Treatment of femoral shaft fractures in young children by Ender’s nail: indications & complications.

Background: Treatment of femoral fractures in age group of 6 – 12 years is controversial. Operative treatment is becoming better accepted. Various modalities of fixation include plate osteosynthesis, External fixation; Antegrade locked nailing, and flexible intramedullary nailing. Methods: 60 children aged 6-12 years (Average age – 8.2 years) with 66 femoral diaphyseal fractures (61 closed and 05 open) in 60 patients were managed with closed Ender’s nailing. Pathological fractures due to unicameral bone cyst were evident in 5 patients. Femoral shaft fractures at the level proximal to distal three fifth with canal diameter of ≥ 6mm were included in the study. Out of 66 traumatic fractures 42 fractures had stable pattern and 19 had unstable fracture pattern. The results were evaluated clinically and radiologically. Results: All the 42 stable femoral fractures showed bridging callus in a mean time of 3.83 weeks (2.5 to 6.5 weeks). Full weight bearing was possible in a mean time of 4.19 weeks. Radiological union was seen in a mean time of 9.4 weeks. 34 fractures were evaluated by scanogram one year after injury and they revealed lengthening of 0.3cms. All the children returned to their previous level of activities. All the 19 unstable femoral fractures showed bridging callus in a mean time of 5.53 weeks (4 – 8 weeks). Full weight bearing was possible in a mean time of 6.21weeks. Radiological union was seen in a mean time of 12 weeks. 8 patients were readmitted for adjunctive procedures like nail impaction, traction and cast immobilization. 20% patients with unstable group had shortening of 1.3cms and 20% had external rotation of lower limb. Conclusions: Ender’s nailing is simple, cost-effective and minimally invasive procedure in 6-12 years of age. It offers stable fixation with rapid healing. There is prompt return of child to normal activity.

Study Of Ender’s Nailing In Subtrochanteric Fracture Of Femur In Adults.

Abstracts: Background: Fractures of the subtrochanteric area of the femur represents a difficult therapeutic problem for the orthopaedic surgeon. Comminution, high stress concentration and osteoporosis in this region can lead to failure of fixation, shortening and nonunion. Favourable mechanical conditions are obtained following flexible intramedullary nailing like Ender’s nailing,because axial forces are distributed along the entire length of the nail and bending moments are minimized. Compression of the fracture fragments occur without excessive stress on the nails, enabling the patient to bear weight on the extremity. Methodology: This is a study of 34 cases of subtrochanteric fractures of femur in adults treated by Ender’s nailing at our place. Age ranging from 19 to 70yrs..In our study patient’s distribution according to frank-seinsheimer classification was as follows : Type I: nil, II-a: 1 pt., II-b: 5 pts., II-c: nil, III-a: 10 pts., III-b: 5 pts., IV: 5 pts., V: 8 pts. All the patients were having close fracture. We used 4.5 Enders nails in all patients. In 24 pts.total 3 nails and in 10 pts.total 4 nails were used. In 5 patients open reduction and encirclage wiring was done. In all other patients close reduction was done. Results: Average union time was 15 weeks. No pt. got postope. infection. Excellent and good results were found in 27 pts.out of 34 pts. Conclusion: Average duration of surgery was 1 hour and 10 minutes. Per-operative average blood loss was only 75cc. Post- operatively 23 patients out of 34 patents started partial weight bearing walking from 1stpost operative day. Union rate was 97%, no malunion in coxavara, 6% patient got external rotation deformity.

