoral sha fractures in adolescents. J Pediatr Orthop 1986; 6(6): 651-5. 10. Karaoğlu S1, Bak r A, Tuncel M, Karakaş ES, Sakir TM.) Closed Ender nailing of adolescent femoral sha fractures. Injury 1994; 25(8): 501-6. 11. Ozturkmen Y, Dogrul C, Karli M. Intramedullary fi xa on of femoral sha fractures in children with elas c Enders nail. Acta Orthop Traumatol Turc 2002; 36(3): 220-7. 12. Shekhar L, Mayanger J C. A clinical study of Ender nails fi xa on in femoral sha fractures in children. Indian J Orthop 2006; 40: 35-7. 13. 13. Kumar S, Roy SK, Jha AK, Cha erjee D, Banerjee D, Garg AK. An evalua on of fl exible intramedullary nail fi xa on in femoral sha fractures in paediatric age group. J Indian Med Assoc 2011; 109(6): 416-7, 425. 14. Lohiya R, Bachhal V, Khan U et al. Flexible intramedullary nailing in paediatric femoral fractures. A report of 73 cases. J Orthop Surg Res 2011, 6: 64