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 Table of Contents  
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 116-120

Functional assessment of diaphyseal femoral fractures in pediatric age group managed by titanium elastic nail system: A prospective study

Department of Orthopaedics, PGIMS, Rohtak, Haryana, India

Date of Submission25-May-2020
Date of Decision06-Jul-2020
Date of Acceptance27-Jul-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Karan Siwach
123, Main Gohana Road, Rajender Nagar, Rohtak - 124 001, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JODP.JODP_17_20

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Background: Femoral shaft fractures are common childhood injuries and are among common causes for hospitalization in children. Treatment varies with child's age. There is little room for question in treatment guidelines in children below the age of 3 years, but in the age group of 4–14 years, it is still a matter of debate. There is a trend toward surgical intervention with the advent of newer surgical techniques. This study aims to evaluate the functional outcome of titanium elastic nail system (TENS) for the treatment of femoral diaphyseal fractures in this age group. Materials and Methods: This study included 63 children between 4 and 14 years of age who sustained femoral diaphyseal fractures and were managed by TENS nailing during the period of the study between April 2017 and April 2020. Results: All patients showed union; there were no cases of nonunion or delayed union or implant failure. Three patients had exposed implant, and 15 developed superficial infections which subsided with antibiotic treatment. Forty-eight patients had excellent Flynn score, and 15 had a satisfactory score. Conclusion: In our series of patients, we concluded that TENS nailing in the study group was easy and reliable. As it is a load-sharing device and does not violate the physis, it allows early mobilization and maintenance of alignment. Other notable advantages include decreased risk of infection and undisturbed fracture hematoma. Superficial infection was one of the commonly observed complications which subsided with oral antibiotics.

Keywords: Pediatric femoral fracture, titanium elastic nail, union

How to cite this article:
Siwach K, Kumar V, Arora K, Beniwal R, Mittal A, Nandal G. Functional assessment of diaphyseal femoral fractures in pediatric age group managed by titanium elastic nail system: A prospective study. J Orthop Dis Traumatol 2020;3:116-20

How to cite this URL:
Siwach K, Kumar V, Arora K, Beniwal R, Mittal A, Nandal G. Functional assessment of diaphyseal femoral fractures in pediatric age group managed by titanium elastic nail system: A prospective study. J Orthop Dis Traumatol [serial online] 2020 [cited 2021 Apr 16];3:116-20. Available from: https://www.jodt.org/text.asp?2020/3/3/116/305736

  Introduction Top

Femoral shaft fractures are among the most common diaphyseal fractures in children with an estimated annual incidence of 19 fractures per 100,000 children and account for one of the common causes of hospitalization for pediatric orthopedic injuries. The treatment for femoral shaft fractures varies based on the child's age and injury with a trend toward operative stabilization. Children younger than 5 years are placed in spica cast.[1] Conservative treatment necessitates a long stay in the hospital for traction and subsequent immobilization in an uncomfortable cast. Barring the patients of age <4 years, this treatment is not well tolerated, especially in adolescence.[2] Operative treatment results in shorter hospitalization and easy mobilization, which has psychological, social, educational, and economic advantages over conservative treatment. A variety of therapeutic alternatives such as external fixator, compression plating, rigid intramedullary nailing, and elastic stable intramedullary nailing (ESIN) are being used for femoral shaft fractures in children. With the use of external fixator, there is a high incidence of pin-tract infection, refracture after the removal of external fixator, and stiffness of the knee joint. Furthermore, the compliance is not good with the use of external fixator as it is uncomfortable for the child. Compression plating needs two major operations and usually is associated with big scar formation.[3] ESIN meets the requirements of this ideal device.[4] Intramedullary titanium elastic nailing is rapidly emerging technique of femoral shaft fracture fixation in children. It involves the insertion of one or two titanium nails into the medullary canal to provide stable fixation. The fixation is not rigid but allows enough stress at the fracture site to encourage abundant callus formation and promote healing. The titanium elastic nail seems advantageous over other surgical methods particularly in the age group of 5–16 because it is a simple procedure, a load-sharing internal splint that does not violate the physis, allows early mobilization, and maintains alignment. Keeping the above facts in view, the purpose of this study is to evaluate the functional outcome of pediatric femoral diaphyseal fractures treated by titanium elastic nail system (TENS) nailing in 4–14 years of age group.

