Introduction. Clavicle fractures accounting for 3–5% of all adult fractures are usually treated non-operatively. There is an increasing trend towards their surgical fixation. Objective. The aim of our study was to investigate the outcome following titanium elastic stable intramedullary nailing (ESIN) for midshaft non-comminuted clavicle fractures with >20mm shortening/displacement. Methods. 38 patients, which met inclusion criteria, were reviewed retrospectively. There were 32 males and 6 females. The mean age was 27.6 years. The patients were assessed for clinical/radiological union and by Oxford Shoulder and QuickDASH scores. 71% patients required open reduction. Results. 100% union was achieved at average of 11.3 weeks. The average follow-up was 12 months. The average Oxford Shoulder and QuickDASH scores were 45.6 and 6.7 respectively. 47% patients had nail removal. One patient had lateral nail protrusion while other required its medial trimming. Conclusion. In our hands, ESIN is safe and minimally invasive with good patient satisfaction, cosmetic appearance and overall outcome

Displaced fractures of the radial neck in children can lead to limitation of elbow and forearm movements if left untreated. Several management techniques are available for the treatment of radial neck fractures in children. Open reduction can disturb the blood supply of the soft tissue surrounding the radial head epiphysis and is associated with more complications. We report our experience of treating 14 children between the age of 4 and 13 years, who had severely displaced radial neck fractures (Judet type 111 and 1V). 12 patients were treated with indirect reduction and fixation using the Elastic Stable Intramedullary Nail (ESIN) technique, (3 with assisted percutaneous K-wire reduction) and 2 had open reduction followed by ESIN fixation of the radial head fragment. This method reduces the need for open reduction and thus the complication rate. Three patients had associated fractures of the same forearm which was also treated surgically at the same time. We routinely immobilised the forearm for two weeks and removed the nail in all cases in an average of 12 weeks. We had no complication with implant removal. All 14 patients have been followed up for average of 28 months. One patient (7%) developed asymptomatic avascular necrosis (AVN) of the head of radius. Thirteen patients (93%) had excellent result on final review. One patient had neuropraxia of the posterior interosseous nerve which recovered within 6 weeks. In conclusion we advocate ESIN for the closed reduction and fixation of severely displaced radial neck fractures in children. It remains a useful fixation method even if open reduction is required and allows early mobilisation

The advent of Elastic Stable Intramedullary Nailing has revolutionised the conservative treatment of long human bone fractures in children (Metaizeau, 1988; Metaizeau et al., 2004). Unfortunately, failures still occur due to excessive bending and fatigue (Linhart et al., 1999; Lascombes et al., 2006), bone refracture or nail failure (Bråten et al., 1993; Weinberg et al., 2003). Ideally, during surgery, nail insertion into the diaphyseal medullary canal should not interrupt or injure cartilage growth; nails should provide an improved rigidity and fracture stabilisation.

This study aims at comparing deflections and stiffnesses of nail-bone assemblies: standard cylindrically-shaped nails (MI) vs. new cylindrical nails (MII) with a flattened face across the entire length allowing more inertia and a curved tip allowing better penetration into the cancellous bone of the metaphysis (Figure 1). MII exhibits a section with two parameters: a diameter C providing nail stiffness and a height C' providing practical dimension when both nails are crossed at the isthmus of the diaphysis: C/C' is set to 1.25 for all MII nails.

A CT scan of a patient aged 22 years was used to segment a 3D model of a 471mm-long right femur model. The medullary canal diameters at the isthmus are 10.8mm and 11.4mm in the ML and AP direction, respectively. Titanium-made CAD models of MI (Ø=4mm) and MII (flat face: Ø=5mm) were pre-curved to maintain their flat face and carefully placed and positioned according to surgeon's instructions. Both nails were inserted via lateral holes in the distal femur with their extremities either bumping against the cortex or lying in the trabecular bone.

Transverse and comminuted fractures were simulated (Figure 1). For each assembly, a Finite Element (FE) tetrahedral mesh was generated (∼100181 nodes and 424398 elements). Grey-scale levels were used to assign heterogeneous material properties to the bone (E=6850 ρ^1.49 (Morgan et al., 2003)). Two modes of loading were considered: 4-point bending (varus and recurvatum: F_max=6000N) and internal torsion (M_max=70kNmm). This led to the simulation of 15 FE models, including a reference intact femur.

