View of Open Tibial Shaft Fractures in Children Treated with Stainless Steel Elastic Nail

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Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 12421 - 12428 Received 25 April 2021; Accepted 08 May 2021.

12421 http://annalsofrscb.ro

Open Tibial Shaft Fractures in Children Treated with Stainless Steel Elastic Nail

*Abobaker Emrehil Mohamed Yosef^[1],Amr Mohamed Eladawy^[2], Riad Mansour Megahed^[2],Mohamed Ibrahim Salama ^[2]

[1]Orthopedic department, Faculty of medicine, Tripoli University- Libya.

[2]Orthopedic department, Faculty of medicine,Zagazeg University, Egypt.

Corresponding Author: Abobaker Emrehil Mohamed Yosef E-mail : [email protected]

ABSTRACT

Background:Elastic intramedullary nailing is a diaphyseal fracture osteosynthesis technique used in children. This method offers numerous advantages. There is primary bone union to avoid growth plate injury, early weight bearing, and minimally invasive surgery with a short hospital stay.In this study, we evaluated radiological and functional results of treatment of open tibial shaft fractures in children using intramedullary elastic nail. Patients and Methods: This study was a prospective clinical study that include 24 cases with open tibial fractures treated with intramedullary elastic nail at Zagazig University Hospital (ZUH), Egypt and in Tripoli Central Hospital in Libya from June 2020 until September 2020 with six months follow-up. All patients were assessed radiological by anterioposterior and lateral plain radiographs of the tibia that include the knee and ankle to limit unnecessary radiation.

Results: The majority of studied group were excellent in 19 cases clinically according to Ketenjian and Shelton Criteria and 23 cases were united with radiological assessment. Only two cases had superficial skin infection and just one case had Delayedunion.Conclusion:Flexible intramedullary nailing is an effective treatment option in patients with open fracture (gustilo type I, II), four to fifteen years age group.

Keywords:Fracture, Open Tibial, Elastic Nail INTRODUCTION

Pediatric tibial fractures are the most prevalent type of fracture in children, accounting for 25–43% of all youth fractures. The annual incidence of childhood fracture varies widely between studies, ranging from roughly 12 fractures per 1000 children to 36.1 fractures per 1000 children, with many factors such as geographic location, age, and gender of the patient being indicated to effect the incidence ⁽¹⁾.

The majority of tibial shaft fractures are treated conservatively. Open fractures, neurovascular deficits, polytrauma, unstable fracture patterns, and fractures that fail to satisfy acceptable reduction requirements (approximately 10 degrees of sagittal angulation, 10 degrees of varus/valgus, >50 percent translation) are all indications for surgical treatment ⁽²⁾.

Pediatric patients with high-energy tibial shaft fractures are a difficult category of injuries for the orthopedic surgeon to treat. The preservation of the proximal tibial physis limits the use of reamed, locked intramedullary nails, as seen in the skeletally mature population, necessitating the employment of alternative methods. External fixation has been utilized to stabilize these fractures, but it has been proven to lengthen the time to union, cause malunion, leg-length disparity, pin-tract infection, and reduce functional result⁽³⁾. Other fixation procedures, such as plates, have limited use due to more extensive dissection, which causes soft-tissue damage. Furthermore, some scientists speculated that using a plate before the age of twelve encourages growth, which may result in a leg length difference ⁽⁴⁾.

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Elastic intramedullary nailing is a diaphyseal fracture osteosynthesis technique used in children ⁽⁵⁾. This method offers numerous advantages. There is primary bone union to avoid growth plate injury, early weight bearing, and minimally invasive surgery with a short hospital stay⁽⁶⁾.This study aimed to evaluate ‏management of open tibial shaft fractures in children with intramedullary elastic nail.

PATIENTS AND METHODS

A prospective clinical study was conducted on 24 patients (18 males and 6 females) age varied from 4 years to 15 years with a mean age(9.63 ± 1.88) years with fracture shaft of open tibial fractures treated with intramedullary elastic nail atZagazig University Hospital (ZUH), Egypt and in Tripoli Central Hospital in Libya from June 2020 until September 2020 with six months follow-up.Approval taking Institutional Review Board (IRB)approval and also informed written consent was taken from patients and/or their caregivers. This Work was performed according to the code of Ethics of the World Medical Association(Declaration of Helsinki) for studies involving humans.Exclusion criteria: Patients with neuromuscular disorders, skeletal dysplasia, and/or metabolic disease affecting the bone, pathological fractures, infected wounds. Medical co-morbidities such as liver disease, and chronic renal disease or unfit for surgery.