  Materials and Methods Top

This study was approved by the Institutional Ethical Committee of PGIMS, Rohtak. A total of 63 pediatric patients with 63 diaphyseal femur fractures who were operated at our institute with TEN nail within the period from April 2017 to April 2020 meeting the following criteria were included and assessed.

Inclusion criteria

The following criteria were included in the study:

  1. All pediatric patients within the age group of 4–14 years with diaphyseal femur fracture
  2. Gender: Both males and females were included.

Exclusion criteria

The following criteria were kept as exclusion criteria in this study:

  1. Age < 4 years and >14 years
  2. Metaphyseal fractures of the femur
  3. Metabolic bone disorders, any associated disorder of the affected side were found and assessed and were excluded for this study
  4. Any other associated injury, bilateral limb injuries if any.

Patients were enrolled in the study only after the informed written consent of legal guardian of the patient was obtained. All cases were given first aid in the casualty, and a thorough examination was done to find any associated injury. And then, X-ray pelvis with both hips and femur with hip and knee was taken in all patients. All cases were given nonadhesive skin traction and symptomatic treatment in the ward. All cases underwent routine preanesthetic workup and investigations. As the titanium nails are elastic, they were precontoured in a way so that the apex of the convex curve of the bent nail should come in contact of the endosteal surface of the bone about the level of the fracture. Two nails of the same size were so prebent, and entry was made with a bone awl about 2.5 cm above the physis from both medial and lateral sides in such a way that after insertion, the convex apex of both the nails should be opposite to each other at the level of the fracture, and the opposite ends of the nails are embedded in the opposite metaphysis. This configuration of nails gave a three-point buttressing imparting maximum stability to the construct and the fracture. This principle of TENS nailing is depicted in the sketch diagram labeled as [Figure 1]. The diameter of each nail selected was about two-fifth/40% of the narrowest internal diameter of the medullary canal. Reduction was checked under the image intensifier before closure. All patients received single I.V antibiotic dose 30 min before the procedure and continued for 48 h after the surgery. Postoperatively, all patients were advised for nonweight-bearing with a range of motion exercises, and further partial to full weight-bearing was gradually started after 6 weeks taking in view of pain relief and callus formation radiologically. Patients were followed up on 3rd, 6th, and 12th weeks after the surgery, and tenderness at the insertion site, range of movement of the knee, range of movement of the hip, squatting, cross-legged sitting, limb length discrepancy, and postoperative x-rays were assessed. During follow-up, these patients were evaluated clinically by Flynn's scoring criteria and radiologically for union and callus formation.
Figure 1: Principle of titanium elastic nail system nailing

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  Observation and Results Top

In our study, patients were of the age group of 4–14 years. The average age was 9.1 years. There was an increased incidence of fracture in the age group of 5–10 years. Among the 63 patients followed, male children were more than female children. There were 45 (71%) male and 18 (29%) female. Sidewise distribution shows that 62% (39) of fractures were on the right side. About 48% (30) were presented within 24 h of injury, whereas 52% of the patients were presented after 24 h of injury. Forty-two patients presented with a history of road traffic accident (RTA), and 21 patients had a history of fall from height. Thirty-six of them were transverse (57%) fractures, and 24 of them were spiral type of fracture (38%), whereas three patients had comminution type of fracture [Table 1]. All cases were done in closed reduction. In all cases, two TEN nails were used except three cases in which three elastic nails were used. In all of the patients, both medial and lateral entry portals were used. The average hospital stay was 4 days. Significant tenderness was seen in 76% (48) of patients at 3 weeks after the TEN nailing, which was decreasing in the next follow-up visit. Further at 12 weeks, only 6 (9%) patients had the significant tenderness. Radiological union was seen in all (100%) patients at 12 weeks. [Figure 2], [Figure 3], [Figure 4] shows pre-operative, post-operative and follow up of a patient showing satisfactory union. Above knee immobilization was needed in six patients at 3 weeks, which was removed at 6 weeks. The knee movement improvement was seen during each follow-up, and full knee extension was seen in 57 (90%) patients, and full knee extension was seen in all 63 (100%) patients by 12 weeks. Cross-legged sitting and squatting were achieved in 57 (90%) patients by 12 weeks. The most common complication encountered in this series was superficial infection at the nail insertion site in 12 (19%) cases, followed by implant exposure in three cases. The final outcome according to Flynn's criteria is seen in [Table 2] that shows that excellent outcome was seen in 48 (76%) of patients, whereas 15 (24%) patients showed satisfactory outcome, and none of the patients showed poor outcome.
Table 1: Patient distribution according to Flynn's criteria

