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J. Scott Doyle, MD, Christopher
Wagener, MD, Michael J. Conklin, MD, The Children's Hospital
of Alabama and UAB Division of Orthopaedic Surgery
The use of unlocked smooth titanium
elastic nails (TEN) for the treatment of pediatric femur fractures
is becoming more widespread in the United States. The purported
advantages are greater convenience to the patient, lower overall
complication rates and cost equivalency to other modes of
treatment. We reviewed our consecutive series of 41 pediatric
femur fractures treated with TEN at The Children's Hospital
in Alabama.
Forty-one femoral shaft fractures
in 35 patients were treated using TEN through a retrograde
technique. The patients average age was 9.6 yrs (range 4+11
to 13+5 yrs). 16/35 patients were polytrauma patients. 33
fractures were stable, 8 were unstable. There was 1 open fracture
in this series. Fracture distributions were 6 upper one third,
28 midshaft, 7 distal one third. Two crossed TEN nails were
inserted retrograde for all femurs except 2 fractures in the
upper one fourth of the shaft which were treated with antegrade
/ retrograde crossed technique. All patients were followed
until complete healing and rehabilitation.
Union was achieved in all 41
fractures within 6 weeks. There were no delayed unions. There
were no infections, cases of refracture, AVN, or neurovascular
injury. There was one case of hardware failure (bending of
rod) associated with an angular union. There were 5 cases
(in 4 pts) of angular union. Three of five cases of angular
union were greater than 10 degrees (range 11 - 16 degrees).
Shortening of greater than 1 cm was present in 2 cases (1.2
cm and 1.5 cm). No femur had shortening or angulation greater
than acceptable limits for age. There were no cases of malrotation.
The most frequent complication was discomfort at the distal
insertion site (17%) but this was generally mild and resolved
with rod removal. Stiffness was seen in 4 patients, but only
2 of these were related to the technique. We were not able
to prove that unstable fractures had a statistically higher
complication rate than stable fractures.
Compared to a series of similar
femur fractures treated at our institution by traction-spica
casting, there was a lower rate of angular union and foreshortening
with TEN. Compared to external fixation, our TEN series has
a lower refracture rate and shorter time to union without
any of the pin tract complications of external fixation. Because
of the risk of AVN, we reserve antegrade locked nailing to
patients approaching maturity. Young children at our institution
are treated with spica casting. We do not believe that TEN
is appropriate for all pediatric femoral shaft fractures but
do conclude that it is a safe effective technique when used
on properly selected fractures. We cannot draw conclusions
from this review, what degree of fracture instability would
lead to an increase rate in loss reduction.
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