Pre-operative:

All patients were subjected to history taking. All patients in the study were classified according to the Gustilo-Anderson classification including 21 cases were (G1) and 3 cases were (G2); and AO classification including 10 cases were (42A1), 8 cases were (42A2), 5 cases were (42A3) and 1 case was (42B2). Allpatients were assessed radiological by anterioposterior and lateral plain radiographs ofthe tibia that include the knee and ankle to limit unnecessary radiation. All patients were put in above knee splint when admitted in emergency department to relieve pain and decrease soft tissue edema and prevent further soft tissue damage. All patients had full preoperative lab done before surgery including; complete blood picture. PT, PTT and INR, random blood sugar, liver and Kidney function tests.

Surgical technique:

The operation was carried out under general anesthesia using a tourniquet and complete aseptic conditions. The patient was positioned in a supine position on a radiolucent table. An image intensifier was positioned so that it can be rotated to obtain antero-posterior and lateral views of the whole tibia from the knee to the ankle joint. The entire leg including the knee and the ankle joints was prepared as an operative field. External manipulation was conducted until adequate reduction was obtained and confirmed by fluoroscopy. The diameter of the individual nail was chosen by calculation (nail diameter = minimum canal diameter x 0.4). To avoid varus or valgus angulation, both nails were always of identical diameter. Each nail was pre-bent at the same point by hand, ensuring that the tip lies in the same plane as the plane formed by bending, and that the apex of curvature lies at the level of the fracture site. In order to achieve optimum reduction, stabilization and alignment of the fracture, the curvature had to be identical in both nails.A 2cm skin incision proximal to the required bone entry hole was made. Starting either on the anterolateral or anteromedial side of the tibia.

Regarding the entry point, the following precautions were taken into consideration;

the entry point should be 2–4cm distal to the proximal tibial physics. The anterolateral and anteromedial entry points should be at the same level. The entry hole should be slightly larger than the diameter of the chosen nail.

The holes were performed by a bone awl. It was directed diagonally at an angle of 45°

towards the far cortex to make the hole accommodating the direction of progressing nail. In

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six cases the holes were performed by 3.2 drill bits by applying a careful angulation movement of the drill bit until the entry hole was at an angle of at least 45°. (Fig. 1)

Figure (1): Entry hole and first nail.

The nail was held on a cannulated T- handle with the horizontal bar of the T-handle and the curved tip of the nail aligned in the same plane (this allowed identification of the curved tip as it passed along the medullary canal). The nail was passed through the entry hole with the curved tip pointing downwards. The nail was driven down the canal by rotating the T-handle back and forth. With a mallet, the nail was gently tapped to cross the fracture site.

The nail was advanced towards the metaphysis to anchor into the cancellous bone (Fig. 2) .

Figure (2): The first nail advanced distally.

The second nail was advanced using the same rotating movements and light taps.

Both nails were advanced and impacted at their final distal points just proximal to the distal tibial epiphyseal plate. (Fig. 3)

a b

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Figure (3): The second nail.

Reduction of the fracture and nail position were confirmed with the image intensifier.

If the fracture was distracted, compression on the fracture was done by impacting on the patient heel.The ends of both nails were cut, ensuring that about 1cm of each nail remains outside the entry hole.Wound irrigation and closure was performed in layers.Sterile dressing and above knee plaster cast was applied.

Postoperative care:

The stitches were removed after two weeks.Post-operative X ray was done for all patients immediately postoperative then every 2 weeks until union then every 3 months until removal of theimplant.Walking cast and Partial weight-bearing with support was allowed when the fracture was pain-free and bridging callus was evident radiologically.According to fracture healing and as soon as the patient felt ready, full weight bearing was allowed (Fractures were determined to be healed with evidence of tricortical callus and no tenderness at the fracture site on clinical examination).

Statistical analysis

Data from the history, basic clinical examination, laboratory tests, and outcome measures were coded, entered, and analyzed in Microsoft Excel software. The data was then imported into the Statistical Package for the Social Sciences (SPSS version 20.0) program for analysis.

For significant results, the P value was set at 0.05, and for highly significant results, it was set at 0.001.

RESULTS

14 cases had right tibial fracture (58.3%), while 10 cases had left tibial fracture (41.7%) Figure (1). The mechanism of injury 16 cases were RTA (66.7%), 5 cases were sport injury (20.8%) and 3 cases were fall down stairs (12.5%) Figure (2).

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Figure (1): Distribution of the patients according to Side affected .

Figure (2): Distribution of the patients according to mechanism of injury.