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Figure 2: Preoperative x-ray showing diaphyseal spiral fracture of the right femur with overriding of fragments

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Figure 3: Immediate postoperative x-ray of the procedure done

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Figure 4: X-ray done at 6 weeks showing satisfactory rate of progression of union

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Table 2: Final outcome according to Flynn's criteria

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  Discussion Top

Femoral shaft fractures constitute fewer than 2% of all pediatric fractures, and the choice of treatment has remained a constant challenge to the orthopedic fraternity. Until recently, conservative treatment was the preferred method for the treatment of diaphyseal fractures in children and young adolescents. However, to avoid the effects of prolonged immobilization to reduce the loss of school days and for better nursing care, the operative approach has been gaining popularity for the past two decades.

Although external fixators, compression plates, rigid intramedullary nails, all have been used for surgical management of pediatric long bone fractures with good results, with certain definite disadvantages such as large exposure and a high risk of fracture at the end of the plate or through screw holes after removal of the plate, pin-tract infection, and higher risk of re-fracture with external fixators along with a risk of restriction of knee movements as excursion of iliotibial band is restrained due to penetration of pins of fixator through it, avascular necrosis of femoral capital epiphysis/trochanteric epiphysis, might also lead to increased femoral neck valgus after rigid intramedullary nailing when done through the piriformis fossa owing to injury of the posterosuperior branches of the medial femoral circumflex artery. The present study consists of 63 patients with 63 diaphyseal femur fractures treated by TENS system. In this study, patients' age ranged from 4 to 14 years, with an average age of 9.1 years. Majority of the patients were in the age group of 4–10 years. Age distribution in Flynn et al.[5] study was 6–16 years with the average age of 10.2. Age distribution in studies done by Saikia et al. and Gyaneshwar et al. has a mean age of fracture femur shaft similar to the present study, i.e., 10 years and 8.6 years, respectively.[6],[7] In the present study, out of 63 patients, 46 (71%) were male patients and 17 (29%) were female. In Flynn study, 60 were male and 33 were female. Similarly, in Saika studies, 18 were boys and 4 were girls. All studies compared had shown male preponderance like in our study. The mode of injury in the present study was RTA in 42 patients and fall from height in 21 patients. These findings coincide with other studies.[4],[6] Fifty-two percent of the patients in the present study were operated within 24–48 h of injury, which is quite good as compared to a study by Gyaneshwar et al.,[7] in which most of the patients were operated after 4–5 days. Furthermore, in the present study, the average hospitalization was 4 days, which is comparable to other studies. The lesser hospital stay can be attributed to the bulk of patients catered by the hospital, making it impossible for a longer stay. In the present study, all the patients had closed femoral diaphyseal fracture. Among them, 36 were transverse, 24 were oblique, and 3 were minimally comminuted. Hence, transverse and spiral were the common types of fracture, which is similar to a study by Ligier et al.[8] and Thapa et al.[9] In the present study, at 6 weeks, 21 fractures were united and 42 were uniting. At 12 weeks, all fractures were united with the average union time of 10 weeks. In Flynn study, the average union time was 9 weeks.[5] In Saika studies, the average union time was 8.7 weeks.[6] Hence, the rate of union was good and comparable to other studies. It might be because of the timely presentation, early surgical intervention with TENS nailing, and robust postoperative rehabilitation. Furthermore, 51 patients achieved full range of movements at 6 weeks, and all patients achieved it at 12 weeks. In our study, at 6 weeks, 54 patients were able to do squatting and cross-legged sitting, and at 12 weeks, all of the patients were able to do squatting and cross-legged sitting. In the present study, the total outcome according to Flynn's criteria[10] was excellent in 48 (76%) patients and satisfactory in 15 (24%), and none had poor results as compared to the study by Gyaneshwar et al.,[7] in which 58.82% had excellent result. The better results may be acknowledged to the fact that early operative procedure was done in every patient. Furthermore, 95% of the patients achieved full knee extension, cross-legged sitting, and squatting position, whereas 100% of the patients achieved full knee extension by 12 weeks. The entry site irritation and pain were the common side effects. However, they were relieved in most of the patients during follow-up visits. No limb length discrepancy was seen in our series. A review by Khoriati et al.[11] also shows that limb length discrepancy is not common with TEN nailing. A frequent complication was superficial infection at the entry site, but all of them healed with oral antibiotic therapy. It was also noticed that all of these 12 patients had hemoglobin <9 g/dl with poor nutritional status which could be the contributing factors for infection. Three patients had implant exposure at 8 weeks which was treated by implant removal as the fracture was found to be uniting. The nursing care of the patients with elastic nails is simpler. Contraindications to its use will include open or severely comminuted fractures.[11] In the present study, titanium elastic nail seems advantageous over other surgical methods particularly in this age group because it is simple, is a load sharing device, internal splint that does not violate the opening of physis, allows early mobilization, and maintains alignment. Micromotion conferred by the elasticity of the fixation promotes faster external bridging callus formation. The periosteum is not disturbed, and being a closed procedure, there is no disturbance of fracture hematoma, thereby less risk of infection. An ideal device for treating pediatric femur fractures would be a simple load-sharing internal splint, allowing the mobilization and maintenance of alignment until bridging callus forms. The device would exploit the rapid healing and ability to remodel without risking the physis or blood supply to the femoral head.[10] We believe that TENS nailing fulfills these qualities and is advantageous over hip spica in the treatment of femoral shaft fractures in children in 4–14 years of age group. The study has certain limitations. As this was a single-center study, the results should be generalized with caution. Furthermore, the cost of treatment was not estimated as no such attempt was made.