Treatment of Supracondylar Fractures Following Total Knee Arthroplasty

Supracondylar fractures of the femur following total knee arthroplasty are rare complication with reported rates ranging from 0.3% to 2.5%. Union of the fracture in proper alignment, without disruption of prosthetic component fixation and with maintenance of 90 of knee motion, is impotant in treatment of this type of fracture. Modalties of treatment are conservative or operative methods and operative treatment are open reduction 4 internal fixation, intramedullary nailing, revision arthroplasty using a prosthesis with a long stem and closed reduction and external fixation, but there are controversies in the method of treatment. Between Apr. 1989 and Jul. 1994, 10 patients were treated for supracondylar fracture of the ipsilaterai femur following total knee atthroplasty and 2 cases of them had arthrop]asty at other hospital. Average age of patients was 53 years (29-68 years), nine patients were women and one was man. The preoperative diagnosis was rheumatoid arthritis in four, degenerative osteoaithritis in three, posttraumatic osteoarthritis in one and tuberculosis sequelae of the knee in two. In nine cases mechanism of injury were slip down and in one was fall down. The interval hetween arthroplasty and fracture was an average of 22 months (9-79months). Two cases we.re treated with closed reduction and cast immobilization, one case was treated with open eduction and in1ernal fixation and seven patients of' ten cases were treated with closed intramedullay Ender nailing. The average foIlow-up period after fracture was 25 months (3 - 74months). We evaluated the results as the range of motion, bony union at simple radiograph and Knee Rating Score of Hospital for Special Surgery at last follow up. Eight cases of supracondylar fracture occuned among 350 patients, 514 cases of total knee arthroplasty which were operated at Kyung Hee Univcrsity Hospital between Apr. 1989 and Jul. 1994 and incidence was 1.6%. At the last follow up, all 10 cases achieved bony union and 7 cases using Ender naiIing achieved clinical bony union which enabled patients to do weight-bearing without pain at postoperative 6-8 weeks and radiological union was achieved at postoperative 12 weeks. Range of motion were average 105 degrees (80 J.20 degrees) hefore fracture and 86 degrees (6S 120 degrees) at the last follow up and HSS Knee rating score were average 80.3 points (59 94 points) before fracture and average 78.8 points (66-89 points) at the last follow up. At 7 cases using Ender nailing, range of motion were average 106 degrees (90 11S degrees) hefore fracture and 91 degrees (6S-105 degrees) at last follow up and HSS Knee rating score were average 80.6 points (59-94 points) before fracture and average 80.3 points (72-89 poiints) at the last follow up. Closed iintramedullary Ender nailing is a gecommendable operative method in the treatment of supracondylar fracture following total knee arthroplasty considering to good bony union, satisfactory functional result, easy operative technique and less postoperative complication.

Treatment of Fracture of Shaft of Humerus by Ender Nailing / 대한정형외과학회잡지

Authors presented the experience of Ender nail treatment for the humeral shaft fractures in 24 patients. The results of treatment in all were satisfactory, though there were four cases of delayed union. Bridging callus was formed at 8.2 weeks on an average. The average clinical union time was 14 weeks. No complications developed during nailing procedure. A case of radial nerve palsy after fracture recovered spontaneously. Longer nails which hit the end of medullary canal of distal fragment distracted the fracture gap, and resulted in delayed union in 4 cases. Therefore, it is recommended to use the proper size of nail to avoid the distraction effect of the inserted nail, and to use two nails at minimum for better fixation. However, when intramedullary Ender nailing is properly done, single nailing also can give consistently good anatomic and functional results.

Ender Nailing with Distal Wiring Technique in the Treatment of Intertrochanteric Femoral Fracture / 대한정형외과학회잡지

In the treatment of elderly hip fracture, early mobilization as a means of reducing early postoperative morbiyt and morbidity is mandatory. Even though Ender nailing have many advantages, most serious problems with use of Ender nailing method are distal migration of nails, subsequent loss of fixation and limited knee joint motion. To prevent these difficult problems, we have used distal wiring technique with Ender nailing since 1988. In operation, we performed Ender nailing as usual manner under image intensifier and for the prevention of the nail migration, we performed circumferential wiring through the each Ender nail eye and above the adducter tubercle of the distal femur. Forty six cases were available with minimum follow-up of six months which were healed radiologically and clinically (Mean follow up: 21 months). The mean age was 74 years (Range: 52 years-88 years)and showed 26 cases of famale and 20 cases of male. The radiological morphometry using Singh index showed poor bone quality: 36 cases were below Grade III and the fracture type was classified by Tronzo criteria. In results, patients who had Ender nailing with distal wiring showed no distal migration, however one case of proximal migration was observed at the beginning stage of this technique. So, in elderly trochanteric fracture, to reduce the complication of the Ender nailing, especially nail migration, the authors recommend the Ender Nailing with distal wiring technique.

