Statement of purpose of study: To determine how effective Flexible Intramedullary Nails are in treating tibial and femoral fractures in adolescents.

Introduction Flexible intramedullary nails (FIN) are increasingly used in the management of paediatric tibial and femoral fractures. Recently, concerns have been raised regarding the use of FIN in older children. The aim of this study was to determine how effective FIN's are in treating tibial and femoral fractures in adolescents.

Methods Hospital records were used to identify all patients aged 11 years or older under going FIN for tibial and femoral fractures between 2003 and 2009. Radiographs and case notes were reviewed to identify complications.

Results 35 consecutive adolescent patients underwent FIN for tibial (n=21) and femoral fractures (n=15) with a mean age of 12.9 years. 2 femoral and 9 tibial fractures were open. Eight patients sustained multiple injuries. Mean radiographic follow up was 29 weeks. 60% (n=9) and 38% (n=9) of femoral and tibial fractures respectively malunited. Fracture severity was associated with increased malunion for both tibial and femoral fractures (P=0.046 and P=0.044 respectively). There were no cases of non-union. 2 femoral fractures took longer than 20 weeks to unite and 7 tibial fractures took longer than 16 weeks to unite. One patient developed post operative compartment syndrome, one patient developed deep infection and two patients were treated with post operative traction for loss of fracture position.

Discussion Previous publications from multiple centres, including ours, have demonstrated excellent results of FIN for tibial and femoral fractures in the general paediatric population. However, concerns have recently been raised about the use of FIN in older, heavier children and with unstable fracture patterns. This is the first published series of adolescent patients undergoing FIN. We conclude that the higher than expected rates of malunion and delayed union suggest that other treatments should be considered when treating adolescents with unstable tibial or femoral fractures.

Materials and Methods: Consecutive 39 patients who underwent first metatarsophalangeal joint (MTPJ) arthrodesis for hallux rigidus were assessed clinically, radiographically and functionally at a mean follow up of 21.45 months. Clinical assessment was performed by two blinded assessors in a specially arranged research clinic. Radiological examinations were performed separately by two independent researchers on digitalised weight bearing radiographs. Functional outcome was assessed using American Orthopaedic Foot and Ankle Society (AOFAS) hallux score and a short form-12 (SF-12) questionnaire.

Results: There were 19 patients who had dorsal contoured titanium plates and 20 patients who had single inter fragmentary screw fixation. Both the groups were comparable preoperatively. All except 5 patients achieved radiological fusion at a mean of 7.64 weeks. Over all rate of fusion in the present series is 87.1%. There were 4 non-unions in the plate group and one in screw group. Mean AOFAS score was 74.94 in the screw group and 70.63 in the plate group. There were no hardware problems in the single screw group. However in the plate group one patient with non-union broke the plate and another patient had back out of screws. There were no statistically significant differences in terms of pain-relief, activity-limitation, cosmetic appearance, foot wear requirements, dorsiflexion angle, hallux-valgus angle and inclination angles and SF 12 scores. Four patients in the plate group and one in screw group were unsatisfied with the surgery.

Conclusions: Solid fusion has resulted in good pain relief and patient satisfaction in both groups. In the dorsal plate group 4 patients (21.6%) had non-unions, two patients had metal problems. We have stopped using the plate alone technique for the fixation of first MTPJ fusion.

Displaced intra-capsular fractures of femoral neck are treated by osteosynthesis in young adults. Using a standard protocol, we have compared the results of internal fixation after closed (CRIF) and open reduction (ORIF) in these patients. We have also studied the risk factors that influence non-union and avascular necrosis (AVN).

Patients in the age group of 15–50 years, who were scheduled for internal fixation within 1 week of injury, were randomized into two groups, one for closed reduction and the other for open reduction. The two groups were compared for factors such as age, gender, time of surgery and posterior comminution as well as union and complications. Using univariate and multivariate methods the factors influencing non-union and AVN were analyzed.

The average duration of surgery in patients undergoing CRIF was less than half of that in the ORIF group. The rates of union (p=0.93) and avascular necrosis at 2 years (p=0.85) were comparable. Rates of complications like deep vein thrombosis and infection were also found to be comparable. Guide wire breakage was found in 2 patients undergoing CRIF. Posterior comminution, poor reduction and improper screw placement were the major factors influencing non-union. An accurate reduction in both the planes and placement of screws parallel or slightly divergent to each other had a positive influence on union. An overall AVN rate of 16.3% (15/92) was encountered and it was not influenced by any of the factors. A delay of more than 48 hrs in surgery did not influence the rates of union or AVN.

Conclusion: Both CRIF and ORIF are credible methods of treatment. Although the duration of surgery in CRIF is less than ORIF, the added time taken in achieving the reduction on the fracture table may actually make the whole procedure longer than ORIF. Posterior comminution, early loss of reduction and convergent screw placement are leading reasons for non-union.

Twenty one cases of ipsilateral hip and femoral shaft fractures, between January 1998 and December 2001, managed by reconstruction nail were reviewed. All patients underwent simultaneous surgery for both fractures and operative treatment was executed as early as general condition of the patient permitted. Delay in treatment was generally because of associated injuries [head, chest or abdominal]. There were 20 males and 1female patients with an average age of 34.5 years. There was delayed diagnosis of neck fracture in 2 cases and these cases were not included in the study.

Our average follow-up is 30.9 months. There was one case of nonunion of a femoral neck fracture, one case of avascular necrosis and one neck fracture that united in varus. There were 4 nonunions and 6 cases of delayed union of femoral shaft fractures. Mean time for union of femoral neck fracture was 15 weeks and for shaft fracture was 22 weeks. In our results, shaft fracture determined the total union period. Though complications involving the femoral shaft fracture were greater than the femoral neck fractures, the shaft complications were more manageable compared to neck complications. This stresses the need to realize the significance and seriousness of both components of this complex injury, in evaluation, management and postoperative care.

Conclusion: Though technically demanding the reconstruction nail is an optimal alternative for management of concomitant fracture of femoral neck and shaft with low rates of complications and good results.