  Conclusion Top

The present study supports the treatment of femoral shaft fractures in children aged 4–14 years with TENS, as the technique is simple and easily reproducible, least invasive with minimal blood loss, amounts to minimal scar, follows the principle of trifocal buttressing and hence provides sufficient axial stability and reasonable rotational stability, preserves fracture hematoma and hence hastens fracture union, reduces the rate of malunion and amount of shortening, and allows earlier rehabilitation and return to school.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Buford D Jr, Christensen K, Weatherall P. Intramedullary nailing of femoral fractures in adolescents. Clinical Orthopaedics and Related Research. 1998:85-9.  Back to cited text no. 1
Metaizeau JP. Stable elastic intramedullary nailing for fracture of the femur in children. J Bone Joint Surg (Br.)2004;86-B:954-7.  Back to cited text no. 2
Linhart WE, Roposch A. Elastic stable intramedullary nailing for unstable femoral fractures in children: Preliminary results of a new method. J Trauma 1999;47:372-8.  Back to cited text no. 3
Flynn JM, Hresko T, Reynolds RA, Blasier RD, Davidson R, Kasser M. Titanium elastic nails for pediatric femur fractures: A multicenter study of early results with analysis of complications. J Pediatr Orthop 2001;21:4-8.  Back to cited text no. 4
Flynn JM, Luedtke LM, Ganley TJ, Dawson J, Davidson RS, Dormans JP, et al. Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children. J Bone Joint Surg Am 2004;86:770-7.  Back to cited text no. 5
Saikia K, Bhuyan S, Bhattacharya T, Saikia S. Titanium elastic nailing in femoral diaphyseal fractures of children in 616 years of age. Indian J Orthop 2007;41:381-5.  Back to cited text no. 6
[PUBMED]  [Full text]  
Gyaneshwar T, Nitesh R, Sagar T, Pranav K, Rustagi N. Treatment of pediatric femoral shaft fractures by stainless steel and titanium elastic nail system: A randomized comparative trial. Chin J Traumatol 2016;19:213-6.  Back to cited text no. 7
Ligier JN, Metaizeau JP, Prevot J, Lascombes P. Elastic stable intramedullary nailing of femoral shaft fracture in children. J Bone Joint Surg 1988;70:74-7.  Back to cited text no. 8
Thapa SK, Poudel KP, Marasini RP, Dhakal S, Shrestha R. Pediatric diaphyseal femur fracture treated with intramedullary titanium elastic nail system. JCMS Nepal 2015;11:20-2.  Back to cited text no. 9
Flynn JM, Hresko T, Reynolds RA, Blasier RD, Davidson R, Kasser J. Titanium elastic nails for pediatric femur fractures: A multicenter study of early results with analysis of complications. J Pediatr Orthop 2001;21:4-8.  Back to cited text no. 10
Khoriati AA, Jones C, Gelfer Y, Trompeter A. The management of paediatric diaphyseal femoral fractures: A modern approach. Strategies Trauma Limb Reconstr 2016;11:87-97.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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