Table 2: Clinical outcome according Ketenjian, Shelton Criteria and Radiological outcome distribution among studied group

N %

Excellent 19 79.2

41.7%

58.3%

Side

Left Right

12.5%

20.8%

66.7%

MOI

Fall down stairs Sport injury RTA

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Clinically by Ketenjian and Shelton Criteria

Good 3 12.5

Fair 2 8.3

No. %

Radiological United 23 95.8

Delayed

union 1 4.2

Nineteen patients (79.2%) were excellent regard clinical assessment.clinical &

radiological assessment.Twenty three patients (95.8%) were united regard radiological assessment.table (2)

Table 3:Statistical analysis of the studied patients according to Time of union (n =24)

Time of union (week) No. %

≤9 8 33.3

≥9 16 66.7

Min. _ Max. 7.0 – 17.0

Mean ± SD. 8.90 ± 1.29

Median 9.0

Eight patients (33.3%) were united in (≤9 weeks) in contrast to 16 patients (66.7%) were united in ( ≥9 weeks).table (3)

Table (4): Relation between score and time before surgery (days) Score

Z p

Time before surgery(days) Fair (n = 2)

Good (n = 3)

Excellent (n = 19) Min. - Max. 1.00 – 7.0 2.00 – 7.0 1.0 – 8.0

0.091 0.928 Mean ± SD. 4.00 ± 2.00 4.00 ± 2.00 3.00 ± 2.00

Median 2.0 3.00 2.0

r_s(p) 0.05 (0.931)

Z: Z for Mann Whitney test rs: Spearman coefficient

There was no statistically significant relation between the time before surgery and the final score. table (4)

Table 5: Complication distribution among studied group.

N %

Complication

No 21 87.5

Superficial infection 2 8.3

Delay union 1 4.2

Total 24 100.0

Only three cases had complication with 12.5%table (5).

DISCUSSION

There were 18 males and 6 females, with the males outnumbering the females. RTA was the most common method of injury involved in 16 cases (66.7 %), followed by sport injury in 5 instances (20.8 percent), and fall down stairs in 3 cases (12.5 %). The most prevalent type of injury is a car accident. The number of motor vehicles on the road is increasing, and traffic laws are not being enforced properly. Because of the region's low socioeconomic position, working parents are unable to keep a watch on their children, resulting in a high number of road traffic accidents ⁽⁷⁾.

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This study's technique steps are consistent with those of Gavaskar and Rithika Singh in terms of age, gender, mode of injury, side affected, time for union, and range of motion at adjacent joints ⁽⁷⁾.

The right side was the most afflicted, with 14 people impacted (58.3 percent) and 10 people impacted on the left side (41.7 %). This finding agreed with the findings of Ligier et al ⁽⁸⁾. The average period of radiological union was ten weeks (10.79 1.1 weeks) in 24 instances, which coincided with VRP Vallamshetla et al ⁽⁹⁾.

This study of 24 cases revealed excellent results in 91.7 percent of all grade I and grade II fractures and good results in 8.3 percent, according to Johnson and Davlin ⁽¹⁰⁾.

O'Brien described 16 tibial fractures that were internally treated with flexible elastic intramedullary nails and had a very satisfactory functional outcome with no substantial angulation or leg length disparity and no infections ⁽¹¹⁾.

Vallamshetla reported on 56 tibia fractures treated internally using intramedullary elastic nails, with satisfactory outcomes in 84% of cases (two persistent angulations of the tibia, two leg-length discrepancies, two deep infections, one delayed union, and two fixation failures)

(9).

The mean time to union in this series was 8.90 1.29 weeks, which was comparable to other studies employing the same method of fixation. The average time to radiological union in Gordon⁽¹²⁾ work was eight weeks (range: four to eighteen weeks), while in Vallamshetla⁽¹³⁾ work was ten weeks (range from seven to eighteen weeks). In addition, in Sankar ⁽¹³⁾. Closed fractures healed faster than open fractures, with a mean time to union of 11 weeks (range 6–

18 weeks).

Our findings were comparable to those of Qidwai ⁽¹⁴⁾. who reported a mean time to union of 9.4 weeks in a study of 84 tibial fractures (including thirty open fractures) in children (mean age, 10.2 years) treated with Kirschner wires implanted in the same manner as described for the flexible intramedullary nails in the current investigation.

At 20.7 weeks (range 8–42 weeks), Srivastava⁽¹⁵⁾ reported a longer time to union than the other studies. The union, on the other hand, was described as ‘‘painless complete weight bearing with radiographic indications of tricortical callous development.' This is in contrast to previous research that only looked at radiographic union.

The most common consequence identified in our investigation was superficial infection and delayed union, which had a low frequency of 12.5 percent, according to Whit Pandya et al

(16).

All fractures are brought together in this series. This was analogous to the findings of other research that used ESIN, such as those reported by Vallamshetla⁽¹³⁾ and Sankar ⁽¹⁶⁾.

However, Srivastava⁽¹⁵⁾ reported two non-united cases, and Gordon⁽¹⁵⁾ likewise reported two non-union cases.

CONCLUSION

Flexible intramedullary nailing is a viable treatment option for patients aged four to fifteen years with open fracture (gustilo type I, II). The surgery has a low morbidity and favorable outcomes with a brief hospital stay. By rigorously following to the basic concepts and technical features, the majority of the associated issues can be avoided.

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