Some children have more complications after elastic nailing

Analysis found that older, heavier children with femoral fractures are at higher risk.

Issue: December 2004

HOLLYWOOD, Fla. — A multicenter analysis of children who underwent titanium elastic stable intramedullary nailing of femoral fractures found that the procedure is largely safe, and children who are older and heavier are at higher risk for serious complications.

Researchers looked at a series of pediatric diaphyseal femur fractures from 1997 to 2002 at six major pediatric trauma centers. All children were treated with two retrograde titanium nails.

Steven Frick, MD, of Carolinas Medical Center in Charlotte, N.C., said that while elastic intramedullary nailing has become a popular method for treating these fractures, there are little published data on the complications associated with the procedure. "We decided that it was important that someone do a careful analysis of a large series," he said in his presentation at the Orthopaedic Trauma Association 20th Annual Meeting in Hollywood, Fla.

The study included 229 patients with 234 femoral shaft fractures. Researchers defined minor complications as nail irritation, loss of knee range of motion, delayed union and minor limb length discrepancies from 5 mm to 15 mm. Major complications — the criteria for a poor outcome — included neurologic damage after nailing, hematoma or infection requiring repeat surgery, loss of reduction requiring new reduction or surgery, refracture after nail removal, mal-union, delayed union or nonunion requiring surgery, and osteonecrosis of the proximal femoral shaft.

Frick said that the criteria for excellent and satisfactory results were very stringent. "I think what we wanted to do when we designed the study was to define excellent results as those that are essentially perfect in terms of their radiographic evaluation as well as any absence of any complications in the perioperative period," he said. "Poor results were those that had malalignment after healing that exceeded previously published guidelines."

Of the 234 fractures, researchers identified 114 complications in 87 patients. Excellent results were found in 64% of patients, satisfactory results in 26% and poor results in 10%.

The most common minor complication was nail irritation. There were major complications in 23 patients, most of them malunions. Two had deep infections, two had refractures, two had protruding nails and one had a hematoma requiring repeat surgery.

Age and weight affected outcome. Children older than 11 had a 3.8 times higher likelihood of a poor outcome. The average weight of children in the excellent and satisfactory groups was 85 pounds, while in the poor group it was 118 pounds. Frick said that they were unable to determine an exact cutoff weight at which a poor outcome could be reliably predicted, but children of at least 108 pounds had a five times higher likelihood of a poor result.

"The take home message would be that if your patient is older than 11 years or weighs more than 108 pounds, perhaps you should consider other treatment options," Frick said. "If you do proceed with titanium elastic intramedullary nailing, then you should follow those patients closely, and if you see that they're developing unacceptable angulation you can switch to an alternative method of treatment."

For more information:

Flynn J, Launay F, Moroz L, et al. An international, multicenter analysis of complications of elastic stable intramedullary nailing of pediatric femur fractures. #43. Presented at the Orthopaedic Trauma Association 20th Annual Meeting. Hollywood, Fla.