management of compound fracture tibia in children with titanium elastic nails
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Management of compound fracture tibia in children with
titanium elastic nails
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a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1e6
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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: drayeshaosman@yahoo.chttp://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
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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
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1e62
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.
nd fracture tibia in childrenwith titanium elastic nails, Apollo
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
Please cite this article in press as: Ali MI, Management of compouMedicine (2015), http://dx.doi.org/10.1016/j.apme.2015.02.017
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
nd fracture tibia in childrenwith titanium elastic nails, Apollo
36males
12females
Pie Chart 1 e Showing number of male to female cases.
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1e64
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.
Please cite this article in press as: Ali MI, Management of compouMedicine (2015), http://dx.doi.org/10.1016/j.apme.2015.02.017
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
nd fracture tibia in childrenwith titanium elastic nails, Apollo
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
Please cite this article in press as: Ali MI, Management of compouMedicine (2015), http://dx.doi.org/10.1016/j.apme.2015.02.017
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
nd fracture tibia in childrenwith titanium elastic nails, Apollo
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1e66
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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nd fracture tibia in childrenwith titanium elastic nails, Apollo
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