Radiological Assessment of Progressing of bony Union after Ender Nailing in Acute Tibia Shaft Fracture / 대한정형외과학회잡지

Acute unstable tibial shaft fractures are common in these days of high energy trauma. There are many options for this common and complicated fracture. Flexible intramedullary nailing using closed technique is prevalent in that this has much technical, functional, and physiological advantages. We reviewed 51 cases of acute tibial shaft fractures treated with flexible intramedullary nailing. There were 3 nonunions (6%), and two refractures. Among 46 united cases, 8 cases (17 %) showed no bridging callus formation within 20 weeks. Followings are the results of average time reaching each of radiological bony progression stage for 46 united cases. l. Average time to earliest discernible callus formation (stage I) was 13.3 weeks (range:8-21 weeks). 2. Average time to definite and bridging callus formation (stage II) was 18.1 weeks (range:8-32 weeks). 3. Average time to some oblitetation of fracture line (stage III) was 32.8 weeks (range:17-50 weeks). 4. Average time to complete obliteration of fracture line (stage IV) was 14.0 months(range:12-18 months).

Treatment of Intertrochanteric Fractures of the Femur under 50 yrs. of age with Ender Nails / 대한정형외과학회잡지

Since Ender introduced the concepts of multiple flexible intramedullary nailing in 1970, Ender nailing has been mostly used in intertrochanteric fractures of the elderly patients, but it has been rarely used in younger patients because of serious complications such as shortening and external rotation deformity. Authors already contended that the incidence of such complications had intimate connection with the quality of bone, and accordingly with the age. To substantiate the contention, we analyzed thirty-four cases with more than one year follow-up among forty cases of intertrochanteric fractures treated with Ender nails during the period from 1982 to 1989. And the results are summarized as follows;1. The average age was 39 yrs., and the most common cause of fractures was fall from a height. 2. According to the Kyle et al. clsssification, stable fractures(type I & II ) were 13 cases(38%), and unstable fractures (type III & IV) were 21 cases(62%). 3. According to the Singh's index, the good in bone quality(Grade 4, 5, & 6) were 31 cases(91 %), and the poor(Grade 1, 2, & 3) were only 3 cases(9%). 4. Postoperative complications occurred in 6 cases(17%), which included ROM limitation of knee joint in three cases(9%), proximal migrations of nails in two(5%), and distal migrations of nails in one(3%). Among them, 4 cases required revisional operations. There was no case with apparent external rotation deformity over 20 and shortening over 2cm. 5. It is thought that, contradictory to common beliefs, Ender nailingis a safe method for intertrochanteric fractures of femur in younger patients with good bone quality, but requires some experiences and cautions to prevent such complications as external rotation deformity and shorterning.

Surgical Treatment of the Trochanteric Fracture of the Femur / 대한정형외과학회잡지

The authors have treated 30 cases of trochanteric fracture of the femur from June 1987, to July 1988 at Dong Suwon General Hospital. The 30 cases included, 8 Condylocephalic Kuentscher nailing, 9 Ender nailing, 7 Multiple pinning, 5 Antegrade Kuentscher nailing and 1 Row plating. 1. The shape of condylocephalic Kuentscher nail should be designed differently, contoured circular arc in anteroposterior and angled in lateral plane. In the anteroposterior plane : The length of the radius of the arc is measured by following way. 1) Design the shape of the nail on the X-ray film of the normal femur which was taken in full internal rotation of the leg. 2) Make three points in the femoral film. One is A, midcentral point of the femoral canal of the isthmus. Point B is center of upper lateral quadrant of the femoral head. Point C is apart from medial cortex 5-7mm at the level of entry portal of the nail. 3) Make point D: Draw the perpendicular lines from the right middle of the AB and AC. These lines meet at the point D. AD is radius of the arc of nail. Draw an arc measuring by the length of AD and mold the nail following the arc. In the lsteral plane ; The nail is bent into three or four segments and the length of the longest segment should not be exceeded the permissible length of straight nail, the latter is distance from entry portal of the nail to anterior cortex of the femur where the tip of the inserted nail is impinged, about 15cm. 2. Two different types of the Ender nailings are used depend on the type of the fracture. In intertrochanteric fracture, the trochanter is remained in the distal fragment and acts as the crane post to fix the proximal fragment(interfragmental compression screw fixation) by horizontal screw inserted through the lateral cortex of the distal fragment into medial cortex of the proximal fragment and fixed with another screw inserted into the distal fragment by tension band wiring. In transtrochanteric frscture, the proximal fragment is fixed by two different kinds of the nails, prior to the nailing medial displacement of the distal fragment is not reduced. The first nail is driven along the medial wall of the medullary canal of the distal fragment, the tip of the nail comes out of the fracture site and impinges to the inferomedeial aspect of the head along the out side of the neck. The nail is inserted into the head after correction of nail direction. The second and third nails are inserted through the medullary canal of the fragments. The proximal fragment is fixed between two nail groups. 3. Antegrade Kuentscher nailing is used for undisplaced trochanteric fracture with segmental fracture or comminuted, segmental subtrochanteric fracture. The open reduction and fixation is preferable in comminuted segmental subtrochanteric fracture for its accurate reduction. The authors msde additional several holes, transverse, sagittal (at the dorsum of the nail) oblique holes around the nail, so the interlocking screw can be easily inserted to the nail when the insertion of the screw through the transverse holes are difficult. 4. It's extremely important to study the fracture carefully when the surgeon plans to use the multiple pinning for trochanteric fracture. The fracture configuration has to be determined in regard to expect stability after local pinning especially in lateral plane. The fracture is fixed by horizontal pin, low angle pin, curved buttress pin(or screw) solidly, not parallel as in neck fracture. The curved buttress rush pin should be inserted as acting as the anteromedial or posteromedial buttress.

