Functional Outcome of Operative Management of Femoral Shaft Fractures in Children with Tens (Titanium Elastic Nailing System)

Abstract

Background: Femoral shaft fractures account for 1.6% of all bony injuries in children, usually caused by assault or fall during normal play. Male to female ratio being 2.6:1. Low velocity trauma leads to transverse fractures and high speed trauma causes comminuted or segmental fractures. In children who are five years of age or younger, early closed reduction and application of a spica cast is an ideal treatment for most diaphyseal femoral fractures. The preferred method of treatment for skeletally mature teenagers is an antegrade solid intramedullary rod. There is considerable disagreement over the ideal course of care for children aged between the ages of six and sixteen. The assessment and management of patients with femoral shaft fractures in children aged 6 to 14 years old is evolving due to a better understanding of the local anatomy, the impact of treatment, and the biomechanics of fixation techniques. Study Duration: 1st September 2014 to 1stSeptember 2015 at the Department of Orthopaedics, Calcutta National Medical College Kolkata Methods and Materials: Nail Selection: Titanium Elastic Nails are available in five diameters: 2.0 mm, 2.5 mm, 3.0 mm, 3.5 mm and 4.0 mm; and are 440 mm in length. The following sizes were typically used for children of Average stature: 6–8 years old 3.0 mm nails 9–11 years old 3.5 mm nails 12–14 years old 4.0 mm nails Two nails of the same diameter were selected so the opposing bending forces are equal, avoiding misalignments. Femoral fractures in children are typically stabilized with two nails inserted in a retrograde manner from medial and lateral entry points above the distal physis • Countouring the nail • Creating the entry points • Insertion of the nail • Reduction of the fracture • Cutting of the nails After Treatment: The patient was kept non weight-bearing for 2 weeks. During this time a long leg back slab was applied for patient comfort. After 2 weeks the back slab along with the skin sutures were removed. Active knee bending exercises were allowed. The patient was allowed partial weight bearing with axillary crutches after 4 weeks. Radiographs were obtained after 6 weeks and progression to full weight bearing was done depending on the status of fracture and amount of callus formation. Removal of the Nails: The patient was planned for implant removal after consolidation of the fracture which was on an average of 6 months from the date of injury. Self locking extraction pliers were used for this purpose Results: During the study period, 30 cases were randomly selected for inclusion in the study following the inclusion criteria mentioned earlier. Cases were managed operatively with internal fixation using titanium elastic nails (TENS). All cases were initially treated by surface traction. Applied at the earliest possible moment. Followed by, the patients underwent proper pre operative investigations and pre-anaesthetic check up followed by the definitive surgical procedure. The age range of the patients in the study was 6-14 years, with a mean of 10.2 years treated operatively by TENS. There is no significant difference in between both groups in terms of demographic data (age, sex), fracture type and pattern, hospital stay and co morbidities at the time of presentation. All fractures in the operative group united clinically by 8 weeks and radiologically by 10 weeks  the difference was statistically significant, proving that patients in the operative group achieved healing milestones at an accelerated pace. Although there was knee flexion (avg. 131.50 in the operative group were found to be insignificant on statistical analysis. Shortening was found in the operative group (mean 0.1 cm), and the difference was found to be highly significant on statistical analysis. Degrees of angular malalignment in the operative group with means of 1.80. No major complications were seen in patients. There is no significant difference in between both groups in terms of demographic data (age, sex), fracture type and pattern, hospital stay and co morbidities at the time of presentation. All fractures in the operative group united clinically by 8 weeks and radiologically by 10 weeks  the difference was statistically significant, proving that patients in the operative group achieved healing milestones at an accelerated pace. Although there was knee flexion (avg. 131.50 in the operative group were found to be insignificant on statistical analysis. Shortening was found in the operative group (mean 0.1 cm), and the difference was found to be highly significant on statistical analysis. Degrees of angular malalignment in the operative group with means of 1.80. No major complications were seen in patients. Conclusion and Recommendations: During the study period, 30 cases were selected to be included in the study which had transverse and short oblique diaphyseal fractures of the femur.30 cases were treated by operative intervention by closed intramedullary nailing with titanium elastic nails. The age range of the patients was from 6-14 years, with a mean of 8.3 years in the operative group. Males were more frequently affected than females, the ratio being 2.3:1. The most common mode of injury was motor vehicle accident (MVA) accounting for 70% of the cases and the rest being falls from height. The left side was more frequently found to be injured (in 60% cases). Most of the cases (in 70% cases) in the operative group had their surgeries completed by the 5th post-injury day.