Results show that in valgus, for the transverse (comminuted) fracture, the mean displacement of the assembly decreased by around 50%: from 15.24mm (27.49mm) to 8.15mm (13.85mm) for MI and MII, respectively, compared to 3.59mm for the intact bone. The assembly stiffness increased by 87% and 99% for transverse and comminuted fracture, respectively (Table 1). Similar trends were found in recurvatum with higher increases in assembly stiffness of 170% and 143% for transverse and comminuted fracture, respectively (Table 1). In torsion, for the transverse (comminuted) fracture, the measured angle of rotation decreased from: 0.43rad (0.66rad) to 0.22rad (0.43rad) for MI and MII, respectively, compared to 0.09rad for the intact bone. This corresponded to an increase of 95% and 55% in assembly stiffness for transverse and comminuted fracture, respectively.

In conclusion, using the 5mm-diameter new nails (MII) for the same intramedullar space, during either bending or torsion, assemblies were always stiffer than when using standard cylindrical nails.

The August 2012 Children’s orthopaedics Roundup. 360. looks at: whether 3D-CT gives a better idea of coverage than plain radiographs; forearm fractures after trampolining accidents; forearm fractures and the Rush pin; the fractured distal radius; elastic stable intramedullary nailing for long-bone fractures; aponeurotic recession for the equinus foot; the torn medial patellofemoral ligament and the adductor tubercle; slipped capital femoral epiphysis; paediatric wrist arthroscopy; and Pirani scores and clubfoot

Elastic stable Intramedullary nailing (ESIN) is a method of treating femoral fractures in older children. The purpose of this study is to report our results over a 9 year period. Between 1998 and 2007, 62 children with femoral shaft fracture were managed at our institution with flexible titanium nailing. There were 44 boys and 18 girls with a mean age of 12.4 years (range 6 to 16 years). The mechanism of injury varied from RTA, falls and sports. The right side was involved in 41 and the left in 23. Two children had bilateral fractures. The fracture was in the proximal one third in 3, middle third in 51 and the distal third of the diaphysis in 8 children. The fracture pattern varied from transverse in 33, oblique in 15, spiral in 10 and comminuted in 4 patients. 11 children had associated injuries and 2 had mild osteogenesis imperfecta and another 3 sustained pathological fractures (fibrous dysplasia - 1 patient; simple bone cyst -1 patient; aneurismal bone cyst – 1 patient). The surgical procedure was retrograde except in one child with a mid third oblique fracture where this technique failed and hence an ante grade insertion was performed. All fractures united at an average follow-up of 18 months (range 12–24 months). The mean union time was 3.8 months (range 1.2 to 7.2 months). All patients were followed until the implant was removed and the mean insertion to removal interval was 13 months (5 to 29 months). The complications noted in our series were knee discomfort with stiffness (8 patients), pain from prominent nails (2 patients), malunion (1 patient), delayed union (1 patient), peri-prosthetic fracture (1 patient). There were no cases of infection. In conclusion, the results of our series showed that Elastic stable Intramedullary nailing gives satisfactory outcome in management of femoral shaft fractures in children

We evaluated the outcomes of fractures of the femoral shaft treated by elastic stable intramedullary nailing (ESIN). From 1994 to 1999, 100 children were treated. The mean age of the 65 boys and 35 girls was 8.7 years. The mean follow-up was 5.4 years. There were 30 type-AII fractures, 21 type-AIII, 17 type-AI, 13 type-BI, nine type-BII, four type-BIII and six type-CI. Implants were inserted using the ascending method in 92 patients and the descending method in eight. The mean period of implant insertion was 172 days. Steel implants (Medin) were used in 54 patients and titanium implants (Synthes) in 46. Evaluated according to Flynn, 86 patients had an excellent outcome, 13 a satisfactory outcome and one a poor outcome. The greatest limb length discrepancy was 3.2 cm. A steel implant was used in eight of the 13 patients whose results were merely satisfactory and in the patient who had a poor outcome. There were no pyogenic complications. In five patients, the inserted implant required shortening during treatment. We believe that in 5 to 12-year-old patients the ESIN method with titanium implants can be used to treat femoral shaft fractures