The Treatment of Open Tibial Fractures by Ender's Nailing / 대한정형외과학회잡지

The treatment of open tibial fracture has become one of the most controversial subjects in orthopedic surgery. Recently flexible intramedullary nails have been used successfully in treatment of Type I, II open fractures of the tibial shaft. In this paper we are reporting our experience with the method in 20 open fractures of the tibia in 18 patients. The results were ss follows. 1. The patients were predominantly more common in male(90%) and the average age was 42.7 years old and the most common cause of fracture was traffic accident. 2. The most common site and shape were at midshaft and comminuted fracture. 3. With early operation the incidence of infection was greatly reduced and wound healing was relatively rapid. 4. The patients were applied with long leg or P.T.B. cast for at least 4 weeks in order to the prevention of re-displacement. 5. The average healing time was 17.7 weeks in 14 cases and union was most rapid at upper third and Type I fractures. 6. The complication was developed in 14 cases, 3 cases of delayed union, nonunion and ankle stiffness was seen respectively. 7. Infection rate was greatly reduced because Ender's nailing procedure was easy to perform, operation time was shortened, good fixation and alignment of fracture fragment was done without periosteal stripping. 8. Ender's nailing is considered to be a good method in the treatment of open tibial fracture associated with soft tissue injurv and multiole iniuries.

The Treatment of Tibial Shaft Fractures By Use of Ender's nailing / 대한정형외과학회잡지

Fracture of the tibial shaft is the most common fracture of the long bones, and due to its frequency, mode of injury and sometimes type of treatment, has become a major source of permanent and temporary disability. The treatment of fractures of the tinial shaft has become one of the most controversial subjects in orthopedic surgery. Recently flexible intramedullary nails have been used successfully in treatment of fractures of the tibial shaft. In this paper we are reporting our experience with the method in 29 selected fractures of the tibia in 28 patients. The results were as follows. l. Of 29 cases, 19 cases were male and 10 cases were female. The average age was 33.4 years and the most common cause of injury was traffic accident. 2. Seventeen cases were closed fractures and twelve cases were open fractures. Nineteen cases were comminuted fracture. The most common level of the fracture was middle third of the tinial shaft. 3. Average interval from injury to Ender nailing was 10.3 days and the mean duration of permmit to full weight bearing was 9.8 weeks. 4. The mean duration of clinical bone union was 10.2 weeks and that of roentgenological bone union was 17.8 weeks. 5. 9 cases of complication were noted among the 29 cases of tibial shaft fracture which was treated by Ender nsiling such as angulation, ankle joint stiffness, and one case of delayed union. 6. Ender nailing are relative ease of nailing, allow early weight bearing and decrease complication. So Ender nailing is considered to be a good methods in treating tibial shaft fracture.