To evaluate the efficacy of elastic stable intramedullary nailing (ESIN) for the treatment of forearm fractures in children and adolescents. Between June 2002 and August 2007, 28 patients (19 boys – 9 girls) with 28 forearm fractures were treated with ESIN in our department. The mean age was 12.88 years (range 10.9–4.82). Both forearm bones were affected in all cases. 13 patients were treated by intra-medullary splinting immediate after the accident whilst 15 children were operated after failure of conservative treatment and fracture redisplacement. The radius was nailed in a retrograde fashion in all cases. On the other hand antegrade nailing of the ulna was performed in 18 cases whilst retrograde nailing in 5 patients. In 8 cases closed reduction was possible whilst a small incision at the fracture site was necessary in 20 children. In all cases an above-elbow cast was applied for 5 – 6 weeks postoperatively. The healing process was determined on the basis of two-projection radiographs. At the latest follow-up elbow and forearm motion were also assessed. Mean follow-up was 16 months (range, 7 – 28). With the exception of one case all fractures healed within 9 weeks. No case of infection, cross-union or non-union occurred. At the latest follow-up all children presented with complete restoration of elbow movement but three of them had a deficit of pronation of 15–20 degrees. In those cases where an open reduction was required the results were the same as in other cases. Based on our results, retrograde, of both bones, nailing is recommended for the treatment of all displaced forearm fractures in children older than 7 years-old. Proper preoperative curving of the nails offers increased stability maintaining the anatomic relation of the forearm bones

For a long time treatment of all forarm fractures was coservatively in principle. Retrospective analysis of more than 1000 fractures showed that 97,8% were treated orthopedically, 22% finished consolidation with an axial malalignment of more than 10∞ and 6,9% showed bad functional results 3–13 years later. Most bad results were found in shaft fractures of both bones on the same level or in oblique fractures with convergent displacement. The introduction of elastic stable intramedullary nailing (ESIN) gave the opportunity to stabilize instable diaphy-seal fractures with less [Aufwand], with an implant adequate for children and with the possibility of immediate postoperative movement. Within three years, 161 diaphy-seal forearm fractures were managed by cast (27%), reduction (32%) or osteosynthesis (41%). In 14 cases (8,7%), secondary osteosynthesis took place because of secondary or re-displacement during orthopedic treatment. The functional results following ESIN are very good. In radial neck fractures with severe displacement of more than 60° an open reduction and fixation by K-wires was the preferred method for a long time. After open reduction, radial head necrosis was the result in a significant part of cases independent of the quality of reduction. Closed reduction with the tip of the nail without touching the fracture region improved the results extremely. Seldom a transcapsular reduction manoever is necessary. In a multicentric study of proximal radius fractures including 67 cases, 27 fractures with a relevant displacement were managed surgically (24 ESIN, 3 K-wire). 3 [Verplumpung] of the radial head, two of them combined with premature closure of epiphyseal plate, and one radial head necrosis took place, but only in one case with ESIN, whereas all cases with open reduction and K-wire use showed problems during the healing course

Aims

To determine the impact of COVID-19 on orthopaediatric admissions and fracture clinics within a regional integrated care system (ICS).

The December 2015 Children’s orthopaedics Roundup³⁶⁰ looks at: Paediatric femoral fractures: a single incision nailing?; Lateral condylar fractures: open or percutaneous?;

Forearm refracture: the risks; Tibial spine fractures; The child’s knee in MRI; The mechanics of SUFE; Idiopathic clubfoot

The August 2015 Children’s orthopaedics Roundup³⁶⁰ looks at: Learning the Pavlik; MRI and patellar instability; Cerebral palsy and hip dysplasia; ‘Pick your poison’: elastic nailing under the spotlight; Club feet and surgery; Donor site morbidity in vascularised fibular grafting; Cartilage biochemistry with hip dysplasia; SUFE and hip decompression: a good option?

The August 2015 Shoulder & Elbow Roundup³⁶⁰ looks at: Clavicular fractures are being fixed – but how?; Propionibacterium acnes: a pain in the shoulder?; Bacteria, armpits and arthroplasty; Living longer, but unhappy: the woes of shoulder arthroplasty in the under 50s; Recurrent dislocations in the adolescent population; Splinting for elbow stiffness; Revision Bankart repair

The October 2014 Children’s orthopaedics Roundup³⁶⁰ looks at: spondylolisthesis management strategies; not all cervical collars are even; quality of life with Legg-Calve-Perthe’s disease; femoral shaft fractures in children; percutaneous trigger thumb release – avoid at all costs in children; predicting repeat surgical intervention in acute osteomyelitis; and C-Arm position inconsequential in radiation exposure

The June 2014 Children’s orthopaedics Roundup³⁶⁰ looks at: plaster wedging in paediatric forearm fractures; the medial approach for DDH; Ponseti – but not as he knew it?; Salter osteotomy more accurate than Pemberton in DDH; is the open paediatric fracture an emergency?; bang up-to-date with femoral external fixation; indomethacin, heterotopic ossification and cerebral palsy hips; lengthening nails for congenital femoral deformities, and is MRI the answer to imaging of the physis?